Tobacco use in the oncology setting: advancing clinical practice and research

Impact of tobacco smoking on disease-specific outcomes in common neurological disorders: A scoping review

Although the association of smoking with the risk of incident neurological disorders is well established, less is known about the impact of smoking and smoking cessation on outcomes of these conditions. The objective of this scoping review was to synthesize what is known about the impact of smoking and smoking cessation on disease-specific outcomes for seven common neurological disorders. We included 67 studies on the association of smoking and smoking cessation on disease-specific outcomes. For multiple sclerosis, smoking was associated with greater clinical and radiological disease progression, relapses, risk for disease-related death, cognitive decline, and mood symptoms, in addition to reduced treatment effectiveness. For stroke and transient ischemic attack, smoking was associated with greater rates of stroke recurrence, post-stroke cardiovascular outcomes, post-stroke mortality, post-stroke cognitive impairment, and functional impairment. In patients with cognitive impairment and dementia, smoking was associated with faster cognitive decline, and smoking was also associated with greater cognitive decline in Parkinson's disease, but not motor symptom worsening. Patients with amyotrophic lateral sclerosis who smoked faced increased mortality. Last, in patients with cluster headache, smoking was associated with more frequent and longer cluster attack periods. Conversely, for multiple sclerosis and stroke, smoking cessation was associated with improved disease-specific outcomes. In summary, whereas smoking is detrimentally associated with disease-specific outcomes in common neurological conditions, there is growing evidence that smoking cessation may improve outcomes. Effective smoking cessation interventions should be leveraged in the management of common neurological disorders to improve patient outcomes.

Prospective cohort of pre- and post-diagnosis alcohol consumption and cigarette smoking on survival outcomes: an Alberta Endometrial Cancer Cohort Study

PURPOSE

To examine the independent and joint relationships between cigarette smoking and alcohol consumption with survival outcomes after endometrial cancer diagnosis.

METHODS

Pre- and post-diagnosis smoking and drinking histories were obtained from endometrial cancer survivors diagnosed between 2002 and 2006 during in-person interviews at-diagnosis and at ~ 3 years post-diagnosis. Participants were followed until death or January 2022. Multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated with Cox proportional hazards regression for associations with disease-free survival (DFS) and overall survival (OS).

RESULTS

During a median 16.9 years of follow-up (IQR = 15.5-18.1 years), 152 of the 540 participants had a DFS event (recurrence: n = 73; deaths: n = 79) and 134 died overall. Most participants in this cohort were current drinkers (pre = 61.3%; post = 64.7%) while few were current cigarette smokers (pre = 12.8%; post = 11.5%). Pre-diagnosis alcohol consumption was not associated with survival, yet post-diagnosis alcohol intake ≥ 2 drinks/week was associated with worse OS compared with lifetime abstention (HR = 2.36, 95%CI = 1.00-5.54) as well as light intake (HR = 3.87, 95% CI = 1.67-8.96). Increased/consistently high alcohol intake patterns were associated with worse OS (HR = 2.91, 95% CI = 1.15-7.37) compared with patterns of decreased/ceased intake patterns after diagnosis. A harmful dose-response relationship per each additional pre-diagnosis smoking pack-year with OS was noted among ever smokers. In this cohort, smoking and alcohol individually were not associated with DFS and combined pre-diagnosis smoking and alcohol intakes were not associated with either outcome.

CONCLUSION

Endometrial cancer survivors with higher alcohol intakes after diagnosis had poorer OS compared with women who had limited exposure. Larger studies powered to investigate the individual and joint impacts of cigarette smoking and alcohol use patterns are warranted to provide additional clarity on these modifiable prognostic factors.

Stakeholder perceptions of using "opt-out" for tobacco use treatment in a cancer care setting: a qualitative evaluation of patients, providers, and desk staff

BACKGROUND

Continued tobacco use in cancer patients increases the risk of cancer treatment failure and decreases survival. However, currently, most cancer patients do not receive evidence-based tobacco treatment. A recently proposed "opt-out" approach would automatically refer all cancer patients who use tobacco to tobacco treatment, but its acceptability to cancer patients and providers is unknown. We aimed to understand stakeholder beliefs, concerns, and receptivity to using the "opt-out" approach for tobacco treatment referrals in a cancer care setting.

METHODS

Semi-structured interviews were conducted with oncology patients, providers, and desk staff. The sample size was determined when theoretical saturation was reached. Given the differences among participant roles, separate interview guides were developed. Transcripts were analyzed using standard coding techniques for qualitative data using the Consolidated Framework for Implementation Research (CFIR) codebook. Emergent codes were added to the codebook to account for themes not represented by a CFIR domain. Coded transcripts were then entered into the qualitative analysis software NVivo to generate code reports for CFIR domains and emergent codes for each stakeholder group. Data were presented by stakeholder group and subcategorized by CFIR domains and emergent codes when appropriate.

RESULTS

A total of 21 providers, 19 patients, and 6 desk staff were interviewed. Overall acceptance of the "opt out" approach was high among all groups. Providers overwhelmingly approved of the approach as it requires little effort from them to operate and saves clinical time. Desk staff supported the opt-out system and believed there are clinical benefits to patients receiving information about tobacco treatment. Many patients expressed support for using an opt-out approach as many smokers need assistance but may not directly ask for it. Patients also thought that providers emphasizing the benefits of stopping tobacco use to cancer treatment and survival would be an important factor motivating them to attend treatment.

CONCLUSIONS

While providers appreciated that the system required little effort on their part, patients clearly indicated that promotion of tobacco cessation treatment by their provider would be vital to enhance willingness to engage with treatment. Future implementation efforts of opt-out systems will require implementation strategies that promote provider engagement with their patients around smoking cessation while continuing to limit burden on providers.

Implementation planning for equitable tobacco treatment services: a mixed methods assessment of contextual facilitators and barriers in a large comprehensive cancer center

Tobacco use among cancer patients is associated with an increased mortality and poorer outcomes, yet two-thirds of patients continue using following diagnosis, with disproportionately higher use among racial/ethnic minority and low socioeconomic status patients. Tobacco treatment services that are effectively tailored and adapted to population characteristics and multilevel context specific to settings serving diverse patients are needed to improve tobacco cessation among cancer patients. We examined tobacco use screening and implementation needs for tobacco treatment services to inform equitable and accessible delivery within a large comprehensive cancer center in the greater Los Angeles region. We conducted a multi-modal, mixed methods assessment using electronic medical records (EMR), and clinic stakeholder surveys and interviews (guided by the Consolidated Framework for Implementation Research). Approximately 45% of patients (n = 11,827 of 26,030 total) had missing tobacco use history in their EMR. Several demographic characteristics (gender, age, race/ethnicity, insurance) were associated with greater missing data prevalence. In surveys (n = 32), clinic stakeholders endorsed tobacco screening and cessation services, but indicated necessary improvements for screening/referral procedures. During interviews (n = 13), providers/staff reported tobacco screening was important, but level of priority differed as well as how often and who should screen. Several barriers were noted, including patients' language/cultural barriers, limited time during visits, lack of smoking cessation training, and insurance coverage. While stakeholders indicated high interest in tobacco use assessment and cessation services, EMR and interview data revealed opportunities to improve tobacco use screening across patient groups. Implementing sustainable system-level tobacco cessation programs at institutions requires leadership support, staff training, on routine screening, and intervention and referral strategies that meet patients' linguistic/cultural needs.

Data envelopment analysis to evaluate the efficiency of tobacco treatment programs in the NCI Moonshot Cancer Center Cessation Initiative

BACKGROUND

The Cancer Center Cessation Initiative (C3I) is a National Cancer Institute (NCI) Cancer Moonshot Program that supports NCI-designated cancer centers developing tobacco treatment programs for oncology patients who smoke. C3I-funded centers implement evidence-based programs that offer various smoking cessation treatment components (e.g., counseling, Quitline referrals, access to medications). While evaluation of implementation outcomes in C3I is guided by evaluation of reach and effectiveness (via RE-AIM), little is known about technical efficiency-i.e., how inputs (e.g., program costs, staff time) influence implementation outcomes (e.g., reach, effectiveness). This study demonstrates the application of data envelopment analysis (DEA) as an implementation science tool to evaluate technical efficiency of C3I programs and advance prioritization of implementation resources.

METHODS

DEA is a linear programming technique widely used in economics and engineering for assessing relative performance of production units. Using data from 16 C3I-funded centers reported in 2020, we applied input-oriented DEA to model technical efficiency (i.e., proportion of observed outcomes to benchmarked outcomes for given input levels). The primary models used the constant returns-to-scale specification and featured cost-per-participant, total full-time equivalent (FTE) effort, and tobacco treatment specialist effort as model inputs and reach and effectiveness (quit rates) as outcomes.

RESULTS

In the DEA model featuring cost-per-participant (input) and reach/effectiveness (outcomes), average constant returns-to-scale technical efficiency was 25.66 (SD = 24.56). When stratified by program characteristics, technical efficiency was higher among programs in cohort 1 (M = 29.15, SD = 28.65, n = 11) vs. cohort 2 (M = 17.99, SD = 10.16, n = 5), with point-of-care (M = 33.90, SD = 28.63, n = 9) vs. no point-of-care services (M = 15.59, SD = 14.31, n = 7), larger (M = 33.63, SD = 30.38, n = 8) vs. smaller center size (M = 17.70, SD = 15.00, n = 8), and higher (M = 29.65, SD = 30.99, n = 8) vs. lower smoking prevalence (M = 21.67, SD = 17.21, n = 8).

CONCLUSION

Most C3I programs assessed were technically inefficient relative to the most efficient center benchmark and may be improved by optimizing the use of inputs (e.g., cost-per-participant) relative to program outcomes (e.g., reach, effectiveness). This study demonstrates the appropriateness and feasibility of using DEA to evaluate the relative performance of evidence-based programs.

Tobacco Smoking Behaviors in Cancer Survivors: The Mediation Effect of Personality and Emotional Intelligence

The smoking behaviour of patients following a cancer diagnosis is a critical risk factor for several physical diseases; it can increase the risk of second primary tumors and lower cancer treatment efficacy. Despite this, a great number of survivors continue to smoke after the diagnosis. This observational, cross-sectional on-line study aimed to assess the relationship between the impact of cancer diagnosis on survivors and their smoking behavior, and whether emotional intelligence and personality might mediate this relationship. Ninety-four Italian survivors completed a set of questionnaires: Big Five Inventory; Fagerström Test for Nicotine Dependence; Impact of Event Scale; Brief Emotional Intelligence Scale. The results obtained from the mediation analyses highlighted that the indirect effect on the relationship between the psychological impact of the diagnosis and smoking behaviors was partially mediated by neuroticism (Intrusion: 95% CI [0.00; 0.11]; Avoidance: 95% CI [0.00; 0.18]). Additionally, the data suggested that the relationship between the psychological impact of the diagnosis and smoking behaviors was partially mediated by the utilization of emotions dimension of emotional intelligence (Intrusion: 95% CI [0.00; 0.10]; Avoidance: 95% CI [0.00; 0.22]). Overall, this study suggests the importance of designing interventions to support smoking interruption based on the "mapping" of individual needs and emotional regulation strategies.

Oncology Patient Smoking Cessation Treatment Preferences: Perceptions Across Former and Current Cigarette Smokers

Although the benefits of smoking cessation following a cancer diagnosis have been well-established, up to 50% of cancer patients continue to smoke. Continued smoking through oncology treatment leads to increased risk of adverse events including reduced effectiveness of treatment, recurrence of additional malignancies, and reduced survival rates. Upon the cancer diagnosis, oncology healthcare providers become the primary trusted source of information and support, which represents a great opportunity to assist these patients to quit smoking. However, it remains unclear how oncology healthcare providers can best address smoking cessation from a patient-centered perspective. The present study surveyed oncology patients from Birmingham, AL, classified as either former (n = 174) or current smokers (n = 81) to identify their perceptions regarding the role of oncology healthcare providers in their smoking cessation efforts. Current smokers were more likely to be younger, received their cancer diagnosis within the past 3 years, and have a cancer diagnosis with high smoking-related public awareness (i.e., head, neck, or lung) compared to former smokers. Additionally, 81% of current smokers reported experiencing smoking cessation discussions with their oncology healthcare providers with the most prominent recommendations being use of nicotine replacement therapies (46.9%) and medication (35.8%). These smoking cessation experiences align with patient preferences. However, despite the frequency of smoking cessation discussions, current smokers demonstrated an ambivalence in understanding the risks of continued smoking during their medical treatment. Overall, this study highlights the important role of oncology healthcare providers on implementing smoking cessation intervention for their patients who continue to smoke.

Treating Smoking in Cancer Patients: An Essential Component of Cancer Care-The New National Cancer Institute Tobacco Control Monograph

PURPOSE

Continued smoking after the diagnosis of cancer can markedly worsen oncology treatment side effects, cancer outcomes, cancer mortality, and all-cause mortality. Conversely, mounting evidence demonstrates that smoking cessation by patients with cancer improves outcomes. A cancer diagnosis often serves as a teachable moment, characterized by high motivation to quit. However, too few patients with cancer who smoke are offered evidence-based smoking cessation treatment, and too few engage in such treatment.

METHODS AND MATERIALS

The National Cancer Institute commissioned Tobacco Control Monograph 23, Treating Smoking in Cancer Patients: An Essential Component of Cancer Care, to review and synthesize the evidence that clarifies the need to intervene with smoking in cancer care.

RESULTS

Although many patients with newly diagnosed cancer who smoke make quit attempts, many of these are unsuccessful, and among those who successfully quit, relapse is common. Indeed, an estimated 12.2% of adults ever diagnosed with cancer reported they currently smoked (National Health Interview Survey, 2020). Patients with cancer who smoke are likely to benefit from smoking cessation treatments, including counseling and US Food and Drug Administration-approved medications, and there are many effective strategies to increase delivery of smoking cessation treatment in cancer care settings.

CONCLUSION

Smoking cessation is among the most effective treatment options for improving the likelihood of survival, quality of life, and overall health of patients with cancer who smoke. It is important for cancer care clinicians and patients to realize that it is never too late to quit smoking and that there are clear benefits to doing so, regardless of cancer type.

Long-term follow-up of smokers following lung and colorectal cancer diagnosis

BACKGROUND

Continued smoking after a cancer diagnosis limits the effectiveness of treatment, increases the risk of cancer recurrence or secondary malignancies, and is associated with poorer quality of life and survival. A cancer diagnosis may provide a meaningful timepoint for quitting, but the prevalence and characteristics of continued smoking through survivorship are poorly understood.

METHODS

In the multi-regional Cancer Care Outcomes Research and Surveillance (CanCORS) cohort, we examined smoking rates and factors associated with continued smoking at long-term follow-up among lung and colorectal cancer patients. This paper builds upon previous CanCORS participant data addressing quit rates and associated characteristics at baseline and 5 months post-diagnosis.

RESULTS

At long-term follow-up (median 7.3 years post-diagnosis [IQR = 5.9-8.7]), 16.7% of lung cancer and 11.6% of colorectal cancer survivors continued to smoke combustible cigarettes. Factors independently associated with continued smoking at long-term follow-up included being male, younger, not married or partnered, having Medicare, Medicaid/other public or no insurance, more depression symptoms, smoking more cigarettes per day, and having a history of lung disease (p < .05). Continued smoking did not vary by lung vs. colorectal cancer diagnosis.

CONCLUSION

Of active smokers at the time of diagnosis, an important minority of lung and colorectal cancer survivors continued to smoke well into survivorship. Understanding characteristics associated with continued smoking after a cancer diagnosis may help inform the development of tobacco treatment programs for cancer patients and survivors.

IMPLICATIONS FOR SURVIVORS

While addressing smoking cessation at the time of diagnosis is critical to ensure better long-term treatment outcomes and quality of life, it is essential to continue smoking cessation discussions and efforts throughout care and survivorship.

Study protocol for a hybrid type 1 effectiveness-implementation trial testing virtual tobacco treatment in oncology practices [Smokefree Support Study 2.0]

BACKGROUND

Persistent smoking among patients diagnosed with cancer is associated with adverse clinical outcomes, yet an evidence-based tobacco use intervention has not been well-integrated into cancer care in community oncology settings. This paper describes the protocol of a nation-wide clinical trial conducted by the ECOG-ACRIN National Cancer Institute (NCI) Community Oncology Research Program (NCORP) Research Base to assess the effectiveness of a virtual tobacco treatment intervention and the process of implementing tobacco treatment in NCORP community oncology settings.

METHODS/DESIGN

This two-arm, multisite (n: 49 NCORP sites) hybrid type 1 effectiveness-implementation randomized controlled trial compares the effectiveness of a Virtual Intervention Treatment (VIT) versus an Enhanced Usual Control (EUC) among English and Spanish speaking patients recently diagnosed with cancer, reporting current smoking and receiving care at a participating NCORP Community or Minority/Underserved Site. The VIT includes up to 11 virtual counseling sessions with a tobacco treatment specialist and up to 12 weeks of nicotine replacement therapy (NRT). The EUC arm receives a referral to the NCI Quitline. The primary study outcome is biochemically confirmed 7-day point prevalence smoking abstinence. Moderators of treatment effect will be assessed. The study evaluates implementation processes from participating NCORP site staff via survey, administrative, and focus group data, including reach, acceptability, appropriateness, fidelity, feasibility, adoption, cost and sustainability outcomes.

DISCUSSION

This trial will generate findings about the effectiveness of an evidence-based virtual tobacco treatment intervention targeting patients diagnosed with cancer and illuminate barriers and facilitators that influence implementing tobacco treatment into community oncology settings nationally. In the era of COVID-19, virtual care solutions are vital for maximizing access and utilization of tobacco treatment delivery.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03808818) on January 18th, 2019; Last update posted: May 21st, 2020.

Role of Long Noncoding RNAs in Smoking-Induced Lung Cancer: An In Silico Study

The prevalence of lung cancer induced by cigarette smoking has increased over time. Long noncoding (lnc) RNAs, regulatory factors that play a role in human diseases, are commonly dysregulated in lung cancer. Cigarette smoking is closely related to changes in lncRNA expression, which can affect lung cancer. Herein, we assess the mechanism of lung cancer initiation induced by smoking. To calculate the impact of smoking on the survival of patients with lung cancer, we extracted data from The Cancer Genome Atlas and Gene Expression Omnibus databases and identified the differentially expressed genes in the lung cancer tissue compared to the normal lung tissue. Genes positively and negatively associated with smoking were identified. Gene Ontology, Kyoto Encyclopedia of Genes and Genomes, and Cytoscape analyses were performed to determine the function of the genes and the effects of smoking on the immune microenvironment. lncRNAs corresponding to smoking-associated genes were identified, and a smoking-related lncRNA model was constructed using univariate and multivariate Cox analyses. This model was used to assess the survival of and potential risk in patients who smoked. During screening, 562 differentially expressed genes were identified, and we elucidated that smoking affected the survival of patients 4.5 years after the diagnosis of lung cancer. Furthermore, genes negatively associated with smoking were closely associated with immunity. Twelve immune cell types were also found to infiltrate differentially in smokers and nonsmokers. Thus, the smoking-associated lncRNA model is a good predictor of survival and risk in smokers and may be used as an independent prognostic factor for lung cancer.

Implementation strategies for integrating tobacco cessation treatment in cancer care: A qualitative study

Purpose

The objective of this study was to determine how to optimize implementation of tobacco cessation treatment interventions in cancer care by (1) investigating the feasibility and acceptability of a multi-level approach to tobacco cessation treatment intervention, (2) identifying barriers and facilitators to implementation, and (3) eliciting additional strategies to improve implementation of the intervention.

Methods

We conducted qualitative interviews with oncologists (n = 15) from one large academic health center in the Southeastern United States. We asked about their knowledge, attitudes, and current practices regarding tobacco use screening and treatment. We also asked about two proposed strategies to support implementation of tobacco cessation treatment: (1) developing a registry of tobacco users in collaboration with the state-run tobacco cessation program, and (2) providing on-site tobacco cessation counseling from trained professionals.

Results

Oncologists saw addressing tobacco use as valuable; however, they felt restricted from consistently addressing tobacco use by multi-level barriers such as workload, electronic health record (EHR) design, patient anxiety, and low self-efficacy for treating tobacco dependence. Oncologists responded positively to on-site treatment and felt this strategy would increase treatment accessibility and enhance engagement. Reaction to developing a registry of tobacco users was mixed, with concerns regarding lack of oncologist involvement and patient privacy expressed. Other suggested strategies for supporting implementation of tobacco cessation treatment included reducing referral complexity, establishing financial or quality incentives for oncologists, and leveraging existing EHR tools to facilitate integration of cessation interventions into clinic workflows.

Conclusion

We identified several challenges to implementing tobacco use treatment in cancer care; however, we considered strategies to overcome these barriers that were viewed as feasible and acceptable. Our work highlights the importance of engaging stakeholders in implementation efforts. Future work should explore the impact of the implementation strategies identified in this study.

National assessment of recommendations from healthcare providers for smoking cessation among adults with cancer

Cancer survivors benefit from evidence-based smoking cessation treatment. A crucial first step in this process is a clinician recommending that the patient quit smoking. However, contemporary delivery of advice to quit among patients with cancer is not well known. In a cross-sectional analysis of all adult smokers included in a prospective population-representative study of US adults, we analyzed the frequency that patients reported receiving advice to quit smoking from a healthcare professional according to reported cancer history (no cancer, tobacco-related cancer, non-tobacco related cancer history). Among an estimated 28.3 million smokers, 9.3% reported a history of cancer, 48.8% of which were tobacco-related cancers. In general, advice to quit was reported by more (67.8%) cancer survivors than those adults without any cancer (56.0%). After adjustment for sociodemographic factors, smokers with a non tobacco-related cancer (0.51, 95% CI 0.32-0.83) and those without any cancer history (0.43, 95% CI 0.30-0.63) were both less likely to report being advised to quit smoking than patients with a tobacco-related cancer history.

Motivation to smoking cessation in head and neck cancer and dysplasia patients in confrontation with the attitudes of otorhinolaryngologists in delivering anti-smoking therapies

Objectives

The aim of the study was to determine the influence of oral, oropharyngeal, laryngeal and hypopharyngeal dysplasia and cancer diagnosis on motivation to smoking cessation in patients. Consecutively, we assessed the competence of ENT specialists in counseling anti-smoking therapies.

Methods

Questionnaire of expected support, Schneider motivation test and Fagerström Test for Nicotine Dependence (FTND) were administered to 50 smoking patients. The online survey was collected from 152 ENT doctors.

Results

Mean FTND score was 4.58 and Heaviness of Smoking Index (HSI) was 3.1. Patients with oral cavity and oropharyngeal cancer showed the greatest dependence to nicotine 7.67 and 5.25, respectively, and with hypopharyngeal cancer had the lowest 3.5, (p = 0.039). The ranges of HSI were significantly higher for younger patients (p = 0.036). 35 patients were adequately motivated to quit smoking, and their mean age was statistically higher (p = 0.05). Self-reported motivation to smoking cessation was 76%. Of 152 surveyed doctors, only 39% declared knowledge of the diagnostic and therapeutic cessation interventions. 75% showed interest in the training programs.

Smoking Cessation in Stroke Survivors in the United States: A Nationwide Analysis

BACKGROUND AND PURPOSE

Continued smoking after stroke is associated with a high risk of stroke recurrence and other cardiovascular disease. We sought to comprehensively understand the epidemiology of smoking cessation in stroke survivors in the United States. Furthermore, we compared smoking cessation in stroke and cancer survivors because cancer is another smoking-related condition in which smoking cessation is prioritized.

METHODS

We performed a cross-sectional analysis of data from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System, an annual, nationally representative health survey. Using pooled data from 2013 to 2019, we identified stroke and cancer survivors with a history of smoking. We used survey procedures to estimate frequencies and summarize quit ratios with attention to demographic and geographic (state-wise and rural-urban) factors for stroke survivors. The quit ratio is conventionally defined as the proportion of ever smokers who have quit. Then, we used multivariable logistic regression to compare quit ratios in stroke and cancer survivors while adjusting for demographics and smoking-related comorbidities.

RESULTS

Among 4 434 604 Americans with a history of stroke and smoking, the median age was 68 years (interquartile range, 59-76), and 45.4% were women. The overall quit ratio was 60.8% (95% CI, 60.1%-61.6%). Quit ratios varied by age group, sex, race and ethnicity, and several geographic factors. There was marked geographic variation in quit ratios, ranging from 48.3% in Kentucky to 71.5% in California. Furthermore, compared with cancer survivors, stroke survivors were less likely to have quit smoking (odds ratio, 0.72 [95% CI, 0.67-0.79]) after accounting for differences in demographics and smoking-related comorbidities.

CONCLUSIONS

There were considerable demographic and geographic disparities in smoking quit ratios in stroke survivors, who were less likely to have quit smoking than cancer survivors. A targeted initiative is needed to improve smoking cessation for stroke survivors.

Tobacco Dependence Treatment: Examining Cessation Effectiveness in Oncology Settings

The Wilmot Cancer Institute launched the Tobacco Dependence Treatment Program in 2015. Formal program evaluation consisted of 324 patients who presented for at least one visit to assess quit rates. The secondary aim was to ascertain the effectiveness of guideline recommendations that four or more visits would be beneficial in an outpatient oncology tobacco treatment program to promote success in smoking cessation. The first 32 months of program data revealed that there were significantly improved quit rates for those who were seen for four or more visits compared to those seen for three or fewer visits.

Best practices for assessing and reporting tobacco use in urology oncology practice and research

Tobacco use is the cause of several urologic cancers. Persistent use after diagnosis is associated with worse cancer-specific, quality of life, and overall mortality outcomes. Cigarette smoking remains the most common form of tobacco use despite significant population-level decline over the past few decades. The burden of smoking-related urologic disease is under appreciated by urologists and patients which has resulted in gaps in clinical care and limitations to research progress. We sought to summarize evidence-based practices and guideline recommendations for assessing and reporting tobacco use in the clinical and research settings. With a focus on smoking, our two primary goals are: 1) to promote the adoption of standardized and validated measures of tobacco use and 2) to highlight evidence-based strategies for urologists to use in clinical practice.

The impact of socioeconomic deprivation on mortality in cervical cancer patients in Cornwall (England)

OBJECTIVES

To assess the association between risk factors, including socioeconomic deprivation, and mortality, recurrence and chemo- or radiation toxicity in cervical cancer patients.

METHODS

Retrospective study of cervical cancer patients diagnosed between January 2007 and July 2018. Patient characteristics and mortality data, including recurrence, were assessed, together with socioeconomic deprivation measures evaluated using the English Indices of Multiple Deprivation. Markov multi-state models were used to model mortality and recurrence, and logistic regression models were used to model chemo- or radiation toxicity.

RESULTS

Included were 243 women with a median age of 49 years. A total of 57 patients died (23%), of which 41 due to cervical cancer, and 21 (9%) had recurrent disease. Hazard ratios (HR) showed no evidence of association between socioeconomic deprivation and cancer-specific hazard of mortality from diagnosis or recurrence, hazard of mortality due to other causes or hazard of cancer recurrence. Furthermore, there was no evidence of association between socioeconomic deprivation and chemo- or radiation toxicity (bowel, bladder or vaginal stenosis).

CONCLUSIONS

No associations were found between socioeconomic deprivation and cancer mortality or recurrence in cervical cancer patients in the population of Cornwall. In addition, no association was found between socioeconomic deprivation and chemo- or radiation toxicity.

Mixed-methods economic evaluation of the implementation of tobacco treatment programs in National Cancer Institute-designated cancer centers

Background

The Cancer Center Cessation Initiative (C3I) was launched in 2017 as a part of the NCI Cancer Moonshot program to assist NCI-designated cancer centers in developing tobacco treatment programs for oncology patients. Participating centers have implemented varied evidence-based programs that fit their institutional resources and needs, offering a wide range of services including in-person and telephone-based counseling, point of care, interactive voice response systems, referral to the quitline, text- and web-based services, and medications.

Methods

We used a mixed methods comparative case study design to evaluate system-level implementation costs across 15 C3I-funded cancer centers that reported for at least one 6-month period between July 2018 and June 2020. We analyzed operating costs by resource category (e.g., personnel, medications) concurrently with transcripts from semi-structured key-informant interviews conducted during site visits. Personnel salary costs were estimated using Bureau of Labor Statistics wage data adjusted for area and occupation, and non-wage benefits. Qualitative findings provided additional information on intangible resources and contextual factors related to implementation costs.

Results

Median total monthly operating costs across funded centers were $11,045 (range: $5129–$20,751). The largest median operating cost category was personnel ($10,307; range: $4122–$19,794), with the highest personnel costs attributable to the provision of in-person program services. Monthly (non-zero) cost ranges for other categories were medications ($17–$573), materials ($6–$435), training ($96–$516), technology ($171–$2759), and equipment ($10–$620). Median cost-per-participant was $466 (range: $70–$2093) and cost-per-quit was $2688 (range: $330–$9628), with sites offering different combinations of program components, ranging from individually-delivered in-person counseling only to one program that offered all components. Site interviews provided context for understanding variations in program components and their cost implications.

Conclusions

Among most centers that have progressed in tobacco treatment program implementation, cost-per-quit was modest relative to other prevention interventions. Although select centers have achieved similar average costs by offering program components of various levels of intensity, they have varied widely in program reach and effectiveness. Evaluating implementation costs of such programs alongside reach and effectiveness is necessary to provide decision makers in oncology settings with the important additional information needed to optimize resource allocation when establishing tobacco treatment programs.

Cross-sectional survey for assessing cancer care providers' characteristics and attitudes on smoking cessation in Colombia and Mexico

OBJECTIVE

Cancer care providers' (CCPs) attitudes towards smoking cessation are influenced by many factors, including their smoking status and knowledge. Our objective was to assess CCPs' characteristics, tobacco use and smoking cessation practices in two Latin American cancer centres.

DESIGN

Cross-sectional survey.

SETTINGS

Two urban cancer centres located in Colombia and Mexico.

PARTICIPANTS

A total of 238 CCPs.

MEASURES

Online survey consisted of 28 close-ended questions adapted from the 2012 International Association for the Study of Lung Cancer survey and the Global Adult Tobacco Survey developed by the WHO. Means, frequencies and proportions were reported for each country. Factors associated to providing of smoking cessation treatment or referral at initial visit were evaluated using logistic regression.

RESULTS

Current smoking prevalence was 10.5% and 12.3% among Colombian and Mexican CCPs, respectively. Around three quarters of the Colombian (86.4%) and Mexican CCPs (66.1%) considered to have inadequate training in smoking cessation. Approximately two-thirds of Colombian (67.5%) and Mexican CCPs (63.9%) reported always or most of the time asking patients about tobacco use during the initial visit. In Colombia and Mexico, the most relevant barriers for providing cessation services were (1) difficulties for motivating patients with cancer, (2) patient resistance in quitting smoking, (3) lack of local resources or referral centres for smoking cessation and (4) lack of training in smoking cessation. CCPs appointed at Instituto Nacional de Cancerología were less likely to provide cessation treatment or referral to their patients if they had less than 50% of their time devoted to patient care and were former or current smokers. The regression model for Instituto de Cancerología did not retain statistically significant variables.

CONCLUSION

Our findings highlight an urgent need for assisting Latin American CCPs in their quitting efforts as well as expanding formal smoking cessation training specifically tailored to these professionals for improving patients' cancer prognosis and quality of life.

Multidisciplinary team discussion results in survival benefit for patients with stage III non-small-cell lung cancer

Background

The treatment for stage III non-small cell lung cancer (NSCLC) often involves multi-modality treatment. This retrospective study aimed to evaluate whether multidisciplinary team (MDT) discussion results in better patient survival.

Materials and methods

MDT discussion was optional before February 2016 and was actively encouraged by the MDT committee beginning February 2016. We reviewed the medical charts and computer records of patients with stage III NSCLC between January 2013 and December 2018.

Results

A total of 515 patients were included. The median survival of all the patients was 33.9 months (M). The median survival of patients who were treated after MDT discussion was 41.2 M and that of patients treated without MDT discussion was 25.7 M (p = 0.018). The median survival of patients treated before February 2016 was 25.7 M and that of patients treated after February 2016 was 33.9 M (p = 0.003). The median survival of patients with stage IIIA tumors and those with stage IIIB tumors was 39.4 M and 25.7 M, respectively (p = 0.141). Multivariate analysis showed that MDT or not (p<0.001), T staging (p = 0.009), performance status (p<0.001), and surgery (p = 0.016) to be significant prognostic factors.

Conclusion

The results of the study show that MDT discussion results in survival benefit in patients with stage III NSCLC. The MDT discussion, performance status, and if surgery was performed were independent prognostic factors for patients with stage III NSCLC.

Oncologic Implications of Chronic Hepatitis C Virus Infection

Chronic hepatitis C virus (HCV) infection increases the risk for several types of cancer, including hepatocellular carcinoma (HCC) and B-cell non-Hodgkin lymphoma, as primary and second primary malignancies. HCV-infected patients with cancer, particularly those undergoing anticancer therapy, are at risk for development of enhanced HCV replication, which can lead to hepatitis flare and progression of liver fibrosis or cirrhosis. Risk factors for HCV infection include injection drug use, blood transfusion, or solid organ transplantation before 1992, receipt of clotting factor concentrates before 1987, long-term hemodialysis, chronic liver disease, HIV positivity, and occupational exposure. Widely available direct-acting antivirals are highly effective against HCV and well tolerated. Identification of HCV-infected individuals is the essential first step in treatment and eradication of the infection. One-time screening is recommended for persons born from 1945 to 1965; screening is also recommended for persons with risk factors. Recently, a public health recommendation has been drafted to screen all adults age 18 to 79 years. Two oncology organizations recommend screening all patients with hematologic malignancies and hematopoietic cell transplant recipients, and a recently published multicenter prospective study supports universal HCV screening for all patients with cancer. HCV screening entails testing for anti-HCV antibodies in serum and, when results are positive, HCV RNA quantitation to confirm infection. Direct-acting antiviral therapy eradicates HCV in almost all cases. Virologic cure of HCV prevents chronic hepatitis and progression to liver fibrosis or cirrhosis. HCV eradication also decreases the risk of developing HCV-associated primary and second primary malignancies, and it may allow HCV-infected patients access to important cancer clinical trials. Patients with HCV-related cirrhosis require lifelong surveillance for HCC, even after viral eradication.

Smoking cessation and survival among people diagnosed with non-metastatic cancer

Background

We aimed to estimate the effects of smoking cessation on survival among people diagnosed with cancer.

Methods

We used data from a Comprehensive Community Cancer Program that is part of a large urban safety-net hospital system. Eligible patients were diagnosed with primary invasive solid tumors between 2013 and 2015, and were current smokers at time of diagnosis. Our exposure of interest was initiation of smoking cessation within 6 months of cancer diagnosis. We estimated inverse probability weighted restricted mean survival time (RMST) differences and risk ratio (RR) for all cause 3-year mortality.

Results

Our study population comprised 369 patients, of whom 42% were aged < 55 years, 59% were male, 44% were racial/ethnic minorities, and 59% were uninsured. The 3-year RMST was 1.8 (95% CL: − 1.5, 5.1) months longer for individuals who initiated smoking cessation within 6 months of cancer diagnosis. The point estimate for risk of 3-year mortality was lower for initiation of smoking cessation within 6 months of diagnosis compared with no initiation within 6 months (RR = 0.72, 95% CL: 0.37, 1.4).

Conclusions

Our point estimates suggest longer 3-year survival, but the results are compatible with 1.5 month shorter or 5.1 longer 3-year overall survival after smoking cessation within 6 months of cancer diagnosis. Future studies with larger sample sizes that test the comparative effectiveness of different smoking cessation strategies are needed for more detailed evidence to inform decision-making about the effect of smoking cessation on survival among cancer patients.

Implications for Cancer survivors

The benefits of smoking cessation after cancer diagnosis may include longer survival, but the magnitude of benefit is unclear.

Assessment of Trends in Cigarette Smoking Cessation After Cancer Diagnosis Among US Adults, 2000 to 2017

IMPORTANCE

Continued cigarette smoking after cancer diagnosis has been shown to adversely alter the cancer survivor's health outcomes and quality of life. Although considerable progress has been made in reducing cigarette smoking in the United States over the last decades, trends in cigarette smoking cessation among cancer survivors have not yet been fully investigated.

OBJECTIVE

To evaluate temporal trends in cigarette smoking cessation and their sociodemographic and behavioral correlates in the US population of adult cancer survivors.

DESIGN, SETTING, AND PARTICIPANTS

This investigation was a serial cross-sectional study of the National Health Interview Survey (NHIS) from 2006 to 2018, a household survey of civilian US residents who were 18 years or older. Data analysis was performed from June to October 2019. The NHIS is population based and representative of the US population. Included in this study were 381 989 respondents to the NHIS in 2006 to 2018.

MAIN OUTCOMES AND MEASURES

The primary outcome was the probability of quitting cigarette smoking after first cancer diagnosis. Secondary outcomes were factors associated with quitting cigarette smoking after cancer diagnosis.

RESULTS

Data on 381 989 adults (weighted N = 239 114 051; mean [SD] age, 48.96 [18.28] years; 211 508 [55.37%] female; 61.90% non-Hispanic White, 13.97% non-Hispanic Black, and 16.22% Hispanic individuals) 18 years or older were analyzed from the 2006 to 2018 NHIS, of whom 8.80% (n = 35 524; weighted n = 21 016 720) were diagnosed with cancer. Among cancer survivors diagnosed between 2000 and 2017, the age-adjusted prevalence of current cigarette smoking at the time of first cancer diagnosis was 24.45% (n = 4054; weighted n = 2 395 173). The probability of reporting a cigarette smoking cessation event after first cancer diagnosis statistically significantly increased with each year of cancer diagnosis (hazard ratio [HR], 1.05; 95% CI, 1.02-1.08), indicating upward trends in the prevalence of quitting cigarette smoking over time. Older individuals (HR, 1.02; 95% CI, 1.01-1.03), individuals diagnosed as having a smoking-related cancer (HR, 1.28; 95% CI, 1.06-1.54), individuals with an undergraduate degree (HR, 1.39; 95% CI, 1.08-1.79) or a postgraduate degree (HR, 1.61; 95% CI, 1.18-2.20), and individuals with obesity (HR, 1.32; 95% CI, 1.06-1.63) had a higher probability of reporting a cigarette smoking cessation event after cancer diagnosis, whereas individuals living below the poverty level (HR, 0.62; 95% CI, 0.48-0.81) had a lower probability of reporting a cigarette smoking cessation event after cancer diagnosis.

CONCLUSIONS AND RELEVANCE

In this nationally representative survey of the US adult population, the likelihood of cigarette smoking cessation among cancer survivors increased with the year of cancer diagnosis from 2000 to 2017; however, the improvement is incremental, and the prevalence of smoking remained high among this population. Considering the projected increase in the population of cancer survivors in the United States, urgent action is needed to increase cigarette smoking cessation rates in this high-risk population.

Leveraging Patient Reported Outcomes Measurement via the Electronic Health Record to Connect Patients with Cancer to Smoking Cessation Treatment

Tobacco use negatively impacts cancer treatment outcomes, yet too few providers actively support their patients in quitting. Barriers to consistently addressing tobacco use and referring to treatment include time constraints and lack of knowledge surrounding treatment options. Patient Reported Outcomes (PRO) measurement is best practice in cancer care and has potential to help address these barriers to tobacco cessation treatment. This descriptive program evaluation study reports preliminary results following implementation of a novel automated PRO tobacco use screener and referral system via the electronic health record (EHR) patient portal (MyChart) that was developed and implemented as a part of a population-based tobacco treatment program at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Between 25 June 2019 and 6 April 2020, 4589 unique patients completed the screener and 164 (3.6%) unique patients screened positive for recent (past month) cigarette smoking. All patients who screened positive were automatically referred to a smoking cessation treatment program integrated within the Lurie Cancer Center, and 71 (49.7%) patients engaged in treatment, as defined by completing at least one behavioral counseling session. Preliminary results indicate that the PRO/MyChart system may improve smoker identification and increase offering of treatment and, despite the "cold call" following a positive screen, may result in a treatment engagement rate that is higher than rates of treatment engagement previously documented in oncology settings. Longer term evaluation with formal statistical testing is needed before drawing conclusions regarding effectiveness, but PRO measurement via the EHR patient portal may serve a potentially important role in a multi-component approach to reaching and engaging cancer patients in comprehensive tobacco cessation treatment.

Smoking Behaviors in Survivors of Smoking-Related and Non-Smoking-Related Cancers

IMPORTANCE

The population of cancer survivors is rapidly growing in the US. Tobacco smoking is associated with many cancers; however, whether cigarette smoking behaviors among cancer survivors vary according to cancer type-that is, smoking-related cancers (SRCs) vs non-smoking-related cancers (NSRCs)-remains unclear.

OBJECTIVES

To examine cigarette smoking prevalence and behaviors (ie, continuing or quitting smoking) among cancer survivors and to compare them between survivors of SRCs and NSRCs.

DESIGN, SETTING, AND PARTICIPANTS

This study was a cross-sectional analysis of the 2017 National Health Interview Survey, a household survey of civilian US residents who were aged 18 years or older. The National Health Interview Survey is population based and is representative of the US population. Data analysis was performed from June to October 2019.

MAIN OUTCOMES AND MEASURES

The primary outcomes were prevalence of current cigarette smoking among cancer survivors and prevalence of continuing smoking and quitting smoking after a cancer diagnosis. Secondary outcomes included factors associated with continued smoking vs quitting smoking after a cancer diagnosis.

RESULTS

A total of 26 742 respondents (mean [SD] age, 50.97 [18.61] years; 14 646 women [51.76%]) to the 2017 National Health Interview Survey were included in this study. Of the 3068 individuals (9.42%) in the study population who had cancer, 589 (19.96%) were SRC survivors, 2297 (74.50%) were NSRC survivors, 168 (4.96%) were survivors of both SRC and NSRC, and the remaining 14 (0.58%) had missing information about the type of cancer. Four hundred forty-nine SRC survivors (54.08%) were women, compared with 1412 NSRC survivors (54.30%). Ninety-six SRC survivors (15.69%) and 151 NSRC survivors (7.99%) were younger than 45 years. Overall, 372 cancer survivors (13.16%) were current smokers. Current smoking prevalence was higher among survivors of SRCs (145 survivors [19.78%]) compared with NSRC survivors (251 survivors [10.63%]). Among cancer survivors, 309 current smokers at cancer diagnosis (43.96%) reported having successfully quit smoking and 372 (56.04%) reported continuing smoking. Among the continuing smokers, 176 (56.49%) reported an unsuccessful quit attempt in the last 12 months. After cancer diagnosis, SRC survivors had higher odds of continued smoking compared with NSRC survivors (odds ratio [OR], 2.10; 95% CI, 1.12-3.93; P = .02). Men (OR, 1.93; 95% CI, 1.05-3.57; P = .04), those with angina pectoris (OR, 5.40; 95% CI, 1.33-21.91; P = .02), and those with chronic bronchitis (OR, 2.55; 95% CI, 1.05-6.19; P = .04) had higher odds of continued smoking, whereas Hispanic participants (compared with non-Hispanic white participants: OR, 0.18; 95% CI, 0.05-0.68; P = .01) and married participants (compared with never married participants: OR, 0.33; 95% CI, 0.12-0.96; P = .04) had lower odds of continued smoking.

CONCLUSIONS AND RELEVANCE

These findings suggest that compared with NSRC survivors, SRC survivors may be at higher risk of being cigarette smokers at cancer diagnosis and of continuing smoking afterward. Although smoking cessation interventions are critically important for all cancer survivors, special efforts should target survivors of SRCs.

Design and Pilot Implementation of an Electronic Health Record-Based System to Automatically Refer Cancer Patients to Tobacco Use Treatment

Continued tobacco use after cancer diagnosis is detrimental to treatment and survivorship. The current reach of evidence-based tobacco treatments in cancer patients is low. As a part of the National Cancer Institute Cancer Center Cessation Initiative, the Mayo Clinic Cancer Center designed an electronic health record (EHR, Epic^©)-based process to automatically refer ambulatory oncology patients to tobacco use treatment, regardless of intent to cease tobacco use(“opt out”). The referral and patient scheduling, accomplished through a best practice advisory (BPA) directed to staff who room patients, does not require a co-signature from clinicians. This process was piloted for a six-week period starting in July of 2019 at the Division of Medical Oncology, Mayo Clinic, Rochester, MN. All oncology patients who were tobacco users were referred for tobacco treatment by the rooming staff (n = 210). Of these, 150 (71%) had a tobacco treatment appointment scheduled, and 25 (17%) completed their appointment. We conclude that an EHR-based “opt-out” approach to refer patients to tobacco dependence treatment that does not require active involvement by clinicians is feasible within the oncology clinical practice. Further work is needed to increase the proportion of scheduled patients who attend their appointments.

Tobacco Dependence Treatment in Oncology: Initial Patient Clinical Characteristics and Outcomes from Roswell Park Comprehensive Cancer Center

Despite the importance of smoking cessation to cancer care treatment, historically, few cancer centers have provided treatment for tobacco dependence. To address this gap, the National Cancer Institute (NCI) launched the Cancer Center Cessation Initiative (C3i). As part of this effort, this study examined implementation outcomes in a cohort of cancer survivors (CSs) who smoked cigarettes in the first year of an ongoing process to develop and implement a robust Tobacco Treatment Service at Roswell Park Comprehensive Cancer Center. We provide a comprehensive description of the new tobacco use assessment and referral process, and of the characteristics of cancer survivors who agreed to treatment including traditional tobacco-related psychosocial and cancer treatment-related characteristics and novel characteristics such as delay discounting rates. We also examine characteristic differences among those who agreed to treatment between those who attended and those who did not attend treatment. As the new tobacco assessment was implemented, the number of referrals increased dramatically. The mean number of treatment sessions attended was 4.45 (SD = 2.98) and the six-month point prevalence intention to treat abstinence rate among those who attended was 22.7%. However, only 6.4% agreed to treatment and 4% attended at least one treatment session. A large proportion of cancer survivors who agreed to treatment were women, of older age, of lower socioeconomic status (SES), and who had high levels of depressive symptomology. The findings demonstrate that the implementation of system changes can significantly improve the identification of cancer survivors who use tobacco and are referred to tobacco use treatment. Among those who attend, treatment is effective. However, the findings also suggest that a systematic assessment of barriers to engagement is needed and that cancer survivors may benefit from additional treatment tailoring. We present plans to address these implementation challenges. Systematic electronic medical record (EMR)-sourced referral to tobacco treatment is a powerful tool for reaching cancer survivors who smoke, but more research is needed to determine how to enhance engagement and tailor treatment processes.

A Lean Quality Improvement Initiative to Enhance Tobacco Use Treatment in a Cancer Hospital

Sustained tobacco use after cancer diagnosis decreases treatment effectiveness while increasing treatment side effects, primary cancer recurrence, and the occurrence of secondary cancers. Delivering tobacco use treatment to fewer patients due to inefficient workflow represents missed opportunities to deliver life-saving care. In 2017, the National Cancer Institute initiated the Cancer Cessation Initiative (C3I) to push new tobacco cessation resources into cancer centers across the United States. This grant allowed the University of North Carolina Tobacco Treatment Program (UNC TTP) to dramatically expand tobacco use treatment (TUT) services to patients at the North Carolina Cancer Hospital (NCCH). With this push, the team saw an opportunity to utilize Lean Six Sigma, a set of quality improvement (QI) tools, to streamline their processes and uncover the root causes of program inefficiencies. A 12-month QI project using the Lean A3 problem-solving tool was implemented to examine the team's workflow. The study team mapped out the processes and, as a result, developed multiple "experiments" to test within the NCCH to address workflow efficiency and clinical reach. Outcome measures from the baseline to follow-up included: (1) the number of new patient referrals per month, and (2) the number of counseling sessions delivered per month. From the baseline to final state, the team's referrals increased from a mean of 10 to 24 per month, and counseling sessions increased from a mean of 74 to 84 per month. This project provided a deeper understanding of how workflow inefficiencies can be eliminated in the clinical setting, how technology can be harnessed to increase reach, and finally, that soliciting and using feedback from NCCH leadership can remove barriers and improve patient care.

Using a Family Systems Approach to Treat Tobacco Use among Cancer Patients

Tobacco use treatment is an essential component of cancer care. Family members play a significant role in smoking behavior, but more research is needed regarding the development, implementation, and impact of family-based interventions in cancer care. The UNC Tobacco Treatment Program conducted an 18-month pilot study to examine the feasibility of implementing a family systems approach to treat tobacco use among patients at the North Carolina Cancer Hospital and to measure the impact of such an approach on patient abstinence. Implementation included four phases: (1) modifying the electronic health record and monthly report generated from the electronic health record; (2) training Tobacco Treatment Specialists to provide family counseling; (3) integrating family members into patients' treatment; and (4) conducting six-month follow-up calls. During the course of the study, 42% (N = 221/532) of patients had family members integrated into their tobacco use treatment. Only 21 patients (4%) had family members present but not integrated into the treatment plan. At the six-month follow up time point, the seven-day point-prevalence quit rate for patients with family integration was 28% (N = 56/200), compared to 23% (N = 67/291) (p = 0.105) for patients without family integration. Integration of family members is clearly possible in an academic medical center's oncology tobacco treatment program. Although pilot results were not statistically significant at 6 months, a potentially higher quit rate suggests a need for expanded research on methods to integrate family members in oncology settings for patients with tobacco-related cancers.

A Smartphone App Designed to Help Cancer Patients Stop Smoking: Results From a Pilot Randomized Trial on Feasibility, Acceptability, and Effectiveness

Background

Persistent smoking after a cancer diagnosis predicts worse treatment outcomes and mortality, but access to effective smoking cessation interventions is limited. Smartphone apps can address this problem by providing a highly accessible, low-cost smoking cessation intervention designed for patients with a recent cancer diagnosis.

Objective

This study aimed to summarize our development process and report the trial design, feasibility, participant acceptability, preliminary effectiveness, and impact on processes of change (eg, cancer stigma) of the first-known smoking cessation smartphone app targeted for cancer patients.

Methods

We used an agile, user-centered design framework to develop a fully automated smartphone app called Quit2Heal that provided skills training and stories from cancer survivors focusing on coping with internalized shame, cancer stigma, depression, and anxiety as core triggers of smoking. Quit2Heal was compared with the National Cancer Institute’s QuitGuide, a widely used stop smoking app for the general population, in a pilot double-blinded randomized trial with a 2-month follow-up period. Participants were 59 adult smokers diagnosed with cancer within the past 12 months and recruited through 2 cancer center care networks and social media over a 12-month period. The most common types of cancer diagnosed were lung (21/59, 36%) and breast (10/59, 17%) cancers. The 2-month follow-up survey retention rate was 92% (54/59) and did not differ by study arm (P=.15).

Results

Compared with QuitGuide participants, Quit2Heal participants were more satisfied with their assigned app (90% [19/21] for Quit2Heal vs 65% [17/26] for QuitGuide; P=.047) and were more likely to report that the app assigned to them was made for someone like them (86% [18/21] for Quit2Heal vs 62% [16/26] for QuitGuide; P=.04). Quit2Heal participants opened their app a greater number of times during the 2-month trial period, although this difference was not statistically significant (mean 10.0, SD 14.40 for Quit2Heal vs mean 6.1, SD 5.3 for QuitGuide; P=.33). Self-reported 30-day point prevalence quit rates at the 2-month follow-up were 20% (5/25) for Quit2Heal versus 7% (2/29) for QuitGuide (odds ratio 5.16, 95% CI 0.71-37.29; P=.10). Quit2Heal participants also showed greater improvement in internalized shame, cancer stigma, depression, and anxiety, although these were not statistically significant (all P>.05).

Conclusions

In a pilot randomized trial with a high short-term retention rate, Quit2Heal showed promising acceptability and effectiveness for helping cancer patients stop smoking. Testing in a full-scale randomized controlled trial with a longer follow-up period and a larger sample size is required to test the effectiveness, mediators, and moderators of this promising digital cessation intervention.

Trial Registration

ClinicalTrials.gov NCT03600038; https://clinicaltrials.gov/ct2/show/NCT03600038

Evaluation of a Dedicated Tobacco Cessation Support Service for Thoracic Cancer Center Patients

CONTEXT

Cancer patients' continued tobacco use results in poorer therapeutic outcomes including decreased quality of life and survival.

OBJECTIVE

To assess reach and impact of a free, opt-out, telephone-based tobacco cessation program for thoracic cancer center patients.

DESIGN

Observational study.

SETTING

Comprehensive Cancer Center in Western New York.

PARTICIPANTS

Current or recent (within past 30 days) tobacco-using thoracic cancer center patients referred to a tobacco cessation support service between October 2010 and October 2012 at a Comprehensive Cancer Center (n = 942/1313 referrals were eligible for cessation support).

INTERVENTION

A free, opt-out, telephone-based cessation service that was implemented as standard of care. Cessation specialists had patient-guided conversations that assessed readiness to quit; methods used in the past provided cessation strategies and worked to set up a quit date. There was an average of 35.9 days between referral and first contact.

MAIN OUTCOME MEASURES

Program reach (referral and participation rates) and impact (as self-reported cessation outcomes measured twice after referral).

RESULTS

Of 942 patients, 730 (77.5%) referred to and called by a tobacco cessation service participated in at least 1 cessation support call, of which 440 of 730 (60.3%) were called for follow-up and 89.5% (394/440) participated. In total, 20.2% (69/342) of current smokers at referral reported at least 7-day abstinence at follow-up. Among current smokers at referral and first contact, being married (odds ratio [OR] = 2.05; 95% confidence interval [CI], 1.01-4.18) and having a lower Eastern Cooperative Oncology Group (ECOG) performance score (OR = 4.05; 95% CI, 1.58-10.39) were associated with quitting at follow-up, after controlling for demographic, clinical, and health behavior characteristics.

CONCLUSIONS

Our results demonstrate that 78% of thoracic cancer center patients, if contacted, participated at least once in this cessation support service; for current smokers at referral and first contact, being married and having a lower ECOG performance score were associated with self-reported quitting at follow-up. Other organizations may find our results useful while implementing a systematic way to identify tobacco-using patients as part of routine care and to improve available cessation support services.

Reversal of Upward Trends in Mortality During the Great Recession by Employment Status at Baseline in a National Longitudinal Study

Because of the healthy worker effect, mortality rates increased in individuals who were employed and those who were unemployed, and decreased in those economically inactive at baseline in reported studies. To determine if such trends continue during economic recessions, we analyzed mortality rates in Spain before and during the Great Recession in these subgroups. We included 21,933,351 individuals who were employed, unemployed, or inactive in November 2001 and aged 30-64 years in each calendar-year of follow-up (2002-2011). Annual age-adjusted mortality rates were calculated in each group. The annual percentage change in mortality rates adjusted for age and educational level in employed and unemployed persons were also calculated for 2002-2007 and 2008-2011. In employed and unemployed men, mortality rates increased until 2007 and then declined, whereas in employed and unemployed women, mortality rates increased and then stabilized during 2008-2011. The mortality rate among inactive men and women decreased throughout the follow-up. In the employed and the unemployed, the annual percentage change was reversed during 2008-2011 compared with 2002-2007 (-1.2 vs. 3.2 in employed men; -0.3 vs. 4.1 in employed women; -0.8 vs. 2.9 in unemployed men; and -0.6 vs. 1.3 in unemployed women). The upward trends in mortality rates among individuals who were employed or unemployed in 2001 were reversed during the Great Recession (2008-2011).

Association of a Comprehensive Smoking Cessation Program With Smoking Abstinence Among Patients With Cancer

IMPORTANCE

Patients with cancer who smoke after diagnosis risk experiencing reductions in treatment effectiveness, survival rates, and quality of life, and increases in complications, cancer recurrence, and second primary cancers. Smoking cessation can significantly affect these outcomes, but to date comprehensive treatment is not widely implemented in the oncologic setting.

OBJECTIVES

To describe a potential model tobacco treatment program (TTP) implemented in a cancer setting, report on its long-term outcomes, and highlight its importance to quality patient care.

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort of smokers was treated in the TTP at a comprehensive cancer center from January 1, 2006, to August 31, 2015. Data analysis was performed from November 2017 to December 2018. Participants included 3245 patients (2343 with current cancer; 309 with previous cancer; 593 with no cancer history) drawn from a population of 5061 smokers referred for treatment in the TTP. Reasons for exclusion included follow-up for a noncancerous disease, no medical consultation, smoked less than 1 cigarette per day; or died before the 9-month follow-up.

EXPOSURES

Treatment consisted of an in-person medical consultation, 6 to 8 in-person and telephone follow-up counseling sessions, and 10 to 12 weeks of pharmacotherapy.

MAIN OUTCOMES AND MEASURES

Primary outcome was 9-month 7-day point-prevalence abstinence evaluated using time-specific (3-, 6-, and 9-month follow-ups) and longitudinal covariate-adjusted and unadjusted regression models with multiple imputation, intention-to-treat, and respondent-only approaches to missing data. The Fagerström Test for Cigarette Dependence was used as a measure of dependence (possible range, 0-10; higher numbers indicate greater dependence).

RESULTS

Of the 3245 smokers, 1588 (48.9%) were men, 322 (9.9%) were of black race/ethnicity, 172 (5.3%) were of Hispanic race/ethnicity, and 2498 (76.0%) were of white race/ethnicity. Mean (SD) age was 54 (11.4) years; Fagerström Test for Cigarette Dependence score, 4.41 (2.2), number of cigarettes smoked per day, 17.1 (10.7); years smoked, 33 (13.2); and 1393 patients (42.9%) had at least 1 psychiatric comorbidity. Overall self-reported abstinence was 45.1% at 3 months, 45.8% at 6 months, and 43.7% at 9 months in the multiply imputed sample. Results across all models were consistent, suggesting that, in comparison with smokers with no cancer history, abstinence rates within this TTP program did not differ appreciably whether smokers had current cancer, were a cancer survivor, or had smoking-related cancers, with the exception of patients with head and neck cancer; the rates were higher at 9 months (relative risk, 1.31; 95% CI, 1.11-1.56; P = .001) and in longitudinal models (relative risk, 1.24; 95% CI, 1.08-1.42; P = .002).

CONCLUSIONS AND RELEVANCE

In this study, mean smoking abstinence rates did not differ significantly between patients with cancer and those without cancer. These findings suggest that providing comprehensive tobacco treatment in the oncologic setting can result in sustained high abstinence rates for all patients with cancer and survivors and should be included as standard of care to ensure the best possible cancer treatment outcomes.

Continued smoking after a cancer diagnosis: a longitudinal study of intentions and attempts to quit

PURPOSE

Continued smoking after a cancer diagnosis is associated with poor treatment outcomes and reduced life expectancy. We aimed to identify the stability of smoking status after diagnosis including quit attempts and quit intentions.

METHODS

Participants with a first primary cancer diagnosis were recruited via two state-based registries in Australia. Questionnaires were mailed at approximately 6 months (T1), 1 year (T2), 2 years (T3), and 3.5 years (T4) post-diagnosis. Smoking status and quitting intentions were assessed at each time point.

RESULTS

A cohort of 1444 people was recruited. People who indicated that they were more than 9 months post-diagnosis are excluded from analysis, leaving 1407 eligible study participants. Sixty-six (37%) of the 178 self-reported smokers at diagnosis had quit in the 6-month post-diagnosis (T1), the remaining 112 (63%) reported being a current smoker. Of the smokers at T1, 40% intended to quit: with 8% having quit smoking by T2; 11% quit by T3; 12% quit by T4. Of those who reported at T1 that they intended to quit in the next 6 months, 10% or fewer reported having quit at any subsequent time point. Quitting attempts decreased in frequency over time post-diagnosis. Less than 15% of respondents who had quit at or shortly before diagnosis reported relapse to smoking at each time point.

CONCLUSIONS

The majority of smokers diagnosed with cancer continue to smoke beyond diagnosis, even in the context of an intention to quit and attempts to do so. Cancer survivors who smoke remain motivated to quit well beyond the initial diagnosis.

IMPLICATIONS FOR CANCER SURVIVORS

There are clear positive clinical effects of smoking cessation for those who have undergone treatment for cancer, both for short-term treatment outcomes, and for long-term survivorship. Given the substantial rates of continued smoking among those who report smoking at diagnosis and their continued attempts to quit during survivorship, there is a need for improved cessation support initiatives for people diagnosed with cancer. These initiatives need to continue to be offered to smokers long after the initial diagnosis and treatment.

Smoking cessation care can translate to lower hazard of death in the short-run in cancer patients - a retrospective cohort study to demonstrate the value of smoking cessation services within the treatment phase of cancer

Background

Smoking cessation is a key step towards improving cancer care and outcomes. However, smoking cessation interventions are underprovided in oncology settings. Within Jordan’s only comprehensive oncology center, we sought to evaluate receipt of care at a smoking cessation clinic and the effect of assisted abstinence through the smoking cessation clinic on short-term (two-year) survival after a cancer diagnosis.

Methods

We employed a retrospective cohort study design. Cancer registry and smoking cessation clinic data for adult Jordanian cancer patients diagnosed between 2009 and 2016, who also were cigarette smokers, and who received full treatment at King Hussein Cancer Center, were analyzed. Specifically, descriptive statistics of patients who visited the smoking cessation clinic were generated, and short-term (two-year) hazard of death of patients based on whether or not smoking cessation clinic-assisted abstinence occurred, were evaluated.

Results

There were 3403 patients who met our inclusion criteria. Approximately 21% of cancer patients were seen at the smoking cessation clinic, and significant demographic and clinical disparities in who was being seen [at the smoking cessation clinic] existed. In 2387 patients with available survival data, smokers who never went to the smoking cessation clinic (or were seen only once, or seen a year or more from diagnosis) had a hazard of death 2.8 times higher than smokers who had visited the smoking cessation clinic and who also confirmed they had not smoked on atleast two of their 3-, 6- or 12-month follow-up visits (95% confidence interval [CI] = 1.7–4.6). Non-abstainers at the smoking cessation clinic exhibited a similar disadvantage (HR 2.7, 95% CI 1.4–5.0).

Conclusions

Although evidence-based smoking cessation interventions increase the likelihood of abstinence and can lower the short-term hazard of death during cancer treatment, there is a deprioritization of smoking cessation interventions during cancer care, as indicated by low proportions of patients seen at the smoking cessation clinic. Our findings emphasize the importance of promoting interventions to avail smoking cessation interventions in oncology settings within the cancer treatment phase.

Update on the approach to smoking in patients with respiratory diseases

Smoking is the leading cause of respiratory disease (RD). The harmful effects of smoking on the respiratory system begin in utero and influence immune responses throughout childhood and adult life. In comparison with "healthy" smokers, smokers with RD have peculiarities that can impede smoking cessation, such as a higher level of nicotine dependence; nicotine withdrawal; higher levels of exhaled carbon monoxide; low motivation and low self-efficacy; greater concern about weight gain; and a high prevalence of anxiety and depression. In addition, they require more intensive, prolonged treatment. It is always necessary to educate such individuals about the fact that quitting smoking is the only measure that will reduce the progression of RD and improve their quality of life, regardless of the duration and severity of the disease. Physicians should always offer smoking cessation treatment. Outpatient or inpatient smoking cessation treatment should be multidisciplinary, based on behavioral interventions and pharmacotherapy. It will thus be more effective and cost-effective, doubling the chances of success.

Mortality in working-age population during the Great Recession and austerity in Spain

OBJECTIVE

To analyze the mortality trend in Spain before, during and after the economic crisis and austerity policies in the working-age population.

METHODS

From 2005 to 2016 we calculated the annual all-cause mortality rate and the annual mortality rate from the main causes of death in the population aged 15 to 64. We also estimated the linear trends in mortality rates during four time intervals-2005-2007 (before crisis), 2008-2010 (first part of the crisis), 2011-2013 (second part of the crisis and implementation of austerity policies) and 2014-2016 (after the crisis)- by the annual percentage change (APC).

RESULTS

The all-cause mortality rate in men and women showed the greatest decline in 2008-2010 and the smallest decline in 2014-2016. The decline in 2011-2013 was higher than in 2014-2016. The APCs in 2005-2007, 2008-2010, 2011-2013 and 2014-2016 were -2.8, -4.1, -3.0 and -1.5 in men and -1.0. -2.1, -1.1 and -0.6 in women, respectively, although the APC in 2014-2016 in women was not significant. In 2014-2016, cancer mortality showed the largest decrease, mortality from cardiovascular diseases (men), respiratory diseases and traffic accidents reversed and showed an upward trend, and the downward trend in mortality from infectious diseases and digestive diseases was equal to or greater than that observed before the crisis.

CONCLUSION

The decline in all-cause mortality in the working-age population during the economic crisis and the introduction of austerity measures was greater than that observed before and after the economic crisis. The slowing of the decline after the crisis was due to the reversal of the trend in mortality from cardiovascular and respiratory diseases.

Impact of smoking on health system costs among cancer patients in a retrospective cohort study in Ontario, Canada

OBJECTIVE

Smoking is the main modifiable cancer risk factor. The objective of this study was to examine the impact of smoking on health system costs among newly diagnosed adult patients with cancer. Specifically, costs of patients with cancer who were current smokers were compared with those of non-smokers from a publicly funded health system perspective.

METHODS

This population-based cohort study of patients with cancer used administrative databases to identify smokers and non-smokers (1 April 2014-31 March 2016) and their healthcare costs in the 12-24 months following a cancer diagnosis. The health services included were hospitalisations, emergency room visits, drugs, home care services and physician services (from the time of diagnosis onwards). The difference in cost (ie, incremental cost) between patients with cancer who were smokers and those who were non-smokers was estimated using a generalised linear model (with log link and gamma distribution), and adjusted for age, sex, neighbourhood income, rurality, cancer site, cancer stage, geographical region and comorbidities.

RESULTS

This study identified 3606 smokers and 14 911 non-smokers. Smokers were significantly younger (61 vs 65 years), more likely to be male (53%), lived in poorer neighbourhoods, had more advanced cancer stage,and were more likely to die within 1 year of diagnosis, compared with non-smokers. The regression model revealed that, on average, smokers had significantly higher monthly healthcare costs ($5091) than non-smokers ($4847), p<0.05.

CONCLUSIONS

Smoking status has a significant impact on healthcare costs among patients with cancer. On average, smokers incurred higher healthcare costs than non-smokers. These findings provide a further rationale for efforts to introduce evidence-based smoking cessation programmes as a standard of care for patients with cancer as they have the potential not only to improve patients' outcomes but also to reduce the economic burden of smoking on the healthcare system.

A review of the effects of tobacco smoking on cancer treatment: smoking cessation intervention should be integrated into the cancer care continuum

Background:

The adverse health effects associated with smoking tobacco have been well investigated, and its detrimental effects on cancer treatment outcomes, efficacy and quality of life (QOL) for cancer patients have also been well documented. Tobacco smoke contains many thousands of chemicals, including a plethora of carcinogens, and the exposure of human cells to these carcinogens, and their metabolic activation, is the main mechanism by which smoking-related cancer is initiated.

Materials and Methods:

This paper reports on a narrative review of recent studies in the field of effects of tobacco smoking on cancer treatment, including the effects of carcinogens in smoke on carcinogenesis, cell mutations and the immune system. The health effects of smokeless tobacco, effects of tobacco smoking on cancer treatment, and its impact on surgery, radiation therapy and chemotherapy are reported. The potential risks of second primary cancers or recurrence from tobacco use, the effects of second-hand smoking and cancer treatment, the impact of smoking on the QOL after cancer treatment and the need to integrate smoking cessation programs into the cancer care continuum are also reported.

Conclusions:

Tobacco use has a direct impact on cellular function by inhibiting apoptosis, stimulating proliferation and decreasing the efficacy of cancer treatment; therefore, quitting its use has the potential to improve treatment response rates and survival, as well as reduces the risk of developing second cancers and potentially improves the QOL after treatment. Smoking cessation is one of the most important interventions to prevent cancer and is also essential after the diagnosis of cancer to improve clinical outcomes. Due to the numerous benefits of smoking cessation, it should become a critical component of the cancer care continuum in all oncology programs – from prevention of cancer through diagnosis, treatment, survivorship and palliative care. Evidence-based smoking cessation intervention should be sustainably integrated into any comprehensive cancer program, and the information should be targeted to the specific benefits of cessation in cancer patients.

Supplement Use and Chemotherapy-Induced Peripheral Neuropathy in a Cooperative Group Trial (S0221): The DELCaP Study

Background

Chemotherapy-induced peripheral neuropathy (CIPN) can interfere with daily function and quality of life, and there are no known preventive approaches. In a cohort of breast cancer patients receiving paclitaxel as part of a clinical trial (SWOG 0221), we examined the use of dietary supplements both before diagnosis and during treatment in relation to CIPN.

Methods

At registration to S0221, 1225 breast cancer patients completed questionnaires regarding the use of multivitamins and supplements before and at diagnosis. A second questionnaire at six months queried use during treatment. Supplement use was evaluated in relation to CIPN, assessed via the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE v. 3.0) and the self-reported Functional Assessment of Cancer Therapy/Gynecologic Oncology Group Neurotoxicity (FACT/GOG-Ntx) subscale. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed with logistic regression for the CTCAE analyses and ordinal regression for the FACT/GOG-Ntx analyses.

Results

Multivitamin use before diagnosis was associated with reduced symptoms of CIPN (CTCAE-adjusted OR = 0.60, 95% CI = 0.42 to 0.87; FACT/GOG-Ntx-adjusted OR = 0.78, 95% CI = 0.61 to 1.00). Use during treatment was marginally inversely associated with CIPN (CTCAE-adjusted OR = 0.73, 95% CI = 0.49 to 1.08; FACT/GOG-Ntx-adjusted OR = 0.77, 95% CI = 0.60 to 0.99). Other supplement use, either before diagnosis or during treatment, was not statistically significantly associated with CIPN.

Conclusions

Multivitamin use may be associated with reduced risk of CIPN, although individual dietary supplement use did not appreciably affect risk. Multivitamin use could be a surrogate for other related behaviors that are the actual drivers of the association with reduced CIPN. Without prospective randomized trials of vitamin supplementation, recommendations for use or changes to clinical practice are clearly not warranted.

Tobacco Use Assessment and Treatment in Cancer Patients: A Scoping Review of Oncology Care Clinician Adherence to Clinical Practice Guidelines in the U.S

BACKGROUND

Smoking after a cancer diagnosis negatively impacts health outcomes; smoking cessation improves symptoms, side effects, and overall prognosis. The Public Health Service and major oncology organizations have established guidelines for tobacco use treatment among cancer patients, including clinician assessment of tobacco use at each visit. Oncology care clinicians (OCCs) play important roles in this process (noted as the 5As: Asking about tobacco use, Advising users to quit, Assessing willingness to quit, Assisting in quit attempts, and Arranging follow-up contact). However, OCCs may not be using the "teachable moments" related to cancer diagnosis, treatment, and survivorship to provide cessation interventions.

MATERIALS AND METHODS

In this scoping literature review of articles from 2006 to 2017, we discuss (1) frequency and quality of OCCs' tobacco use assessments with cancer patients and survivors; (2) barriers to providing tobacco treatment for cancer patients; and (3) the efficacy and future of provider-level interventions to facilitate adherence to tobacco treatment guidelines.

RESULTS

OCCs are not adequately addressing smoking cessation with their patients. The reviewed studies indicate that although >75% assess tobacco use during an intake visit and >60% typically advise patients to quit, a substantially lower percentage recommend or arrange smoking cessation treatment or follow-up after a quit attempt. Less than 30% of OCCs report adequate training in cessation interventions.

CONCLUSION

Intervention trials focused on provider- and system-level change are needed to promote integration of evidence-based tobacco treatment into the oncology setting. Attention should be given to the barriers faced by OCCs when targeting interventions for the oncologic context.

IMPLICATIONS FOR PRACTICE

This article reviews the existing literature on the gap between best and current practices for tobacco use assessment and treatment in the oncologic context. It also identifies clinician- and system-level barriers that should be addressed in order to lessen this gap and provides suggestions that could be applied across different oncology practice settings to connect patients with tobacco use treatments that may improve overall survival and quality of life.