Implementing a 3As and 'Opt-Out' Tobacco Cessation Framework in an Outpatient Oncology Setting

Implementation, enrollment, and engagement in an opt-out telehealth pharmacist-assisted tobacco treatment program for patients seen in oncology outpatient clinics

OBJECTIVE

To describe the workflow, reach, cost, and self-reported quit rates for an opt-out tobacco treatment program (TTP) for patients seen in 43 oncology outpatient clinics.

METHODS

Between May 25, 2021, and December 31, 2022, adult patients (≥18 years) visiting clinics affiliated with the Medical University of South Carolina Hollings Cancer Center were screened for smoking status. Those currently smoking were referred to a telehealth pharmacy-assisted TTP. An attempt was made to contact referred patients by phone. Patients reached were offered free smoking cessation counseling and a 2-week starter kit of nicotine replacement medication. A random sample of 420 patients enrolled in the TTP were selected to participate in a telephone survey to assess smoking status 4 to 12 months after enrollment.

RESULTS

During the reference period 35,756 patients were screened and 9.3% were identified as currently smoking. Among the 3319 patients referred to the TTP at least once, 2393 (72.1%) were reached by phone, of whom 426 (12.8%) were ineligible for treatment, 458 (13.8%) opted out of treatment, and 1509 (45.5%) received treatment. More than 90% of TTP enrollees smoked daily, with an average of 13.1 cigarettes per day. Follow-up surveys were completed on 167 of 420 patients, of whom 23.4% to 33.5% reported not smoking; if all nonresponders to the survey are counted as smoking, the range of quit rates is 9.3% to 13.3%.

CONCLUSION

The findings demonstrate the feasibility of reaching and delivering smoking cessation treatments to patients from a diverse set of geographically dispersed oncology clinics.

Bladder cancer patient and provider perspectives on smoking cessation

BACKGROUND

Smoking is the most common risk factor for bladder cancer and is associated with adverse clinical and cancer-related outcomes. Increasing understanding of the patient and provider perspectives on smoking cessation may provide insight into improving smoking cessation rates among bladder cancer survivors. We sought to inform strategies for providers promoting cessation efforts and help patients quit smoking.

METHODS

Using a modified Delphi process with multidisciplinary input from bladder cancer providers, researchers, and a patient advocate, 2 surveys were created for bladder cancer patients and providers. Surveys included multiple-choice questions and free answers. The survey was administered electronically and queried participants' perspectives on barriers and facilitators associated with smoking cessation. Survey responses were anonymous, and participants were provided with a $20 Amazon gift card for participating. Patients were approached through the previously established Bladder Cancer Advocacy Network (BCAN) Patient Survey Network, an online bladder cancer patient and caregiver community. Providers were recruited from the Society of Urologic Oncology (SUO) and the Large Urology Group Practice Association (LUGPA).

RESULTS

From May to June 2021, 308 patients and 103 providers completed their respective surveys. Among patients who quit smoking, most (64%) preferred no pharmacologic intervention ("cold turkey") followed by nicotine replacement therapy (28%). Repeated efforts at cessation commonly occurred, and 67% reported making more than one attempt at quitting prior to eventual smoking cessation. Approximately 1 in 10 patients were unaware of the association between bladder cancer and smoking. Among providers, 75% felt that barriers to provide cessation include a lack of clinical time, adequate training, and reimbursement concerns. However, 79% of providers endorsed a willingness to receive continuing education on smoking cessation.

CONCLUSIONS

Bladder cancer patients utilize a variety of cessation strategies with "cold turkey" being the most used method, and many patients make multiple attempts at smoking cessation. Providers confront multiple barriers to conducting smoking cessation, including inadequate time and training in cessation methods; however, most would be willing to receive additional education. These results inform future interventions tailored to bladder cancer clinicians to better support provider efforts to provide smoking cessation counseling.

IMPACT smoking cessation support for people with severe mental illness in South Asia (IMPACT 4S): A protocol for a randomised controlled feasibility trial of a combined behavioural and pharmacological support intervention

INTRODUCTION

The prevalence of smoking is high among people living with severe mental illness (SMI). Evidence on feasibility, acceptability and effectiveness of smoking cessation interventions among smokers with SMI is lacking, particularly in low- and middle-income countries. We aim to test the feasibility and acceptability of delivering an evidence-based intervention,i.e., the IMPACT smoking cessation support for people with severe mental illness in South Asia (IMPACT 4S) intervention that is a combination of behavioural support and smoking cessation pharmacotherapies among adult smokers with SMI in India and Pakistan. We will also test the feasibility and acceptability of evaluating the intervention in a randomised controlled trial.

METHODS

We will conduct a parallel, open label, randomised controlled feasibility trial among 172 (86 in each country) adult smokers with SMI in India and Pakistan. Participants will be allocated 1:1 to either Brief Advice (BA) or the IMPACT 4S intervention. BA comprises a single five-minute BA session on stopping smoking. The IMPACT 4S intervention comprises behavioural support delivered in upto 15 one-to-one, face-to-face or audio/video, counselling sessions, with each session lasting between 15 and 40 minutes; nicotine gum and/or bupropion; and breath carbon monoxide monitoring and feedback. Outcomes are recruitment rates, reasons for ineligibility/non-participation/non-consent of participants, length of time required to achieve required sample size, retention in study and treatments, intervention fidelity during delivery, smoking cessation pharmacotherapy adherence and data completeness. We will also conduct a process evaluation.

RESULTS

Study will address- uncertainty about feasibility and acceptability of delivering smoking cessation interventions, and ability to conduct smoking cessation trials, among adult smokers with SMI in low- and middle-income countries.

CONCLUSIONS

This is to inform further intervention adaptation, and the design and conduct of future randomised controlled trials on this topic. Results will be disseminated through peer-review articles, presentations at national, international conferences and policy-engagement forums.

TRIAL REGISTRATION

ISRCTN34399445 (Updated 22/03/2021), ISRCTN Registry https://www.isrctn.com/.

Developing a Collaborative, Team-Based Smoking Cessation Treatment Program in an Outpatient Oncology Setting

PURPOSE

Because clinical specialists often lack time and training to address secondary health issues such as smoking cessation, the National Cancer Institute Cancer Center Cessation Initiative (C3I) has mobilized cancer centers to develop systems for treating patients' tobacco dependence.

METHODS

One university-based cancer center was able to develop a program that formalized smoking treatment using a collaborative, multidisciplinary care team with overlapping expertise in cancer care, medication management, and tobacco cessation. Program planners delivered tobacco cessation services in the outpatient setting by automating identification of eligible patients using a tobacco registry in the electronic health records, directly involving oncology pharmacists in medication oversight, using dedicated tobacco treatment specialists to provide cessation services, and engaging oncologists through active communications protocols. Evaluators used Practical Robust Implementation and Sustainability Model as the guiding framework for a qualitative assessment of program development and implementation. Evaluators also measured provider satisfaction and utilization of services, program reach, and smoking cessation outcomes 6 months post enrollment.

RESULTS

During the evaluation period (July 1, 2018-September 30, 2019), the smoking cessation program engaged 96% of eligible patients (n = 214 of 223 eligible); 82% of those enrolled in the program (n = 183). At 6-month follow-up, 29.1% of enrolled patients self-reported 30-day point prevalence abstinence (n = 53) and 34.9% (n = 64) reported 7-day point prevalence abstinence (intent-to-treat rates).

CONCLUSION

Using a team-based approach that leverages individual expertise and interprofessional collaboration to provide patient-centered treatment, a smoking cessation program can identify and treat eligible patients in specialty clinics.

Attitudes towards the integration of smoking cessation into lung cancer screening in the United Kingdom: A qualitative study of individuals eligible to attend

INTRODUCTION

There is limited research exploring how smoking cessation treatment should be implemented into lung cancer screening in the United Kingdom. This study aimed to understand attitudes and preferences regarding the integration of smoking cessation support within lung cancer screening from the perspective of those eligible.

METHODS

Thirty-one lung cancer screening eligible individuals aged 55-80 years with current or former smoking histories were recruited using community outreach and social media. Two focus groups (three participants each) and 25 individual telephone interviews were conducted. Data were analysed using the framework approach to thematic analysis.

RESULTS

Three themes were generated: (1) bringing lung cancer closer to home, where screening was viewed as providing an opportunity to motivate smoking cessation, depending on perceived personal risk and screening result; (2) a sensitive approach to cessation with the uptake of cessation support considered to be largely dependent on screening practitioners' communication style and expectations of stigma and (3) creating an equitable service that focuses on ease of access as a key determinant of uptake, where integrating cessation within the screening appointment may sustain increased quit motivation and prevent loss to follow-up.

CONCLUSIONS

The integration of smoking cessation into lung cancer screening was viewed positively by those eligible to attend. Screening appointments providing personalized lung health information may increase cessation motivation. Services should proactively support participants with possible fatalistic views regarding risk and decreased cessation motivation upon receiving a good screening result. To increase engagement in cessation, services need to be person-centred.

PATIENT OR PUBLIC CONTRIBUTION

This study has included patient and public involvement throughout, including input regarding study design, research materials, recruitment strategies and research summaries.

Smoking cessation: health system challenges and opportunities

The systematic integration of evidence-based tobacco treatment has yet to be broadly viewed as a standard-of-care. The Framework Convention on Tobacco Control recommends the provision of support for tobacco cessation. We argue that the provision of smoking cessation services in clinical settings is a fundamental clinical responsibility and permits the opportunity to more effectively assist with cessation. The role of clinicians in prioritising smoking cessation is essential in all settings. Clinical benefits of implementing cessation services in hospital settings have been recognised for three decades-but have not been consistently provided. The Ottawa Model for Smoking Cessation has used an 'organisational change' approach to its introduction and has served as the basis for the introduction of cessation programmes in hospital and primary care settings in Canada and elsewhere. The significance of smoking cessation dwarfs that of many preventive interventions in primary care. Compelling evidence attests to the importance of providing cessation services as part of cancer treatment, but implementation of such programmes has been slow. We recognise that the provision of such services must reflect the realities and resources of a particular health system. In low-income and middle-income countries, access to treatment facilities pose unique challenges. The integration of cessation programmes with tuberculosis control services may offer opportunities; and standardisation of peri-operative care to include smoking cessation may not require additional resources. Mobile phones afford unique opportunities for interactive cessation programming. Health system change is fundamental to improving the provision of cessation services; clinicians can be powerful advocates for such change.