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Borger T, Feather AR, Wakeman KE, Bowling W, Burris JL. Understanding cancer patients' desire to quit tobacco without assistance: A mixed-methods study. J Health Psychol 2024:13591053231223345. [PMID: 38282364 DOI: 10.1177/13591053231223345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
While many cancer patients who use tobacco try to quit post-diagnosis, some prefer to quit without using tobacco treatment, despite evidence against unassisted quit attempts. This study aimed to understand the rationale for some cancer patients' desire to quit tobacco without assistance. Thirty-five adult cancer patients who currently used tobacco and declined tobacco treatment because of the desire to quit unassisted provided data via a standardized questionnaire and a semi-structured interview. The sample was predominately White, non-Hispanic (85.71%) and female (68.57%). The most common cancer site was gynecological. Key themes that emerged from the interviews were: self-reliance, willpower, social norms, and negative attitudes toward tobacco treatment. The most frequently endorsed barrier to tobacco treatment was "I know others who have quit without tobacco treatment" (82.86%). This study with cancer patients identified affective, cognitive, and personality factors related to quitting unassisted, and social and systemic reasons to not use tobacco treatment.
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Affiliation(s)
- Tia Borger
- University of Kentucky, Lexington, KY, USA
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Jenssen BP, Schnoll R, Beidas RS, Bekelman J, Bauer AM, Evers-Casey S, Fisher T, Scott C, Nicoloso J, Gabriel P, Asch DA, Buttenheim AM, Chen J, Melo J, Grant D, Horst M, Oyer R, Shulman LN, Clifton AB, Lieberman A, Salam T, Rendle KA, Chaiyachati KH, Shelton RC, Fayanju O, Wileyto EP, Ware S, Blumenthal D, Ragusano D, Leone FT. Cluster Randomized Pragmatic Clinical Trial Testing Behavioral Economic Implementation Strategies to Improve Tobacco Treatment for Patients With Cancer Who Smoke. J Clin Oncol 2023; 41:4511-4521. [PMID: 37467454 PMCID: PMC10552951 DOI: 10.1200/jco.23.00355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/25/2023] [Accepted: 06/15/2023] [Indexed: 07/21/2023] Open
Abstract
PURPOSE Few cancer centers systematically engage patients with evidence-based tobacco treatment despite its positive effect on quality of life and survival. Implementation strategies directed at patients, clinicians, or both may increase tobacco use treatment (TUT) within oncology. METHODS We conducted a four-arm cluster-randomized pragmatic trial across 11 clinical sites comparing the effect of strategies informed by behavioral economics on TUT engagement during oncology encounters with cancer patients. We delivered electronic health record (EHR)-based nudges promoting TUT across four nudge conditions: patient only, clinician only, patient and clinician, or usual care. Nudges were designed to counteract cognitive biases that reduce TUT engagement. The primary outcome was TUT penetration, defined as the proportion of patients with documented TUT referral or a medication prescription in the EHR. Generalized estimating equations were used to estimate the parameters of a linear model. RESULTS From June 2021 to July 2022, we randomly assigned 246 clinicians in 95 clusters, and collected TUT penetration data from their encounters with 2,146 eligible patients who smoke receiving oncologic care. Intent-to-treat (ITT) analysis showed that the clinician nudge led to a significant increase in TUT penetration versus usual care (35.6% v 13.5%; OR = 3.64; 95% CI, 2.52 to 5.24; P < .0001). Completer-only analysis (N = 1,795) showed similar impact (37.7% clinician nudge v 13.5% usual care; OR = 3.77; 95% CI, 2.73 to 5.19; P < .0001). Clinician type affected TUT penetration, with physicians less likely to provide TUT than advanced practice providers (ITT OR = 0.67; 95% CI, 0.51 to 0.88; P = .004). CONCLUSION EHR nudges, informed by behavioral economics and aimed at oncology clinicians, appear to substantially increase TUT penetration. Adding patient nudges to the implementation strategy did not affect TUT penetration rates.
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Affiliation(s)
- Brian P. Jenssen
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robert Schnoll
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rinad S. Beidas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Justin Bekelman
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Anna-Marika Bauer
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sarah Evers-Casey
- Comprehensive Smoking Treatment Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tierney Fisher
- Comprehensive Smoking Treatment Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Callie Scott
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jody Nicoloso
- Comprehensive Smoking Treatment Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Peter Gabriel
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David A. Asch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alison M. Buttenheim
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Jessica Chen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Julissa Melo
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Dwayne Grant
- Penn Medicine Lancaster General Health, Lancaster, PA
| | - Michael Horst
- Penn Medicine Lancaster General Health, Lancaster, PA
| | - Randall Oyer
- Penn Medicine Lancaster General Health, Lancaster, PA
| | - Lawrence N. Shulman
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alicia B.W. Clifton
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adina Lieberman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tasnim Salam
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Katharine A. Rendle
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Krisda H. Chaiyachati
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Verily Life Sciences, San Francisco, CA
| | - Rachel C. Shelton
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY
| | - Oluwadamilola Fayanju
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - E. Paul Wileyto
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sue Ware
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel Blumenthal
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel Ragusano
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Frank T. Leone
- Pulmonary, Allergy, & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Tsui J, Sloan K, Sheth R, Ewusi Boisvert E, Nieva J, Kim AW, Pang RD, Sussman S, Kirkpatrick M. Implementation planning for equitable tobacco treatment services: a mixed methods assessment of contextual facilitators and barriers in a large comprehensive cancer center. Transl Behav Med 2023; 13:539-550. [PMID: 36940412 PMCID: PMC10848232 DOI: 10.1093/tbm/ibac122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
Abstract
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.
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Affiliation(s)
- Jennifer Tsui
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Kylie Sloan
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rajiv Sheth
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Jorge Nieva
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
- Department of Medicine, Division of Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anthony W Kim
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Raina D Pang
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
- Department of Psychology, University of Southern California, Los Angeles, CA, USA
| | - Steve Sussman
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Matthew Kirkpatrick
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
- Department of Psychology, University of Southern California, Los Angeles, CA, USA
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Yang MJ, Martínez Ú, Fulton HJ, Maconi ML, Turner K, Powell ST, Chern JY, Brandon TH, Vidrine JI, Simmons VN. Qualitative evaluation of the implementation and future sustainability of an e-referral system for smoking cessation at a US NCI-designated comprehensive cancer center: lessons learned. Support Care Cancer 2023; 31:483. [PMID: 37480364 PMCID: PMC10577649 DOI: 10.1007/s00520-023-07956-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/18/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Promoting smoking cessation is recognized as an essential part of cancer care. Moffitt Cancer Center, supported by the National Cancer Institute Cancer Moonshot Cancer Center Cessation Initiative, developed and implemented an opt-out-based automatic electronic health record (EHR)-mediated referral (e-referral) system for Tobacco Quitline services along with options for local group cessation support and an in-house tobacco treatment specialist. This study evaluated barriers and facilitators for implementation of the e-referral system. METHOD Steering committee members (N=12) responsible for developing and implementing the new clinical workflow and nurses (N=12) who were expected to use the new e-referral system completed semi-structured interviews. Qualitative thematic content analyses were conducted. RESULTS Interviewees perceived the e-referral system as an effective strategy for identifying and referring smokers to cessation services. However, barriers were noted including competing demands and perceptions that smoking cessation was a low priority and that some patients were likely to have low motivation to quit smoking. Suggestions to improve future implementation and sustainability included providing regular trainings and e-referral outcome reports and increasing the visibility of the e-referral system within the EHR. CONCLUSION Initial implementation of the e-referral system was perceived as successful; however, additional implementation strategies are needed to ensure sustainability at both the clinician and system levels. Recommendations for future modifications include providing regular clinician trainings and developing a fully closed-loop system. Implications for cancer survivors Initial implementation of an e-referral system for smoking cessation for cancer patients revealed opportunities to improve the smoking cessation referral process at cancer centers.
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Affiliation(s)
- Min-Jeong Yang
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA.
| | - Úrsula Martínez
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - Hayden J Fulton
- Participant Research, Intervention, and Measurements Core, Moffitt Cancer Center, Tampa, FL, USA
| | - Melinda Leigh Maconi
- Participant Research, Intervention, and Measurements Core, Moffitt Cancer Center, Tampa, FL, USA
| | - Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
| | - Sean T Powell
- Social Work and Patient Support Services, Moffitt Cancer Center, Tampa, FL, USA
| | - Jing-Yi Chern
- Gynecologic Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Thomas H Brandon
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA
- Department of Psychology, University of South Florida, Tampa, FL, USA
| | - Jennifer I Vidrine
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA
- Department of Psychology, University of South Florida, Tampa, FL, USA
| | - Vani N Simmons
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA
- Department of Psychology, University of South Florida, Tampa, FL, USA
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Jarelnape AA, Ahmed W, Omer S, Fadlala A, Ali Z, Hassan M, Ahmed R, Hakami M, Ali M, Mohammed K, Sagiron E, Abdalla YH, Osman A, Abdelazeem E, Balola H. Prevalence of smoking cigarettes and beliefs regarding smoking habits among medical students: a cross-sectional study in Sudan. Front Public Health 2023; 11:1193475. [PMID: 37427282 PMCID: PMC10325783 DOI: 10.3389/fpubh.2023.1193475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/30/2023] [Indexed: 07/11/2023] Open
Abstract
Background Smoking is a common problem in university students worldwide. Smoking is one of the most dangerous social phenomena and has a significant impact on public health. This study investigated the beliefs and attitudes of medical students toward smoking in Sudan. Methods A cross-sectional study was conducted among medical students at Al Neelain University, Sudan, from March to June 2022 using a web-based questionnaire. The questionnaire consisted of eight items on demographic characteristics and 13 on the beliefs and attitudes toward smoking. Other data included smoking status, smoking habits, the number of cigarettes smoked per day, and smoking duration. Data analysis was performed descriptively, and chi-square test and logistic regression were conducted using SPSS version 24. Statistical significance was set at 0.05. Results A total of 336 students participated in this study, and the smoking prevalence was 48.8% (41.1% in men and 7.7% in women). In total, 76.8% reported smoking daily at a rate of 5-10 cigarettes per day. In terms of students' beliefs about smoking, 86.8% disagreed with selling cigarettes at the university. Of the respondents, 68.4% did not approve smoking on campus. There was a relationship between smoking habits and the age group of 22-25 years, which was the highest smoking category among students (p-value = 0.01). Conclusion The prevalence of cigarette smoking among medical students is disturbing, particularly as they are future doctors. There is a need to include plans to reduce smoking among students that can be incorporated into courses and special programs.
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Affiliation(s)
| | - Waled Ahmed
- Department of Nursing, Al Baha University, Al Bahah, Saudi Arabia
| | - Suaad Omer
- Department of Nursing, Al Baha University, Al Bahah, Saudi Arabia
| | - Aida Fadlala
- Department of Nursing, Al Baha University, Al Bahah, Saudi Arabia
| | - Zeinab Ali
- Department of Nursing, Al Baha University, Al Bahah, Saudi Arabia
| | - Mohamed Hassan
- Department of Nursing, Al Baha University, Al Bahah, Saudi Arabia
| | - Ragaa Ahmed
- Department of Nursing, Al Baha University, Al Bahah, Saudi Arabia
| | - Manal Hakami
- Department of Nursing, Al Baha University, Al Bahah, Saudi Arabia
| | - Mujtaba Ali
- Faculty of Medicine, Al Baha University, Al Bahah, Saudi Arabia
| | - Khalid Mohammed
- Faculty of Medicine, Al Baha University, Al Bahah, Saudi Arabia
| | - Elwaleed Sagiron
- Department of Community and Mental Health, Najran University, Najran, Saudi Arabia
| | | | - Abdalla Osman
- Department of Community and Mental Health, Najran University, Najran, Saudi Arabia
| | | | - Hamza Balola
- Department of Community, Batterjee Medical College, Khamis Mushait, Saudi Arabia
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Siegel SD, Tindle HA, Bergen AW, Tyndale RF, Schnoll R. The Use of Biomarkers to Guide Precision Treatment for Tobacco Use. ADDICTION NEUROSCIENCE 2023; 6. [PMID: 37089247 PMCID: PMC10121195 DOI: 10.1016/j.addicn.2023.100076] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
This review summarizes the evidence to date on the development of biomarkers for personalizing the pharmacological treatment of combustible tobacco use. First, the latest evidence on FDA-approved medications is considered, demonstrating that, while these medications offer real benefits, they do not contribute to smoking cessation in approximately two-thirds of cases. Second, the case for using biomarkers to guide tobacco treatment is made based on the potential to increase medication effectiveness and uptake and reduce side effects. Next, the FDA framework of biomarker development is presented along with the state of science on biomarkers for tobacco treatment, including a review of the nicotine metabolite ratio, electroencephalographic event-related potentials, and other biomarkers utilized for risk feedback. We conclude with a discussion of the challenges and opportunities for the translation of biomarkers to guide tobacco treatment and propose priorities for future research.
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Levy DE, Regan S, Perez GK, Muzikansky A, Friedman ER, Rabin J, Rigotti NA, Ostroff JS, Park ER. Cost-effectiveness of Implementing Smoking Cessation Interventions for Patients With Cancer. JAMA Netw Open 2022; 5:e2216362. [PMID: 35679043 PMCID: PMC9185176 DOI: 10.1001/jamanetworkopen.2022.16362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE Guidelines recommend cancer care clinicians offer smoking cessation treatment. Cost analyses will help stakeholders understand and plan for implementation of cessation programs. OBJECTIVE To estimate the incremental cost per quit (ICQ) of adopting an intensive smoking cessation intervention among patients undergoing treatment at cancer care clinics, from a clinic perspective. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation, a secondary analysis of the Smokefree Support Study (conducted 2013-2018; completed 2021), used microcosting methods and sensitivity analyses to estimate the ICQ of the interventions. Participants included patients undergoing treatment for a broad range of solid tumors and lymphomas who reported current smoking and were receiving care at cancer care clinics within 2 academic medical centers. EXPOSURES Intensive smoking cessation treatment (up to 11 counseling sessions with free medications), standard of care (up to 4 counseling sessions with medication advice), or usual care (referral to the state quitline). MAIN OUTCOMES AND MEASURES Total costs, component-specific costs, and the ICQ of the intensive smoking cessation treatment relative to both standard of care (comparator in the parent randomized trial) and usual care (a common comparator outside this trial) were calculated. Overall and post hoc site-specific estimates are provided. Because usual care was not included in the parent trial, sensitivity analyses were conducted to assess how assumptions about usual care quit rates affected study outcomes (ie, base case [from a published smoking cessation trial among patients with thoracic cancer], best case, and conservative case scenarios). RESULTS The per-patient costs of offering intensive smoking cessation treatment, standard of care, and usual care were $1989, $1482, and $0, respectively. For intensive treatment, the dominant costs were treatment (35%), staff supervision (26%), and patient enrollment (24%). Relative to standard of care, intensive treatment had an overall ICQ of $3906, and one site had an ICQ of $2892. Relative to usual care, intensive treatment had an ICQ of $9866 overall (base case), although at one site, the ICQ was $5408 (base case) and $3786 (best case). CONCLUSIONS AND RELEVANCE In this economic evaluation study, implementation of an intensive smoking cessation treatment intervention was moderately to highly cost-effective, depending on existing smoking cessation services in place.
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Affiliation(s)
- Douglas E. Levy
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Susan Regan
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Giselle K. Perez
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Health Promotion and Resiliency Intervention Research Program, Massachusetts General Hospital, Boston
- Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Alona Muzikansky
- MGH Biostatistics Center, Massachusetts General Hospital, Boston
| | - Emily R. Friedman
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston
| | - Julia Rabin
- Department of Psychology, University of Cincinnati, Cincinnati, Ohio
| | - Nancy A. Rigotti
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Jamie S. Ostroff
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elyse R. Park
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Health Promotion and Resiliency Intervention Research Program, Massachusetts General Hospital, Boston
- Department of Psychiatry, Massachusetts General Hospital, Boston
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8
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Rodgers-Melnick SN, Zanotti K, Lee RT, Webb Hooper M. Demographic and Clinical Predictors of Engaging in Tobacco Cessation Counseling at a Comprehensive Cancer Center. JCO Oncol Pract 2022; 18:e721-e730. [PMID: 34995104 DOI: 10.1200/op.21.00458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To address challenges promoting tobacco cessation in oncology settings, it is important to understand characteristics associated with patient engagement in tobacco cessation treatment. This analysis examined predictors of participating in at least one tobacco cessation counseling session among patients referred to a comprehensive cancer center's Tobacco Intervention and Psychosocial Support (TIPS) service. METHODS Patients with cancer who reported current smoking or recently quitting and referred to TIPS between June 2017 and February 2020 were included in the analysis. Independent variables included sex, race and ethnicity, insurance type, cancer diagnosis (tobacco-related or not), age, nicotine dependence, and cigarettes smoked per day at baseline. The outcome variable was completion of at least one tobacco cessation counseling session among those assessed by the TIPS program. Unadjusted and adjusted analyses tested associations between the independent variables and tobacco cessation counseling engagement. RESULTS Of 360 oncology patients referred to the TIPS program, 224 (62.2%) were assessed and 120 (33%) engaged in at least one counseling session. After controlling for sociodemographics and tobacco use, the results demonstrated that patients diagnosed with tobacco-related cancers were 45.3% less likely to engage in the tobacco cessation program compared with those with non-tobacco-related cancers (P = .041). CONCLUSION Patients diagnosed with tobacco-related cancers were less likely to engage in TIPS. Additional therapeutic resources may be needed to engage these patients to address potential explanatory factors, such as stigma, guilt, and fatalism. More research is needed to explore the impact of a tobacco-related cancer diagnosis on treatment engagement.
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Affiliation(s)
- Samuel N Rodgers-Melnick
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH.,University Hospitals Connor Whole Health, Cleveland, OH
| | - Kristine Zanotti
- University Hospitals Cleveland Medical Center, Cleveland, OH.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Richard T Lee
- University Hospitals Cleveland Medical Center, Cleveland, OH.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Monica Webb Hooper
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
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Rate and correlates of tobacco treatment during a primary care visit for a largely urban and African American sample of smokers. DRUG AND ALCOHOL DEPENDENCE REPORTS 2021; 1:100006. [PMID: 36843905 PMCID: PMC9948888 DOI: 10.1016/j.dadr.2021.100006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/08/2021] [Accepted: 11/15/2021] [Indexed: 11/20/2022]
Abstract
Introduction Evidence-based treatments for tobacco use are under-utilized and primary care visits may be an opportune time to address this gap. This study examined the rate at which primary care visits included tobacco use treatment and examined patient demographics, smoking characteristics, attitudes about tobacco use treatments, and comorbidities as correlates of treatment provision. Methods This prospective study assessed demographics, smoking characteristics, attitudes about tobacco use treatments, and comorbidities via interview prior to a primary care visit among 105 patients. One week following the appointment, 85 patients were reassessed for the tobacco use treatments they received during their appointment (i.e., asked about their tobacco use, advised to quit, and provided with a referral to a tobacco use treatment program or an FDA-approved tobacco use medication). Results 93% of patients were asked about their tobacco use, 74% were advised to quit, 37% were provided with a referral for tobacco use treatment, and 27% received an FDA-approved medication (16% NRT, 11% varenicline or bupropion). Patients with higher quit motivation and who endorsed that medications can reduce cravings were more likely to report receiving tobacco use medication. Patients with a self-reported substance abuse history were less likely to report receiving tobacco use medications. Conclusions The provision of tobacco use medications within primary care remains low. Strategies to increase patient quit motivation and help patients understand that tobacco use medications can mitigate cravings may increase use. Strategies may also be needed to ensure that patients with comorbid substance abuse still receive tobacco use treatments.
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10
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Katz DA, Mott SL, Utech JA, Bahlmann AC, Dukes KA, Seaman AT, Laux DE, Furqan M, Pollock ZJ, Vander Weg MW. Time to put it out - nurse-facilitated tobacco treatment in a comprehensive cancer center. Transl Behav Med 2021; 11:1726-1738. [PMID: 34347876 PMCID: PMC8529899 DOI: 10.1093/tbm/ibab073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Few cancer patients receive guideline-concordant care for treatment of tobacco dependence. The purpose of this pilot trial was to obtain preliminary estimates of effectiveness of an evidence-based practice intervention on the delivery of tobacco treatment and cessation outcomes in cancer patients. We conducted a pragmatic implementation trial with a before-after design in 119 current or recently quit adult smokers with cancer who met with a clinician at a single National Cancer Institute designated comprehensive cancer center (CCC) (n = 61 pre-implementation, n = 58 post-implementation). We used a multi-component strategy based on the Chronic Care Model to implement National Comprehensive Cancer Network (NCCN) guidelines for smoking cessation. Smoking cessation counseling during the index visit was assessed by exit interview and patients were interviewed by phone to assess cessation outcomes at 3-month follow-up. Performance of cessation counseling and 7-day point prevalence abstinence (PPA) were compared across the pre- and post-implementation periods using log-logistic regression, accounting for clustering by nursing staff. More patients had received assistance in quitting at the index visit during the post-implementation period compared to the pre-implementation period (30 vs. 10%, p < .01). At 3-month follow-up, 38 and 14% of participants had discussed smoking cessation medication with a CCC healthcare professional and 57 and 27% of participants had used pharmacotherapy, respectively (p < .01 for both comparisons). Seven-day PPA at 3-month follow-up was similar in both periods, however (14 vs. 12%, respectively). A multi-component tobacco treatment intervention increased the proportion of smokers who received assistance in quitting smoking during usual cancer care but did not improve cessation outcomes.
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Affiliation(s)
- David A Katz
- Department of Medicine, University of Iowa,
Iowa City, IA, USA
- Department of Epidemiology, University of Iowa,
Iowa City, IA, USA
| | - Sarah L Mott
- The Holden Comprehensive Cancer Center, University of Iowa Hospitals
& Clinics, Iowa City, IA, USA
| | - Jane A Utech
- The Holden Comprehensive Cancer Center, University of Iowa Hospitals
& Clinics, Iowa City, IA, USA
| | - Autumn C Bahlmann
- The Holden Comprehensive Cancer Center, University of Iowa Hospitals
& Clinics, Iowa City, IA, USA
| | | | - Aaron T Seaman
- Department of Medicine, University of Iowa,
Iowa City, IA, USA
- The Holden Comprehensive Cancer Center, University of Iowa Hospitals
& Clinics, Iowa City, IA, USA
- Department of Community and Behavioral Health, University of
Iowa, Iowa City, IA, USA
| | - Douglas E Laux
- Department of Medicine, University of Iowa,
Iowa City, IA, USA
- The Holden Comprehensive Cancer Center, University of Iowa Hospitals
& Clinics, Iowa City, IA, USA
| | - Muhammad Furqan
- Department of Medicine, University of Iowa,
Iowa City, IA, USA
- The Holden Comprehensive Cancer Center, University of Iowa Hospitals
& Clinics, Iowa City, IA, USA
| | - Zachary J Pollock
- The Holden Comprehensive Cancer Center, University of Iowa Hospitals
& Clinics, Iowa City, IA, USA
| | - Mark W Vander Weg
- Department of Medicine, University of Iowa,
Iowa City, IA, USA
- Department of Community and Behavioral Health, University of
Iowa, Iowa City, IA, USA
- Department of Psychological and Brain Sciences, University of
Iowa, Iowa City, IA, USA
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11
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Jenssen BP, Schnoll R, Beidas R, Bekelman J, Bauer AM, Scott C, Evers-Casey S, Nicoloso J, Gabriel P, Asch DA, Buttenheim A, Chen J, Melo J, Shulman LN, Clifton ABW, Lieberman A, Salam T, Zentgraf K, Rendle KA, Chaiyachati K, Shelton R, Wileyto EP, Ware S, Leone F. Rationale and protocol for a cluster randomized pragmatic clinical trial testing behavioral economic implementation strategies to improve tobacco treatment rates for cancer patients who smoke. Implement Sci 2021; 16:72. [PMID: 34266468 PMCID: PMC8281481 DOI: 10.1186/s13012-021-01139-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/21/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care. METHODS A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or "nudges") promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges. DISCUSSION This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers. TRIAL REGISTRATION Clinicaltrials.gov, NCT04737031 . Registered 3 February 2021.
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Affiliation(s)
- Brian P. Jenssen
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Robert Schnoll
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Rinad Beidas
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, USA
- Penn Implementation Science Center (PISCE@LDI), Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
| | - Justin Bekelman
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Penn Implementation Science Center (PISCE@LDI), Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Anna-Marika Bauer
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Callie Scott
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Sarah Evers-Casey
- Comprehensive Smoking Treatment Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Jody Nicoloso
- Comprehensive Smoking Treatment Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Peter Gabriel
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - David A. Asch
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Alison Buttenheim
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, USA
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Jessica Chen
- University of Pennsylvania Health System, Philadelphia, USA
| | - Julissa Melo
- University of Pennsylvania Health System, Philadelphia, USA
| | - Lawrence N. Shulman
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Alicia B. W. Clifton
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Adina Lieberman
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Tasnim Salam
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Kelly Zentgraf
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Katharine A. Rendle
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Krisda Chaiyachati
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Rachel Shelton
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, USA
| | - E. Paul Wileyto
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Sue Ware
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Frank Leone
- Pulmonary, Allergy, & Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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12
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Ohde JW, Master Z, Tilburt JC, Warner DO. Presumed Consent With Opt-Out: An Ethical Consent Approach to Automatically Refer Patients With Cancer to Tobacco Treatment Services. J Clin Oncol 2021; 39:876-880. [PMID: 33439692 DOI: 10.1200/jco.20.03180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Joshua W Ohde
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN
| | - Zubin Master
- Biomedical Ethics Research Program and Center for Regenerative Medicine, Mayo Clinic, Rochester, MN
| | - Jon C Tilburt
- Biomedical Ethics Research Program; Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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13
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May JR, Klass E, Davis K, Pearman T, Rittmeyer S, Kircher S, Hitsman B. Leveraging Patient Reported Outcomes Measurement via the Electronic Health Record to Connect Patients with Cancer to Smoking Cessation Treatment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E5034. [PMID: 32668758 PMCID: PMC7399884 DOI: 10.3390/ijerph17145034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/05/2020] [Accepted: 07/08/2020] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Julia R. May
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA;
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL 60611, USA; (T.P.); (S.K.)
| | - Elizabeth Klass
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA;
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL 60611, USA; (T.P.); (S.K.)
| | - Kristina Davis
- Quality Innovation Center, Northwestern Medicine, Chicago, IL 60611, USA;
| | - Timothy Pearman
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL 60611, USA; (T.P.); (S.K.)
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Steven Rittmeyer
- Information Systems, Northwestern Medicine, Chicago, IL 60611, USA;
| | - Sheetal Kircher
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL 60611, USA; (T.P.); (S.K.)
| | - Brian Hitsman
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA;
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL 60611, USA; (T.P.); (S.K.)
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14
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Design and Pilot Implementation of an Electronic Health Record-Based System to Automatically Refer Cancer Patients to Tobacco Use Treatment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17114054. [PMID: 32517176 PMCID: PMC7312526 DOI: 10.3390/ijerph17114054] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 12/13/2022]
Abstract
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.
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