Implementing Evidence-Based Tobacco Treatment Interventions in Oncology to Achieve Optimal Outcomes

Among the thousands of individuals diagnosed with cancer each year, a substantial minority of individuals smoke or use other tobacco products at the time of diagnosis,¹ with particularly high rates among individuals diagnosed with lung or head/neck cancer.² It is without doubt that quitting tobacco use after a cancer diagnosis is associated with improved outcomes across many domains, including mortality, morbidity, and quality of life.³ However, individuals who smoke or use tobacco at the time of diagnosis face significant challenges in achieving cessation, including stigma and biases stimulated by decades of effective but aggressive public health and tobacco control messages.⁴ A group of clinicians and researchers led by National Cancer Institute (NCI)⁵ has recently published a monograph comprehensively addressing the importance of integrating evidence-based tobacco treatment and smoking cessation into the cancer care setting.⁶ Unfortunately, data have consistently documented limited implementation of tobacco treatment in oncology,⁷ whether it be at NCI-designated cancer centers,⁸ among the broader cancer care community,⁹ or among more targeted malignances that are more likely to be linked to smoking and tobacco use as a potential cause.¹⁰

THE TAKEAWAY

• In the article accompanying this editorial,¹¹ the investigators present compelling data regarding the reach and effectiveness of diverse evidence-based approaches to tobacco treatment delivery in the oncology setting. Although solely drawn from National Cancer Institute–designated cancer centers, the breadth and depth of data provide insights and guidance to inform integration of tobacco treatment as an integral component of cancer care in all settings.

In the article that accompanies this editorial, Hohl et al¹¹ report on the reach and effectiveness of integrated tobacco treatment programs (TTPs) across 28 funded Cancer Center Cessation Initiative (C3I) centers during the first 6 months of 2021. This large-scale assessment, involving diverse settings, strategies, and treatment approaches, provides an unprecedented opportunity to inform implementation and optimize TTPs in cancer care settings. Of note, cancer care settings may be able to use these data to best determine strategies, interventions, and personnel that best match their unique and varying resources, populations, and settings.

Admittedly, there are limited randomized trial data specifically in the cancer care setting to guide clinician and patient decision making regarding treatment options, yet robust evidence from outside the oncology setting¹² provides a host of options to consider and can help clinicians integrate strong patient preferences into the coselection of treatment options. Building on the foundation of the Treating Tobacco Use and Dependence Clinical Practice Guideline¹² and the cancer-specific research literature, several professional organizations have established guidelines and clinical practice recommendations supporting smoking cessation¹³ and broader tobacco treatment recommendations that target the oncology setting.^14-17

Recognizing the need to address the fundamental implementation question, the NCI allocated funds from the Cancer Moonshot Initiative to facilitate and evaluate broader implementation of cessation services within NCI-designated cancer centers.¹⁸ C3I provided an opportunity for funded centers to fit implementation strategies and evidence-based treatment approaches to their specific settings and resources. Data from the current assessment of 28 NCI-designated centers showed high levels of tobacco use screening (median, 96%) with a total of 44,437 patients reporting current smoking. The median service reach, defined as the proportion of individuals who currently smoked and received at least one evidence-based tobacco treatment, was 15.4%, and the effectiveness median, defined by the proportion of patients who reported abstinence of at least 1 week at a 6-month follow-up, was 18.4%.

The C3I work has undoubtedly sped the process of achieving implementation in NCI-designated cancer centers and facilitated the development of possible approaches for other care settings. Prompted by the C3I work, the Commission on Cancer (CoC) has championed the need to stimulate implementation of evidence-based tobacco treatment interventions throughout the cancer care settings, including community cancer care settings where the majority of individuals receive treatment. The CoC-led Just ASK initiative adopts a Plan-Do-Study-Act quality improvement approach to enhancing delivery of smoking cessation by helping cancer programs develop systematic approaches to asking about smoking and tobacco use—inspiring programs to achieve universal assessment of smoking status.¹⁹ Although this initiative starts small in terms of the scope of cessation services by focusing on only the first of the 5As (ask, advise, assess, assist, and arrange), it compensates with substantial reach. Over 700 cancer care programs across the United States have participated in the initiative, expanding consideration of tobacco use after a cancer diagnosis and continuing a trajectory toward greater implementation, impact, and improved outcomes for individuals facing cancer.

Overall, the integration trajectory is positive and continues to gain momentum toward improving cancer care delivery and outcomes by integrating evidence-based tobacco treatment interventions into the oncology care setting. Despite favorable steps toward building engagement within cancer care facilities, providing data to guide adoption and implementation, and consideration of local contexts and adaptations to meet the unique needs of individuals diagnosed with cancer who continue to use tobacco, there will continue to be a need for more data and guidance to improve delivery of tobacco treatment services in the oncology care setting. Although scientific data from randomized trials, clinical practice recommendations, and adaptations and implementation strategies uncovered by the C3I and Just ASK initiatives provide vital foundations, optimal delivery is unlikely to be achieved without assigning greater societal value to tobacco treatment and smoking cessation interventions in terms of reimbursements for service delivery or incorporation into other care models. Further integration of routine tobacco treatment interventions could also be aided by considering tobacco treatment to be adjuvant cancer therapy and another tool to achieve optimal cancer care outcomes.

In closing, to achieve optimal and equitable implementation of cessation services, not only must interventions be driven by evidence, but services must also be delivered with a thorough understanding of the persistent stigma and biases experienced by individuals who continue to smoke or use tobacco after a cancer diagnosis.^20,21 By implementing empathic communication strategies regarding the assessment of tobacco use and cessation opportunities,²² not only can cancer care clinicians increase the likelihood of improving cessation and cancer outcomes, but also services and support can be delivered in a manner that enhances the clinician-patient relationship.

AUTHOR CONTRIBUTIONS

Conception and design: Jamie L. Studts

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Implementing Evidence-Based Tobacco Treatment Interventions in Oncology to Achieve Optimal Outcomes

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center.

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