Current Practices, Perceived Barriers, and Promising Implementation Strategies for Improving Quality of Smoking Cessation Support in Accredited Cancer Programs of the American College of Surgeons

Abstract

PURPOSE

Persistent smoking is associated with poor outcomes in cancer care. It is strongly recommended that oncology care providers provide cessation support; however, there is limited information about smoking cessation assessment and treatment patterns in routine oncology practice.

METHODS

Leaders of the American College of Surgeons Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (National Accredited Program for Breast Cancer) elected to participate in a national quality improvement initiative (Just ASK) focused on smoking assessment/treatment in cancer care. Online baseline survey responses were received from 762 accredited programs.

RESULTS

Most programs reported regularly asking about smoking (89.9%), documenting smoking history and current use (85.8%), and advising patients to quit (71.2%). However, less than half of programs reported documenting a smoking cessation treatment plan (41.7%). Even fewer programs reported regularly assisting patients with quitting (41.3%), providing self-help information (27.2%), providing individual counseling (18.2%), and referring patients to an affiliated tobacco treatment program (26.1%) or external Quitline (28.5%). Very few programs reported regularly prescribing medications (17.6%). Principal barriers to tobacco treatment delivery were lack of staff training (68.8%), lack of designated specialists (61.9%), perceived patient resistance (58.3%), lack of available resources (53.3%), competing clinical priorities (50.9%), inadequate program funding (40.6%), insufficient staff time (42.4%), and inadequate reimbursement (31.0%).

CONCLUSION

Although programs reported a high rate of smoking assessment, critical gaps in advising and assisting patients with cessation were found. Improving equitable delivery of smoking assessment/treatment in cancer care will require addressing key organizational and provider barriers for implementation of best practices.

A new paper published in the JCO Journal of Oncology Practice summarizes the quality of tobacco treatment delivery in 762 cancer care programs accredited by the Commission on Cancer, that participated in the Just ASK project. As the largest national survey examining quality of tobacco treatment in cancer care, these findings support a strong call to action to improve adoption of smoking cessation guidelines in cancer care. #CancerCare #SmokingCessation #Cancer@CoC

INTRODUCTION

Persistent smoking among patients diagnosed with cancers is associated with increased risk for poor quality of life, treatment-related complications, recurrence, second primary, poor survival, and increased cancer treatment costs.^1-4 Despite this, population-based surveys suggest that nearly 25% of new patients with cancer report current smoking,⁵ and of the 18 million cancer survivors in the United States,⁶ 16% report current smoking.⁷ Smoking assessment and treatment delivery are recommended by leading oncology organizations including ASCO, Oncology Nursing Society, and American Association for Cancer Research.^8,9 Tobacco treatment guidelines for patients with cancer have also been developed by national groups, including the National Comprehensive Cancer Network.¹⁰

CONTEXT

• Key Objective

• This article identifies the current practice patterns and organizational readiness for smoking assessment and treatment delivery among cancer care programs accredited by the Commission on Cancer or National Accredited Program for Breast Cancer.

• Knowledge Generated

• Strong participation (762 accredited programs) in the Just ASK project clearly demonstrates commitment to addressing the clinical challenge of treating persistent smoking among patients with cancer. Although smoking assessment and cessation advice were widely reported as routinely conducted, the findings highlight multiple missed opportunities for improving smoking cessation assistance and the delivery of evidence-based tobacco treatment in cancer care settings.

• Relevance

• The results reported from the baseline survey represent, to our knowledge, the largest national data set describing the smoking assessment and treatment practice patterns, perceived barriers, and implementation strategies in clinical oncology settings. The findings have strong implications for improving adherence to national guidelines for managing smoking cessation in clinical care.

Smoking assessment/treatment delivery is an important component of high-quality cancer care,^11,12 and smoking cessation can improve clinical outcomes after cancer diagnosis.¹³ However, surveys of National Cancer Institute (NCI)–Designated Cancer Centers suggest limited availability of resources to help patients quit smoking¹⁴ and previous surveys of a wider swath of oncology providers have demonstrated that while most providers ask about smoking and advise quitting, few regularly assist patients with quitting.^15,16 Commonly identified barriers to smoking assessment/treatment as part of standard care include lack of training, time, and resources.¹⁷

National initiatives have begun to address key gaps for tobacco treatment delivery in cancer care.^18,19 In 2017, the Cancer Centers Cessation Initiative (C3I) was launched to improve implementation of tobacco treatment for patients with cancer across NCI-Designated Cancer Centers in the United States.^20,21 Parallel efforts have been launched in Canada¹⁹ and most recently by the American College of Surgeons (ACS) Cancer Programs (ie, Commission on Cancer [CoC] and National Accreditation Program for Breast Cancer [NAPBC]). To extend previous research by engaging a more diverse and representative sample of cancer care facilities, this article aims to (1) describe the baseline practice patterns, organizational readiness, priority, and resources for smoking assessment/treatment among CoC- or NAPBC-accredited programs; (2) examine perceived multilevel barriers and implementation strategies related to smoking assessment/treatment; and (3) identify program and organizational characteristics potentially associated with variation in smoking assessment/treatment practices.

METHODS

Launched in 2022 by the Just ASK Task Force of the ACS Cancer Programs and led by diverse stakeholders from CoC- and NAPBC-accredited programs, leaders, and staff, the Just ASK Quality Improvement (QI) project was initiated to improve identification of current smoking among patients with cancer. This project focused on smoking assessment, as it is foundational for improving delivery of equitable, high-quality tobacco treatment. The CoC is a consortium of approximately 1,500 health care organizations dedicated to improving survival and quality of life for patients with cancer. Similarly, the roughly 550 NAPBC programs focus on delivering high-quality care for breast disease. All CoC and NAPBC programs have an accreditation standard requiring yearly participation in one or more QI initiatives. Accreditation confers value by demonstrating to patients, providers, payors, and governments the programs' investment in the delivery of high-quality, coordinated cancer care.

Just ASK focused on strengthening adoption of universal assessment and documentation of smoking status in the electronic health record (EHR). The goal of this 1-year QI project was to integrate routine delivery of smoking assessment into standard of care, as demonstrated by achieving a 90% rate of asking about smoking status in patients with newly diagnosed cancer and pursuing meaningful improvements in assessing smoking over time. Physicians, nurses, and other clinic staff were encouraged to ask all patients about current smoking and advise patients that quitting can improve cancer outcomes. Programs were also encouraged to consider how they would go beyond asking toward assisting patients via delivery of, or referral to, tobacco treatment. Just ASK was promoted to all CoC- and NAPBC-accredited programs through e-newsletters, social media, and e-mail listservs maintained by the ACS Cancer Programs communications team. The initiative was submitted to the ACS Institutional Review Board and determined not to meet the Department of Health and Human Services definition of human subject research under 45 Code of Federal Regulations 46; therefore, this project did not require Institutional Review Board oversight.

CoC and NAPBC Programs that enrolled in Just ASK were encouraged to develop and implement changes using the well-established Plan-Do-Study-Act QI methodology.²² After baseline survey completion, programs were provided a robust practice change package including educational webinars, virtual peer-to-peer support, and 1:1 technical assistance from the Just ASK Task Force as needed. Programs were encouraged to establish a local QI team and select one or more intervention strategies to improve the quality of smoking assessment in their settings.

Online surveys were developed by Just ASK Task Force members with expertise in QI, implementation science, tobacco treatment, and cancer care. The 98-item, baseline survey assessed readiness and capacity of practices to implement smoking assessment/treatment in routine cancer care of patients with newly diagnosed cancer. The survey consisted of six sections: (1) Program Characteristics, (2) Assessment of Current Practices, (3) Implementation Barriers, (4) Implementation Strategies, (5) Organizational Readiness and Priority, and (6) Clinical Data. In addition to the baseline survey (capturing January-December 2021 and administered before dissemination of the Just ASK QI practice change package), mid-year (capturing January-June 2022) and final (capturing July-December 2022) surveys were planned to assess change over time. Survey completion was a requirement for meeting the QI-related Standard for CoC/NAPBC program accreditation. This article focuses on baseline survey findings.

1. Program Characteristics were measured to summarize the participating cancer care programs in terms of type of program and geographic location. CoC programs are routinely categorized as follows: (1) academic facilities are institutions with >500 newly diagnosed cancer cases per year and are associated with either an NCI-Designated Cancer Center or a provider of postgraduate medical education; (2) comprehensive community cancer programs have > 500 newly diagnosed cancer cases per year; (3) community cancer programs have 100-500 newly diagnosed cancer cases per year; and (4) integrated network cancer programs are a network of multiple facilities providing integrated cancer care, with at least one facility being a hospital. NAPBC-accredited programs must meet compliance with the set standards and provide comprehensive breast cancer care. Other programs without minimum caseload requirements (eg, hospital associate cancer programs, Veterans Affairs programs) are categorized as other.

2. Assessment of Current Smoking Assessment/Treatment Practices included 12 items assessing adoption of best practices for smoking assessment/treatment such as asking about smoking, advising cessation, providing counseling, prescribing medication, and providing referrals. Items were adapted from previous relevant oncology provider surveys assessing practice patterns.^15,23 Items were measured on a 5-point Likert scale from 1 = never/rarely to 5 = almost always, with endorsement of 4 = usually and 5 = almost always collapsed for analysis. We also assessed patients' access to and availability of tobacco treatment resources, including a tobacco treatment specialist (TTS), a universal smoking screening system, and workflow for assessing and documenting smoking status.

3. Implementation Barriers were assessed with 11 items from previous relevant work²⁴ identifying patient-, provider-, and organizational/system-level barriers for promoting smoking assessment/treatment delivery. Example items assessed lack of staff time, lack of available referral resources, and competing clinical priorities. The items were rated on 5-point Likert scales from 1 = agree to 5 = disagree.

4. Implementation Strategies involved ratings of perceived feasibility and effectiveness for seven potential implementation strategies for improving the integration of smoking assessment/treatment in cancer care. Informed by previous work²⁴ and aligned with implementation science strategies,²⁵ these strategies included but were not limited to providing staff training, identifying tobacco treatment champions, and improving EHR documentation of smoking history.¹⁷

5. Organizational Readiness and Priority for tobacco treatment was measured with items adapted from the Organization Readiness for Implementing Change,²⁶ three measuring Change Commitment and two measuring Change Efficacy, all measured on a 5-point Likert scale from 1 = disagree to 5 = agree.

6. Clinical Data on Screening and Prevalence of Smoking. Focusing on clinical metrics from the year before Just ASK QI participation (ie, 2021), respondents were asked to provide baseline data on the number of newly diagnosed patients who (1) were asked about smoking history and current use, (2) reported current smoking, and (3) were provided with tobacco treatment resources or referred to a TTS.

RESULTS

Program Participants

Of approximately 2,000 invited programs, 776 (approximately 40% participation), 731 CoC (approximately 49% participation) and 45 NAPBC (approximately 9% participation), enrolled and completed the baseline survey; 14 Veterans Affairs programs participated, but data are excluded here. The characteristics of participating programs were similar to those of nonparticipating programs with respect to the program type and geographic location. Comprehensive community cancer programs represented, to our knowledge, the largest number of sites (32.5%) followed by integrated networks (25.9%), community cancer programs (20.7%), academic facilities (9.8%), and other programs (5.1%). There are no data available regarding reasons for refusal. It is equally plausible that some programs opted out because of perceived poor performance concerns, whereas some programs opted out because they perceived strong performance and did not see an opportunity for further improvement.

Practice Patterns

Among participating programs, 82.5% reported having a system in place for asking patients about smoking status, which was more frequently assessed and documented at new patient visits (89.2%) than follow-up visits (55.6%). Despite the very high proportion of sites reporting a system for identifying and documenting smoking status, 16% of participating programs could not provide the number of patients with newly diagnosed cancer who were asked about smoking status in the past year. Most programs reported assessing smoking in the clinic before seeing a provider (74.1%) and/or during the provider visit (61.9%). Assessment of smoking status was conducted by a variety of staff including oncology nurses (60.2%), oncology physicians (56.9%), medical assistants (55.4%), primary care physicians (40.9%), nurse practitioner's or physicians' assistants (39.6%), other oncology support staff (28.6%), and nonclinical personnel (19.8%); options are not mutually exclusive.

Practice patterns during a new patient visit are detailed in Table 1. Most programs reported regularly asking about smoking (89.9%), documenting smoking history and current use (88.2%), and advising patients to quit smoking (71.3%). Far fewer sites reported regularly assisting patients with quitting (41.3%); providing self-help information (27.2%); providing individual counseling in person (18.1%), by phone (7.5%), or via telehealth (5.6%); and referring to a quitline (28.5%) or an affiliated tobacco treatment program (26.1%). Less than half of programs documented a tobacco treatment plan (41.7%), and very few reported regularly prescribing medications (17.6%).

TABLE 1.

Delivery of Smoking Assessment/Treatment During New Patient Visits (N = 762)

Practice Behavior	Frequency, No. (%)
	Almost Always	Usually	Sometimes	Occasionally	Rarely or Never	Missing
Ask patients about smoking	532 (69.8)	153 (20.1)	43 (5.6)	14 (1.8)	4 (0.5)	16 (2.1)
Advise patients who smoke about smoking cessation	338 (44.4)	205 (26.9)	140 (18.4)	39 (5.1)	24 (3.1)	16 (2.1)
Assist patients who smoke in smoking cessation	121 (15.9)	194 (25.5)	246 (32.3)	104 (13.6)	78 (10.2)	19 (2.5)
Refer patients who smoke to quitline	96 (12.6)	121 (15.9)	184 (24.1)	156 (20.5)	185 (24.3)	20 (2.6)
Refer patients who smoke to program-affiliated TTS	95 (12.5)	104 (13.6)	164 (21.5)	114 (15.0)	264 (34.6)	21 (2.8)
Provide patients who smoke self-help information	93 (12.2)	114 (15.0)	179 (23.5)	152 (19.9)	202 (26.5)	22 (2.9)
Provide individual counseling in person to patients who smoke	62 (8.1)	76 (10.0)	154 (20.2)	159 (20.9)	290 (38.1)	21 (2.8)
Provide individual counseling by phone to patients who smoke	22 (2.9)	35 (4.6)	105 (13.8)	101 (13.3)	481 (63.1)	18 (2.4)
Provide individual counseling by telehealth or text message to patients who smoke	17 (2.2)	26 (3.4)	109 (14.3)	83 (10.9)	509 (66.8)	18 (2.4)
Prescribe FDA-approved cessation medications to patients who smoke	61 (8.0)	73 (9.6)	220 (28.9)	156 (20.5)	229 (30.1)	23 (3.0)
Document smoking history and current use	508 (66.7)	146 (19.2)	62 (8.1)	22 (2.9)	9 (1.2)	15 (2.0)
Document smoking cessation treatment plan	148 (19.4)	170 (22.3)	211 (27.7)	102 (13.4)	115 (15.1)	16 (2.1)

Abbreviations: FDA, US Food and Drug Administration; TTS, tobacco treatment specialist.

Organizational Readiness, Perceived Barriers, and Implementation Strategies

Physician/staff commitment (4.3 ± 0.8) and motivation (4.2 ± 0.8) to implement smoking assessment/treatment were rated as high as was commitment from facility leadership (4.2 ± 0.9). However, confidence in coordinating tasks to implement smoking assessment/treatment and confidence in handling challenges were slightly lower (3.9 ± 1.0 and 3.7 ± 1.0, respectively). Several implementation strategies were endorsed for improving smoking assessment/treatment in cancer care (Fig 1). Although there were some small differences in perceived feasibility and effectiveness of the proposed implementation strategies, all strategies were endorsed by most sites (54%-73%). Developing patient educational materials was seen as a highly feasible but a less effective strategy, whereas identifying a tobacco treatment champion was reported as the least feasible but likely most effective strategy.

FIG 1.

Perceptions of the feasibility and effectiveness of various implementation strategies to improve smoking assessment/treatment (N = 762).

Perceived barriers to implementing routine smoking assessment/treatment are shown in Table 2. Most programs agreed or somewhat agreed that a lack of staff training (68.8%), lack of designated TTSs (61.9%), patient resistance to smoking cessation (58.3%), lack of available resources (53.3%), and competing priorities (50.9%) were barriers. Many programs also reported lack of staff time (42.4%), inadequate funding (40.6%), and inadequate reimbursement (31.0%) as barriers. By contrast, most disagreed that addressing tobacco was not in alignment with clinical workflow (55.0%) or was not identifiable in the EHR (66.7%).

TABLE 2.

Perceived Barriers to Delivery of Smoking Cessation Treatment

Perceived Barriers	Level of Agreement/Disagreement, No. (%)
	Agree	Somewhat Agree	Neither Agree nor Disagree	Somewhat Disagree	Disagree	Missing
Lack of designated TTS	291 (38.2)	181 (23.8)	113 (14.8)	53 (7.0)	107 (14.0)	17 (2.2)
Lack of staff training	261 (34.3)	263 (34.5)	103 (13.5)	43 (5.6)	76 (10.0)	16 (2.1)
Competing priorities	191 (25.1)	197 (25.9)	147 (19.3)	78 (10.2)	132 (17.3)	17 (2.2)
Patient resistance to smoking cessation	185 (24.3)	259 (34.0)	225 (29.5)	55 (7.2)	21 (2.8)	17 (2.2)
Lack of available resources	183 (24.0)	223 (29.3)	121 (15.9)	98 (12.9)	121 (15.9)	16 (2.1)
Inadequate funding to support smoking cessation	150 (19.7)	159 (20.9)	244 (32.0)	56 (7.3)	121 (15.9)	32 (4.2)
Lack of time to address smoking cessation	119 (15.6)	204 (26.8)	124 (16.3)	108 (14.2)	184 (24.1)	23 (3.0)
Inadequate reimbursement for smoking cessation treatment	113 (14.8)	123 (16.1)	338 (44.4)	42 (5.5)	129 (16.9)	17 (2.2)
Asking about smoking is not aligned with clinic workflow	64 (8.4)	100 (13.1)	161 (21.1)	155 (20.3)	264 (34.6)	18 (2.4)
Lack of leadership support	62 (8.1)	107 (14.0)	229 (30.1)	103 (13.5)	243 (31.9)	18 (2.4)
Unable to identify within the electronic health record	62 (8.1)	74 (9.7)	100 (13.1)	137 (18.0)	371 (48.7)	18 (2.4)

Abbreviation: TTS, tobacco treatment specialist.

Finally, in terms of organizational tools available, 71.5% of respondents denied having in-house TTSs. Referral to a community-based tobacco treatment program was the most common resource available (53.1%), followed by referral to local hospitals (37.1%), treatment delivery in clinic (31.0%), and finally referral to a local facility other than a hospital (28.3%).

DISCUSSION

The Just ASK baseline survey findings from a national sample of CoC- and NAPBC-accredited cancer care programs represent, to our knowledge, the largest data set reporting practice patterns, perceived barriers, and implementation of tobacco treatment across a broad range of cancer treatment settings in the United States. With over 750 participating cancer care programs, including many community-based sites, these Just ASK QI results provide the most robust and generalizable description of smoking assessment/treatment delivery in cancer care settings.²⁰ Given that accredited Cancer Programs select their own annual QI project, the strong participation response suggests that smoking assessment/treatment is a high national priority for QI in cancer care. Indeed, the current high level of interest in Just ASK is similar to the participation rate for the highly successful Return-to-Screening QI initiative, which addressed the precipitous drop in cancer screening during the COVID-19 pandemic.²⁷

Despite near universal endorsement of its clinical importance, much variability was reported in the routine and widespread implementation of smoking assessment/treatment, underscoring a persistent gap in quality cancer care delivery across the United States. Consistent with surveys of oncology providers and demonstrating consistency over time,^15,16,28 many programs reported regularly asking about smoking and advising patients to quit, but less than half of the programs reported regularly assisting patients with cessation, and few programs reported having cessation resources embedded within their cancer care setting. While most programs reported having universal smoking screening systems, some had difficulties in providing objective data on the proportion of patients with cancer screened for smoking status at baseline. Many sites reported difficulties in querying their EHR and determining the actual prevalence of current smoking in their population. Programs reported that assessment of smoking status is more likely to occur during an initial visit than at follow-up and is performed by a variety of providers and staff. As reported here, common barriers to assessment/treatment include lack of staff time, lack of staff training, and lack of resources. In addition to significantly expanding knowledge of practice patterns in what are largely community-based cancer care programs, this study expands previous work by reporting that lack of a dedicated TTS and competing clinical priorities are seen as barriers.

These findings suggest practical recommendations for advancing national efforts to improve the quality of tobacco treatment for patients with cancer and ensure equitable delivery of this evidence-based component of cancer care.^{2,13,18,19,29} First, having a proactive system in place for screening patients for current smoking is essential for identifying all patients who should receive tobacco treatment.³⁰ While most EHRs require documentation of smoking status as a core clinical data element, it is evident that technical support from staff with expertise in health informatics may be necessary for successful implementation of a clinically actionable screening system. Second, greater attention to staff training and practice facilitation is likely needed to increase organizational readiness and support local champions to adopt best practices for tobacco treatment throughout diverse cancer care settings. In addition to traditional delivery channels of continuing medical education and TTS training programs,^31,32 the establishment of learning collaboratives³³ or communities of practice would accelerate the implementation of clinical practice guidelines for tobacco treatment and could be tailored to the local context and available resources. In Just ASK, participating programs readily volunteered to share solutions and effective models of care during webinars, suggesting the feasibility of this evidence-based implementation strategy for practice innovation and the value of shared problem-solving. Finally, identifying and disseminating local referral and other community resources is a critical step if providers are to routinely advise their patients about tobacco cessation and provide (or refer them to) evidence-based tobacco treatment. Research is needed to evaluate the impact of such implementation strategies on the widespread and equitable uptake of evidence-based tobacco treatment in community-based and other cancer care settings.

Despite the strengths inherent in this large, comprehensive baseline survey, there are limitations. While not all accredited centers participated, the approximate 40% QI participation is comparable with previous national QI initiatives (27) and represents, to our knowledge, the largest and most robust report on smoking assessment across a broad dimension of cancer treatment settings. While previous studies report on the attitudes and practices of individual oncology providers, Just ASK is a QI initiative focused on organizational perspectives and represents collective perceptions that may not accurately reflect perceptions of all individual oncology care clinicians. Furthermore, the baseline survey did not collect specific information about the survey respondents at each site, which could produce variability (eg, professional background or QI project role) across sites. Common to all surveys, there is the possibility that self-reported data are subject to social desirability bias. The findings represent baseline assessments from a single point in time, and responses are expected to change as programs progress with the Just ASK QI initiative. Furthermore, results reflect perceptions held by oncology providers and staff in the United States and may not generalize to other countries, especially those with different care patterns, insurance coverage and reimbursement priorities, public health policy, tobacco use patterns, or clinical practice guidelines related to cancer care. Since smoking is associated with substantial increases in cancer treatment costs, particularly related to the need for second-line treatment,^3,34 the survey's lack of attention to revenue and cost-savings associated with smoking cessation treatment could be a weakness.

In conclusion, smoking after a cancer diagnosis is a critical and underaddressed risk factor for poor cancer outcomes. Strong opt-in participation in Just ASK clearly demonstrates CoC- and NAPBC-accredited programs' commitment to address the clinical and public health challenge of persistent smoking in patients with cancer consistent with ACS's focus on providing high-quality cancer care across diverse settings and populations. As it is possible that some programs chose not to participate because of perceptions of having very low or very high rates of smoking assessment/treatment delivery, these baseline survey findings might represent a conservative estimate of the quality practice gap. Findings highlight the opportunities for improving the delivery of evidence-based tobacco treatment in routine cancer care, laying the foundation via asking about and documenting smoking status in the EHR. Just ASK follow-up surveys are expected to demonstrate progress in the initiative's QI goals and provide additional support for the feasibility and importance of establishing tobacco use assessment/treatment as a new Standard for Cancer Care across accredited ACS Cancer Programs.

APPENDIX 1. Just ASK Quality Improvement Task Force

Rob Adsit, Med; Lisa Allison, BSN, RN, MS; Daniel Boffa, MD; Jessica Burris, PhD; Asa Carter, MBA, CTR; Audrey Darville, PhD, APRN; Michael Fiore, MD; Ellen Hahn, RN, PhD; James Harris, MD; Laurie Kirstein, MD; Danielle McCarthy, PhD; Timothy Mullett, MD; Heidi Nelson, MD; Jamie Ostroff, PhDORCID; Eileen Reilly, MSW; Erin Reuter, JD; Sarah Shafir, MPH; Rachel Shelton, ScD, MPH; Elisa Tong, MD; Graham Warren MD, PhD

AUTHOR CONTRIBUTIONS

Conception and design: Jamie S. Ostroff, Eileen M. Reilly, Jessica L. Burris, Graham W. Warren, Rachel C. Shelton, Timothy W. Mullett

Administrative support: Eileen M. Reilly

Collection and assembly of data: Jamie S. Ostroff, Eileen M. Reilly, Graham W. Warren, Rachel C. Shelton

Data analysis and interpretation: Jamie S. Ostroff, Jessica L. Burris, Graham W. Warren, Rachel C. Shelton, Timothy W. Mullett

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

Current Practices, Perceived Barriers, and Promising Implementation Strategies for Improving Quality of Smoking Cessation Support in Accredited Cancer Programs of the American College of Surgeons

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/op/authors/author-center.

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