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. 2024 May 15;19(5):e0299321. doi: 10.1371/journal.pone.0299321

Protocol for the ‘Supporting Young Cancer Survivors who Smoke’ study (PRISM): Informing the development of a smoking cessation intervention for childhood, adolescent and young adult cancer survivors in England

Morven C Brown 1,2,*, Vera Araújo-Soares 3, Roderick Skinner 2,4, Jamie Brown 5, Adam W Glaser 6,7, Helena Hanratty 8, Martin G McCabe 9,10, Ana-Ecaterina Amariutei 11, Sabrina Mauri 11, Linda Sharp 1,2
Editor: Jesse T Kaye12
PMCID: PMC11095735  PMID: 38748708

Abstract

Background

Childhood, adolescent and young adult (CAYA) cancer survivors are vulnerable to adverse late-effects. For CAYA cancer survivors, tobacco smoking is the most important preventable cause of ill-health and early death. Yet, effective strategies to support smoking cessation in this group are lacking. The PRISM study aims to undertake multi-method formative research to explore the need for, and if appropriate, inform the future development of an evidence-based and theory-informed tobacco smoking cessation intervention for CAYA cancer survivors.

Materials and methods

PRISM involves three phases of: 1) an environmental scan using multiple strategies to identify and examine a) smoking cessation interventions for CAYA cancer survivors that are published in the international literature and b) current smoking cessation services in England that may be available to, or tailorable to, CAYA cancer survivors; 2) a qualitative study involving semi-structured interviews with CAYA cancer survivors (aged 16–29 years and who are current or recent ex-smokers and/or current vapers) to explore their views and experiences of smoking, smoking cessation and vaping; and 3) stakeholder workshops with survivors, healthcare professionals and other stakeholders to consider the potential for a smoking cessation intervention for CAYA cancer survivors and what such an intervention would need to target and change. Findings will be disseminated to patient groups, healthcare professionals and researchers, through conference presentations, journal papers, plain English summaries and social media.

Discussion

PRISM will explore current delivery of, perceived need for, and barriers and facilitators to, smoking cessation advice and support to CAYA cancer survivors from the perspective of both survivors and healthcare professionals. A key strength of PRISM is the user involvement throughout the study and the additional exploration of survivors’ views on vaping, a behaviour which often co-occurs with smoking. PRISM is the first step in the development of a person-centred, evidence- and theory-based smoking cessation intervention for CAYA cancer survivors who smoke, which if effective, will reduce morbidity and mortality in the CAYA cancer survivor population.

Introduction

Childhood, adolescent and young adult (CAYA) cancer survivors are a growing population. Approximately 4000 young people aged 0–24 years are diagnosed with cancer in the United Kingdom (UK) annually [1, 2]. Due to treatment advances, over 80% of those diagnosed will achieve long-term cure [1, 2]. However, late-effects of some cancer treatments—in particular, pulmonary and cardiac toxicities—can leave survivors vulnerable to chronic health conditions.

For CAYA cancer survivors, as with the general population, smoking tobacco is the most important health behaviour associated with ill-health and early death [3]. Smoking is particularly risky for this group because their health is already compromised by the cancer and its treatment. Smoking exacerbates survivors’ risks of cardiovascular and respiratory diseases, and increases risk of a subsequent cancer, making these the most common causes of morbidity and mortality in this population [4, 5].

Children diagnosed with cancer have 3.6 to 6.4-fold increased risk of developing another cancer in later life compared to those in the general population [6]. Using both non-cancer controls and population data, those diagnosed in adolescence or young adulthood have been found to have a 2 to 3-fold increased risk of developing smoking-related cancers (e.g., lung) [6–8]; this rises to a 5-fold excess risk among some subgroups (e.g., survivors of Hodgkin lymphoma) [7]. British CAYA survivors diagnosed up to 19 years of age have 3–4 times excess risk of cardiac mortality than the general population [9, 10]. In addition, by the age of 40, half of UK survivors have been admitted to hospital for a respiratory condition [11], and the risk of respiratory mortality is raised 2-fold in those diagnosed with cancer in adolescence or young adulthood, and 7-fold in those diagnosed as children compared to what would be expected in the general population [12]. Despite these risks, a substantial proportion of CAYA survivors in the UK and United States (US) smoke tobacco: surveys of self-reported smoking cite figures of 14–35% [13–16]. However, it is worth nothing that these may be underestimates as in clinical groups, where smoking is especially stigmatized (e.g., pregnant women, patients with cardiac disease, cancer patients), patients may be particularly reticent about disclosing their tobacco use [17, 18].

Clinical practice guidelines for the follow-up care of CAYA cancer survivors from the UK and US, as well as recent harmonized international guidelines [19–22], state that survivors should be advised on both tobacco smoking and smoking cessation. However, a large proportion of CAYA survivors (including those who smoke) report not receiving such advice [23]. A UK survey of 95 healthcare professionals (HCPs) caring for these survivors found that only 50% of physicians and 36% of nurses reported providing smoking advice to most patients, with many stating they felt they were not the right person to do so [24]. This echoes findings from adult oncology in the UK, which shows that HCPs can feel uneasy discussing smoking with survivors, and lack awareness and knowledge of smoking cessation services [25]. Moreover, it is not known what—and how—smoking cessation support should be provided to CAYA cancer survivors to promote successful quitting, and whether existing services could support this (either in their current format, or if appropriately adapted). However, it also needs to be highlighted that although there is much evidence to support effective strategies for smoking cessation in adults, and the provision of cessation services, there is still limited evidence for how to effectively help young people in general to quit smoking.

There is limited empirical research on the views and attitudes of CAYA cancer survivors regarding smoking [23, 26]. Although cancer diagnosis, treatment and survivorship are often thought to offer ‘teachable moments’ for a lifestyle change such as quitting smoking [27], evidence suggests that survivors of adult cancers experience barriers to smoking cessation that are specific to their illness experience (e.g., smoking to help with cancer-related stress and to maintain personal control after their diagnosis [25, 27]), and which may affect the uptake, and effectiveness, of current smoking cessation services and support [28]. Whether this also holds in survivors of CAYA cancer is unclear and fundamental evidence is lacking on why CAYA cancer survivors’ smoke, what affects whether they want to quit and what helps and hinders successful quitting.

In exploring CAYA survivors’ views of smoking, it would be pertinent to also explore their views of e-cigarette use (also known as vaping). In England, around a quarter of young people aged 16–24 use e-cigarettes, whilst 14–20% smoke [29, 30]; evidence suggests that around half of those who vape, also smoke tobacco (i.e., are dual users) [29]. Dual users may find it harder to quit smoking and may not view themselves as ‘smokers’ [31], thus they may not perceive a study, or indeed an intervention, for smoking cessation to be relevant to them.

There is an urgent need to develop effective strategies to support smoking cessation among CAYA cancer survivors [3]. However, few interventions exist and of those that have been published [16, 32–34], none appear to have involved: (i) a systematic framework of intervention development; (ii) a thorough understanding of smoking behaviours in CAYA survivors; (iii) user involvement; or (iv) application of appropriate theory. These are prerequisites for developing successful interventions [35–38], suggesting considerable groundwork is needed to inform the development of effective smoking cessation interventions for CAYA cancer survivors.

The PRISM study will begin to address tobacco smoking in CAYA cancer survivors by undertaking formative research in order to provide a foundation for the future development of a smoking cessation intervention targeted to this population, with the ultimate goal of reducing smoking-related morbidity and mortality.

Materials and methods

Aim

PRISM aims to inform the future development of a person-centred, evidence-based and theoretically-informed tobacco smoking cessation intervention which can be tailored, as required, to the needs of CAYA cancer survivors.

Objectives

  1. a) To identify and describe the features of tobacco smoking cessation interventions for CAYA cancer survivors which have been published internationally; b) To identify and describe the features of tobacco smoking cessation services which currently exist for i) adolescents and/or young people with a medical diagnosis (cancer or another diagnosis) or ii) people of any age with cancer/cancer survivors in England;

  2. To identify and explore perceived influences on tobacco smoking and vaping behaviour among CAYA cancer survivors;

  3. To identify and explore perceived barriers to, and facilitators for, tobacco smoking cessation among CAYA cancer survivors;

  4. To explore CAYA cancer survivors’ views and experiences of tobacco smoking cessation advice and services, and what may help or hinder them to engage with such advice/services;

  5. To engage with survivors, healthcare professionals and other key stakeholders to develop a preliminary logic model of the problem and identify areas for future development of a tobacco smoking cessation intervention for CAYA cancer survivors.

Overall study design

PRISM will address shortcomings of previous research by following established guidance to generate evidence to inform intervention development [35–38]. It focuses on the planning domain of intervention development—that is, it will seek to understand the problem being addressed, agree the aims and goals of the future intervention, identify possible ways of addressing the problem, and consider real-world issues which may affect future implementation [39].

Phase 1 will involve an environmental scan where we will identify smoking cessation interventions for CAYA cancer survivors that have been published internationally. We will also identify existing smoking cessation services in England that may be relevant for CAYA cancer survivors (objective 1). Phase 2 will involve semi-structured interviews with 25–30 CAYA cancer survivors who are current or recent ex-smokers and/or current vapers (objectives 2–4). Evidence gathered from these phases will feed into Phase 3 (objective 5), which will involve workshops with key stakeholders and development of a preliminary logic model of the problem which will begin to define what an intervention will need to target and change, and its expected outcomes [37, 40].

The methods for each phase are presented below.

Phase 1: Environmental scan

Environmental scans seek, gather and interpret data from a wide range of sources, enabling assessment of the current state of healthcare services [41]. We will utilise multiple strategies to identify and characterise existing smoking interventions and cessation services which are either currently available to, or which could be adapted to the needs (retrofitted), of CAYA cancer survivors in England. These strategies will encompass: 1) a scoping search of published literature; 2) a comprehensive search of grey literature and 3) consultation with key informants and stakeholders.

Scoping search of published literature. We will search bibliographic databases (MEDLINE, Embase, PsycINFO, CINAHL, Scopus) to identify smoking cessation interventions with CAYA cancer survivors in the published literature. Search strategies will be informed by PICO search strategy tool [42]. Search terms will relate to CAYA cancer survivors, interventions and smoking cessation and a combination of subject headings and key words and will be adapted for each database. Searches will be limited to the English language.

Comprehensive search of grey literature. To rigorously identify grey information, we will search: 1) clinical trial registries (ISRCTN registry, ClinicalTrials.gov) and a grey literature database (OpenGrey); 2) results from a popular Internet search engine (Google.co.uk); 3) web-sites of relevant organisations (e.g., National Health Service (NHS); and 4) App stores (Google Play and Apple App Store) [43, 44].

A Medical Sciences Librarian will advise on a customised search strategy for each source. Search strategies will be based on two components–the intervention/services of interest (e.g., smoking cessation) and population of interest (e.g., young people, cancer patients/survivors).

1. Grey literature and trial database

In trial databases, advanced search functions will be utilised to identify smoking cessation trials. Separate searches will be run with restrictions for participant age (child) and condition/disease (cancer). Searches will include all trial statuses (e.g., ongoing, completed, suspended) and will be limited by country (England/UK, as database allows). The OpenGrey database will also be searched.

2. Google

Multiple combinations of terms for the two search components will be run using Google Advanced Search. Searches will be restricted to the UK and language (English) and to the first 100 results of each search. Results will be archived by copying results into a Microsoft Word document, retaining the page titles, site links and brief description of the page to enable review for eligibility.

3. Websites

Using Google Advanced Search, searches will use a combination of key terms and will be restricted by domain name in order to search the content of specific websites (e.g., cancerresearchuk.org) and language (English). The first 50 results of each search will be archived for review.

4. App stores

Google Play (via play.google.com) and the Apple App store (via an Iphone13) will be searched using lay language keywords for smoking cessation (e.g., stop smoking, quit smoking), limiting to the first 100 results. App stores do not enable results to be exported, therefore eligibility will be determined by one researcher based on the app’s marketing description. Any apps deemed potentially relevant will be downloaded.

Consultation with key informants and stakeholders. Consultation with key informants. To identify services we will consult with key informants (e.g., smoking cessation services, Cancer Alliances, relevant HCPs in primary and secondary/tertiary care, local public health departments, smoking cessation researchers). We will use a snowball approach by asking contacts if they are aware of other relevant organisations or individuals.

Healthcare professional survey

We will disseminate a brief online survey via professional associations for HCPs involved in the care of CAYA cancer survivors (Children’s Cancer and Leukaemia Group; Teenagers and Young Adults with Cancer; Teenage Cancer Trust) and social media. The survey will seek information on which (if any) smoking cessation services HCPs refer patients/survivors to. Additional questions will investigate current practices of HCPs with regards to offering advice and support about smoking/smoking cessation to survivors, and the perceived influences on these behaviours. These questions will be informed by the Theoretical Domains Framework (TDF) [45, 46], a widely used theoretical approach for identifying determinants of behaviour.

Identifying relevant interventions and services. Eligible studies identified via the scoping search of published literature must report on a smoking cessation intervention for CAYA cancer survivors in any geographical location. To be eligible for inclusion in the grey literature scan, services, interventions and apps must state that they are targeted towards either 1) adolescents and/or young people with a medical diagnosis (cancer or another diagnosis) or 2) people of any age with cancer/cancer survivors. These interventions and services must be available to individuals residing in England, and any apps must be in English. We envisage that few, if any, services will be aimed specifically to CAYA cancer survivors; conducting a wider search will therefore identify services which may provide a basis for a future smoking cessation intervention for CAYA survivors.

Data extraction and analysis. Information will be extracted on the name of service/intervention; target population (who is eligible to access the service); any tailoring; how it is accessed; location and/or type or format; aim and description of what it entails; who provides or delivers it; how long individuals are enrolled in the service and how frequently they are asked to attend (if applicable); how many individuals access it annually; cost (if applicable); and whether it has been evaluated [47]. Excel will be used to build a database of extracted information to enable synthesis. Narrative synthesis will be undertaken [48].

Phase 2: Qualitative study

Study setting and participants. Phase 2 will involve semi-structured interviews with CAYA cancer survivors who are current or recent tobacco smokers and/or current vapers (Table 1 shows eligibility/exclusion criteria). Survivors will be primarily recruited via four clinical sites (Newcastle upon Tyne Hospitals NHS Foundation Trust; Leeds Teaching Hospitals NHS Trust; Sheffield Teaching Hospitals NHS Foundation Trust; and The Christie NHS Foundation Trust) which provide care for CAYA cancer survivors. To reach a wider range of survivors we will also promote the study via the social media pages of the research team and, with permission, the pages of local charities (e.g., Children’s Cancer North). Phase 2 received approval from West Midlands–South Birmingham Research Ethics Committee (REC reference: 22/WM/0102).

Table 1. Childhood, adolescent and young adult cancer survivors’ inclusion and exclusion criteria.
Inclusion criteria Exclusion criteria
1) Were diagnosed with cancer or a brain tumour aged 0–24 years
2) Are currently aged 16–29 years
3) Are cancer free and at least 12 months from the end of treatment
4) Have the ability to speak and understand English
5) Are a regular current tobacco smoker or an ex-smoker who stopped smoking tobacco within the last 12 months and/or are a current user of e-cigarettes		 1) Only smoke tobacco when mixed with cannabis (and do not use e-cigarettes)
2) Have a cognitive impairment which would significantly impact their understanding of the study or their ability to give informed consent
3) Are unfit to take part due to issues such as the presence of serious psychological problems which may mean they would find taking part distressing (as deemed by the oncologist/nurse specialist)
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Recruitment. Identification and screening of CAYA cancer survivors began in January 2023, with recruitment expected to end 01 July 2024. Young people’s disclosure of tobacco smoking can be influenced by the setting they are in, the perceived disapproval of others and anonymity [49], and indeed whether they view themselves as a smoker or not. Therefore, we will adopt a range of approaches for recruitment. Maximum variation purposive sampling (with strata including age, gender, ethnicity, socio-economic status, diagnosis, treatment) will be used to ensure elicitation of varied views and experiences.

The primary recruitment route will be via CAYA cancer survivor follow-up services in the Trusts. HCPs will identify potentially eligible survivors through medical records and at clinic, and inform them about the study by letter, telephone or verbally face-to-face. All those approached will receive a participant information sheet. Those interested in participating will either contact the study’s researcher directly or give permission for their details to be provided to the researcher. Where possible, the researcher will attend clinics to be able to speak to eligible patients about the study. We have successfully used these approaches to recruit CAYA survivors to several studies [50, 51]. In describing the study to survivors (both verbally and via the participant information sheet) neutral, non-judgmental language will be used. It will be made clear that it is not assumed that they wish to stop smoking or vaping, nor does the study involve efforts to persuade them to do so; we simply want to hear their views on smoking and vaping.

These targeted methods rely on the HCPs identifying CAYA survivors whom they know, or suspect, to smoke tobacco or vape. If required, this approach will be supplemented by Trusts distributing a brief screening questionnaire to survivors who fulfil inclusion criteria 1–4 (Table 1). Those who declare themselves to be current smokers, recent ex-smokers and/or current vapers will be invited to provide their contact details if they are interested in receiving information about the study. Survivors will return the questionnaire in a sealed envelope to the researcher to ensure confidentiality.

For recruitment via social media, posts promoting the study will ask interested survivors to contact the researcher who will screen them against the inclusion criteria and send them a participant information sheet.

Procedures/data collection and analysis. CAYA cancer survivors wishing to take part will be able to choose their preferred mode of interview—telephone, online (e.g., Zoom) or face-to-face at a location of their choice. Offering multiple options can increase research participation of more marginalised groups, or those traditionally less likely to participate [52]. Prior to interview, participants will provide informed consent. Written consent will be obtained from those interviewed in person. For interviews conducted remotely, verbal consent will be audio-recorded. The researcher will read out each point of the consent form and will ask the participant to indicate their agreement or otherwise. The researcher will then complete a form on the participant’s behalf. Interviews will be guided by a topic guide, which will be used flexibly (available in S1 File). Interviews will adopt a non-judgemental attitude and will explore: cancer beliefs; awareness of late-effects; smoking and vaping-related health beliefs/risk perceptions; views and experiences of smoking cessation advice/resources/services; quit attempts; perceived influences on their smoking and/or vaping behaviour.

Elements of the interview will be informed by the TDF to: help support comprehensive assessment of behavioural determinants; enable subsequent identification of the most relevant theory; and identify what needs to be targeted by strategies to bring about behaviour change [45]. As recommended [53], the TDF will be used flexibly to support identification of key determinants of (i) tobacco smoking and vaping and (ii) successful smoking cessation. Interviews are expected to last approximately 60–90 minutes. All interviewees will be offered a £20 shopping voucher to thank them for their time, as well as reimbursement of any travel expenses.

Interviews will be audio-recorded and transcribed verbatim. Inductive reflexive analysis will occur concurrently with data collection to ensure any new issues raised are explored in subsequent interviews [54]. Two team members will code preliminary interviews, discuss and agree codes and themes. These codes will be applied to the remaining interviews, incorporating any new codes and themes as they are identified. In a second, deductive, phase of analysis, codes which relate to the influences on smoking/smoking cessation (and vaping) will be mapped onto the TDF, distinguishing between those factors which can, and cannot, be modified. Coding and analysis will be facilitated by QSR International’s NVivo software (Release 1.6, 2022).

Sample size and data saturation. Recruitment will continue until reasonable data saturation has been achieved [55]. Determination of data saturation will be primarily based on theoretical sufficiency (conceptual depth) regarding survivors’ perceived influences on smoking behaviour. In addition, we will ensure no new themes have been identified in the last three interviews as regards other objectives [56]. Based on our past research [50, 51], and recommendations for sample size for semi-structured interviews [57], we anticipate 25–30 interviews will be required.

Phase 3: Stakeholder workshops

Study setting and participants. Phase 3 will involve working with CAYA cancer survivors, HCPs (e.g., oncologists, nurses, general practitioners) and other stakeholders (e.g., public health, smoking cessation service providers) to begin to identify what a smoking cessation intervention for CAYA cancer survivors will need to target.

We will hold two (parallel) workshops, one for survivors, and the other for HCPs (oncologists, nurses, general practitioners) and other stakeholders (e.g., public health, service providers). If required, and if time permits, additional workshops may be held.

Recruitment to survivor workshop

CAYA survivors who participate in Phase 2 will be asked to register their interest in workshop attendance. Clinical co-applicants/collaborators will advertise this Patient and Public Involvement (PPI) opportunity via their service and appropriate links at their Trusts (e.g., support groups). We will also invite members of our network of CAYA cancer survivors interested in PPI in Northern England to participate. For greater reach, the opportunity will be advertised via cancer charities and organisations (e.g., Children’s Cancer North), support groups and social media.

Recruitment to professional workshop

Stakeholders (e.g., public health, smoking cessation service providers) will be identified via Phase 1. HCPs (e.g., oncologists, nurses, general practitioners) who care for CAYA cancer survivors will be identified via the contacts of the clinical co-applicants and advertisement via professional associations (e.g., Children’s Cancer and Leukaemia Group) and social media.

Procedures/data collection and analysis. If the workloads of HCPs permit, workshops will take place face-to-face at an easily accessible location; if this is not possible, remote workshops will be held using a video conferencing platform that is accessible to workshop participants (e.g., Zoom for survivors, MS Teams for HCPs). These workshops will draw on co-design approaches [58], in that the research team and stakeholders will work together during them to co-create an understanding of the problem and the potential for a solution.

At each workshop, the Phase 1 and 2 findings will be presented (in the form of evidence statements) [58], and initial ideas for what would be useful, and what is needed, to promote smoking cessation among CAYA cancer survivors will be explored. The survivor workshop will explore issues around the acceptability of any intervention to support smoking cessation (e.g., perceived need for intervention, potential stigma of using intervention), factors which may encourage or prevent CAYA survivors engaging in an intervention (e.g., referral by HCP, low readiness to quit), and initial views on intervention delivery (e.g., where, how and by whom). Attendees at the survivor workshop will be offered a £75 honorarium [59]. The workshop with HCPs and wider stakeholders will begin to consider issues around the feasibility of health service/HCP involvement in any intervention and potential contextual factors that might affect an intervention. Based on these workshops, the logic model of the problem will be refined and potential areas for future intervention development identified.

Dissemination of findings

To reach academic and clinical audiences, dissemination will be via journal publications and conferences. We will work with our PPI co-applicants on dissemination methods to reach CAYA cancer survivors. We will produce a plain English summary of the project results for dissemination through HCP and survivor networks and organisations (e.g., Children’s Cancer and Leukaemia Group).

Patient and public involvement

PPI input shaped the study. A brief survey about smoking/smoking cessation was posted in two Facebook groups for CAYA cancer survivors. Discussions were held with members of Perspectives, an adult cancer PPI group. Members of the Young Person’s Advisory Group North-East provided input on the content of participant information sheets, recruitment methods and the appropriateness and conduct of interviews. PPI co-applicants (AA and SM) will advise and assist with strategies and patient-facing materials for recruitment to Phase 2 and 3. They will help to shape project direction and decision making, and be invited to contribute to the interpretation and dissemination of study findings. We will use the GRIPP2 short form checklist to report PPI involvement in our research in publications [60].

Discussion

The increased risk of smoking-related health conditions among CAYA cancer survivors indicates the need for smoking cessation interventions, but high-quality, evidence-based and theoretically-informed interventions are currently lacking. There is also a lack of research exploring CAYA survivors’ perceived needs for smoking cessation advice and support, and perceived barriers and facilitators to smoking cessation. To our knowledge, there are also no studies which explore the views of CAYA cancer survivors who vape, a behaviour which may have important implications for smoking cessation efforts. PRISM will generate this information to underpin future development of tobacco smoking cessation interventions for this group.

Evidence suggests that cancer professionals lack awareness of what smoking cessation services are available [25]. By mapping the smoking cessation landscape in England, PRISM will both identify any interventions/services which could potentially be retrofitted to CAYA cancer survivors (thus enabling agile intervention development) [35], and provide information that may help professionals in the short-term to implement the guidelines advising CAYA survivors on smoking cessation [19–21].

Tobacco smoking often co-occurs with other behaviours such as vaping e-cigarettes and smoking cannabis [61, 62]. These are related but distinct behaviours, all of which have very different drivers [61–64]. In the UK, e-cigarettes are tightly regulated and recommended as a smoking cessation aid for those aged 18 and above and while 16% of young people report using cannabis [65], it remains to be illegal. PRISM focuses specifically on smoking tobacco as CAYA cancer survivors have increased risk of tobacco-related diseases but due to the complexities that may be caused by dual use of e-cigarettes and tobacco cigarettes (e.g., dual users not identifying as smokers), we also include CAYA survivors who vape in this study. Contrary to the public health recommendations of other countries (e.g., Australia, the US), vaping is promoted as a much safer alternative to smoking in the UK. However, little is known about the possible long-term health risks of vaping, and emerging evidence suggests links to increased risk of respiratory and cardiovascular diseases [66], which should be of particular concern to CAYA survivors. CAYA cancer survivors who smoke cannabis will also be eligible for Phase 2 provided they also smoke tobacco separately (and/or vape), thus the study may also provide some (albeit limited) information about cannabis smoking in this population.

Adolescence is a critical period for smoking initiation, therefore, addressing tobacco use in this patient group will likely benefit from efforts to both prevent uptake in survivors and also support smoking cessation for those who already smoke. By speaking to survivors who smoke and vape we hope to be able to explore their views on the initiation of these behaviours (e.g., when and why they started), by doing so, this may provide information useful to the consideration of smoking prevention in this group.

PRISM is the first step in the development of a person-centred, evidence- and theory-based smoking cessation intervention aimed at CAYA cancer survivors who smoke tobacco. This intervention will seek to support smoking cessation, in order to reduce long-term morbidity and mortality. Therefore, in the long-term the project has considerable potential to yield significant benefits for the CAYA cancer survivor population. In addition, if, in the long-term, it results in an effective tobacco smoking cessation intervention for CAYA cancer survivors, it could yield significant cost savings for the NHS, by preventing admissions of respiratory and cardiac conditions and second cancers.

Supporting information

S1 File

(PDF)

pone.0299321.s001.pdf (212.3KB, pdf)

Data Availability

This a protocol paper and there is no associated data. For future publications resulting from this study, data will be assigned a persistent identifier (DOI) that will allow the data to be discoverable but not openly accessible. The DOI will be included in any data access statement in publications. The corresponding author can be contacted for the data availability of future publications.

Funding Statement

This article presents independent research funded by the National Institute for Health Research (NIHR) under the Research for Patient Benefit programme [NIHR202768]. The project was subjected to an external peer review as part of the application process. The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

References

  • 1.Cancer Research UK. Young People’s Statistics 2017. Available from: https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/young-peoples-cancers#heading-Two. [Google Scholar]
  • 2.Cancer Research UK. Children’s Cancers 2020. Available from: https://www.cancerresearchuk.org/about-cancer/childrens-cancer/about. [Google Scholar]
  • 3.Nathan PC, Ford JS, Henderson TO, Hudson MM, Emmons KM, Casillas JN, et al. Health behaviors, medical care, and interventions to promote healthy living in the Childhood Cancer Survivor Study cohort. J Clin Oncol. 2009;27(14):2363–73. doi: 10.1200/JCO.2008.21.1441 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Armstrong GT, Liu Q, Yasui Y, Neglia JP, Leisenring W, Robison LL, et al. Late mortality among 5-year survivors of childhood cancer: a summary from the Childhood Cancer Survivor Study. Journal of clinical oncology: official journal of the American Society of Clinical Oncology. 2009;27(14):2328–38. doi: 10.1200/JCO.2008.21.1425 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Reulen RC, Winter DL, Frobisher C, Lancashire ER, Stiller CA, Jenney ME, et al. Long-term cause-specific mortality among survivors of childhood cancer. JAMA. 2010;304(2):172–9. doi: 10.1001/jama.2010.923 [DOI] [PubMed] [Google Scholar]
  • 6.Lee JS, DuBois SG, Coccia PF, Bleyer A, Olin RL, Goldsby RE. Increased risk of second malignant neoplasms in adolescents and young adults with cancer. Cancer. 2016;122(1):116–23. doi: 10.1002/cncr.29685 [DOI] [PubMed] [Google Scholar]
  • 7.Bright CJ, Reulen RC, Winter DL, Stark DP, McCabe MG, Edgar AB, et al. Risk of subsequent primary neoplasms in survivors of adolescent and young adult cancer (Teenage and Young Adult Cancer Survivor Study): a population-based, cohort study. The Lancet Oncology. 2019;20(4):531–45. doi: 10.1016/S1470-2045(18)30903-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Chao C, Bhatia S, Xu L, Cannavale KL, Wong FL, Huang P-YS, et al. Incidence, Risk Factors, and Mortality Associated With Second Malignant Neoplasms Among Survivors of Adolescent and Young Adult Cancer. JAMA Netw Open. 2019;2(6):e195536–e. doi: 10.1001/jamanetworkopen.2019.5536 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Fidler MM, Reulen RC, Henson K, Kelly J, Cutter D, Levitt GA, et al. Population-Based Long-Term Cardiac-Specific Mortality Among 34 489 Five-Year Survivors of Childhood Cancer in Great Britain. Circulation. 2017;135(10):951–63. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Henson KE, Reulen RC, Winter DL, Bright CJ, Fidler MM, Frobisher C, et al. Cardiac Mortality Among 200 000 Five-Year Survivors of Cancer Diagnosed at 15 to 39 Years of Age: The Teenage and Young Adult Cancer Survivor Study. Circulation. 2016;134(20):1519–31. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Smith L, Glaser AW, Peckham D, Greenwood DC, Feltbower RG. Respiratory morbidity in young people surviving cancer: Population-based study of hospital admissions, treatment-related risk factors and subsequent mortality. Int J Cancer. 2019;145(1):20–8. doi: 10.1002/ijc.32066 [DOI] [PubMed] [Google Scholar]
  • 12.Fidler MM, Reulen RC, Bright CJ, Henson KE, Kelly JS, Jenney M, et al. Respiratory mortality of childhood, adolescent and young adult cancer survivors. Thorax. 2018;73(10):959–68. doi: 10.1136/thoraxjnl-2017-210683 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Frobisher C, Winter D.L., Lancashire E.R., Reulen R.C., Taylor A.C., Eiser C., et al. Extent of Smoking and Age at Initiation of Smoking Among Adult Survivors of Childhood Cancer in Britain. Journal of the National Cancer Institute 2008;100:1068–81. doi: 10.1093/jnci/djn210 [DOI] [PubMed] [Google Scholar]
  • 14.Gibson TM, Liu W, Armstrong GT, Srivastava DK, Hudson MM, Leisenring WM, et al. Longitudinal smoking patterns in survivors of childhood cancer: An update from the Childhood Cancer Survivor Study. Cancer. 2015;121(22):4035–43. doi: 10.1002/cncr.29609 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Kaul S, Veeranki SP, Rodriguez AM, Kuo YF. Cigarette smoking, comorbidity, and general health among survivors of adolescent and young adult cancer. Cancer. 2016;122(18):2895–905. doi: 10.1002/cncr.30086 [DOI] [PubMed] [Google Scholar]
  • 16.Klesges RC, Krukowski RA, Klosky JL, Liu W, Srivastava DK, Boyett JM, et al. Efficacy of a tobacco quitline among adult survivors of childhood cancer. Nicotine & tobacco research: official journal of the Society for Research on Nicotine and Tobacco. 2015;17(6):710–8. doi: 10.1093/ntr/ntu216 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Petruzella S, Bochner BH, Kenney J, Whiting K, Sadeghi K, Benfante N, et al. Examining the Accuracy of Self-Reported Smoking-Related Exposure among Recently Diagnosed Nonmuscle Invasive Bladder Cancer Patients. J Urol. 2021;205(5):1321–5. doi: 10.1097/JU.0000000000001571 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Scheuermann TS, Richter KP, Rigotti NA, Cummins SE, Harrington KF, Sherman SE, et al. Accuracy of self-reported smoking abstinence in clinical trials of hospital-initiated smoking interventions. Addiction. 2017;112(12):2227–36. doi: 10.1111/add.13913 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Children’s Oncology Group (COG). Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Version 5.0. 2018. [Google Scholar]
  • 20.Skinner R. WWHB, Levitt G.A. Therapy based long-term follow up. A practice statement 2005.; 2005. [Google Scholar]
  • 21.Scottish Intercollegiate Guidelines Network. Long term follow up of survivors of childhood cancer. (SIGN Guideline 132). 2013. [Google Scholar]
  • 22.Armenian SH, Hudson MM, Mulder RL, Chen MH, Constine LS, Dwyer M, et al. Recommendations for cardiomyopathy surveillance for survivors of childhood cancer: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group. The Lancet Oncology. 2015;16(3):e123–e36. doi: 10.1016/S1470-2045(14)70409-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Ford JS, Puleo E, Sprunck-Harrild K, deMoor J, Emmons KM. Perceptions of risk among childhood and young adult cancer survivors who smoke. Support Care Cancer. 2014;22(8):2207–17. doi: 10.1007/s00520-014-2165-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Pugh G, Hough R, Gravestock H, Williams K, Fisher A. Lifestyle advice provision to teenage and young adult cancer patients: the perspective of health professionals in the UK. Support Care Cancer. 2017;25(12):3823–32. doi: 10.1007/s00520-017-3814-5 [DOI] [PubMed] [Google Scholar]
  • 25.Wells M, Aitchison P, Harris F, Ozakinci G, Radley A, Bauld L, et al. Barriers and facilitators to smoking cessation in a cancer context: A qualitative study of patient, family and professional views. BMC Cancer. 2017;17(1):348. doi: 10.1186/s12885-017-3344-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Emmons K, Li FP, Whitton J, Mertens AC, Hutchinson R, Diller L, et al. Predictors of smoking initiation and cessation among childhood cancer survivors: a report from the childhood cancer survivor study. J Clin Oncol. 2002;20(6):1608–16. doi: 10.1200/JCO.2002.20.6.1608 [DOI] [PubMed] [Google Scholar]
  • 27.Mcbride CM, Ostroff JS. Teachable Moments for Promoting Smoking Cessation: The Context of Cancer Care and Survivorship. Cancer Control. 2003;10(4):325–33. doi: 10.1177/107327480301000407 [DOI] [PubMed] [Google Scholar]
  • 28.Burris JL, Borger TN, Shelton BJ, Darville AK, Studts JL, Valentino J, et al. Tobacco Use and Tobacco Treatment Referral Response of Patients With Cancer: Implementation Outcomes at a National Cancer Institute–Designated Cancer Center. JCO Oncology Practice. 2022;18(2):e261–e70. doi: 10.1200/OP.20.01095 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Smoking in England. Trends in electronic cigarette use in England 2023. [cited 2023 4/10]. Available from: https://smokinginengland.info/graphs/e-cigarettes-latest-trends. [Google Scholar]
  • 30.Smoking in England. Top-line findings on smoking in England from the Smoking Toolkit Study 2023. [cited 2023 4/10]. Available from: https://smokinginengland.info/graphs/top-line-findings. [Google Scholar]
  • 31.Vandrevala T, Coyle A, Walker V, Cabrera Torres J, Ordoña I, Rahman P. ‘A good method of quitting smoking’ or ‘just an alternative to smoking’? Comparative evaluations of e-cigarette and traditional cigarette usage by dual users. Health Psychology Open. 2017;4(1):2055102916684648. doi: 10.1177/2055102916684648 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Emmons KM, Puleo E, Mertens A, Gritz ER, Diller L, Li FP. Long-term smoking cessation outcomes among childhood cancer survivors in the Partnership for Health Study. J Clin Oncol. 2009;27(1):52–60. doi: 10.1200/JCO.2007.13.0880 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Emmons KM, Puleo E, Park E, Gritz ER, Butterfield RM, Weeks JC, et al. Peer-delivered smoking counseling for childhood cancer survivors increases rate of cessation: the partnership for health study. J Clin Oncol. 2005;23(27):6516–23. doi: 10.1200/JCO.2005.07.048 [DOI] [PubMed] [Google Scholar]
  • 34.Emmons KM, Puleo E, Sprunck-Harrild K, Ford J, Ostroff JS, Hodgson D, et al. Partnership for health-2, a web-based versus print smoking cessation intervention for childhood and young adult cancer survivors: randomized comparative effectiveness study. J Med Internet Res. 2013;15(11):e218. doi: 10.2196/jmir.2533 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Araújo-Soares V, Hankonen N, Presseau J, Rodrigues A, Sniehotta FF. Developing Behavior Change Interventions for Self-Management in Chronic Illness. Eur Psychol. 2019;24(1):7–25. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Bartholomew Eldredge LK, Markham C. M., Ruiter R. A. C., Fernandez M. E., Kok G, & Parcel G. S. Planning health promotion programs: An intervention mapping approach 4th ed. San Fransisco, CA:: Jossey-Bass.; 2016. [Google Scholar]
  • 38.O’Cathain A, Croot L, Duncan E, Rousseau N, Sworn K, Turner KM, et al. Guidance on how to develop complex interventions to improve health and healthcare. BMJ open. 2019;9(8):e029954. doi: 10.1136/bmjopen-2019-029954 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.O’Cathain A, Croot L, Sworn K, Duncan E, Rousseau N, Turner K, et al. Taxonomy of approaches to developing interventions to improve health: a systematic methods overview. Pilot Feasibility Stud. 2019;5:41. doi: 10.1186/s40814-019-0425-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Green L, Kreuter M. Health program planning: An educational and ecological approach. 4th Edition ed. New York: McGraw Hill; 2005. [Google Scholar]
  • 41.Charlton P, Doucet S, Azar R, Nagel DA, Boulos L, Luke A, et al. The use of the environmental scan in health services delivery research: a scoping review protocol. BMJ open. 2019;9(9):e029805. doi: 10.1136/bmjopen-2019-029805 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Richardson WS, Wilson MC, Nishikawa J, Hayward RS. The well-built clinical question: a key to evidence-based decisions. ACP J Club. 1995;123(3):A12–3. [PubMed] [Google Scholar]
  • 43.Adams J, Hillier-Brown FC, Moore HJ, Lake AA, Araújo-Soares V, White M, et al. Searching and synthesising ‘grey literature’ and ‘grey information’ in public health: critical reflections on three case studies. Systematic Reviews. 2016;5(1):164. doi: 10.1186/s13643-016-0337-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Hillier-Brown FC, Summerbell CD, Moore HJ, Wrieden WL, Adams J, Abraham C, et al. A description of interventions promoting healthier ready-to-eat meals (to eat in, to take away, or to be delivered) sold by specific food outlets in England: a systematic mapping and evidence synthesis. BMC Public Health. 2017;17(1):93–. doi: 10.1186/s12889-016-3980-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14. doi: 10.1136/qshc.2004.011155 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Cane J O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Science. 2012;7(1):37. doi: 10.1186/1748-5908-7-37 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687. doi: 10.1136/bmj.g1687 [DOI] [PubMed] [Google Scholar]
  • 48.Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the Conduct of Narrative Synthesis in Systematic Reviews. A Product from the ESRC Methods Programme.; 2006. [Google Scholar]
  • 49.Metzger A, Wakschlag LS, Anderson R, Darfler A, Price J, Flores Z, et al. Information management strategies within conversations about cigarette smoking: parenting correlates and longitudinal associations with teen smoking. Dev Psychol. 2013;49(8):1565–78. doi: 10.1037/a0030720 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Brown MC, Haste A, Araújo-Soares V, Skinner R, Sharp L. Identifying and exploring the self-management strategies used by childhood cancer survivors. J Cancer Surviv. 2020;(in press). doi: 10.1007/s11764-020-00935-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Brown MC, Araújo-Soares V, Skinner R, Glaser AW, Sarwar N, Saxton JM, et al. Using qualitative and co-design methods to inform the development of an intervention to support and improve physical activity in childhood cancer survivors: a study protocol for BEing Active after ChildhOod caNcer (BEACON). BMJ open. 2020;10(12):e041073. doi: 10.1136/bmjopen-2020-041073 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Bamidele OO H EM, Lagan BM, Chinegwundoh F, Ali N, McCaughan E. "Hard to reach, but not out of reach": Barriers and facilitators to recruiting Black African and Black Caribbean men with prostate cancer and their partners into qualitative research. Eur J Cancer Care (Engl). 2019;28(2):e12977. doi: 10.1111/ecc.12977 [DOI] [PubMed] [Google Scholar]
  • 53.McGowan LJ, Powell R, French DP. How can use of the Theoretical Domains Framework be optimized in qualitative research? A rapid systematic review. Br J Health Psychol. 2020;25(3):677–94. doi: 10.1111/bjhp.12437 [DOI] [PubMed] [Google Scholar]
  • 54.Braun V, Clarke V. Successful qualitative research: a practical guide for beginners. London: SAGE; 2013. [Google Scholar]
  • 55.Braun V, Clarke V. To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales. Qualitative Research in Sport, Exercise and Health. 2019:1–16. [Google Scholar]
  • 56.Francis JJ, Johnston M, Robertson C, Glidewell L, Entwistle V, Eccles MP, et al. What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol Health. 2010;25(10):1229–45. doi: 10.1080/08870440903194015 [DOI] [PubMed] [Google Scholar]
  • 57.Dworkin SL. Sample Size Policy for Qualitative Studies Using In-Depth Interviews. Arch Sex Behav. 2012;41(6):1319–20. doi: 10.1007/s10508-012-0016-6 [DOI] [PubMed] [Google Scholar]
  • 58.O’Brien N, Heaven B, Teal G, Evans EH, Cleland C, Moffatt S, et al. Integrating Evidence From Systematic Reviews, Qualitative Research, and Expert Knowledge Using Co-Design Techniques to Develop a Web-Based Intervention for People in the Retirement Transition. J Med Internet Res. 2016;18(8):e210. doi: 10.2196/jmir.5790 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 59.National Institute for Health and Care Research. Payment guidance for researchers and professionals 2022. Available from: https://www.nihr.ac.uk/documents/payment-guidance-for-researchers-and-professionals/27392. [Google Scholar]
  • 60.Staniszewska S, Brett J, Simera I, Seers K, Mockford C, Goodlad S, et al. GRIPP2 reporting checklists: tools to improve reporting of patient and public involvement in research. BMJ. 2017;358:j3453. doi: 10.1136/bmj.j3453 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.Foster DW, Allan NP, Schmidt NB, Zvolensky MJ. Cannabis Motives and Quitting Tobacco: Smoking Expectancies and Severity among Treatment-seeking Cigarette Smokers. Addict Disord Their Treat. 2015;14(3):139–51. doi: 10.1097/ADT.0000000000000065 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 62.Action on Smoking and Health. Use of e-cigarettes among young people in Great Britain. 2020. Available from: https://ash.org.uk/wpcontent/uploads/2021/02/YouthEcig2020.pdf. [Google Scholar]
  • 63.Action on Smoking and Health. Young people and smoking 2019. Available from: https://ash.org.uk/wp-content/uploads/2019/09/190913-ASH-Factsheet_Youth-Smoking.pdf. [Google Scholar]
  • 64.Lemyre A, Poliakova N, Bélanger RE. The Relationship Between Tobacco and Cannabis Use: A Review. Subst Use Misuse. 2019;54(1):130–45. doi: 10.1080/10826084.2018.1512623 [DOI] [PubMed] [Google Scholar]
  • 65.Office for National Statistics. Drug misuse in England and Wales: year ending June 2022. 2022 [Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/drugmisuseinenglandandwales/yearendingjune2022#:~:text=Cannabis%3A%20Since%20estimates%20began%20in,level%20to%20the%20year%20ending. [Google Scholar]
  • 66.Ogunwale MA, Li M, Ramakrishnam Raju MV, Chen Y, Nantz MH, Conklin DJ, et al. Aldehyde Detection in Electronic Cigarette Aerosols. ACS Omega. 2017;2(3):1207–14. doi: 10.1021/acsomega.6b00489 [DOI] [PMC free article] [PubMed] [Google Scholar]

Decision Letter 0

Jesse T Kaye

13 Dec 2023

PONE-D-23-33074Protocol for the Supporting Young Cancer Survivors who Smoke Study (PRISM): Informing the development of a smoking cessation intervention for childhood, adolescent and young adult cancer survivorsPLOS ONE

Dear Dr. Brown,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

This manuscript addresses an incredibly important area for clinical care and public health. Please see my specific comments below in the section "Additional Editor Comments".==============================

Please submit your revised manuscript by Jan 26 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Jesse T. Kaye, PhD

Academic Editor

PLOS ONE

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Additional Editor Comments:

I thank Dr. Brown and colleagues for this report of a protocol for a multi-phased study of that aims to inform smoking cessation interventions for survivors of cancer during young adulthood and earlier. This represents an incredibly important topic as much is still unknown regarding the best approaches to engage this population in tobacco treatment and the most effective intervention components. The evidence is clear regarding the detrimental health effects of smoking after a cancer diagnosis and treatment. However, we still don't know the best way to treat smoking in this population - and survivors of cancer tend to be under-treated due to a variety of individual, clinician, and system level factors. It is not clear if treatment tailoring is required or beneficial for this population, though it warrants research into the key stakeholders beliefs in this area. I applaud the patient-centered approach to this protocol design. The two reviewers provide thoughtful comments that I encourage the authors to consider in their revision. Of course, all comments may not be addressable given that this study is already partially underway; but those aspects that can be addressed I would encourage thoughtful integration.

Reviewer 2 provides very comprehensive suggestions that I believe will improve both the manuscript and the execution of the overall project. As PLOS One has an international readership, highlighting some of the unique features of the UK healthcare system and tobacco control approach (including re e-cigarettes) is appropriate. The reviewer also highlights a number of valuable resources from the US (e.g., Surgeon General Report, NCI Monograph 23) that would likely have many relevant studies that are relevant to the UK tobacco treatment landscape as well. In addition to these resources, I would point the authors to one other website resource from the Cancer Center Cessation Initiative (C3I) in the US, supported by the National Cancer Institute (https://www.oncologytobaccotreatment.org/). This C3I Roadmap provides a plethora of resources to help cancer treatment centers to incorporate tobacco assessment and treatment into standard of care for patients with and survivors of cancer. The website is a work in progress that will be developed over the next year. I do not point out this resource to necessarily be cited or referenced in this PLOS One manuscript, but thought it may be a useful resource in the future as the PRISM study progresses.

Lastly, I would encourage to the authors to include the semi-structured interview guides as a supplement to the resubmission if they are prepared and ready to disseminate. I realize that they may very likely be adapted based on the information gleaned from early interviews, but would still be a valuable resource for readers to be available.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Overall: A valuable and ambitious protocol.

Introduction: Well-written and compelling.

--Lines 57-64 should be re-written as I cannot understand the point being made in lines 58-62. I think the point is that this is a 'unique' population with unique barriers (stress) and facilitators (list one?) to healthy behavior that exist due to their cancer history. The first and last sentence are stating the same thing, would make the first sentence even more general and keep last sentence specific.

--Line 67: instead of "many" of those who vape. Could you list the percentage from the reference?

Materials and Methods: Well organized and thoughtful, comprehensive approach.

--line 85: Centred spelled incorrectly.

--Line 89 (Objective 1): you mention searching for interventions for young people with a "medical diagnosis (cancer or another diagnosis)" but then in the environmental scan (line 125), mention limiting the intervention search to those "with CAYACS". I think either option; limiting to CAYACS or keeping it broad "cancer or another diagnosis" is reasonable though the latter will certainly lead to a larger field of results. Would try to clarify objectives with search descriptions to make this consistent (you make this argument more clearly in lines 172-178).

Table 1: Personal preference but would take out the row bars between the criteria.

-Qualitative approach appears methodologically solid.

-Workshops in person appear unlikely so appreciate the backup option

Reviewer #2: This is an extremely well written and thoughtful protocol which addresses an important topic. The authors’ plan to engage survivors of childhood, adolescent, and young adult cancer themselves, as well as clinicians who may be involved in delivering cessation treatment to this population is a significant strength. Below are suggestions that the authors may find helpful to improve an already excellent manuscript.

General Comments:

I understand the rationale (saving space) for using the abbreviation CAYACS but note that it is not a standard abbreviation and may confuse some readers.

The proposed age range for study and intervention is quite broad (16-29 years). Will different populations within this broad age range need somewhat different approaches? Also, given that this age group encompasses the time period when people are most likely to initiate smoking, prevention of initiation and progress to established smoking should also be an important component of ensuring this population does use tobacco products. Although not the focus of this study, suggest noting that addressing tobacco use, through both prevention of onset and cessation after onset, in the population of childhood, adolescent and young adult cancer survivors is an area in need of additional research.

Research on cessation treatments for childhood, adolescent and young adult smokers should be put in the larger context of research studies on the general population of smokers. For example, I would suggest noting that while there are effective treatments to promote cessation among adult smokers (age 21 +) there is a limited evidence base to assist people younger than age 21 to quit. In 2020, the U.S. Preventive Services Task Force published a report which identified the need for additional studies “to identify effective interventions to help children and adolescents who use tobacco products to quit.” The report also provided specific suggestions for research studies. See: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-and-nicotine-use-prevention-in-children-and-adolescents-primary-care-interventions#bootstrap-panel--9

The age range of 16-29 years includes the reproductive age for women. This topic is especially complex for survivors of childhood, adolescent and young adult cancer, but nonetheless may be a useful focus for discussion in the focus groups of patients and clinicians.

The title may want to make clear that the focus of the study is England. Related to this, the authors may consider ways to make the study generalizable to survivors of childhood, adolescent and young adult cancers living in other countries.

It is helpful to more clearly distinguish between studies, recommendations and guidelines that have been produced for England/U.K. and those produced for other countries. This is particularly important where studies address topics that are strongly influenced by policies and healthcare systems that differ across countries.

The study’s focus is on addressing cessation at the individual/clinical level is useful and appropriate, especially because this population typically has more contact with the health care system than same age peers. However, it is worth noting that population-level interventions (e.g., significant increases in tobacco taxes, smoke-free air laws, anti-tobacco counter marketing) have been shown to promote smoking cessation among the general population of smokers and are also likely to promote cessation in this specific population as well. See for example chapter 7 (Clinical-, System-, and Population-Level Strategies that Promote Smoking Cessation) of the 2020 U.S. Surgeon General’s Report, Smoking Cessation. Available here: https://www.cdc.gov/tobacco/sgr/2020-smoking-cessation/index.html

I would also draw the authors’ attention to this publication: NCI Tobacco Control Monograph 23, Treating Smoking in Cancer Patients: An Essential Component of Cancer Care. Smoking Cessation among childhood, adolescent and young adult cancer survivors is addressed on pages 92-95. Available here: https://cancercontrol.cancer.gov/brp/tcrb/monographs/monograph-23

As I’m sure the authors are aware, smoking cessation typically requires numerous attempts to quit, and tobacco dependence is often viewed as a “chronic condition” until complete and long-term cessation can be achieved. This emphasizes the need for continued vigilance when working with tobacco users, including those who are survivors of childhood, adolescent, and young adult cancers.

Specific Comments:

Lines 38-40 do not define the comparison/reference group. Suggest do so consistently.

Lines 44-46. Suggest explaining that while self-report is considered reliable in the general population, this is not true in cancer survivors and other populations (e.g., pregnant women) who feel significant stigma if they acknowledge tobacco use.

Line 65-70. Given the high prevalence of use of e-cigarettes (and dual use of e-cigarettes and conventional cigarettes) in this age group, exploring use of and views on e-cigarette use is important to consider.

Lines 78-80. As regards development of smoking cessation interventions targeted to this population, I would encourage the authors to consider both the content of the intervention and the proposed mode of delivery (e.g., in person during clinical visits, telephone quitlines, digital health modalities.)

Lines 108. Suggest providing the number of survivors who will be included in semi-structured interviews.

Line 123. As regards the scope of the literature search, suggest the authors consider where it makes sense to restrict to England/UK, and where it is reasonable to expand to other countries. While health care policy and delivery is typically country specific, the experience helping survivors to quit may well be relevant across countries.

Line 207. In addition to variables related to age, gender, diagnosis, and treatment, if efforts will be made to recruit a diverse sample of survivors (e.g., based on socio-economic status, race/ethnicity or other variables) suggest note this.

Line 243. I would suggest that the stakeholder interviews examine the survivors’ exposure to secondhand tobacco smoke, at work and in the home. (I am aware that smoking is banned in most workplaces in the UK, but exposure may still occur in these areas.) Exposure to secondhand smoke impedes quitting; conversely, workplace and home smoking bans facilitate quitting. As noted in this U.S. report: https://cancercontrol.cancer.gov/sites/default/files/2020-06/tus-cps_2014-15_summarydocument.pdf, “Smoking status is a strong predictor of whether a home smoking ban is reported, with current smokers far less likely to report a ban than former/never smokers.”

Line 328: Use of e-cigarettes has potential implications for smoking cessation efforts. However, it may also be worth noting that not enough is known about the short- and long-term health effects of e-cigarette use, specifically in the high-risk population of cancer survivors. As noted on line 338, e-cigarettes are recommended as a smoking cessation aid in the U.K.; the authors study may wish to consider whether this recommendation is appropriate for childhood, adolescent and young adult cancer survivors.

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PLoS One. 2024 May 15;19(5):e0299321. doi: 10.1371/journal.pone.0299321.r002

Author response to Decision Letter 0

6 Feb 2024

We thank the Editor and the reviewers for such positive and constructive comments. We hope we have addressed these satisfactorily and are particularly appreciative of the documents which have been suggested to us.

Below we have addressed each comment. Where relevant we have indicated where the edit can be found in the clean manuscript.

Additional Editor Comments:

As PLOS One has an international readership, highlighting some of the unique features of the UK healthcare system and tobacco control approach (including re e-cigarettes) is appropriate.

- Thank you. In response to this comment, and others from the reviewers, we have now added extra information regarding the situation in the UK and how this may differ from other public health approaches in other countries. This includes stating “e-cigarettes are tightly regulated and recommended as a smoking cessation aid for those aged 18 and above” (Discussion, line 368).

- Also “Contrary to the public health recommendations of other countries (e.g., Australia, the US), vaping is promoted as a much safer alternative to smoking in the UK.” (Discussion, line 373).

I would encourage to the authors to include the semi-structured interview guides as a supplement to the resubmission if they are prepared and ready to disseminate.

- Yes, we are happy to provide this and it has been uploaded.

Reviewers' comments to the Author:

Reviewer #1:

Lines 57-64 should be re-written as I cannot understand the point being made in lines 58-62. I think the point is that this is a 'unique' population with unique barriers (stress) and facilitators (list one?) to healthy behavior that exist due to their cancer history. The first and last sentence are stating the same thing, would make the first sentence even more general and keep last sentence specific.

- This paragraph has been edited and we hope it is clearer now (Introduction; line 72-80): There is limited empirical research on the views and attitudes of CAYA cancer survivors regarding smoking [23, 26]. Although cancer diagnosis, treatment and survivorship are often thought to offer ‘teachable moments’ for a lifestyle change such as quitting smoking [27], evidence suggests that survivors of adult cancers experience barriers to smoking cessation that are specific to their illness experience (e.g., smoking to help with cancer-related stress and to maintain personal control after their diagnosis [25, 27]), and which may affect the uptake, and effectiveness, of current smoking cessation services and support [28]. Whether this also holds in survivors of CAYA cancer is unclear and fundamental evidence is lacking on why CAYA cancer survivors’ smoke, what affects whether they want to quit and what helps and hinders successful quitting.

Line 67: instead of "many" of those who vape. Could you list the percentage from the reference?

- The sentence has been amended to (Introduction; line 82-84): In England, around a quarter of young people aged 16-24 use e-cigarettes, whilst 14-20% smoke [25, 26]; evidence suggests that around half of those who vape, also smoke tobacco (i.e., are dual users) [25].

Line 85: Centred spelled incorrectly.

- We have used the UK English spelling for centred (and also other words throughout the manuscript, such as behaviour, organisation). However, if the Editor requires US spellings we are happy to change throughout.

Line 89 (Objective 1): you mention searching for interventions for young people with a "medical diagnosis (cancer or another diagnosis)" but then in the environmental scan (line 125), mention limiting the intervention search to those "with CAYACS". I think either option; limiting to CAYACS or keeping it broad "cancer or another diagnosis" is reasonable though the latter will certainly lead to a larger field of results. Would try to clarify objectives with search descriptions to make this consistent (you make this argument more clearly in lines 172-178).

- Thank you for highlighting this. We have amended the text to distinguish between a) our search for smoking interventions for CAYA cancer survivors that have been published in the international literature and b) our search for smoking cessation services in that are available in England, and may be adaptable to CAYA cancer survivors. The text for objective one now is as follows (Materials and methods; line 105-109: 1. a) To identify and describe the features of tobacco smoking cessation interventions for CAYA cancer survivors which have been published internationally; b) To identify and describe the features of tobacco smoking cessation services which currently exist for i) adolescents and/or young people with a medical diagnosis (cancer or another diagnosis) or ii) people of any age with cancer/cancer survivors in England;

Table 1: Personal preference but would take out the row bars between the criteria.

- The borders between rows have now been deleted.

Reviewer #2:

I understand the rationale (saving space) for using the abbreviation CAYACS but note that it is not a standard abbreviation and may confuse some readers.

- Yes, we entirely agree with the reviewer. This acronym was used to reduce the word count. We are more than happy to change this to childhood, adolescent and young adult (CAYA) cancer survivors and use CAYA cancer survivors or CAYA survivors throughout the rest of the paper.

The proposed age range for study and intervention is quite broad (16-29 years). Will different populations within this broad age range need somewhat different approaches?

- The aim of this project is to undertake formative research which will generate evidence of the factors which either help or hinder survivors attempts to quit, and which will enable us to have a better understanding of the support which may be needed by survivors. During analysis, we may be able to identify if different approaches are needed and if these appear to be associated with particular groups/characteristics (e.g., younger vs older survivors; female vs male survivors).

- The phase 3 workshops aim to discuss issues and generate ideas concerning smoking cessation interventions for CAYA survivors, such as: is a there a need to develop a smoking cessation intervention for this patient group? How acceptable or feasible would a smoking cessation intervention be in this patient group? What does the intervention need to target in order to help survivors to increase their chances of successfully quitting? Therefore, we expect issues such as the one raised above, to be discussed at this point.

- This project does not aim develop an intervention, but to explore the need for one, and begin to generate which will be used to inform future development efforts.

- We have slightly edited our aim to make it clearer that this intervention will be designed so that it can be tailored to the needs of CAYA survivors: PRISM aims to inform the future development of a person-centred, evidence-based and theoretically-informed tobacco smoking cessation intervention which can be tailored, as required, to the needs of CAYA cancer survivors.

Also, given that this age group encompasses the time period when people are most likely to initiate smoking, prevention of initiation and progress to established smoking should also be an important component of ensuring this population does use tobacco products. Although not the focus of this study, suggest noting that addressing tobacco use, through both prevention of onset and cessation after onset, in the population of childhood, adolescent and young adult cancer survivors is an area in need of additional research.

Yes we agree that prevention of smoking in CAYA survivors is also an area of importance. We have added the following sentence in the discussion (Discussion; line 380-385): Adolescence is a critical period for smoking initiation, therefore, addressing tobacco use in this patient group will likely benefit from efforts to both prevent uptake in survivors and also support smoking cessation for those who already smoke. By speaking to survivors who smoke and vape we hope to be able to explore their views on the initiation of these behaviours (e.g., when and why they started), by doing so, this may provide information useful to the consideration of smoking prevention in this group.

Research on cessation treatments for childhood, adolescent and young adult smokers should be put in the larger context of research studies on the general population of smokers. For example, I would suggest noting that while there are effective treatments to promote cessation among adult smokers (age 21 +) there is a limited evidence base to assist people younger than age 21 to quit.

- Thank you for highlighting the U.S. Preventive Services Task Force document to us. To address the above point we have added the following to the introduction (Introduction; line 69-71)): However, it also needs to be highlighted that although there is much evidence to support effective strategies for smoking cessation in adults, and the provision of smoking cessation services, there is still limited evidence for how to effectively help young people in general to quit smoking.

The age range of 16-29 years includes the reproductive age for women. This topic is especially complex for survivors of childhood, adolescent and young adult cancer, but nonetheless may be a useful focus for discussion in the focus groups of patients and clinicians.

- Thank you for this suggestion. We expect that this issue may be raised in the interviews with young women who smoke. However, we agree this is something we should also take forward to the discussion groups in Phase 2.

The title may want to make clear that the focus of the study is England. Related to this, the authors may consider ways to make the study generalizable to survivors of childhood, adolescent and young adult cancers living in other countries.

- Yes, we agree it would be useful to make it clear to readers that we are focusing on England and have added this to the title, as suggested.

- By recruiting a diverse range of survivors (e.g., in terms of clinical and socio-demographic characteristics) for the Phase 2 interviews this will benefit the study by enabling us to access a wide range of views and experiences and a comprehensive understanding of smoking in CAYA cancer survivors.

- These findings may indeed be considered transferrable and applicable to other CAYA survivors (with similar characteristics as those included in our study). Our findings will provide useful insights into the views and experiences of not just the survivors we interview, but of those in the UK and beyond. By presenting the findings of the Phase 2 interviews to survivors in the Phase 3 workshops, we will be able to see how well they relate to the views and experiences reported by other survivors.

It is helpful to more clearly distinguish between studies, recommendations and guidelines that have been produced for England/U.K. and those produced for other countries. This is particularly important where studies address topics that are strongly influenced by policies and healthcare systems that differ across countries.

- We now state that the referenced clinical practice guidelines for survivors are for the UK, US and also international guidelines (Introduction; line 58): Clinical practice guidelines for the follow-up care of CAYA cancer survivors from the UK and US, as well as recent harmonized international guidelines, state that survivors should be advised on both tobacco smoking and smoking cessation.

- Throughout the introduction we have tried to make it clearer what countries the studies concerning health risks in survivors and also smoking rates in survivors have originated from.

- In the discussion we have highlighted that public health recommendations concerning vaping differ between countries (Discussion; line 373: Contrary to the public health recommendations of other countries (e.g., Australia, US), vaping is promoted as a much safer alternative to smoking in the UK.

The study’s focus is on addressing cessation at the individual/clinical level is useful and appropriate, especially because this population typically has more contact with the health care system than same age peers. However, it is worth noting that population-level interventions (e.g., significant increases in tobacco taxes, smoke-free air laws, anti-tobacco counter marketing) have been shown to promote smoking cessation among the general population of smokers and are also likely to promote cessation in this specific population as well.

- We agree that population-level interventions are also important for smoking cessation and there are many factors in a person’s wider environment which influences their choice to smoke and their ability to quit. We hope to explore the survivors’ views on these initiatives in the interviews for both smoking and vaping, for instance whether cost influences their smoking/vaping behaviours/desire to quit, where they smoke as smoking is banned in public places and workplaces, and the impact of the wide availability of disposable vapes in the UK.

- Thank you very much for drawing our attention to this document.

I would also draw the authors’ attention to this publication: NCI Tobacco Control Monograph 23, Treating Smoking in Cancer Patients: An Essential Component of Cancer Care. Smoking Cessation among childhood, adolescent and young adult cancer survivors is addressed on pages 92-95. Available here: https://cancercontrol.cancer.gov/brp/tcrb/monographs/monograph-23

- Thank you for drawing our attention to this document too. We were not aware of it, and it looks incredibly useful.

As I’m sure the authors are aware, smoking cessation typically requires numerous attempts to quit, and tobacco dependence is often viewed as a “chronic condition” until complete and long-term cessation can be achieved. This emphasizes the need for continued vigilance when working with tobacco users, including those who are survivors of childhood, adolescent, and young adult cancers.

- Thank you for highlighting this issue. This issue may be raised by the survivors we interview as we will be asking them about any attempts to quit which will hopefully enable them to share if they have had previously failed attempts and their experiences around this. This is also an issue which we should certainly take into account if developing any smoking cessation intervention.

Lines 38-40 do not define the comparison/reference group. Suggest do so consistently.

- This text (Introduction; line 43-52) has now been amended to make it clearer what the comparison group was for each study.

Lines 44-46. Suggest explaining that while self-report is considered reliable in the general population, this is not true in cancer survivors and other populations (e.g., pregnant women) who feel significant stigma if they acknowledge tobacco use.

- We have now expanded on this point (Introduction; line 54-57): However, it is worth nothing that these may be underestimates as in clinical groups, where smoking is especially stigmatized (e.g., pregnant women, patients with cardiac disease, cancer patients), patients may be particularly reticent about disclosing their tobacco use.

Lines 78-80. As regards development of smoking cessation interventions targeted to this population, I would encourage the authors to consider both the content of the intervention and the proposed mode of delivery (e.g., in person during clinical visits, telephone quitlines, digital health modalities.)

- Thank you for this comment. In our Phase 3 workshops we hope to touch upon some of the above (e.g., how/where would any intervention be delivered). After this project, should we proceed with developing an intervention for survivors, we will carry out in-depth research and co-design with survivors and stakeholders (including smoking cessation experts) to inform the decisions regarding content and mode. We have edited the text concerning the survivor workshop to make it more clear what issues we expect to discuss and explore (Phase 3; line 323-327): The survivor workshop will explore issues around the acceptability of any intervention to support smoking cessation (e.g., perceived need for an intervention, potential stigma of using intervention), factors which may encourage or prevent CAYA survivors engaging in an intervention (e.g., referral by HCP, low readiness to quit), and initial views on intervention delivery (e.g. where, how and by whom).

Lines 108. Suggest providing the number of survivors who will be included in semi-structured interviews.

- This information has now been added on line 128.

Line 123. As regards the scope of the literature search, suggest the authors consider where it makes sense to restrict to England/UK, and where it is reasonable to expand to other countries. While health care policy and delivery is typically country specific, the experience helping survivors to quit may well be relevant across countries.

- We thank you for drawing our attention to this. We realise that we have not been clear on the limits for our searches. First, we will be carrying out a search of published literature of smoking cessation interventions for CAYA cancer survivors in which we will not be limited in terms of geographical location. The aim of this search is to identify and describe these interventions in the literature.

- Where we are searching for services specific to England is through the grey literature searches (e.g., Google searches, searching websites) to identify any currently available services for 1) adolescents and/or young people with a medical diagnosis (cancer or another diagnosis) or 2) people of any age with cancer/cancer survivors. The aim of this search is to identify any existing services in England that may be adaptable to the needs of CAYA cancer survivors.

- In response to your comment, and a comment from reviewer 1 we have amended the text for objective one (line 105) to read: a) To identify and describe the features of tobacco smoking cessation interventions for CAYA cancer survivors which have been published internationally; b) To identify and describe the features of tobacco smoking cessation services which currently exist for i) adolescents and/or young people with a medical diagnosis (cancer or another diagnosis) or ii) people of any age with cancer/cancer survivors in England.

- The text under ‘Overall study design’ (line 126-128) has also been amended to reflect the above and make it the distinction between the two searches.

- Likewise the abstract has been amended to reflect this (line 10-13): PRISM involves three phases of: 1) an environmental scan using multiple strategies to identify and examine a) smoking cessation interventions for CAYA cancer survivors that are published in the international literature and b) current smoking cessation services in England that may be available to, or tailorable to, CAYA cancer survivors.

Line 207. In addition to variables related to age, gender, diagnosis, and treatment, if efforts will be made to recruit a diverse sample of survivors (e.g., based on socio-economic status, race/ethnicity or other variables) suggest note this.

- Yes, we aim to recruit a diverse sample in terms of ethnicity and socio-economic status, and the other variables we mention as much as we can. We realise we failed to include ethnicity and socio-economic status and have amended this.

Line 243. I would suggest that the stakeholder interviews examine the survivors’ exposure to second-hand tobacco smoke, at work and in the home. (I am aware that smoking is banned in most workplaces in the UK, but exposure may still occur in these areas.) Exposure to secondhand smoke impedes quitting; conversely, workplace and home smoking bans facilitate quitting.

- Thank you for the above information – this is really helpful. In the semi-structured interview guide (now included) we have questions which ask about the influence of the people around them (e.g., friends and family) and the environments that they spend their time in.

Line 328: Use of e-cigarettes has potential implications for smoking cessation efforts. However, it may also be worth noting that not enough is known about the short- and long-term health effects of e-cigarette use, specifically in the high-risk population of cancer survivors. As noted on line 338, e-cigarettes are recommended as a smoking cessation aid in the U.K.; the authors study may wish to consider whether this recommendation is appropriate for childhood, adolescent and young adult cancer survivors.

- We had added that e-cigarettes are only recommended for adult smokers (Discussion; line 360-370): In the UK, e-cigarettes are tightly regulated and recommended as a smoking cessation aid for those aged 18 and above…

- We have also added text to highlight the debate about the safety of vaping (Discussion; line 374-378): Contrary to the public health recommendations of other countries (e.g., Australia, the US), vaping is promoted as a much safer alternative to smoking in the UK. However, little is known about the possible long-term health risks of vaping, and emerging evidence suggests links to increased risk of respiratory and cardiovascular diseases [66], which should be of particular concern to CAYA survivors.

Attachment

Submitted filename: PRISM_Response to reviewers_25Jan24.docx

pone.0299321.s002.docx (33.8KB, docx)

Decision Letter 1

Jesse T Kaye

9 Feb 2024

Protocol for the Supporting Young Cancer Survivors who Smoke Study (PRISM): Informing the development of a smoking cessation intervention for childhood, adolescent and young adult cancer survivors in England

PONE-D-23-33074R1

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Reviewers' comments:

Acceptance letter

Jesse T Kaye

22 Feb 2024

PONE-D-23-33074R1

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