Training oncology care providers in the assessment and treatment of tobacco use and dependence

Abstract

Background.

Clinical practice guidelines for promoting smoking cessation in cancer care exist; however, most oncology settings have not established tobacco use assessment and treatment as standard care. Inadequate staff training and other implementation challenges have been identified as barriers for delivery of evidence-based tobacco treatment. Providing training in tobacco treatment tailored to the unique needs of tobacco-dependent cancer patients is one strategy to improve adoption of best practices to promote smoking cessation in cancer care.

Methods.

We developed and implemented a tobacco treatment training program for oncology care providers (Tobacco Treatment Training-Oncology; TTT-O), consisting of a two-day didactic and experiential workshop followed by six, monthly, collaboratory videoconference calls supporting participants in their efforts to implement NCCN guidelines in their oncology settings. This paper presents preliminary results on program evaluation, changes in participants’ self-efficacy, and progress in implementing tobacco treatment.

Results.

Data have been obtained from the first five cohorts of TTT-O participants (n=110) who completed training, course evaluations, baseline and follow-up surveys. Participants rated the training as highly favorable and reported significant gains in self-efficacy in their ability to assess and treat tobacco dependence. Participants also demonstrated significant improvements in tobacco treatment skills and implementation of several indicators of improved adoption of best practices for tobacco treatment in their cancer care settings.

Conclusion.

Implementation of tobacco treatment training for cancer care providers is feasible, acceptable and can have a significant positive impact on participants’ tobacco treatment skills, self-efficacy, and greater adoption of tobacco treatment delivery in cancer care.

Precis:

Inadequate training is widely acknowledged as key barrier for implementation of tobacco use assessment and treatment in cancer care. These program evaluation findings demonstrate that tobacco treatment training for cancer care providers is feasible, acceptable and can improve tobacco treatment skills, self-efficacy, and greater adoption of tobacco treatment delivery in cancer care.

Background

Approximately 10–30% of cancer patients report current smoking at diagnosis and approximately 70% of patients who report current smoking at the time of diagnosis will continue smoking after diagnosis.^1,2 According to the Surgeon General’s Report on the Health Consequences of Smoking (2014),^3,4 persistent smoking among cancer patients is associated with increased risk of cancer-specific and all-cause mortality, likelihood for second primary cancer, risk for disease recurrence, and poor response to treatment, treatment-related toxicity and quality of life. Evidence demonstrating that persistent smoking is a modifiable risk factor for adverse cancer-related outcomes has led oncology professional organizations such as the American Society of Clinical Oncology, American Association of Cancer Research, Oncology Nursing Society and the Commission on Cancer to strongly endorse tobacco use assessment and treatment as indicators of high-quality cancer care. Similarly, the National Comprehensive Cancer Network (NCCN)⁵ has developed evidence-based, clinical guidelines for tobacco use assessment and cessation treatment delivery within cancer care.

Unfortunately, patient, provider and systems-level barriers for tobacco use assessment and treatment (TUT) implementation exist and adoption of TUT into real world practice settings has been slow.^6–8 Whereas oncology providers agree that assessing smoking status and advising cessation is important,⁶ only 30% of survey respondents report routinely assisting patients with making a quit attempt.⁹ Lack of adequate training is widely acknowledged as the key barrier.^10–12

In order to overcome this significant evidence-to-practice gap, a highly interactive TUT skills workshop and follow-up collaborative learning initiative (Tobacco Treatment Training-Oncology; TTT-O) was developed to train multidisciplinary cancer care clinicians and tobacco treatment specialists to implement TUT among tobacco-dependent cancer patients. The ongoing TTT-O program consists of a 2-day, in-person workshop (Workshop) followed by six monthly videoconferences (Collaboratory) co-facilitated by training faculty with relevant TUT delivery expertise in cancer. A collaboratory is an organizational entity typically without walls that supports shared interaction and accelerates diffusion of innovation around a common goal¹³, in this case, tobacco treatment delivery in cancer care. This paper provides a description of the TTT-O Workshop and Collaboratory and presents preliminary evaluation data on participants’ TUT attitudes, self-efficacy, skills and progress in TUT implementation collected from the initial five training cohorts.

Methods

The TTT-O Workshop and Collaboratory is funded by the National Cancer Institute (R25CA217693) and led by clinicians at Memorial Sloan Kettering Cancer Center (MSKCC) with expertise in treating tobacco dependence in oncology settings. The Institutional Review Board determined this training and evaluation exempt from human subjects’ research oversight (45 CFR, Part 46.101, Category [b][1]).

Development of the TTT-O Curriculum

Multidisciplinary clinician-educators with relevant expertise in oncology-specific tobacco treatment developed the TTT-O content and format. Program faculty developed a comprehensive outline of learning objectives, foundational knowledge and clinical competencies necessary to prepare front-line oncology clinicians and tobacco treatment specialists to assess and treat tobacco dependence in cancer care settings. The learning objectives and accompanying slide presentations for the TTT-O Workshop were guided by the PHS Guidelines for Treating Tobacco Use and Dependence¹⁴ and the NCCN Guidelines for Smoking Cessation.⁵ An External Advisory Committee comprised of clinician-educators with expertise in tobacco treatment, psychosocial oncology, oncology nursing and implementation science reviewed the course outline and provided constructive feedback. Prior to launching each new cohort, the TTT-O faculty conduct an interim literature review for new publication of relevant articles and clinical practice guidelines. The content of the Collaboratory videoconferences was guided by TTT-O participants’ endorsement of common challenges encountered in implementing tobacco treatment in oncology settings.

Recruitment and Eligibility of TTT-O Participants

Potential TTT-O participants were recruited via email and listserv outreach to relevant professional organizations such as the Society for Research on Nicotine and Tobacco (SRNT), Association for the Treatment of Tobacco Use and Dependence (ATTUD) and Oncology Nursing Society (ONS). Course brochures were also sent to NCI-Designated Cancer Centers participating in the Cancer Centers Cessation Initiative (C3I),⁶ and posted on LinkedIn. Additional marketing and outreach were also facilitated by MSKCC’s Immigrant Health and Cancer Disparities Service and the Office of Diversity and Inclusion to increase the diversity of training participants working in cancer care settings serving low income and other vulnerable cancer patients.

To be eligible for the TTT-O, participants must be clinicians who dedicate at least 40% of their work each week to providing clinical care. Multidisciplinary members of the oncology care team including physicians, oncology nurses, nurse practitioners, psychologists, social workers, physician assistants, navigators, and respiratory therapists were encouraged to participate. Tobacco treatment specialists (TTS) were also eligible if they expressed strong interest in expanding their practice to work with cancer patients. All TTT-O applicants were required to submit an online application describing their work roles, professional backgrounds, prior training and training goals. Finally, a letter of support was required from a clinical oncology leader/supervisor at their work setting attesting to their endorsement of full participation in all TTT-O Workshop and Collaboratory activities. Program faculty reviewed each eligible applicant and accepted participants based on consensus agreement of likelihood to apply the training towards delivery and implementation of TUT at their home institutions.

Participants received 14 continuing education (CE) credits at the completion of the 2-day training workshop (with up to 6 additional CE credits corresponding to attendance at the monthly Collaboratory videoconferences). Hotel lodging, up to $500 for travel, and meals were also provided. No financial incentives were provided for completion of the baseline and follow-up surveys or attendance at the Collaboratory conference calls.

Workshop Schedule

Beginning in December, 2017, TTT-O Workshops (Supplemental Figure 1) were held in New York City. Over the course of the 2-day training, participants attended didactic presentations, participated in three simulated role play exercises and were engaged in an interactive think tank session focused on contextual appraisal and goal setting for improving implementation of TUT at their home institutions. Small group exercises were used for experiential simulated role play sessions including standardized patients (SPs, i.e., trained actors) using cancer-specific, clinical vignettes focused on empathic assessment of tobacco use and treatment history, giving personalized quitting advice, behavioral and motivational interventions, promoting shared decision-making and use of cessation pharmacotherapy. Day 1 included faculty presentations, a cancer patient panel of former smokers and role play exercises. The morning of Day 2 included a small group exercise, followed by a wrap-up discussion about participants’ reactions to the small group exercise. The Day 2 afternoon session included a didactic presentation focusing on the challenges of implementing TUT in cancer care settings followed by guided, small group exercise in formulating SMART (i.e., Specific, Measurable, Achievable, Relevant, Time Frame) goals for implementing TUT in their settings. As a requirement of the grant, participants also received an overview presentation on the Responsible Conduct of Research (RCR).

Collaboratory Videoconferences

In order to facilitate and provide ongoing support for participants’ efforts to address barriers to integrating TUT in oncology care, six, monthly, 60-minute TTT-O Collaboratory videoconferences were incorporated into the TTT-O curriculum. The Collaboratory videoconferences were scheduled beginning one month after each TTT-O Workshop concluded using the WebEx videoconferencing platform. Each Collaboratory videoconference session included a presentation delivered by one of the TTT-O program faculty, a case presentation by one of the cohort participants, and a featured article pertinent to facilitating tobacco treatment in cancer care settings. In addition, each participant shared updates on progress in achieving their TUT implementation goals. At the conclusion of the Collaboratory videoconferences, all participants completed post-training surveys evaluating the TTT-O Workshop and Collaboratory videoconference sessions and were invited to do a follow-up virtual role play exercise with an SP enabling them to demonstrate progress in developing their tobacco treatment counseling skills. Overall, participant attendance was 70% for at least 3 out of the 6 Collaboratory videoconferences.

TTT-O Training Resources

Participants received a binder with relevant clinical resources (toolkit) including the latest NCCN clinical practice guidelines, templated examples of clinical interviews and documentation, all presentation slides, an algorithm and decision support tool for selection of cessation pharmacotherapy options and relevant recent publications¹. Additional resources were shared prior to each Collaboratory videoconference.

Evaluation Plan

The evaluation of the TTT-O program was based on the Kirkpatrick model.¹⁵ Widely used to test the effectiveness of professional training activities, the Kirkpatrick model is comprised of four levels that measure participant: (1) reaction, (2) learning, (3) behavior, and (4) patient outcomes. For evaluation of the TTT-O, we focused on the first three of the Kirkpatrick levels operationalized as the participants’: (1) perceptions of the training, (2) self-reported and demonstrated learning as evidenced by participant-reported TUT self-efficacy and behavior change as well as faculty rating of clinical competencies observed during role play exercises, and (3) rating of progress in implementing TUT in their cancer care settings. Several sources of evaluation data were collected: (1) Baseline (pre-training) Survey; (2) Workshop and Collaboratory Evaluation Survey; (3) Faculty Ratings of Clinical Competencies; and (4) Follow-Up (post-training) Survey.

Baseline (pre-training) Survey.

Upon acceptance, participants completed a baseline survey assessing background characteristics including demographics, prior education and training, and employment setting. The baseline survey also assessed TUT attitudes and beliefs (4 items), perceived barriers for implementing TUT in their clinical settings (15 items), current TUT delivery practices for new and follow-up patients (14 items), and self-efficacy for TUT delivery (6 items); all measured with 5-point Likert response scales ranging from ‘very confident, quite a bit confident, moderately confident, a little bit confident and not at all confident’. There were also 11 items that assessed baseline TUT implementation activities using a 3-point scale indicating “none,” “partial,” and “full” adoption of various implementation strategies (e.g., all patients are screened for current smoking status) recommended for integration of TUT in cancer care settings.

Workshop and Collaboratory Evaluation Survey.

At the end of the 2-day TTT-O workshop, participants completed a brief workshop evaluation survey that included 17 items with Likert-type responses ranging from 1 (Not at all satisfied) to 5 (Highly satisfied) assessing their satisfaction with specific training components as well as 7 items with Likert-type responses ranging from 1 (Strongly disagree) to 5 (Strongly agree) assessing global ratings of satisfaction with the TTT-O workshop. At the completion of the six, monthly Collaboratory videoconference calls, participants completed a measure assessing usefulness of the Collaboratory calls on a 5-point response scale ranging from 1 (Not useful) to 5 (Extremely useful).

Faculty Ratings of Clinical Competencies.

During the TTT-O workshop, participants engaged in role play exercises with trained actors simulating tobacco-dependent cancer patients portraying common clinical scenarios enabling participants to receive in vivo practice and feedback on their TUT skills. TTT-O program faculty observed the three SP-participant simulated clinical encounters (role plays) and rated (ranging from Emerging, Proficient, to Mastered) each participant on their performance of six clinical competencies (i.e. tobacco use assessment, empathic listening, behavioral counseling, education about the risks of persistent smoking, education about the benefits to cessation, and shared decision-making regarding medication options).

Follow-Up (post-training) Survey.

Finally, a 6 months follow-up survey assessed current TUT attitudes, delivery practices, self-efficacy for TUT delivery, and progress made in implementing TUT in their cancer care settings. Higher score indicated greater success in TUT implementation. The majority (n=88, 80%) of participants completed the 6-month follow-up survey.

Analyses

Descriptive statistics were calculated using IBM SPSS Version 25. We then analyzed differences between pre-and post-training scores of the continuous variables using a series of paired samples t-tests and exact Wilcoxon signed rank tests in the case of non-normal data (i.e., TUT self-efficacy).

Results

Participants

Of the 185 applications received, 110 participants from 64 different clinical settings were accepted: Cohort 1 (n=16); Cohort 2 (n=25); Cohort 3 (n=23); Cohort 4 (n=24) and Cohort 5 (n=22). Of the remaining 75 who were not accepted, 32 were ineligible, 16 declined and 27 were wait-listed. Table 1 summarizes participant background characteristics. The majority of participants self-identified as non-Hispanic and white and two-thirds had at least a master’s degree. Nearly half of the participants were affiliated with a cancer center and accepted applicants represented a range of disciplines reflective of a multidisciplinary oncology care team. Overall, participants reported strong endorsement for tobacco cessation as a standard part of cancer treatment (Mean=4.91, SD=.47). At baseline, the majority (more than 50%) of respondents endorsed the following TUT implementation barriers: lack of staff training (79%); staff lack of knowledge about cessation medications (61%); lack of cessation resources (58%); staff lack of self-confidence (56%); lack of tobacco cessation champion (57%) and lack of staff time (57%). Participant attendance was 70% for at least 3 out of the 6 Collaboratory videoconferences and 88 (80%) of the participants completed the 6-month follow-up survey.

Table 1.

Participant Characteristics (n=110)

Background Characteristics	n (%)
Age, Mean [range] (n=108)	44 [23–69]
Gender
Female	99 (90%)
Male	11 (10%)
Race1
White	89 (81%)
Black	10 (9%)
Asian	8 (7%)
Other	3 (3%)
Ethnicity
Hispanic	10 (9%)
Non-Hispanic	100 (91%)
Education1
Bachelor’s degree	26 (24%)
Master’s degree	51 (47%)
Doctorate	22 (20%)
Other	10 (9%)
Professional role1
Patient Care/Clinician	78 (72%)
Other	31 (28%)
If clinician, what profession2
Tobacco Treatment Specialist (TTS)	41 (37%)
RN/NP	38 (35%)
Health Educator/Other	27 (25%)
Social Worker	11 (10%)
Physician	6 (6%)
Primary Employment Setting1
Cancer Center	45 (41%)
Hospital	33 (30%)
University Medical Center	22 (20%)
Community Oncology Practice	9 (9%)
Prior Tobacco Treatment Training1
None	68 (62%)
Certified TTS Training	36 (33%)
Other	5 (5%)

¹missing data from 1 participant

²participants allowed to choose multiple options

TTT-O Workshop/Course Evaluation

Consistent with Kirkpatrick’s first level, 107 participants provided analyzable data on the evaluation of the TTT-O workshop. The global evaluations were highly favorable as evidenced by mean ratings for all satisfaction items exceeding 4.5 (range 1–5) indicating a high degree of satisfaction with the TTT-O workshop (Table 2). Participants strongly agreed that they would recommend the TTT-O workshop to a colleague (mean=4.91; SD=0.18).

Table 2.

Workshop and Collaboratory Evaluation (n=107)

Participant Satisfactiona – Workshop Day 1	Mean (SD)
Experiential Small Group Roleplay Exercise: Behavioral Interventions	4.83 (0.32)
Experiential Small Group Roleplay Exercise: Assessing Tobacco Use and Treatment History, Readiness to Quit	4.81 (0.42)
Overview: Making the Case for Treating Tobacco Dependence in Cancer Patients	4.78 (0.57)
Evidence-Based Treatment of Tobacco Dependence II: Pharmacotherapy Interventions	4.77 (0.42)
Empathic Assessment of Tobacco Use and Treatment History, Readiness to Quit	4.77 (0.42)
Group Discussion of Skill Acquisition Experiences, Q&A	4.70 (0.52)
Evidence-Based Treatment of Tobacco Dependence I: Behavioral interventions	4.69 (0.53)
Patient Perspectives Panel	4.81 (0.42)
Participant Satisfactiona – Workshop Day 2	Mean (SD)
Experiential Small Group Roleplay Exercise: Cessation Pharmacotherapy	4.84 (0.29)
Group Discussion of Skill Acquisition Experience, Q&A	4.73 (0.55)
Implementing a TUT Program Within Your Cancer Care Setting	4.71 (0.41)
Group Discussion of Implementation Experiences	4.54 (0.62)
Group Think Tank: Managing Patient, Provider & Systems-Level Barriers	4.56 (0.64)
Participant Satisfactionb – Workshop Overall	Mean (SD)
Presenters were knowledgeable and had expertise relevant to tobacco treatment in cancer care	4.94 (0.20)
I would recommend the MSK TTT-O Program to other colleagues/coworkers	4.91 (0.18)
Throughout the training, concepts and skills were presented in a logical order	4.86 (0.45)
My cancer patients will benefit from the time I spent attending the TTT-O workshop	4.84 (0.43)
As a result of attending the TTT-O workshop, I feel more confident addressing tobacco dependence with my cancer patients	4.84 (0.43)
I am satisfied with the balance of lecture, interactive Q & A discussion, and small group activities	4.79 (0.51)
The TTT-O workshop materials were practical, informative and comprehensive	4.75 (0.49)
Collaboratory Videoconference Call c	Mean (SD)
Virtual roleplay of tobacco use assessment and treatment with simulated cancer patient	4.20 (0.93)
TTT-O Collaboratory clinical vignettes and case examples	4.01 (0.87)
TTT-O Collaboratory resources and readings	3.90 (0.92)
Educational emails sent via the TTT-O Listserv	3.66 (1.08)
Collaborative videoconference calls with implementation progress check-ins	3.58 (1.04)

Note: All course evaluation questions were scored on a 5-point Likert scale.

^a1 = not at all satisfied to 5 = highly satisfied

^b1 = strongly disagree to 5 = strongly agree

^c1 = Not at all useful to 5 = extremely useful

Faculty Ratings of Clinical Competencies

TTT-O program faculty rated participants on six clinical skills observed during the role play exercises. The following skills were observed demonstrating at least proficient (proficient and mastery combined) competencies: 77.4% empathic listening and patient engagement; 68.3% assess smoking and quitting history; 52.9% education about cancer-specific risks of persistent smoking; 51.9% motivational counseling; 41.5% behavioral counseling; and 38.7% education and shared decision making about cessation pharmacotherapy options.

Participant-Reported TUT Behavior and Self-Efficacy

Aligned with Kirkpatrick’s second level focus on participant learning (behavior change and self-efficacy), we examined pre- and post-training participant surveys. Comparison of pre- and post-training TUT summary scores showed marked post-training increases in self-efficacy and delivery of assessing and treating tobacco dependence. Specifically, mean self-efficacy scores increased nearly a full point (3.68 to 4.57, Wilcoxon signed rank p < 0.01), mean initial delivery increased nearly 1.5 points (1.71 to 3.20, p < 0.01), and mean followup delivery increased more than a half point (2.51 to 3.13, p < 0.01). Mean attitude scores did not significantly change but were near the scale maximum at baseline (pre-training mean = 4.57, SD = 0.54). Individual self-efficacy item mean scores, pre- and post-training, are presented in Table 3. Individual TUT delivery scores, for both initial encounters and followup encounters, are depicted in Figure 1.

Table 3.

Comparison of TUT Self-Efficacy, pre- and post-training (n= 88)

Item	Pre, M (SD)	Post, M (SD)	p
Assess cancer patients’ tobacco use, nicotine dependence, quitting history and readiness to quit smoking	3.87 (1.09)	4.65 (0.63)	<.01
Demonstrate empathic listening and patient engagement skills	4.36 (0.78)	4.75 (0.55)	<.01
Demonstrate effective use of motivational counseling with an unmotivated patient	3.35 (1.00)	4.37 (0.77)	<.01
Provide education about the risks of persistent smoking and the benefits of cessation	3.81 (1.04)	4.67 (0.60)	<.01
Provide evidence-based, practical behavioral counseling to a tobacco-dependent cancer patient	3.26 (1.19)	4.53 (0.73)	<.01
Provide education about cessation pharmacotherapy and foster shared decision-making about medication options	3.33 (1.19)	4.43 (0.77)	<.01

¹= Not at all confident to 5 = very confident

Figure 1.

Comparison of Pre- and Post-training TUT Delivery for Initial and Follow-up Visits (n = 88)

Pre- and Post-Training Changes in TUT Implementation in Clinical Settings

As shown in Figure 2, comparison of pre- and post-training surveys of TUT implementation revealed significant improvement. Participants reported statistically significant improvement for all 11 TUT implementation activities (all p values < 0.05). Averaging across items, pre-training TUT were rated as ranging from not at all to partially occurring (mean=0.80; SD=0.45) and post-training ratings increased from partially to fully occurring (mean=1.16; SD=0.48). Especially notable gains were seen in mean scores for implementing an automated referral system (0.43 to 0.80) and provided staff training (0.62 to 1.11).

Figure 2.

Comparison of Pre- and Post-training TUT implementation activities

Discussion

This paper describes the content and format of the first known tobacco treatment training program targeting cancer care providers working with cancer patients struggling with tobacco dependence. Findings demonstrate strong demand for professional education in tobacco treatment, acceptability of training content and format, as well as encouraging improvements in participants’ self-confidence in assessing and treating tobacco dependence among cancer patients.¹⁶ Pre- and post-training surveys revealed strong gains in adoption of TUT implementation and delivery during initial and follow-up patient visits. Nevertheless, the post-training surveys reveal persistent areas of needed improvement in TUT implementation particularly in automating the referral (opt-out) of all patients who report current smoking, prescribing cessation medication, providing cessation support and behavioral counseling and conducting quality improvement projects to improve TUT delivery reach and effectiveness. Improving implementation of assessment and treatment of all cancer patients who report current smoking will require addressing systems-level challenges encountered with electronic health record, establishing collaborative relationships with key health informatics staff and full buy-in from hospital leadership for sustained progress to be achieved.¹⁷

The translational implications of these results are seen as highly impactful for improving the standard of tobacco treatment in oncology settings. As commonly reported in other health care settings, lack of staff training was identified as the primary barrier for assessing and treating tobacco dependence in cancer care.¹⁸ These promising findings encourage broad dissemination and training of an oncology workforce better able to promote tobacco cessation in cancer care settings. Driven by the NCI Cancer Moonshot-Funded C3I,^6,19,20 there is strong and growing momentum for implementation of tobacco treatment in cancer care. This cancer education program is expected to increase oncology staff capacity needed to establish best practices for training cancer care providers to deliver and disseminate tobacco treatment to cancer patients struggling to quit smoking. With demonstrated increases in participants’ tobacco treatment delivery and systems-level changes in adoption of clinical practice guidelines, the TTT-O program shows much promise for facilitating improved implementation of TUT in cancer care settings. We suggest requiring advanced training and education of oncology care providers to assess and treat tobacco dependence among cancer patients.

There are some noteworthy limitations. First, the results are largely based on participant self-report. This must be taken into consideration when interpreting the data as providers tend to over-report the frequency with which they engage in tobacco treatment activities. Second, as prohibited by this funding mechanism, no patient outcomes (cessation) were collected. Although we were not able to directly observe quitting behaviors of patients, there is a robust literature showing that greater adoption of clinical practice guidelines for assessment and treatment of tobacco dependence by health care providers is strongly associated with patient smoking cessation outcomes²¹. Finally, we acknowledge the potential limitations of self-reported self-efficacy as an indicator of training effectiveness, particularly the potential for social desirability on self-appraisal of TUT skills. Consistent with our institutional standards for evaluation of other professional educational efforts, we have adopted multiple levels of assessment, as defined by the well-established Kirkpatrick Model of Evaluation²². We recognize the limitations of comparing faculty and trainee ratings of clinical competencies in TTT-O skills and are planning to improve the methodological rigor of evaluating TTT-O skills by assessing use of TUT skills in encounters with standardized patients portraying common clinical vignettes relevant to assessment and treatment of tobacco dependence in cancer care. Nonetheless, these encouraging findings provide a strong empirical foundation to support the importance of broad dissemination and training of oncology providers in order to facilitate implementation of tobacco treatment in cancer care settings. Future research is needed to further examine training uptake and sustainability associated with broad dissemination of TTT-O training.

In March, 2020, COVID-19 travel restrictions necessitated pivot from in-person to virtual TTT-O training. Demand for virtual TTT-O training has remained strong. Using videoconference (Zoom) software, all of the didactic seminars were conducted with minimal disruption and the chat function enabled high level interaction and real time sharing of relevant resources. Experiential role play sessions also transitioned to virtual format using the breakout feature of the videoconference platform with small group role play exercises conducted remotely with our standardized patients. Faculty and participants have informally expressed appreciation for the attention to personal safety and team-building efforts to foster cohesive training cohorts within a virtual cancer education space. Formal evaluation comparing in-person and virtual TTT-O training will be conducted in the future.

TTT-O is a 5-year training program and further analyses of a larger pool of participants will reveal new directions for improving the integration and training of oncology care providers in delivery of tobacco use assessment and treatment delivery. The utilization of SPs provided a novel, interactive experiential opportunity to practice challenging clinical scenarios and learn by observing peer behavior within the small group exercises. This integration of didactic presentations with innovative, clinically relevant role play exercises with SPs is an evidence-based model of training and heightened the training impact of the TTT-O.^23,24

In summary, the strength of the TTT-O Workshop and Collaboratory is translation of evidence-based best practices in tobacco treatment to meet the specific needs of oncology patients. This was achieved through a highly interactive training format combining didactic presentations by clinician-educators with expertise in tobacco treatment, patient panel, standardized role play exercises with simulated patients, post-workshop collaborative learning, and extensive program faculty support and coaching for sustained TUT behavior change and implementation.