Special Issue "Tobacco Use and Treatment among Cancer Survivors"

Special Issue Editors

Prof. Dr. Adam O. Goldstein
Website
Guest Editor
Department of Family Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
Interests: tobacco use; tobacco policy; tobacco treatment; tobacco-related cancers; smoking cesssation; e-cigarettes
Prof. Dr. Graham W. Warren
Website
Guest Editor
Department of Cell and Molecular Pharmacology, Medical University of South Carolina, Charleston, South Carolina, USA
Interests: tobacco use in cancer patients; cancer biology; tobacco; smoking cessation; tobacco policy; cost outcomes; process improvement; value-based care; implementation and dissemination

Special Issue Information

Dear Colleagues,

Helping patients to curb their tobacco use is an essential component of cancer care, as patients who continue to use tobacco have an increased risk of mortality, cancer recurrence, development of secondary cancers, exacerbation of comorbid conditions, worsened outcomes of cancer surgery, chemotherapy, and radiation, and negative impacts on quality of life. Despite tremendous advancements in the science of tobacco cessation, insufficient research exists to demonstrate optimal approaches and outcomes of tobacco use treatment in patients with cancer, both in primary care and in oncology settings. While a diagnosis of cancer is an optimal time to assist patients who are still using tobacco products to quit, too many patients continue to smoke, and support for quitting is inconsistently applied. Recently, the National Cancer Institute in the US began offering funding to many comprehensive cancer centers to expand or initiate tobacco use treatment programs for patients with cancer who continue to smoke or use other forms of tobacco.

Multiple reasons exist for the lack of treatment in this population, including physician factors (insufficient time or training), patient factors (lack of interest, stress, and addiction), health system factors (competing priorities or lack of leadership), and economic factors (insufficient funding or reimbursement). However, as health care systems begin to implement value-based care, the benefits of reducing tobacco consumption among cancer survivors will only grow in importance. Further, research on outcomes associated with electronic cigarettes and cancer, including any potential impact of such use on cessation, are important but lacking.

This Special Issue is designed to highlight current research on tobacco use treatment and cessation among patients across the cancer spectrum, including recent advances in assessment, counselling, pharmacotherapy, population-based approaches to treatment, second-hand smoke prevention, e-cigarette use, policy dissemination, guidelines for cancer care, impacts of co-morbid mental health on cessation outcomes, quality improvement, and improved methods of cessation. We welcome all inquiries from authors who are examining issues around tobacco use and cancer care.

Prof. Dr. Adam O. Goldstein
Prof. Dr. Graham W. Warren
Guest Editor

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Keywords

  • Smoking tobacco
  • Smoking behaviors
  • Cigarette smoking
  • Quitting smoking
  • Long-term cancer survivors
  • Secondhand smoke
  • Lung cancer
  • Tobacco cessation
  • Smokeless tobacco cessation
  • Cigar smoking
  • e-cigarette use

Published Papers (10 papers)

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Research

Open AccessCommunication
Leveraging Patient Reported Outcomes Measurement via the Electronic Health Record to Connect Patients with Cancer to Smoking Cessation Treatment
Int. J. Environ. Res. Public Health 2020, 17(14), 5034; https://doi.org/10.3390/ijerph17145034 (registering DOI) - 13 Jul 2020
Abstract
Tobacco use negatively impacts cancer treatment outcomes, yet too few providers actively support their patients in quitting. Barriers to consistently addressing tobacco use and referring to treatment include time constraints and lack of knowledge surrounding treatment options. Patient Reported Outcomes (PRO) measurement is [...] Read more.
Tobacco use negatively impacts cancer treatment outcomes, yet too few providers actively support their patients in quitting. Barriers to consistently addressing tobacco use and referring to treatment include time constraints and lack of knowledge surrounding treatment options. Patient Reported Outcomes (PRO) measurement is best practice in cancer care and has potential to help address these barriers to tobacco cessation treatment. This descriptive program evaluation study reports preliminary results following implementation of a novel automated PRO tobacco use screener and referral system via the electronic health record (EHR) patient portal (MyChart) that was developed and implemented as a part of a population-based tobacco treatment program at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Between June 25, 2019 and April 6, 2020, 4589 unique patients completed the screener and 164 (3.6%) unique patients screened positive for recent (past month) cigarette smoking. All patients who screened positive were automatically referred to a smoking cessation treatment program integrated within the Lurie Cancer Center, and 71 (49.7%) patients engaged in treatment, as defined by completing at least one behavioral counseling session. Preliminary results indicate that the PRO/MyChart system may improve smoker identification and increase offering of treatment and, despite the “cold call” following a positive screen, may result in a treatment engagement rate that is higher than rates of treatment engagement previously documented in oncology settings. Longer term evaluation with formal statistical testing is needed before drawing conclusions regarding effectiveness, but PRO measurement via the EHR patient portal may serve a potentially important role in a multi-component approach to reaching and engaging cancer patients in comprehensive tobacco cessation treatment. Full article
(This article belongs to the Special Issue Tobacco Use and Treatment among Cancer Survivors)
Open AccessArticle
An Evaluation of the Process and Quality Improvement Measures of the University of Virginia Cancer Center Tobacco Treatment Program
Int. J. Environ. Res. Public Health 2020, 17(13), 4707; https://doi.org/10.3390/ijerph17134707 - 30 Jun 2020
Abstract
Tobacco use after a cancer diagnosis can increase risk of disease recurrence, increase the likelihood of a second primary cancer, and negatively impact treatment efficacy. The implementation of system-wide comprehensive tobacco cessation in the oncology setting has historically been low, with over half [...] Read more.
Tobacco use after a cancer diagnosis can increase risk of disease recurrence, increase the likelihood of a second primary cancer, and negatively impact treatment efficacy. The implementation of system-wide comprehensive tobacco cessation in the oncology setting has historically been low, with over half of cancer clinicians reporting that they do not treat or provide a referral to cessation resources. This quality improvement study evaluated the procedures for assessing and documenting tobacco use among cancer survivors and referring current smokers to cessation resources at the University of Virginia Cancer Center. Process mapping revealed 20 gaps across two major domains: electronic health record (EHR), and personnel barriers. The top identified priority was inconsistent documentation of tobacco use status as it impacted several downstream gaps. Eleven of the 20 gaps were deemed a high priority, and all were addressed during the implementation of the resulting Tobacco Treatment Program. Prioritized gaps were addressed using a combination of provider training, modifications to clinical workflow, and EHR modifications. Since implementation of solutions, the number of unique survivors receiving cessation treatment has increased from 284 survivors receiving cessation support during Year 1 of the initiative to 487 in Year 3. The resulting Tobacco Treatment Program provides a systematic, personalized, and sustainable comprehensive cessation program that optimizes the multifaceted workflow of the Cancer Center and has the potential to reduce tobacco use in a population most in need of cessation support. Full article
(This article belongs to the Special Issue Tobacco Use and Treatment among Cancer Survivors)
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Open AccessArticle
Design and Pilot Implementation of an Electronic Health Record-Based System to Automatically Refer Cancer Patients to Tobacco Use Treatment
Int. J. Environ. Res. Public Health 2020, 17(11), 4054; https://doi.org/10.3390/ijerph17114054 - 06 Jun 2020
Cited by 1
Abstract
Continued tobacco use after cancer diagnosis is detrimental to treatment and survivorship. The current reach of evidence-based tobacco treatments in cancer patients is low. As a part of the National Cancer Institute Cancer Center Cessation Initiative, the Mayo Clinic Cancer Center designed an [...] Read more.
Continued tobacco use after cancer diagnosis is detrimental to treatment and survivorship. The current reach of evidence-based tobacco treatments in cancer patients is low. As a part of the National Cancer Institute Cancer Center Cessation Initiative, the Mayo Clinic Cancer Center designed an electronic health record (EHR, Epic©)-based process to automatically refer ambulatory oncology patients to tobacco use treatment, regardless of intent to cease tobacco use(“opt out”). The referral and patient scheduling, accomplished through a best practice advisory (BPA) directed to staff who room patients, does not require a co-signature from clinicians. This process was piloted for a six-week period starting in July of 2019 at the Division of Medical Oncology, Mayo Clinic, Rochester, MN. All oncology patients who were tobacco users were referred for tobacco treatment by the rooming staff (n = 210). Of these, 150 (71%) had a tobacco treatment appointment scheduled, and 25 (17%) completed their appointment. We conclude that an EHR-based “opt-out” approach to refer patients to tobacco dependence treatment that does not require active involvement by clinicians is feasible within the oncology clinical practice. Further work is needed to increase the proportion of scheduled patients who attend their appointments. Full article
(This article belongs to the Special Issue Tobacco Use and Treatment among Cancer Survivors)
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Open AccessArticle
Tobacco Dependence Treatment in Oncology: Initial Patient Clinical Characteristics and Outcomes from Roswell Park Comprehensive Cancer Center
Int. J. Environ. Res. Public Health 2020, 17(11), 3907; https://doi.org/10.3390/ijerph17113907 - 31 May 2020
Abstract
Despite the importance of smoking cessation to cancer care treatment, historically, few cancer centers have provided treatment for tobacco dependence. To address this gap, the National Cancer Institute (NCI) launched the Cancer Center Cessation Initiative (C3i). As part of this effort, this study [...] Read more.
Despite the importance of smoking cessation to cancer care treatment, historically, few cancer centers have provided treatment for tobacco dependence. To address this gap, the National Cancer Institute (NCI) launched the Cancer Center Cessation Initiative (C3i). As part of this effort, this study examined implementation outcomes in a cohort of cancer survivors (CSs) who smoked cigarettes in the first year of an ongoing process to develop and implement a robust Tobacco Treatment Service at Roswell Park Comprehensive Cancer Center. We provide a comprehensive description of the new tobacco use assessment and referral process, and of the characteristics of cancer survivors who agreed to treatment including traditional tobacco-related psychosocial and cancer treatment-related characteristics and novel characteristics such as delay discounting rates. We also examine characteristic differences among those who agreed to treatment between those who attended and those who did not attend treatment. As the new tobacco assessment was implemented, the number of referrals increased dramatically. The mean number of treatment sessions attended was 4.45 (SD = 2.98) and the six-month point prevalence intention to treat abstinence rate among those who attended was 22.7%. However, only 6.4% agreed to treatment and 4% attended at least one treatment session. A large proportion of cancer survivors who agreed to treatment were women, of older age, of lower socioeconomic status (SES), and who had high levels of depressive symptomology. The findings demonstrate that the implementation of system changes can significantly improve the identification of cancer survivors who use tobacco and are referred to tobacco use treatment. Among those who attend, treatment is effective. However, the findings also suggest that a systematic assessment of barriers to engagement is needed and that cancer survivors may benefit from additional treatment tailoring. We present plans to address these implementation challenges. Systematic electronic medical record (EMR)-sourced referral to tobacco treatment is a powerful tool for reaching cancer survivors who smoke, but more research is needed to determine how to enhance engagement and tailor treatment processes. Full article
(This article belongs to the Special Issue Tobacco Use and Treatment among Cancer Survivors)
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Open AccessArticle
The Emergence of a Sustainable Tobacco Treatment Program across the Cancer Care Continuum: A Systems Approach for Implementation at the University of California Davis Comprehensive Cancer Center
Int. J. Environ. Res. Public Health 2020, 17(9), 3241; https://doi.org/10.3390/ijerph17093241 - 06 May 2020
Abstract
Tobacco treatment is increasingly recognized as important to cancer care, but few cancer centers have implemented sustainable tobacco treatment programs. The University of California Davis Comprehensive Cancer Center (UCD CCC) was funded to integrate tobacco treatment into cancer care. Lessons learned from the [...] Read more.
Tobacco treatment is increasingly recognized as important to cancer care, but few cancer centers have implemented sustainable tobacco treatment programs. The University of California Davis Comprehensive Cancer Center (UCD CCC) was funded to integrate tobacco treatment into cancer care. Lessons learned from the UCD CCC are illustrated across a systems framework with the Cancer Care Continuum and by applying constructs from the Consolidated Framework for Implementation Research. Findings demonstrate different motivational drivers for the cancer center and the broader health system. Implementation readiness across the domains of the Cancer Care Continuum with clinical entities was more mature in the Prevention domain, but Screening, Diagnosis, Treatment, and Survivorship domains demonstrated less implementation readiness despite leadership engagement. Over a two-year implementation process, the UCD CCC focused on enhancing information and knowledge sharing within the treatment domain with the support of the cancer committee infrastructure, while identifying available resources and adapting workflows for various cancer care service lines. The UCD CCC findings, while it may not be generalizable to all cancer centers, demonstrate the application of conceptual frameworks to accelerate implementation for a sustainable tobacco treatment program. Key common elements that may be shared across oncology settings include a state quitline for an adaptable intervention, cancer committees for outer/inner setting infrastructure, tobacco quality metrics for data reporting, and non-physician staff for integrated services. Full article
(This article belongs to the Special Issue Tobacco Use and Treatment among Cancer Survivors)
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Open AccessFeature PaperArticle
An Implementation Trial to Improve Tobacco Treatment for Cancer Patients: Patient Preferences, Treatment Acceptability and Effectiveness
Int. J. Environ. Res. Public Health 2020, 17(7), 2280; https://doi.org/10.3390/ijerph17072280 - 28 Mar 2020
Cited by 1
Abstract
Continued smoking after a cancer diagnosis increases mortality, risk of recurrence, and negatively impacts treatment effectiveness. However, utilization of tobacco use cessation treatment among cancer patients remains low. We conducted a clinical trial assessing patient preferences, treatment acceptability, and preliminary effectiveness (7-day point [...] Read more.
Continued smoking after a cancer diagnosis increases mortality, risk of recurrence, and negatively impacts treatment effectiveness. However, utilization of tobacco use cessation treatment among cancer patients remains low. We conducted a clinical trial assessing patient preferences, treatment acceptability, and preliminary effectiveness (7-day point prevalence at 12 weeks) of three tobacco treatment options among cancer patients at an academic health center. Implementation strategies included electronic referral and offering the choice of three treatment options: referral to external services, including the quitline (PhoneQuit) and in-person group counseling (GroupQuit), or an internal service consisting of 6-week cognitive behavioral therapy delivered via smartphone video conferencing by a tobacco treatment specialist (SmartQuit). Of 545 eligible patients, 90 (16.5%) agreed to enroll. Of the enrolled patients, 39 (43.3%) chose PhoneQuit, 37 (41.1%) SmartQuit, and 14 (15.6%) GroupQuit. Of patients reached for 12-week follow-up (n = 35), 19 (54.3%) reported receiving tobacco treatment. Of all patients referred, 3 (7.7%) PhoneQuit, 2 (5.4%) SmartQuit, and 2 (14.3%) GroupQuit patients reported 7-day point prevalence abstinence from smoking at 12 weeks. Participants rated the SmartQuit intervention highly in terms of treatment acceptability. Results indicate that more intensive interventions may be needed for this population, and opportunities remain for improving reach and utilization. Full article
(This article belongs to the Special Issue Tobacco Use and Treatment among Cancer Survivors)
Open AccessArticle
A Lean Quality Improvement Initiative to Enhance Tobacco Use Treatment in a Cancer Hospital
Int. J. Environ. Res. Public Health 2020, 17(6), 2165; https://doi.org/10.3390/ijerph17062165 - 24 Mar 2020
Cited by 1
Abstract
Sustained tobacco use after cancer diagnosis decreases treatment effectiveness while increasing treatment side effects, primary cancer recurrence, and the occurrence of secondary cancers. Delivering tobacco use treatment to fewer patients due to inefficient workflow represents missed opportunities to deliver life-saving care. In 2017, [...] Read more.
Sustained tobacco use after cancer diagnosis decreases treatment effectiveness while increasing treatment side effects, primary cancer recurrence, and the occurrence of secondary cancers. Delivering tobacco use treatment to fewer patients due to inefficient workflow represents missed opportunities to deliver life-saving care. In 2017, the National Cancer Institute initiated the Cancer Cessation Initiative (C3I) to push new tobacco cessation resources into cancer centers across the United States. This grant allowed the University of North Carolina Tobacco Treatment Program (UNC TTP) to dramatically expand tobacco use treatment (TUT) services to patients at the North Carolina Cancer Hospital (NCCH). With this push, the team saw an opportunity to utilize Lean Six Sigma, a set of quality improvement (QI) tools, to streamline their processes and uncover the root causes of program inefficiencies. A 12-month QI project using the Lean A3 problem-solving tool was implemented to examine the team’s workflow. The study team mapped out the processes and, as a result, developed multiple “experiments” to test within the NCCH to address workflow efficiency and clinical reach. Outcome measures from the baseline to follow-up included: (1) the number of new patient referrals per month, and (2) the number of counseling sessions delivered per month. From the baseline to final state, the team’s referrals increased from a mean of 10 to 24 per month, and counseling sessions increased from a mean of 74 to 84 per month. This project provided a deeper understanding of how workflow inefficiencies can be eliminated in the clinical setting, how technology can be harnessed to increase reach, and finally, that soliciting and using feedback from NCCH leadership can remove barriers and improve patient care. Full article
(This article belongs to the Special Issue Tobacco Use and Treatment among Cancer Survivors)
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Open AccessArticle
Integration of Tobacco Treatment Services into Cancer Care at Stanford
Int. J. Environ. Res. Public Health 2020, 17(6), 2101; https://doi.org/10.3390/ijerph17062101 - 22 Mar 2020
Cited by 1
Abstract
As part of a National Cancer Institute Moonshot P30 Supplement, the Stanford Cancer Center piloted and integrated tobacco treatment into cancer care. This quality improvement (QI) project reports on the process from initial pilot to adoption within 14 clinics. The Head and Neck [...] Read more.
As part of a National Cancer Institute Moonshot P30 Supplement, the Stanford Cancer Center piloted and integrated tobacco treatment into cancer care. This quality improvement (QI) project reports on the process from initial pilot to adoption within 14 clinics. The Head and Neck Oncology Clinic was engaged first in January 2019 as a pilot site given staff receptivity, elevated smoking prevalence, and a high tobacco screening rate (95%) yet low levels of tobacco cessation treatment referrals (<10%) and patient engagement (<1% of smokers treated). To improve referrals and engagement, system changes included an automated “opt-out” referral process and provision of tobacco cessation treatment as a covered benefit with flexible delivery options that included phone and telemedicine. Screening rates increased to 99%, referrals to 100%, 74% of patients were reached by counselors, and 33% of those reached engaged in treatment. Patient-reported abstinence from all tobacco products at 6-month follow-up is 20%. In July 2019, two additional oncology clinics were added. In December 2019, less than one year from initiating the QI pilot, with demonstrated feasibility, acceptability, and efficacy, the tobacco treatment services were integrated into 14 clinics at Stanford Cancer Center. Full article
(This article belongs to the Special Issue Tobacco Use and Treatment among Cancer Survivors)
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Open AccessFeature PaperArticle
Using a Family Systems Approach to Treat Tobacco Use among Cancer Patients
Int. J. Environ. Res. Public Health 2020, 17(6), 2050; https://doi.org/10.3390/ijerph17062050 - 19 Mar 2020
Abstract
Tobacco use treatment is an essential component of cancer care. Family members play a significant role in smoking behavior, but more research is needed regarding the development, implementation, and impact of family-based interventions in cancer care. The UNC Tobacco Treatment Program conducted an [...] Read more.
Tobacco use treatment is an essential component of cancer care. Family members play a significant role in smoking behavior, but more research is needed regarding the development, implementation, and impact of family-based interventions in cancer care. The UNC Tobacco Treatment Program conducted an 18-month pilot study to examine the feasibility of implementing a family systems approach to treat tobacco use among patients at the North Carolina Cancer Hospital and to measure the impact of such an approach on patient abstinence. Implementation included four phases: (1) modifying the electronic health record and monthly report generated from the electronic health record; (2) training Tobacco Treatment Specialists to provide family counseling; (3) integrating family members into patients’ treatment; and (4) conducting six-month follow-up calls. During the course of the study, 42% (N = 221/532) of patients had family members integrated into their tobacco use treatment. Only 21 patients (4%) had family members present but not integrated into the treatment plan. At the six-month follow up time point, the seven-day point-prevalence quit rate for patients with family integration was 28% (N = 56/200), compared to 23% (N = 67/291) (p = 0.105) for patients without family integration. Integration of family members is clearly possible in an academic medical center’s oncology tobacco treatment program. Although pilot results were not statistically significant at 6 months, a potentially higher quit rate suggests a need for expanded research on methods to integrate family members in oncology settings for patients with tobacco-related cancers. Full article
(This article belongs to the Special Issue Tobacco Use and Treatment among Cancer Survivors)
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Open AccessArticle
Low Burden Strategies Are Needed to Reduce Smoking in Rural Healthcare Settings: A Lesson from Cancer Clinics
Int. J. Environ. Res. Public Health 2020, 17(5), 1728; https://doi.org/10.3390/ijerph17051728 - 06 Mar 2020
Cited by 1
Abstract
Rural populations face significant smoking-related health disparities, such as a higher prevalence of lung cancer and cancer mortality, higher prevalence of smoking, and lower likelihood of receiving cessation treatment than urban counterparts. A significant proportion of health disparities in rural populations could be [...] Read more.
Rural populations face significant smoking-related health disparities, such as a higher prevalence of lung cancer and cancer mortality, higher prevalence of smoking, and lower likelihood of receiving cessation treatment than urban counterparts. A significant proportion of health disparities in rural populations could be eliminated with low-barrier, easy-access treatment delivery methods for smoking cessation. In this study, we assessed treatment engagement among patients in rural and urban settings. Then, we examined the effect of an electronic health record-based smoking cessation module on patient receipt of evidence-based cessation care. As part of a quality improvement project, we retrospectively observed 479,798 unique patients accounting for 1,426,089 outpatient clinical encounters from June 2018–March 2019 across 766 clinics in the greater St. Louis, southern Illinois, and mid-Missouri regions. Smoking prevalence was higher in rural versus urban clinics (20.7% vs. 13.9%, 6.7% [6.3, 7.1], odds ratio = 1.6 [1.6, 1.6], p < 0.0001), and yet rural smokers were nearly three times less likely than their urban counterparts to receive any smoking cessation treatment after adjusting for patients clustering within clinics (9.6% vs. 25.8%, −16.2% [−16.9, −15.5], odds ratio = 0.304 [0.28, 0.33], p < 0.0001). Although not yet scaled up in the rural setting, we examined the effects of a low-burden, point-of-care smoking module currently implemented in cancer clinics. After adjusting for patient clustering within clinics, patients were more likely to receive smoking treatment in clinics that implemented the module versus clinics that did not implement the module (31.2% vs. 17.5%, 13.7% [10.8, 16.6], odds ratio = 2.1 [1.8, 2.6], p < 0.0001). The point-of-care treatment approach offers a promising solution for rural settings, both in and outside the context of cancer care. Full article
(This article belongs to the Special Issue Tobacco Use and Treatment among Cancer Survivors)
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