Smoking Cessation Programs Display Reach and Efficacy But Gaps Remain

Smoking cessation programs that are cancer center-wide, offer both inpatient and outpatient services, and have a high staff-to-patient ratios, appear to reach more patients than programs that are not center-wide, only offer outpatient services, and have low staff-to-patient ratios—although these programs may be more effective at helping the patients that they reach, according to findings from a cross-sectional study published in the Journal of Clinical Oncology.¹

Results from the study showed that among 692,662 unique patients seen across 28 centers associated with The Cancer Center Cessation Initiative, a median of 95.5% (range, 47.5%-100.0%) were screened for tobacco use. Median center smoking prevalence was 7.4% (range, 2.3%-37.0%). Additionally, the median ratio observed across centers was 1 full-time tobacco treatment specialist per 682 patients who smoke (range, 18-4232).

The center-level median treatment reach, defined by investigators as the proportion of unique patients seen during the 6-month reporting period who reported current smoking and who received at least one evidence-based tobacco treatment component, was 15.4% (range, 2.5%-97.9%). Moreover, the median smoking cessation effectiveness, defined as the proportion of patients currently smoking who reported 7-day point prevalence abstinence 6 months following receipt of evidence-based tobacco treatment, was 18.4% (range, 0.0%-66.7%).

Increased median treatment reaches compared with the overall median were observed across a number of subgroups of centers, most notably including centers with less than 700 patients who smoke (n = 8; median treatment reach, 42.8%; range, 8.5%-97.9%; P = .03), centers with less than 12,000 total patients (n = 9; median treatment reach, 25.3%; range, 2.8%-52.8%; P = .13), and centers with a smoking prevalence above 7.4% (n = 14; median treatment reach, 22.5%; range, 2.8%-97.9%). Median smoking cessation effectiveness improved most dramatically relative to the overall median in centers with over 27,000 total patients (n = 9; median effectiveness, 20.4%; range, 5.4%-35.3%), centers with a smoking prevalence above 7.4% (median effectiveness 19.7%; range, 0.0%-66.7%), and centers with at least 2500 patients who smoke (n = 9; median effectiveness, 19.2%; 2.6%-66.7%).

To conduct this study, investigators from The Cancer Center Cessation Initiative Coordinating Center at the University of Wisconsin Carbone Cancer Center sent a web-based survey to their affiliated centers every 6 months. The questions were formulated to assess center characteristics and tobacco treatment program implementation outcomes. The study included 6-month data from 28 National Cancer Institute–designated cancer centers that submitted a report from January 2021 to June 2021.

To be included in the final analysis, centers needed to include data concerning both treatment reach and smoking cessation effectiveness. Methods for follow-up with patients were left up to the individual centers and includedautomated or staff-initiated phone calls, data extracted from the electronic health record, patient portals, and manual chart reviews. All patients who received treatment or who were referred to treatment were included in the effectiveness analysis.

Study authors assessed each center for the delivery of 8 evidence-based tobacco treatment components: quitline (n = 26), cessation medication (n = 25), telephone-based counseling (n = 25), text- or web-based program referral (n = 21), point-of-care counseling (n = 17), video-based counseling (n = 13), in-person counseling (n = 12), and automated calls (n = 4). The median treatment reaches associated with these components were 17.7% (range, 2.5%-97.9%), 15.0% (range, 2.5%-97.9%), 15.8% (range, 2.5%-97.9%), 15.0% (range, 3.3%-97.9%), 15.0% (range, 3.3%-97.9%), 14.6% (range, 2.5%-50.6%), 14.8% (range, 3.3%-97.9%), and 25.0% (range, 20.4%-50.6%), respectively. Additionally, centers that offered 5 components (n = 6) and 6 components (n = 6) displayed the highest median treatment reach, at 25.9% (range, 5.5%-52.8%) and 32.3% (range, 4.0%-97.9%), respectively.

In terms of smoking cessation effectiveness, the median was highest among centers that offered in person counseling (19.9%; range, 0.0%-36.4%), quitline (18.9%; range, 0.0%-66.7%), and cessation medication (18.5%; range, 0.0%-36.4%). Median smoking cessation effectiveness exceeded the overall median at centers that offered 6 components (20.3%; range, 2.4%-36.4%) and 4 components (n = 7; 20.1%; range, 15.2%-29.3%).

The characteristics of the tobacco treatment program employed by the center also had an impact on median treatment reach and median smoking cessation efficacy. Regarding median treatment reach, centers that used a program that included inpatients and outpatients (n = 9; 26.5%; range, 3.3%-52.8%), had less than 500 patients who smoke per each tobacco treatment specialist full-time equivalent (n = 7; 26.5%; range, 8.5%-97.9%), and/or used a cancer-center wide program (n = 21; 20.4%; range, 2.8%-97.9%) all outperformed the overall median. Greater median smoking cessation effectiveness compared with the overall median was observed in centers with over 1000 patients who smoke per each tobacco treatment specialist full-time equivalent (n = 7; 20.4%; range, 2.6%-4.9%), those with 500 to 1000 patients who smoke per each tobacco treatment specialist full-time equivalent (n = 12; 20.1%; range, 3.9%-66.7%), those where the program was part of the center (n = 7; 19.2%; range, 3.2%-20.5%), and those with programs that included outpatients only (n = 19; 18.5%; range, 2.4%-66.7%).

Investigators noted that the inverse relationship between reach and effectiveness that was observed across multiple cancer centers and tobacco treatment programs could potentially be because of the fact that centers with lower reach typically having fewer patients or be correlated with the dose or intensity of the treatment components that were administered. They also posited that centers with lower reach could be providing treatment services to patients who are more receptive and more likely to achieve smoking abstinence.

Study authors went on to note that the inclusion of patients who are more difficult to refer to programs and more difficult to treat for smoking cessation could have led to reaching patients less likely to achieve abstinence, therefore resulting in the lower smoking cessation effectiveness rates. In the future, studies like this one should be clearer in terms of assessing patient characteristics and evaluate approaches that will better reach and engage patients who are likely to participate in smoking cessation treatments, they wrote.

“Understanding treatment reach and smoking cessation effectiveness will help guide cancer centers and community oncology practices to select and implement evidence-based interventions and strategies that fit the needs and resources available and improve patient outcomes. However, continued innovative efforts are needed to identify optimal strategies to engage patients in tobacco treatment, to determine which patients would benefit from more intensive tobacco treatment interventions, and to improve treatment reach and smoking cessation effectiveness and its reporting,” study authors wrote in conclusion.

Reference

Hohl SD, Matulewicz RS, Salloum RG, et al. Integrating tobacco treatment into oncology care: reach and effectiveness of evidence-based tobacco treatment across national cancer institute–designated cancer centers. J Clin Oncol. Published online December 6, 2022. doi:10.1200/JCO.22.00936