Tobacco use in patients diagnosed with cancer increases the risk of adverse outcomes, and patients diagnosed with cancer experience direct benefits of smoking cessation.1 Evidence-based approaches to smoking cessation can improve survival by approximately 1.8 years if a patient quits within 6 months of a cancer diagnosis. A 2023 survey of the National Cancer Database® (NCDB®) revealed that approximately 14.7% of newly diagnosed patients reported smoking at the time of diagnosis.2,3
Guidelines from the National Comprehensive Cancer Network support assessment and assistance for smoking cessation in patients with cancer. Evidence-based cessation efforts include in-office behavioral counseling, referral to a tobacco quitline, referral to a certified tobacco treatment specialist, or pharmacotherapy.
Building upon results from the ACS national quality improvement (QI) initiative Just ASK, which focused on addressing cigarette smoking by asking newly diagnosed patients with cancer about their smoking status,4 Beyond ASK was developed and launched in 2023 to support programs in taking steps to support cessation efforts in patients who report being smokers.
The primary aim of the Beyond ASK QI initiative was to increase smoking cessation assistance for newly diagnosed patients with cancer by at least 20% from the individual program baseline or maintain assistance provided at less than 90%.
A total of 324 ACS Commission on Cancer (CoC) and National Accreditation Program for Breast Centers programs participated in the initiative, which spanned 12 months. The initiative included the formation of a QI team, response to five data collection surveys, and participation in educational webinars and collaborative learning sessions. Programs also were given access to an online practice change package that contained information about evidence-based smoking assessment and cessation tools, practice workflow, and electronic health record (EHR) guidance. Individualized technical assistance was offered, and participants shared local implementation strategies and success stories during bimonthly national calls.
To assess progress over time, surveys were collected at five time points during the year. These surveys included metrics on newly diagnosed patients, featured questions about current smoking status, and if the status positive, included the number of patients who received evidence-based smoking cessation assistance. Surveys also collected data on implementation strategies (e.g., identifying a cessation treatment champion, adding a prompt within clinical workflow, and obtaining leadership support).
A publication reporting outcomes data is pending; however, it is clear that this national QI project is producing results, specifically at the local level. During the 12-month initiative, “ask” rates started high and remained high at the programmatic level. Overall, assist rates increased and more than 65% of programs reached their goal of increasing these rates by 20% or more.
The most commonly identified strategies to assist patients included in-office brief counseling, in-office behavioral counseling, referral to a smoking cessation treatment program, and referrals to community-based treatment. Referrals to quitlines and prescription of cessation medication were strategies used more by programs that reached the goal of a 20% increase in assisting patients versus those that did not. Common implementation strategies for achieving this increase include gaining support from program leadership, increasing or modifying EHR documentation, developing patient education materials, and identifying organization resources.
Overall, these results demonstrate that improvements in evidence-based smoking cessation assistance can be scaled and sustained across cancer care settings in a relatively short amount of time with modest changes to current workflow and processes.
Barriers to achieving the goal of a 20% increase in assistance included lack of training, lack of time, and competing clinical priorities. Additional support is indicated for programs to increase patient engagement in smoking cessation programs.
While previously recognized as a barrier in the 2022 Just ASK initiative, the inability to use the EHR to identify patients who currently smoke or to capture smoking history was reported by fewer than 8% of participating programs. Tobacco is now a core data element in most EHRs, which removes the EHR as a barrier, and as of 2023, tobacco use is reported in the NCDB.
Beyond ASK represents the largest known national project to address smoking cessation efforts in patients with cancer. Despite strong evidence and clinical practice guideline recommendations, delivery of smoking cessation treatment in oncology settings has remained subpar. Leveraging lessons learned from Beyond ASK and Just ASK, the CoC has developed a new standard on smoking cessation for patients with newly diagnosed cancer, which aims to provide evidence-based interventions for patients with cancer who are current smokers. This standard supports universal screening and assistance when indicated, encouraging opt-out treatment and referral approaches that are appropriate for the context and resources of local programs.
The findings from the Beyond ASK initiative strongly demonstrate the feasibility of distributing evidence-based smoking cessation support across various cancer programs nationwide. Considering the negative impact of ongoing smoking on cancer treatment results and the indisputable benefits of quitting, implementing sustainable smoking cessation programs universally across all US cancer care programs has strong potential to impact treatment outcomes.
Eileen Reilly is the Quality Improvement Manager for ACS Cancer Programs in Chicago, IL.
References
- Cinciripini PM, Kypriotakis G, Blalock JA, et al. Survival outcomes of an early intervention smoking cessation treatment after a cancer diagnosis. JAMA Oncology. 2024;10(12):1689-1696.
- Caturegli G, Zhu X, Palis B, Mullett TW, et al. Smoking status of the US cancer population and a new perspective from the National Cancer Database. JAMA Oncol. 2028;11(5)564-566.
- Lowy DR, Fiore MC, Willis G, Mangold KN, et al. Treating smoking in cancer patients: An essential component of cancer care-the new National Cancer Institute Tobacco Control Monograph. JCO Oncol Pract. 2022;18(12):e1971-e1976.
- Burris JL, Ostroff JS, Reilly EM, et al. Longitudinal results from the nationwide Just ASK initiative to promote routine smoking assessment in American College of Surgeons–accredited cancer programs. J Clin Oncol. 2025;43(7):821-828.
