Cancer patients and survivors have an increased risk of adverse health outcomes1—including overall mortality—and smoking at the time of a cancer diagnosis is conservatively estimated to add $3.4 billion in cancer treatment costs in the US annually.2
Smoking cessation by cancer patients leads to a reduction in mortality risk,3 and most leading cancer organizations advocate for cessation as the standard of clinical cancer care.4,5 Still, many cancer programs do not regularly address smoking in cancer care, and many oncologists do not regularly provide assistance with smoking cessation.6,7,8
A guideline from the National Comprehensive Cancer Network (NCCN) supports assessment, advisement, and assistance of smoking cessation in patients with cancer. To support accredited cancer programs in their compliance with this guideline, the Just ASK Quality Improvement Project and Clinical Study was launched in April 2022 and enrolled 776 accredited Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC) programs.
The elective quality improvement initiative focused on strengthening adoption of universal assessment and documentation of his or her smoking status in the electronic health record (EHR). Just ASK encouraged smoking assessment as a standard of care, demonstrated by asking 90% of newly diagnosed cancer patients about smoking status or by asking at least 20% more patients about smoking following enrollment.
Programs also were encouraged to consider how they would go “beyond asking” by assisting patients to quit smoking with delivery of, or referral to, smoking cessation support.
To meet this goal, programs assessed current systems and workflows that supported asking all newly diagnosed cancer patients about their smoking status and evaluated barriers and facilitators for a more systematic approach. Programs participated in didactic webinars, received access to a Just ASK change package, and were offered technical assistance from a multidisciplinary committee of experts from the Just ASK task force. Peer-to-peer learning and sharing of innovations were encouraged through a series of webinars.
To assess progress over time, surveys were collected three times that captured current smoking assessment and treatment practices, organizational priority, implementation barriers, and feasibility and effectiveness of potential implementation strategies. The findings from these surveys represented the largest dataset reporting current practices, perceived barriers, and implementation of smoking cessation treatment across a broad range of cancer treatment settings in the US.
Programs completed at least one intervention to improve their smoking assessment practice. The interventions, chosen locally and adapted to context, included:
- Educating team members and staff about the benefits of encouraging smoking cessation in cancer patients
- Enhancing EHR for ease of data collection, capture, reporting, and action
- Improving workflow to more efficiently and effectively capture smoking status
- Identifying additional organizational resources to support smoking cessation
Data collection and subsequent analysis for the Just ASK project will be completed in early 2023, and since a publication reporting baseline survey outcomes is pending, outcome data will be reported later this year. However, program gains from baseline to midyear are evident and illustrated through aggregate reviews survey data.
For example, in April 2022, a vast majority of programs reported that they had a system in place to ask newly diagnosed cancer patients about their smoking status. However, far fewer programs were able to provide actual data to support how many patients were asked. This finding demonstrated an immediate area for programs to begin partnering with their information technology resources to build a better system of data output. Midyear survey results reported an increase in programs with the ability to provide data, indicating a change at the local level driven by process improvement.
Accredited programs remained highly engaged over the course of the yearlong collaborative, indicating a strong national interest in addressing smoking among cancer patients. Preliminary data reveal there are gaps in program capacity to obtain information about patients’ current smoking status, suggesting the need for systems-level strategies for improving patient assessment, clinical workflow, and documentation—all areas in which the Just ASK task force sought to support programs over the course of the quality improvement project. These findings highlight challenges and opportunities for implementing smoking assessment and treatment in cancer care settings.
