Strategy may reduce tobacco treatment disparities among people with cancer
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A universal screening and opt-out referral strategy may reduce disparities in tobacco treatment access and increase use of smoking cessation services by people with cancer, according to results of a qualitative improvement study.
“Everyone knows that smoking is bad and that smoking causes cancer, but there is much less appreciation that continued smoking after diagnosis matters,” study senior co-author Jamie S. Ostroff, PhD, clinical health psychologist and director of Memorial Sloan Kettering’s tobacco treatment program, told Healio. “Our paper shows that if you adopt universal tobacco screening and referral for smoking cessation as your standard of care, you’re able to address longstanding tobacco-related disparities and promote health equity.”
Challenging previous findings
Prior research has demonstrated smoking cessation after cancer diagnosis can provide considerable benefits, including improved treatment efficacy, reduced risk for recurrence or incidence of second primary cancers, fewer treatment complications and longer survival.
However, Black and Hispanic patients historically have had less access to tobacco treatment services and typically utilize these services less frequently.
In 2011, Memorial Sloan Kettering adopted universal screening of tobacco use and implemented an opt-out tobacco treatment referral as its standard of care.
Ostroff and colleagues — including Gleneara E. Bates-Pappas, PhD, LMSW, and Chris Kotsen, PsyD, of Memorial Sloan Kettering Cancer Center’s department of psychiatry and behavioral sciences — assessed data from patients diagnosed with cancer at Memorial Sloan Kettering between 2018 and 2022.
All patients who identified themselves as current smokers received offers for tobacco treatment. Researchers defined treatment acceptance as scheduling at least one counseling session with a clinician with expertise in tobacco treatment.
Investigators examined differences in prevalence of tobacco use, tobacco treatment referral, and acceptance by race and ethnicity.
Of the 302,971 patients seen during the study interval, 18,475 (6.1%) reported current tobacco use, mostly smoking cigarettes. Consistent with the general population, Black or African American patients reported a higher rate of tobacco use (7.1%) than white patients (6.2%), Asian patients (3.8%) or those of other races (6.1%).
Most (87.1%) patients who reported current tobacco use were referred for tobacco treatment and 69.3% of those who met eligibility had been reached for scheduling.
More than half (54.8%) of those reached for scheduling accepted tobacco treatment, with surprisingly higher acceptance rates among Black or African American patients (66.3%) than white patients (53.7%), Asian patients (46.5%) or those of other races (58.1% P <.001). Results also showed a higher acceptance rate among Hispanic or Latino patients than non-Hispanic/non-Latino patients (60.5% vs. 54.3%; P = .005).
“The prior literature was saying that Black and African American and Hispanic/Latino patients don’t accept or engage in tobacco treatment,” Bates-Pappas said. “It’s likely that they weren’t being offered cessation support at the same rate.”
‘You belong here’
The universal tobacco screening and opt-out treatment referral model is considered to be a standardized and inclusive approach to improve equity in tobacco treatment for people at any point in the cancer journey, Bates-Pappas said.
“This systems-level strategy is likely effective because it leverages our multidisciplinary teams and their shared commitment to providing individualized care to all of our patients,” she said. “Every patient who enters our system completes a universal screener for tobacco use.”
The questions on the screener are designed to assess current tobacco use, as well as tobacco use history. Oncology care providers review tobacco use information with the patient and advise cessation for those who report currently smoking.
Notably, in an ‘opt-out’ program, every patient who reports current tobacco use is automatically referred for tobacco treatment services. This default workflow decreases potential provider bias in making referrals, Bates-Pappas said.
“The literature says that some providers don’t refer patients for tobacco treatment because they perceive that it isn’t a priority,” she said. “Some literature shows large racial and ethnicity disparities in terms of who is being referred. With our program, we want patients to know they belong here. We understand the power of nicotine addiction and that all patients need compassion as they struggle with the challenges of fighting nicotine addiction.”
All patients referred to the program receive three ”proactive reach-outs” by phone. Bates-Pappas said this step is helpful to people with cancer, who often are dealing with an overwhelming amount of information, appointments, decisions and confusion about what tobacco treatment entails.
“We know tobacco use can be stigmatizing, particularly after a cancer diagnosis,” Bates-Pappas said. “Patients can feel nervous or reluctant about engaging in a conversation about smoking. So, we call them.”
All patients referred to the program receive educational materials, and those who are interested are scheduled for consultation and follow-up cessation support with a tobacco treatment specialist. After 6 months following enrollment, patients are asked about whether they quit smoking, the challenges they faced, and their experiences seeking tobacco treatment. Those who haven’t quit or have resumed smoking after quitting are invited to resume tobacco treatment and get back on track to success.
“Then we go one step further and check in with them again after another 6 months, so they have some connection with us for an entire year,” Bates-Pappas said. “Regardless of where patients are in the continuum of cancer care, we find ways to make sure they’re all getting the tailored services they need.”
An ‘essential’ service
The universal screening and opt-out tobacco treatment strategy represents a feasible, effective and scalable way of closing gaps in care around tobacco treatment delivery, Ostroff said.
“The key takeaway from our paper is that for [people with cancer] who smoke cigarettes, cancer care settings should adopt an opt-out approach to tobacco treatment delivery, defined as provision of medication and counseling to all patients regardless of their readiness to quit,” Ostroff said.
Ostroff and her team participate in NCI’s Cancer Center Cessation Initiative, part of the Cancer Moonshot. Many of the cancer centers in this consortium either are moving toward or have established an opt-out universal tobacco treatment referral model, Ostroff said.
“In the old days, we asked if a patient wanted to quit and if they said no, we would just leave it be,” Ostroff said. “Now, we proactively advise all patients to quit smoking and provide safe and effective tobacco treatment services because it’s essential for improving patient outcomes.”
For more information:
Gleneara E. Bates-Pappas, PhD, LMSW, can be reached at batespag@mskcc.org.
Jamie S. Ostroff, PhD, can be reached at ostroffj@mskcc.org.
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