Feasibility of Point-of-Care Assessment for Smoking Cessation in Cancer Clinics

As every clinician knows, tobacco-smoking patients who receive a cancer diagnosis should abstain from smoking; and as all clinicians also know, stopping smoking is incredibly difficult. Patients going through the process need a great deal of support. Can that support come from their cancer clinic?

In a multifacility study, researchers evaluated the feasibility of the Electronic Health Record-Enabled Evidence-Based Smoking Cessation Treatment Program (ELEVATE), a low-burden point-of-care model of smoking cessation treatment (ClinicalTrials.gov Identifier: NCT4107857).¹

ELEVATE facilitates systematic implementation of the “5 As” of tobacco cessation intervention²:

• Ask about the patient’s history of using tobacco;
• Advise that stopping smoking is the best thing the patient can do for their health;
• Assess the patient’s interest in smoking cessation advice;
• Assist the patient with finding cessation counseling options;
• Arrange tracking and follow-up care for Tobacco Use Disorder. ²

The program utilizes a smoking module that is coupled to the Epic electronic health record (EHR) system that uses electronic alerts and decision support tools to prompt clinicians to offer screening and referrals.

Many effective smoking cessation programs are available, but because there also are many barriers to their access, patients may not utilize these options. Most cancer care programs do not offer smoking cessation as part of their curriculum, so patients who have cancer and would like to quit smoking usually have to go it alone. EHR-based programs may be used to encourage referrals to external programs, but those simply do not result in smoking cessation. Therefore, the researchers sought to determine if use of an in-house point-of-care program would increase both reach and effectiveness of evidence-based smoking cessation interventions in the cancer clinic setting.

Reach and Effectiveness

The study included patients treated at medical oncology (ELEVATE) clinics and internal medicine and surgical oncology (usual care) clinics affiliated with a large Midwestern healthcare system. Primary outcomes were reach, the proportion of current smokers assessed at the point of care, and effectiveness, the proportion of current smokers who quit, in the postimplementation period (June through December 2018) compared with the preimplementation period (January through May 2018).

Among patients in the ELEVATE clinics, assessment increased from 44.3% to 92.4% in the preimplementation and postimplementation periods, respectively. The proportion of identified smokers who quit increased from 12% to 17.2% in the pre- and postimplementation periods, respectively.

Among patients in the usual care clinics, assessment increased from 81.4% in the preimplementation period to 85.6% in the postimplementation period. However, no change was observed in the proportion of identified smokers who quit in the postimplementation period compared with the preimplementation period in either usual care clinics (internal medicine and surgical oncology).

Comparing the results of the ELEVATE clinics with those of the usual care clinics, reach was 4 times greater and effectiveness was significantly greater in the postimplementation period with the ELEVATE program.

The EHR-enabled point-of-care program removed financial barriers related to transportation costs and time barriers, which can be significant for cancer patients who often have multiple appointments. The program made scheduling in-person appointments, as well as to travel to those appointments, easier for patients.

“ELEVATE, a low-burden point-of-care intervention, was associated with increased reach and effectiveness of smoking cessation treatment,” the researchers concluded. Three times as many smokers who were treated in this program were more likely to quit smoking compared with smokers who had not been treated. Even a low-intensity intervention such as brief advice prompted by an EHR script is effective in supporting smoking cessation.

References

1. Ramsey AT, Baker TB, Stoneking F, et al. Increased reach and effectiveness with a low-burden point-of-care tobacco treatment program in cancer clinics. J Natl Compr Canc Netw. 2022;20(5):488-495. doi:10.6004/jnccn.2021.7333
2. Ramsey AT, Chiu A, Baker T, et al. Care-paradigm shift promoting smoking cessation treatment among cancer center patients via a low-burden strategy, Electronic Health Record-Enabled Evidence-Based Smoking Cessation Treatment. Transl Behav Med. 2020;10(6):1504-1514. doi:10.1093/tbm/ibz107