Advancing Equitable Treatment for Smoking Cessation in Cancer Patients

Summary

In the United States, smoking is the leading cause of preventable deaths.¹ Smoking is also associated with worse treatment outcomes for patients with cancer, including higher risk of additional cancers and higher risk of death.¹ Reports estimate that as many as 33-75% of patients with cancer may smoke.^2–5 Many patients with cancer are unaware of the potential negative effects of smoking on their cancer treatment.⁶ To not only increase this awareness but also help patients quit smoking, oncology providers can provide smoking cessation programs. Cancer care programs do not usually emphasize smoking cessation programs, and this is a missed opportunity to improve patient outcomes.⁷ Below, we describe a body of work meant to address this missed opportunity. 

Dr. Chen, Dr. Ramsey, and their research team used electronic health record (EHR) data to look for patterns in how smoking cessation medications are prescribed to patients receiving inpatient care.⁸ They found that rates of prescriptions varied a lot between medical specialties and patient characteristics, like patient race. To address these disparities and improve prescribing practices across medical specialties and patient characteristics, Chen and Ramsey proposed using the EHR to increase prescribing rates – an approach that could be extended widely to outpatient settings as well. The team developed ELEVATE, or EHR-Enabled Evidence-Based Smoking Cessation Treatment, with provider and patient input.⁹ When providers see patients, ELEVATE prompts providers to initiate the Ask, Advise, Connect (AAC) model of tobacco cessation treatment directly at the point of care for patients during routine oncology visits.^9,10 First, a medical assistant or nurse is prompted by the EHR system to ask each patient if they use tobacco. For patients who use tobacco, ELEVATE prompts the oncology care team member to advise patients that quitting smoking is the best thing they can do for their health. Next, ELEVATE prompts the team member to connect patients with the phone-based Quitline and SmokeFree apps and text message programs. At this time, the medical assistant or nurse can also add ICD-10 code Nicotine Dependence to facilitate follow-up care and queue tobacco cessation medication orders for the medical provider to approve. Because the intervention is built into the EHR system that the oncology team already uses, it is very sustainable and not burdensome for providers. Patients also favor this approach because they receive tobacco treatment during routine visits rather than being referred out for a separate tobacco treatment specialist visit. 

Significance

ELEVATE addresses three barriers to successful tobacco cessation treatment for patients with cancer: lack of provider time, lack of provider knowledge, and lack of referral to cessation specialists.⁷ Because patients with cancer have complex needs, providers often did not feel they had enough time to discuss tobacco use in appointments. And because smoking cessation is often viewed by providers as a specialty care need, providers often lacked the self-efficacy to engage patients about smoking cessation and also lacked referral access to reliable tobacco treatment specialists to arrange smoking cessation care for patients. In response to these challenges, ELEVATE was developed as a low-cost and low-burden intervention that leverages the broader care team including medical assistants and nurses, and provides standardized scripts and decision support tools, making smoking cessation treatment at the point of routine care much easier for both providers and patients. ELEVATE has significantly increased the reach of tobacco treatment for patients from 1.6% to 27.9%.⁷ Additionally, ELEVATE increased the effectiveness of patient smoking cessation from 12.0% to 17.2%.⁷ 

ELEVATE addresses equity in many ways. First, typical practices in smoking cessation treatment, like referrals to a specialist, are often only accessed by patients who are highly motivated to quit smoking.⁹ Specialists may be out of reach for rural communities and not pragmatic for patients who are not fully prepared to quit smoking; with ELEVATE, providers can prescribe medication or provide a phone number for a quitline during the appointment, thus removing the barrier for visiting another specialist. This is very important, because additional research has shown that patients in rural communities are three times less likely to quit smoking than patients in urban areas.¹¹ ELEVATE also prompts a provider to engage in conversations with their patients who smoke about the consequences of smoking. This means that more patients will be engaged in conversations about their smoking, regardless of patient characteristics. This is important because some research has shown that Black patients are about 35% less likely to receive smoking cessation treatment than White patients.⁸ 

Benefits

Demonstrated benefits are those that have been observed and are verifiable.

Potential benefits are those logically expected with moderate to high confidence.

Integrated the ELEVATE module for smoking cessation into the EHR system for clinic workflow use.  demonstrated.

Clinical

Software technologies

Created an EHR-driven system to improve smoking cessation treatment referral, uptake, and outcomes.  demonstrated.

Clinical

Therapeutic procedures

Increased amount of cancer patients who smoke quit smoking following the ELEVATE intervention.  demonstrated.

Community

Disease prevention & reduction

Incorporated the ELEVATE module into all clinic workflows so any patient who smokes receives the same intervention, regardless of patient characteristics.  demonstrated.

Community

Health care accessibility

Provided smoking cessation treatment referral and medication when indicated. demonstrated.

Community

Health care delivery

Improved efficiency for smoking cessation treatment referral for both providers and patients. demonstrated.

Community

Health care quality

Improved quality of life, improved treatment response, and improved life expectancy is expected for cancer patients following quitting smoking. potential.

Community

Life expectancy & quality of life

Improve treatment outcomes for cancer patients by standardizing assessment and administration of smoking cessation programs.  potential.

Community

Public health practices

Integrated ELEVATE, a low-cost and low-burden module, into the pre-existing EHR clinical workflow.  demonstrated.

Economic

Cost effectiveness

Reduced median cost for patient care by 85% with ELEVATE intervention.¹²

  demonstrated.

Economic

Cost savings

Providing smoking cessation treatment with a larger reach will reduce societal costs associated with healthcare spending and lost productivity.  potential.

Economic

Societal & financial cost of illness

This research has clinical, community, and economic implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.¹³  

Clinical

The ELEVATE intervention affects smoking cessation treatment at multiple levels; ELEVATE makes it easier for providers to ask patients about their smoking habits, to advise patients about their smoking habits, and to connect patients with smoking cessation treatments. This intervention is built directly into the EHR system that providers use to monitor patient clinical history and to document patient visits. ELEVATE is completely embedded into the clinical workflow, so cancer patients interested in quitting smoking do not have to add a new specialist to their cancer care team.  

Community

The ELEVATE intervention has many community impacts. Because the intervention is activated for any cancer patient with a smoking history, patients that may not have been screened for smoking cessation interest – perhaps due to provider lack of time or perceived patient lack of interest – will now be screened. Any patient who has interest in quitting smoking will choose to either start smoking cessation medication or will be referred to a quitline. These treatment options remove the need for additional appointments and streamline the smoking cessation treatment. This intervention is successful and sustainable; as of 2023, over 900 clinics across two health care systems had incorporated ELEVATE into their practice.¹⁴ 

Economic

ELEVATE has both demonstrated and potential economic benefits. Recent research has shown that as much of 85% of the median cost associated with treating cancer patients is reduced when providers utilize ELEVATE.⁷ This indicates that this low-burden and low-cost smoking cessation intervention reduces costs for cancer care. The consequences of smoking are associated with as much as $240 billion spent in healthcare costs annually and a loss of $372 billion from lost productivity.¹⁵ Thus, prioritizing smoking treatment in cancer patients will address both inflated healthcare costs and economic burden from lost productivity through disability and premature death.   

Lessons Learned

1. We found that, unlike our past experience and the usual approach in this field, we could successfully use a low-burden point of care model. This model made things easier for both patients and providers, without adding extra work or requiring new staff. 
2. We learned that using a learning health system approach helped drive change in how tobacco treatment is provided at the point of care. This approach involved three key steps: using data to identify gaps, working with providers to improve strategies, and continuously reviewing data to see what works. This cycle strengthened both the culture and the shift in practice. 
3. We learned that using a team-based care approach, one in which the roles and responsibilities of asking, advising, and connecting patients to tobacco use treatment are shared by physician and the care team, leads to a higher quality of care provided to patients who smoke.