Providing tobacco cessation treatment to patients with cancer is critically important for improving a broad range of cancer-relevant outcomes, including surgical wound healing, treatment morbidity, efficacy of radiation and chemotherapy, time to cancer recurrence, disease progression, development of second primary cancers, and, ultimately, mortality.^1,2 Although most patients with cancer who smoke want to quit, notably limited availability and markedly low rates of engagement with smoking cessation treatment are pressing concerns.^2,3 Numerous scientific and professional organizations, including ASCO, the National Comprehensive Cancer Network, the American Association for Cancer Research, and the National Cancer Institute (NCI), have recognized these issues as high priority and supported practice guidelines and initiatives to develop new and enhanced infrastructures for addressing tobacco use among patients with cancer who smoke.

In the article that accompanies this editorial, Ostroff et al⁴ examined baseline survey responses reported by members of the American College of Surgeons (ACS) Cancer Programs (ie, Commission on Cancer [CoC] and National Accreditation Program for Breast Cancer [NAPBC]) who chose to participate in Just ASK, a national Quality Improvement (QI) initiative designed to improve smoking status assessment in community-based cancer care settings. Findings are important because they represent a systematic, organization-wide effort to engage a large, diverse, and nationally representative sample of cancer care facilities in an initiative to improve the quality of smoking assessment (and, ultimately, treatment delivery) among individuals diagnosed with cancer. The 2,000 programs invited to participate collectively provide treatment to approximately 70% of all newly diagnosed patients with cancer in the United States. With a 40% response rate (n = 762 accredited programs), this survey represents the largest study ever conducted examining tobacco use assessment, practice patterns, and barriers in clinical oncology settings.

The baseline data reported in the article were collected before implementation of the Just ASK QI initiative to allow for a comparison of future practice changes after implementation. After baseline completion, Just ASK participants received a practice change package that included a variety of resources to support the systematic assessment and documentation of tobacco use among patients with cancer who smoke, including webinars, virtual peer-to-peer support, and technical assistance. Once available, the postimplementation results will be useful for elucidating which approaches performed optimally in various settings. Importantly, it is highly likely that long-term sustainability will necessitate ongoing educational efforts, such as providing booster trainings. Sustained educational efforts are needed for maintaining the prioritization of smoking cessation, which becomes especially important because of the regular staff turnover rates in cancer care settings.⁵

It is notable that the reported baseline rates of routine initial smoking status assessment (90%) and documentation of smoking status (86%) were quite high. These results are consistent with findings from NCI cancer centers.⁶ However, most programs (54%) were unable to extract data from their electronic health records to report smoking prevalence among their patients. This discrepancy highlights that work is clearly needed to improve the accuracy of smoking status assessment and documentation. Furthermore, rates of repeat smoking status assessments were substantially lower (56%), which draws attention to an important target for improvement.

More than 3 decades ago, Fiore⁷ advocated that smoking status be conceptualized as the fifth vital sign and incorporated as a part of every clinical patient encounter. Given that the experience of being diagnosed with cancer and initiating treatment frequently motivates smoking cessation attempts, smoking status may change frequently during this period and should be conceptualized as dynamic, necessitating repeated assessment. This practice should help ensure that patients who smoke are accurately identified and offered tobacco cessation treatment at points in time when they are likely to engage in treatment. Initiatives such as Just Ask offer tremendous potential to ensure that patients with cancer who smoke are systematically identified and efficiently offered treatment in a standardized and sustainable way.

A related area that warrants careful attention is the degree to which patients may be underreporting their smoking in cancer care settings.^8,9 As elucidated in another recent study by Warner et al,¹⁰ patients with cancer endure significant feelings of shame and stigma associated with smoking, and this psychological burden may be intensified when seeking cancer care. Thus, improving both the quality and accuracy of smoking status assessment should be an important target for initiatives such as Just Ask.

The Just ASK initiative represents an essential first step in addressing smoking among patients with cancer. Progress in the careful, accurate, and systematic assessment and documentation of smoking will lay the groundwork for effectively and efficiently treating tobacco use among patients with cancer. Yet, the baseline survey results revealed that less than half of respondents reported assisting patients with quitting. This represents an important and persistent gap in the quality of cancer care, and resources and infrastructure will be needed to effectively close this gap. There is also a need to better understand potential inequities in access to, and engagement with, smoking cessation resources. Individuals with cancer who come from disadvantaged backgrounds may have greater challenges in accessing cessation resources because of various social determinants of health (eg, poverty, education level, housing). In addition, cultural or language barriers can result in disparities in communication between the health care team and patients, thus affecting the delivery of cessation services.

The breadth of the Just Ask QI initiative reported in this study highlights multiple important considerations. First, although the focus of Just ASK is on providing centralized tools and guidance to enhance the routine and systematic assessment and documentation of smoking status among patients in a variety of community cancer care settings, programs reported substantial difficulty related to assisting patients with quitting smoking and connecting them with tobacco cessation treatment resources. Key barriers cited included a lack of staff training in how to assist patients with tobacco cessation, inadequate resources, and perceived patient resistance. These barriers are challenging and will require substantial resources and planning to effectively address.

One potential solution to addressing barriers could involve providing a standardized set of tobacco cessation resources to community cancer care practices through a virtual, centralized resource. State quitlines offer one such resource, but utilization rates are poor, and the efficacy of Quitline-delivered treatment among patients with cancer is unknown. The NCI has provided support to NCI-designated cancer centers to integrate tobacco treatment within the cancer care experience through its Cancer Center Cessation Initiative (C3I). Recently published data from 28 NCI-designated cancer centers participating in the C3I reflect limited reach and effectiveness, and characteristics associated with greater reach included having a higher smoking prevalence at the center, the availability of a center-wide tobacco treatment program, and a lower patient-to-tobacco treatment specialist ratio. In addition, centers that had a higher prevalence of smoking and reported use of a closed-loop electronic health record tobacco treatment referral system reported higher effectiveness.⁶ Given that a lack of dedicated resources and not having a tobacco treatment specialist (72%) were endorsed as important barriers to assisting patients with quitting in the study by Ostroff,⁴ virtually delivered, centralized tobacco cessation treatment resources may have tremendous potential to extend reach and improve the efficacy of tobacco treatment in community cancer practices. However, such a resource would likely need to incorporate some flexibility as approaches that work in one setting may not work in others, and some degree of personalization is likely needed.

A related issue that is of paramount clinical importance is the efficacy of existing tobacco cessation interventions among patients with cancer. A 2019 meta-analysis examining 21 randomized clinical trials published between 1993 and 2018 evaluated the efficacy of smoking cessation interventions for cancer survivors. The results indicated that these interventions have failed to demonstrate efficacy and that high-quality, effective interventions are critically needed, particularly for subpopulations at elevated risk. Specific recommendations included increasing the length and intensity of interventions and ensuring that nicotine replacement therapy is provided.¹¹ As new interventions are developed, it will be critical for researchers to carefully consider how to address implementation barriers in cancer care settings. A fundamental challenge is that available treatments may be perceived by patients as burdensome or unappealing, leading to a lack of engagement. Digital health interventions may hold great promise for improving reach and efficacy, yet, to date, supporting data—particularly among patients with cancer—are limited.

Taken together, this study identifies important barriers to facilitating smoking cessation among patients with cancer at the patient, provider, and system levels within real-world community practices. Participation in Just ASK fulfills accreditation standards for CoC or NAPBC, which represents a step in the right direction. Formal policies that dedicate resources to support the efficient delivery of evidence-based tobacco cessation treatments could also lead to meaningful improvement. Providing smoking cessation treatment for patients with cancer is a crucial component of cancer care. Meaningful change will only be possible through a multi-level, sustained commitment to addressing the problem.