Across the United States, approximately one-third of all cancer deaths are attributed to smoking. In addition to the carcinogens found in tobacco products, continued smoking after a cancer diagnosis can complicate cancer treatments by interacting with medications, increasing the risk of treatment side effects, and increasing the healing time overall. So, when a person who smokes is diagnosed with cancer, it is essential that they stop as soon as possible to improve their response to treatment, reduce the risk of developing a secondary cancer, and improve survival.
However, quitting smoking can be challenging. Most people try multiple times to quit before they are successful, and treatment increases the likelihood of success. As part of a National Cancer Institute (NCI) Moonshot P30 Supplement, the Stanford Cancer Center received funding to integrate tobacco treatment into cancer care. With a menu of telehealth treatment options, including counseling, cessation medications, and digital health programs, patients and their family members have access to resources to aid them in their journey to get free from tobacco.
“Our quality improvement (QI) project is a merging of the best of clinical service, education, and outcomes evaluation,” said SCI member Judith Prochaska, PhD, MPH, Professor of Medicine and Director of Tobacco Treatment Services. “We provide personalized treatment at no cost to patients and their families, and our tobacco quit rates at two-year follow-up are best in class.”
When the QI project was first initiated in 2018, Stanford’s pre-existing service for addressing tobacco was largely volunteer-oriented and lacked a systematic approach. At the time, less than 1% of patients who reported tobacco use engaged in treatment. Barriers to participation included distance to the clinic, a reliance on clinician referrals, and lack of insurance coverage. When Stanford received NCI funding, joining a community of comprehensive cancer centers across the country, the team was able to develop a new model for outreach, engagement, and evaluation, diversifying treatment options for patients and extending care to their families.
In collaboration with Cindy Tran, MPH, Ashley Bragg, and Rachelle Mirkin, MPH of Stanford Health Care’s Health Education and Engagement Program (HEEP), the team studied workflows in Stanford’s cancer care clinics and obtained buy-in from leadership to shift from an opt-in to an opt-out model. Instead of relying on referrals from busy clinicians, the team’s tobacco treatment specialist Ann Cao-Nasalga, MBA, TTS pro-actively calls all patients seen for cancer care who report tobacco use to their provider. To remove travel barriers, the team implemented a telehealth platform for counseling and cessation medication consultations. The funding allowed for the team to provide treatment as a covered benefit, removing cost as a barrier to access.
To personalize treatment and enrich clinical training for future psychologists, the team partners with the PGSP-Stanford PsyD Consortium. Prochaska supervises the predoctoral students who provide individual, family, and group tobacco treatment counseling. The treatment team includes addiction medicine psychiatrists Michael Polignano, MD, and Smita Das, MD, PhD, MPH. Amy Chieng leads the evaluation of patient-reported outcomes. Most notably, patient engagement rates have skyrocketed from 1% to over 40% in just a few years, and one in three patients report being tobacco-free at two-year- follow-up.
“One of the reasons we’ve been so successful is because of the person-to-person contact that our service offers,” Prochaska remarked, citing the project’s emphasis on individual and group counseling, as opposed to a patient receiving automated outreach and referral through the form of robocalls.
The project has received positive feedback from its participants. Seven out of ten participants would recommend the program to others. While cigarettes are the leading form of tobacco use, the program also treats patients for nicotine vaping, cigar use, and smokeless tobacco product use.
Currently, the team is looking to expand the treatment program to other Stanford Health Care locations, such as Tri-Valley and Emeryville, with the ultimate goal of delivering tobacco treatment to patients at Stanford Health Care enterprise-wide.
Tobacco treatment programs and services are offered to all Stanford Health Care patients who live in California. If you are a patient of the Stanford Cancer Center or the parent or spouse of a Stanford Cancer Center patient, you also have access to tobacco treatment services. If you do not live in California, resources include your state quitline (1-800-QUIT-NOW) and the National Cancer Institute’s www.tobaccofree.gov website.