Highlights
A smoking cessation initiative embedded into routine oncology care achieved a 100% tobacco-use screening rate among 667 newly diagnosed cancer patients by using a mandatory electronic medical record hard stop.
Among 111 identified smokers, cessation assistance was delivered to 41 patients, yielding assist rates that varied from 35% to 54% over time, despite standardized workflows and referral tools.
The intervention combined brief screening, quit kits, Quitline referral, in-person cessation classes, and follow-up calls from certified smoking cessation facilitators.
The project illustrates a familiar implementation challenge in cancer care: systematic identification of smokers is feasible, but converting identification into timely treatment remains operationally difficult without optimized workflows, dedicated personnel, and strong clinician engagement.
Background
Tobacco use after a cancer diagnosis is associated with worse treatment outcomes, higher treatment toxicity, increased risk of recurrence, second primary malignancies, and reduced overall survival. Continued smoking can also impair wound healing, reduce the efficacy of radiation and systemic therapy, and worsen symptom burden. For these reasons, smoking cessation is increasingly regarded not as an optional wellness service but as a core component of cancer treatment.
The quality improvement project reported by Astarita and Fitzgerald arose from a local and national care gap. At the local level, Harford County had persistently higher smoking rates than the state of Maryland, while public health cessation resources were diminishing. At the health-system level, gaps had been identified in routine provider-patient conversations about smoking status and readiness to quit. These are common barriers in oncology practice, where time constraints, fragmented workflows, and competing clinical priorities often displace behavioral interventions despite their importance.
The initiative was aligned with the American College of Surgeons Commission on Cancer tobacco treatment framework, including the Just ASK and Beyond ASK efforts. These programs emphasize that every cancer patient should be asked about tobacco use, advised to quit, and connected with evidence-based support. The central clinical question for this project was not whether tobacco treatment matters, but how to operationalize it reliably across routine care settings in a community cancer program.
Proposed Article Structure
This topic is best addressed through a clinically oriented implementation framework: background and rationale; project design and workflow; key outcomes with emphasis on screening and assistance rates; interpretation in the context of oncology quality standards; implementation barriers and facilitators; and practical implications for cancer programs seeking to build or strengthen tobacco treatment services.
Project Design and Intervention
Setting and population
The University of Maryland Upper Chesapeake Health Center integrated smoking cessation support into care for newly diagnosed cancer patients across several clinical sites, including the breast center, radiation oncology, and thoracic surgery. The target population was all new patients entering the cancer program, reflecting a broad real-world oncology population rather than a narrow disease-specific cohort.
Workflow redesign
The intervention centered on three linked steps: identify, briefly intervene, and refer. A standardized two-question tobacco screening tool was embedded into the electronic medical record intake workflow. Medical assistants and nurses administered the screening during routine rooming or intake. A key implementation feature was the electronic hard stop, which required completion of smoking-status documentation before the workflow could proceed.
Patients who indicated readiness to quit received a quit kit. This kit included educational materials, cessation aids, information on lung cancer screening, and referral information for Maryland Quitline services and on-site cessation classes. The intervention therefore moved beyond simple advice and attempted to provide actionable treatment resources at the point of care.
Additional support came through follow-up phone calls conducted by certified smoking cessation facilitators. These calls were intended to reinforce education, assess motivation, and provide ongoing encouragement. This step is important because tobacco dependence is a chronic relapsing condition, and brief in-clinic advice alone is often insufficient to sustain abstinence.
Quality improvement orientation
This was a quality improvement project rather than a randomized trial. There was no comparator group, and outcomes were assessed primarily as implementation metrics: screening completion, assistance rates, and patient-reported behavior change in post-project phone surveys. The design is therefore most useful for understanding feasibility, workflow performance, and health-system barriers rather than for estimating the causal effect of the intervention on long-term smoking abstinence.
Key Results
Universal tobacco screening was achieved
The most striking finding was the 100% ask rate among 667 new patients. This result strongly suggests that electronic workflow design can overcome one of the most common failures in tobacco treatment delivery: inconsistent identification of current tobacco use. The hard stop in the electronic medical record appears to have been the main driver of this success.
From an implementation standpoint, this is highly relevant. In many oncology practices, screening rates depend heavily on clinician enthusiasm or local culture and can fluctuate substantially. Here, the system design produced a reliable behavior across clinics and staff roles. That is an important lesson for quality improvement leaders: when tobacco assessment is treated as discretionary, performance often lags; when it is embedded as a required element of intake, reliability improves dramatically.
The assist rate remained modest and variable
Among the 667 screened patients, 111 were identified as smokers. Of these, 41 received cessation assistance. The reported assist rate varied over time, ranging from 35% to 54%. This is the central implementation gap exposed by the project. In other words, asking was successfully routinized, but assisting remained less dependable.
This pattern is not surprising. Screening is a relatively simple task that can be standardized with a binary workflow requirement. Assistance is more complex. It may require readiness assessment, counseling, provision of materials, referral completion, documentation, and follow-up coordination. Each step introduces opportunities for drop-off. The project demonstrates that building a tobacco treatment pathway requires more than screening infrastructure; it requires robust downstream operational support.
Patient-reported improvement signals potential benefit
Post-project phone surveys indicated that more than half of patients who received quit kits reported reduced or discontinued tobacco use. This is encouraging, particularly in a population newly confronting cancer treatment. However, the result should be interpreted cautiously. The abstract does not provide the number of patients reached by survey, the timing of follow-up, biochemical validation, or durable abstinence endpoints such as 6-month or 12-month quit rates.
Even so, from a pragmatic care-delivery perspective, self-reported reduction or cessation suggests that at least some patients engaged meaningfully with the intervention. In quality improvement work, such patient signals can justify continued investment while more rigorous outcome tracking is developed.
Clinical Interpretation
The project’s main contribution is practical rather than statistical. It shows that cancer programs can reliably normalize tobacco-use assessment across multiple clinics when the process is embedded in intake and supported by executive leadership. It also shows that universal screening does not automatically translate into universal treatment, even when cessation support materials and referrals are available.
For oncology clinicians, the take-home message is that tobacco treatment should be approached like any other supportive cancer intervention. Identification is analogous to diagnosis; assistance is analogous to treatment initiation. A health system that excels at the first but inconsistently delivers the second has only partially implemented care.
The findings also reinforce an important concept in guideline-concordant cancer care: smoking cessation should be framed as a treatment modality. This wording matters. When tobacco treatment is discussed as part of the anticancer plan, rather than as a lifestyle add-on, both staff and patients may view it as more urgent and legitimate.
Strengths of the Initiative
Strong alignment with established oncology quality standards
The project was clearly linked to Commission on Cancer tobacco treatment expectations. That alignment improves the relevance of the work for other accredited cancer programs.
Multidisciplinary and cross-clinic implementation
The intervention crossed several service lines, including surgical, radiation, and breast oncology settings. This broader scope increases its real-world applicability.
Pragmatic use of existing staff and workflows
Using medical assistants and nurses for intake screening reflects operational realism. Many programs do not have dedicated tobacco treatment specialists in every clinic, so designing workflows around existing personnel is often necessary.
Combination of point-of-care and follow-up support
The intervention included both immediate resources and subsequent outreach by certified facilitators. This layered model is more consistent with the chronic nature of tobacco dependence than a one-time brief intervention alone.
Limitations and Implementation Barriers
No control group and limited outcome granularity
Because this was a quality improvement project without a comparator, one cannot determine how much of the observed behavior change was attributable to the intervention itself. The absence of detailed cessation endpoints, response denominators, and long-term follow-up limits conclusions about clinical effectiveness.
Electronic medical record constraints
The abstract identifies workflow limitations and delayed, manual reporting as persistent problems. This is a common health-system challenge. An electronic health record can enforce screening, but if referral tracking, closed-loop follow-up, and reporting dashboards are poorly designed, treatment delivery remains hard to monitor and improve.
Leadership turnover and absent physician champion
Leadership instability and lack of a physician champion likely contributed to inconsistent assistance rates. In implementation science, local champions frequently determine whether a project becomes embedded or remains peripheral. This may be especially true in oncology, where competing clinical priorities are intense and where physician endorsement can influence team behavior and patient uptake.
Competing demands in busy cancer clinics
New cancer consultations are information-dense and emotionally charged. Even highly motivated staff may struggle to prioritize cessation counseling amid treatment planning, consent discussions, symptom assessment, and psychosocial needs. The variable assist rate in this project likely reflects this reality.
Context From Guidelines and Prior Literature
Major oncology and public health authorities have consistently recommended routine, evidence-based smoking cessation treatment for patients with cancer. The U.S. Public Health Service clinical practice guideline established the effectiveness of counseling and pharmacotherapy for tobacco dependence. More recently, oncology-specific initiatives have emphasized systematic integration of cessation support into cancer care pathways.
The National Comprehensive Cancer Network recommends that all patients with cancer be assessed for tobacco use and offered evidence-based cessation interventions, including behavioral counseling and FDA-approved pharmacotherapy when appropriate. Similarly, the American Society of Clinical Oncology has stated that addressing tobacco use should be part of standard oncology practice. The present quality improvement project is therefore well aligned with current professional expectations.
Importantly, prior implementation work across NCI-designated cancer centers and community oncology settings has shown similar patterns: tobacco-use assessment is often easier to standardize than treatment engagement. Common obstacles include lack of staffing, limited clinician training, inconsistent referral systems, and inadequate EHR functionality. In that sense, the Maryland experience is not an outlier; it is a representative example of the last-mile problem in tobacco treatment delivery.
Implications for Practice
What cancer programs can learn
First, make screening mandatory and simple. The hard stop worked. Second, reduce friction in the assist step. Referral pathways should be automatic where possible, with prebuilt order sets, templated counseling documentation, and direct electronic links to Quitline or internal services. Third, identify ownership. A physician champion, nurse leader, or dedicated tobacco treatment coordinator can help sustain momentum. Fourth, build reporting tools that allow near-real-time review of ask, advise, assist, and follow-up metrics.
How to strengthen the next phase
Programs seeking to improve beyond screening should consider adding default pharmacotherapy workflows, warm handoffs to cessation specialists, opt-out referral models, and structured follow-up intervals. Measuring meaningful outcomes will also matter. In addition to process indicators, programs should track quit attempts, 30-day abstinence, 6-month abstinence, treatment uptake, and referral completion.
There is also a case for integrating tobacco treatment more tightly with disease-specific pathways. For example, thoracic surgery and radiation oncology clinics may be ideal sites for intensified intervention because the harms of continued smoking may be more directly linked to procedural risk, radiation tolerance, and lung cancer outcomes.
Conclusion
Astarita and Fitzgerald describe a pragmatic and clinically important quality improvement initiative that successfully normalized tobacco-use screening in a cancer program. The 100% ask rate demonstrates the power of electronic workflow design and organizational commitment. At the same time, the modest and fluctuating assist rate reveals the harder challenge: transforming identification of smokers into consistent, durable tobacco treatment delivery.
The project’s value lies in its honesty about implementation barriers and its relevance to everyday oncology practice. For cancer programs, the message is clear. Tobacco treatment can be embedded into routine care, but success depends on more than asking the question. It requires operational infrastructure, accountable leadership, clinician engagement, and systems that support not only screening but treatment initiation and follow-up. In cancer care, smoking cessation is not ancillary care. It is part of the treatment plan.
Funding and Trial Registration
No funding information or ClinicalTrials.gov registration number is provided in the abstract. This is consistent with a local quality improvement project rather than a registered interventional clinical trial.
References
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