Implementing Smoking Cessation Interventions for Tobacco Users Within Oncology SettingsA Systematic Review

Question  What are the implementation strategies associated with improved screening, advice-giving, and referral in oncology settings and changing the smoking behaviors of tobacco users recently diagnosed with cancer?

Findings  This systematic review of 43 articles found that the strategy associated with a change in smoking behavior and attitudes was to identify a trained tobacco specialist who could assist patients in achieving abstinence, and it was found that standardizing screening and advice can be improved by modifying electronic record systems. Clinicians must be trained and educated; relationships with implementation stakeholders must be developed to make referral systems associated with positive outcomes.

Meaning  A program that supports and educates clinicians, reshapes infrastructure, and builds relationships with implementation stakeholders can improve screening, advice, and referrals; this systematic review is an example of the methodological synthesis of implementation science research more broadly.

Importance  Patients with cancer who continue to smoke tobacco experience greater treatment-related complications, higher risk of secondary cancers, and greater mortality. Despite research to improve smoking cessation care within clinical oncology, implementation of proposed interventions within routine care remains challenging.

Objective  To identify and recommend implementation strategies for smoking cessation interventions associated with improved screening, advice-giving, and referral for tobacco users recently diagnosed with cancer, as well as shifting smoking behaviors and attitudes in this patient population.

Evidence Review  MEDLINE, CINAHL, Embase, and PsycINFO databases, as well as Google Scholar, were searched for articles published before September 7, 2020, using terms related to cancer, smoking cessation, and implementation science. Outcomes of interest were study characteristics, implementation strategies, and outcome measures (screening, advice, referral, abstinence rates, and attitudes). The Cochrane Risk of Bias Tool for randomized and nonrandomized studies was used to assess bias. The review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and Synthesis Without Meta-analysis (SWiM) guideline. Implementation strategies were categorized according to Expert Recommendations for Implementing Change (ERIC) study taxonomy. A systematic analysis was conducted focusing on studies with low or moderate risk of bias due to high heterogeneity in outcome measurement.

Findings  In total, 6047 records were screened, yielding 43 articles (10 randomized clinical trials and 33 nonrandomized studies). Four strategies were associated with improved screening, advice-giving, and referral: (1) supporting clinicians, (2) training implementation stakeholders (including clinicians), (3) changing the infrastructure, and (4) developing stakeholder interrelationships.

Conclusions and Relevance  In this systematic review, supporting clinicians by providing cessation care through a trained tobacco specialist was identified as important for achieving short-term abstinence and changing attitudes among patients with cancer. Combined with a theoretical framework and stakeholder involvement, these strategies provide the basis for successful implementation of cessation support; this systematic review serves as an illustration of the methodological application and synthesis of implementation studies and other medical conditions more generally.