To our knowledge, this study is the first to describe the smoking cessation beliefs and behaviors of a sample of U.S. oncology physicians and midlevel providers. Although most oncology providers reported advising patients to quit smoking, only 15%–30% reported providing interventions to assist their patients in smoking cessation. Providers reported moderate confidence and success in their counseling efforts. Up to 40% of clinicians stated that they lacked training in, forgot about, or did not know where to refer patients for further tobacco treatment. Our finding that providers who did not know where to refer provided more intervention may reflect more intervention efforts by those who perceived great need but few resources for smoking cancer patients. Our results are consistent with the findings of a national survey of non-oncology health care providers that also found relatively low rates of self-reported smoking cessation interventions by specialists (15%–29% of emergency medicine and 29%–64% of psychiatry providers [34
]). The results are also similar to a previous study of oncology nurses, which found limited knowledge and relatively low rates of tobacco cessation intervention and also identified perceived low patient motivation as a key barrier [35
It has recently been argued that oncologists have an ethical responsibility to strongly advise all their patients to quit smoking and to offer cessation treatment [36
]. The American Society of Clinical Oncology (ASCO) has also urged all oncologists to integrate tobacco cessation and control in their practices [37
] and has developed a tobacco control module in its Cancer Prevention Curriculum [38
]. Smoking status documentation and cessation counseling by the second visit are included as ASCO Quality Oncology Practice Initiative (QOPI) quality measures. The National Cancer Institute (NCI) recently sponsored a meeting on treatment of tobacco dependence at NCI-designated cancer centers [39
]. Recommendations from this conference included treating tobacco use as a “vital sign” on patient charts and implementation of evidence-based tobacco treatment guidelines in the oncology setting. Barriers identified qualitatively during this conference were confirmed by our survey (e.g., limited knowledge about tobacco treatment, perception that patients are not motivated to quit). However, our respondents placed less importance on other identified barriers (e.g., low prioritization of smoking by providers, lack of time, and lack of reimbursement) [39
The high perceived importance of smoking cessation but only moderate levels of confidence and perceived success among oncology providers in our sample suggest that provider education might increase the proportion of cancer patients who receive evidence-based treatment for tobacco cessation, especially because providers who expressed that lack of training was a barrier to offering tobacco interventions were significantly less likely to do so. Our data suggest that oncology providers are open to receiving such training. Rx for Change [40
], an online training program, offers a tailored program targeted to cancer care providers drawing on the Public Health Service (PHS) guidelines [22
A recent meta-analysis suggests that even 3 minutes of provider advice and counseling may increase the odds of tobacco abstinence by 30% [22
]. However, in a study of physician-based intervention consisting of quit advice and assistance in 432 cancer patients, no significant differences emerged between the usual care and intervention groups at either 6 or 12 months, and quit rates were relatively low (12%–14%) [41
]. Physician-based interventions may need to be combined with higher-intensity behavioral and pharmacologic interventions to increase long-term cessation among cancer patients.
The PHS Guidelines also recommend the following system-level interventions: (a) implementing a tobacco-user identification system; (b) providing education, resources, and feedback to promote provider intervention; (c) dedicating staff to provide tobacco dependence treatment; (d) promoting policies that support services; (e) including evidence-based tobacco treatments as paid or covered services; and (f) reimbursing clinicians for delivery of evidence-based treatments. Research is needed to test whether these system-level strategies would effectively augment provider training in the oncology setting. Smoking cessation in the oncology setting has also been highlighted as an area for dissemination and implementation research in the cancer survivorship context [42
Although rates of documentation of smoking status at the initial visit were high, less than half of current or recent smokers had smoking status documented at one or more follow-up visits. This finding is consistent with our provider reports. Higher rates of smoking assessment documentation may have been related to use of clinic note templates that included a field for smoking history. Medical records do not indicate whether smoking status was actually assessed at follow-up rather than simply copied forward from a previous note. We found that smoking cessation interventions were documented in the charts of <20% of identified smokers at the initial visit. These data are very similar to those reported from oncology practices participating in the QOPI program, which found documentation of smoking cessation counseling in only 25% of smoking oncology patients [43
]. Lack of documentation does not mean lack of intervention, but documentation is necessary for reimbursement for smoking cessation counseling (allowable under new Medicare guidelines) and to ensure continuity between visits and among providers. Continuity is especially important for a condition like nicotine addiction, characterized by high rates of relapse and the need for multiple interventions to achieve lasting cessation.
Primary limitations of this study include collection of data at a single institution and exclusion of oncology nurses who may also provide smoking cessation advice and treatment [44
]. Although non-advanced practice nurses cannot be reimbursed for smoking cessation advice, they may offer more informal interventions to cancer patients. At the time of the survey, there was not a formal tobacco dependence treatment program for cancer patients at the surveyed institution. The results of this survey would likely not generalize to institutions with more comprehensive treatment programs in place. Our response rate, while modest, mirrors other non-oncology physician study samples on this topic [34
]. Future studies should include a national sample of outpatient oncology providers (physicians, physician assistants, and nurses) and examine both local and national provider training efforts. In addition, future studies should examine the frequency and types of tobacco cessation interventions delivered to hospitalized oncology patients.
National data suggest that 40% of smoking cancer survivors report a quit attempt in the prior year [24
], but their success at achieving lasting cessation may be limited without effective treatment. Both physician training and clinic-based systems for tobacco treatment could improve rates of delivery of empirically supported tobacco dependence treatments in the outpatient oncology setting, ultimately improving the health and well-being of oncology patients who smoke. These survey data suggest clear opportunities for oncology healthcare providers to encourage and assist patients in smoking cessation efforts that will likely have an impact on treatment-related outcomes.