Improving Tobacco Treatment Rates for Outpatient Cancer Patients Who Smoke
Improving Tobacco Treatment Rates for Outpatient Cancer Patients Who Smoke
The main purpose of this research study is to evaluate the effectiveness of "nudges" to
 clinicians, to patients, or to both in increasing Tobacco Use Treatment Service (TUTS)
 referral and engagement; and to explore clinician, patient, inner setting (e.g., clinic), and
 outer setting (e.g., payment structures) mechanisms related to TUTS referral and engagement.
 The investigators will employ rapid-cycle approaches to optimize the framing of nudges to
 clinicians and patients prior to initiating the trial and mixed methods to explore contextual
 factors and mechanisms.

 The investigators will conduct a four-arm pragmatic cluster randomize clinical trial to test
 the effectiveness of nudges to clinicians, nudges to patients, or nudges to both in
 increasing TUTS referral and engagement in cancer patients who smoke, vs. usual care (UC).
 The investigators hypothesize that each of the implementation strategy arms will
 significantly increase TUTS referral and engagement compared to UC and that the combination
 of nudges to clinicians and to patients will be the most effective.
Continued tobacco smoking negatively impacts survival among patients with cancer. Routinely
 delivered evidence-based tobacco use treatment (TUT) would minimize cancer-specific and
 all-cause mortality, reduce treatment-related toxicity, and improve quality of life. About
 50% of cancer patients who smoked prior to their diagnosis continue to smoke after diagnosis
 and during treatment. The National Comprehensive Cancer Network, American Society of Clinical
 Oncology, and American Association for Cancer Research, call for implementation of TUT within
 oncology care. In 2015, TUT received an "A" recommendation from the US Preventive Services
 Task Force, given the high level of certainty of resulting benefit. The approval specifically
 focused on clinicians asking all adults about smoking, prescribing FDA-approved cessation
 medications for smokers, and offering appropriate behavioral interventions.

 Despite the importance of TUT, only half of cancer centers consistently identify patient
 tobacco use, and few cancer centers employ systematic mechanisms to refer patients to
 evidence-based cessation services. Acknowledging this gap, the National Cancer Institute
 (NCI) launched the Cancer Center Cessation Initiative (C3I) as part of the Moonshot to help
 centers develop effective ways to identify and engage patients who smoke. Penn ISC3 MPI Dr.
 Schnoll was a member of the NCI advisory board that developed this initiative, and Penn
 Medicine's Abramson Cancer Center (ACC) was in the first funded cohort. Because clinician
 expertise in TUT is a known barrier, the initial strategy used an automatic "default"
 electronic medical record (EMR) referral to the ACC Tobacco Use Treatment Service (TUTS).
 Engagement increased, but clinicians turned off the default 60% of the time, implicating
 additional important barriers to change.

 This study aims to produce dramatic change within oncology by refining and testing
 implementation strategies informed by behavioral economics. The investigators' work has
 identified specific cognitive biases among clinicians and patients that prevent TUTS referral
 and engagement, including clinician pessimism regarding the ability to help patients stop
 using tobacco, misconceptions about patient resistance to treatment, and implicit biases
 regarding the capacity for patients to volitionally alter the course of illness. These
 motivators are related to clinician willingness to invest effort in help giving and may
 prevent acquisition of new knowledge and skills. From the patient perspective, several
 studies identify unique challenges that individuals with cancer face when engaging in tobacco
 cessation efforts, including low self-efficacy, low perceived benefits of quitting, and
 perceived risk of treatment. Thus, this study focuses on addressing these barriers, in a
 pragmatic and innovative way, to increase TUTS referral and engagement in cancer care.

 The investigators' objectives are to evaluate the effectiveness of "nudges" to clinicians, to
 patients, or to both in increasing in TUTS referral and engagement; and to explore clinician,
 patient, inner setting (e.g., clinic), and outer setting (e.g., payment structures)
 mechanisms related to TUTS referral and engagement. The investigators will employ rapid-cycle
 approaches to optimize the framing of nudges to clinicians and patients prior to initiating
 the trial and mixed methods to explore contextual factors and mechanisms.

 The investigators will conduct this study with 100 clinicians and 900 smokers across Penn
 Medicine's ACC. They expect the study to yield essential insights into the effectiveness of
 nudges as an implementation strategy to speed the uptake of high value evidence-based TUT
 within cancer care, and to advance the understanding of the multilevel contextual factors
 that drive response to these strategies. These results will lay the foundation for how cancer
 care settings can ensure that patients with cancer who smoke are engaged with evidence-based
 TUT and may lead to a future R01 focused on scaling-up this approach across other cancer
 centers involved in the C3I.
Inclusion Criteria:

 Clinician participants must meet the following criteria for enrollment:

 1. Currently in practice at an Implementation Lab site (UPHS)

 2. Prescribing authority in Pennsylvania (i.e., physician, nurse practitioner, physician
 assistant)

 3. Cared for at least 1 tobacco-using patient in 30 days prior to recruitment

 4. English-speaking (messages will be in English)

 Patient participants must be diagnosed with cancer and report current tobacco smoking (as
 assessed by an MA during an Index Visit).