Exploring Practices for Implementing Smoking Cessation in Oncology Settings: A Rapid Systematic Review Update

Abstract

Introduction

Smoking cessation among individuals with cancer increases the effectiveness of cancer treatments and reduces the risks of death. However, individuals receiving cancer treatments in Ontario’s 14 regional cancer centres are provided advice on the benefits of quitting smoking and referrals to smoking cessation treatments at different rates. This rapid systematic review was conducted, with funding from the Canadian Cancer Society, to update a published systematic review (Young et al, 2023) and to (1) identify implementation strategies and related implementation outcomes used in oncology settings; (2) describe the characteristics of these implementation strategies and implementation outcomes; and (3) determine whether specific implementation strategies are associated with increased smoking cessation efforts, referred to as the 3As (Ask, Advise, and Act) approach to smoking cessation.

Methods

This rapid systematic review was registered in The International Prospective Register of Systematic Reviews (registration number CRD42023491391). Three databases were searched for relevant studies: MEDLINE, Embase, and Cochrane Library. The quality of included studies was assessed based on their study design and narrative synthesis was used to summarize the data extracted.

Results

3158 studies were found, and eighteen new studies met our inclusion criteria. All eighteen studies had a low to moderate risk of bias. The implementation strategies training and educating stakeholders, using evaluative and iterative strategies, providing interactive assistance, supporting clinicians, and developing stakeholder interrelationships were associated with increased asking, advising, and acting, although these associations do not imply causality. Only 5 studies measured implementation outcomes; however, heterogeneity in the measurement tools used prevented analysis.

Conclusion

Although abundant data on implementation strategies was found, implementation outcomes were sparse and connections between the implementation strategies and implementation outcomes could not be drawn. Future studies should pilot the implementation strategies associated with increased asking, advising, and acting, and measure their success, considering both implementation strategies and implementation outcomes, as this information is lacking in the current literature.

Plain Language Summary

Strategies for helping individuals with cancer stop smoking: Smoking increases the likelihood of treatment-related complications, additional cancers, and poorer survival for individuals with cancer. However, helping individuals with cancer stop smoking can improve the effectiveness of cancer treatment and survival. Specifically, the treatment approaches for individuals with cancer vary across cancer settings. While strategies to support smoking cessation in individuals with cancer are available, there remains a gap between recognizing the benefits of smoking cessation in such individuals and its clinical implementation in cancer settings. This gap is known as the knowing and doing gap in implementation science and can be examined using an implementation science perspective. In our rapid systematic review, we explored strategies to help individuals with cancer stop smoking. We searched three literature databases and included 18 studies. Our findings suggest that strategies incorporating training and education, evaluations, interactive assistance, support, and relationship-building with care partners, including healthcare providers and individuals with cancer, could help individuals with cancer stop smoking. This rapid systematic review contributes to the growing literature looking to understand how to successfully implement smoking cessation in cancer settings. Future treatment approaches should integrate the identified strategies to support individuals with cancer who smoke in cancer settings and measure their success using relevant implementation science frameworks.

Introduction

Continued tobacco use after a cancer diagnosis increases the risks of treatment-related complications and secondary cancers and leads to poorer survival. ¹ Smoking cessation in individuals with cancer increases the effectiveness of cancer treatments and reduces the risks of death by 30%-40%. ² For some diagnoses, the benefits of smoking cessation may be equal to or greater than cancer treatments. ²

Many guidelines, including those from the National Comprehensive Cancer Network, ³ Ontario Health Cancer Care Ontario, ⁴ and the Canadian Partnership Against Cancer ⁵ recommend the delivery of evidence-based smoking cessation treatments to all individuals with cancer. Evidence-based smoking cessation treatments include combinations of behavioural counselling, such as individual, group, and telephone counselling, and pharmacotherapy, including nicotine replacement therapy, varenicline, and bupropion. ⁶

In Ontario, Canada, Ontario Health Cancer Care Ontario oversees cancer care delivery and has advised Ontario’s 14 regional cancer centres since 2017 to follow the 3As (Ask, Advise, and Act) approach to smoking cessation. ⁷ The 3As approach to smoking cessation involves asking new individuals receiving ambulatory cancer treatment at Ontario regional cancer centres about their tobacco use (Ask), advising all current or recent tobacco users on the benefits of quitting smoking (Advise), and referring all current or recent tobacco users to evidence-based smoking cessation treatments (Act). ⁷ The 3As approach to smoking cessation established a guideline; however, Ontario regional cancer centres were afforded flexibility in how the 3As were implemented, within their resource limitations. ⁷

Considerable variation exists among Ontario’s 14 regional cancer centers in the rates of asking (63% [Range: 44%-100%]), advising (69% [Range: 17%-100%]), and acting (60% [Range: 18%-82%]). ⁸ In Ontario, only 22% [Range: 7%-53%] of individuals receiving cancer treatment at regional cancer centres accepted referrals to evidence-based smoking cessation treatments. ⁸ Therefore, despite the existence of effective evidence-based smoking cessation treatments and guidelines for use in cancer care, an implementation gap remains. This gap is not unique to Ontario; shortcomings in the delivery of smoking cessation are found globally.^9,10

Consequently, numerous studies have been conducted to explore which strategies support the successful implementation of smoking cessation in oncology settings. In other words, what actions can be taken to support the delivery of smoking cessation for individuals with cancer? Our research team acknowledges that the term stakeholder(s) is inappropriate and will refrain from using it, except when referencing established frameworks. In 2023, a systematic review was published by Young et al., ¹ which revealed that the implementation strategies supporting clinicians, training and educating stakeholders, changing infrastructure, and developing stakeholder interrelationships, improved the delivery of smoking cessation for individuals with cancer.

Their systematic review included studies published up to September 7, 2020, ¹ and as such does not address any changes in healthcare delivery following the declaration of COVID-19 as a pandemic in March 2020. ¹¹ During the COVID-19 pandemic, identifying and implementing strategies for delivering optimal healthcare to individuals with cancer while managing the pandemic response emerged as a public health priority. ¹² Although the Young systematic review ¹ was published in 2023, it only included studies up to 2020 and does not capture the potential impact the COVID-19 pandemic had on healthcare delivery. Notably, the COVID-19 pandemic accelerated the adoption of digital health tools and forced adaptations in healthcare delivery, particularly in oncology settings. ¹³ Given the potential for new implementation strategies in response to these changes, we conducted a rapid systematic review to efficiently update the evidence base. We decided to conduct a rapid systematic review, as its methodology, allowed us to balance methodological rigour with the need to deliver timely, relevant findings to Ontario Health Cancer Care Ontario and our funder, the Canadian Cancer Society.

The specific aims of our rapid systematic review are to update a systematic review published in 2023 by Young et al. ¹ and to (1) identify implementation strategies and related implementation outcomes used in oncology settings; (2) describe the characteristics of these implementation strategies and implementation outcomes; and (3) determine whether specific implementation strategies are associated with increased smoking cessation efforts, referred to as the 3 As approach to smoking cessation.

Methods

This rapid systematic review was conducted following directives from the Cochrane Rapid Reviews Methods Group, ¹⁴ the World Health Organization’s practical guide for rapid reviews, ¹⁵ and the reporting standards outlined in the Preferred Reported Items for Systematic Reviews and Meta-Analyses statement. ¹⁶ This rapid systematic review was registered in The International Prospective Register of Systematic Reviews (registration number CRD42023491391). This rapid systematic review did not require research ethics board approval because we used published data, not collected by our research team. No data was collected from human participants and informed consent was not required.

Eligibility Criteria

Searches were limited to peer-reviewed, empirical research published in English between September 8, 2020, and August 1, 2023. This extended beyond the timeframe covered in the Young systematic review ¹ (Inception-September 7, 2020). The research question was developed using the population, intervention, comparison, and outcome framework.

• Population: Healthcare providers or individuals with cancer who smoke in oncology settings.

• Intervention: Implementation strategies and implementation outcomes for implementing smoking cessation.

• Comparison: Other implementation strategies and implementation outcomes or no comparison.

• Outcome: Implementation strategies organized using the Expert Recommendations for Implementing Change (ERIC) strategies ¹⁷ ; implementation outcomes organized using the framework presented by Proctor et al. ¹⁸ and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework ¹⁹ .

Exclusion Criteria

1. Studies published before September 8, 2020.

2. Non-English language studies.

3. Non-peer-reviewed studies.

4. Non-empirical study designs, including reviews, meta-analyses, protocols, abstracts, conference papers, book chapters, thesis dissertations, case reports, case series, editorials, and commentaries. Protocols were excluded to prioritize a streamlined approach aligned with the objectives of rapid systematic reviews. While protocols might outline implementation strategies, implementation outcomes and changes in asking, advising, and acting are not included, as their data has not yet been collected.

5. Cross-sectional study designs. Cross-sectional studies were excluded to prioritize a streamlined approach aligned with the objectives of rapid systematic reviews.

6. Studies of healthcare providers and individuals with cancer who smoke in non-oncology settings.

7. Studies where implementation strategies and implementation outcomes were not listed.

Information Sources and Search Strategy

The search strategy was replicated from search strings provided in the Young systematic review ¹ and carried out by our research team, with guidance from an academic librarian at the Centre for Addiction and Mental Health. Three databases were searched for relevant studies: MEDLINE, Embase, and Cochrane Library. Search terms included cancer, smoking cessation, and implementation science. The final search for studies published between September 8, 2020, and August 1, 2023, was conducted in November 2023. All studies were imported into Covidence for title and abstract screening, full-text review, data extraction, and quality assessment. For studies where the timeframe was unavailable, we contacted the corresponding author twice via email. The search strategy and inclusion and exclusion criteria are defined in S1 Table and S2 Table, respectively.

Study Selection Process

Following guidance on rapid systematic reviews from the Cochrane Rapid Reviews Methods Group, a pilot calibration exercise was conducted among reviewers (I.D., S.P., N.L., B.W.) at all stages, including the title and abstract screening, full-text screening, data extraction, and quality assessment. ¹⁴ Any discrepancies were discussed until a consensus was reached. For the pilot calibration exercise, all reviewers conducted title and abstract screening on 50 studies and conducted full-text screening on 5 studies. Two reviewers (S.P.) and (N.L.) independently screened 493 studies. One reviewer (N.L.) screened the remaining abstracts and a second reviewer (S.P.) screened all excluded abstracts by the first reviewer. One reviewer (N.L.) screened the remaining full-text studies and a second reviewer (S.P.) screened all excluded full-text studies by the first reviewer. Any conflicts were resolved either through consensus among the 2 reviewers or by a third reviewer (N.M.).

Data Extraction

The data extraction template was guided by the Young systematic review. ¹ Extracted information included: Study characteristics, participant and sociodemographic characteristics, intervention characteristics, implementation strategies, implementation outcomes, and changes in asking, advising, and acting. Both the publication date and timeframe during which the study was conducted were recorded. Data was extracted by 1 reviewer (I.D.) and verified for accuracy and completeness by a second reviewer (S.P.). Any conflicts were resolved either through consensus among the 2 reviewers or by a third reviewer (N.M.).

Implementation strategies were organized using the ERIC strategies ¹⁷ which includes 73 strategies clustered into 9 domains: (1) Using evaluative and iterative strategies, (2) providing interactive assistance, (3) adapting and tailoring to context, (4) developing stakeholder interrelationships, (5) training and educating stakeholders, (6) supporting clinicians, (7) engaging consumers, (8) utilizing financial strategies, and (9) changing infrastructure. Implementation outcomes were organized using the framework presented by Proctor et al., ¹⁸ which includes acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability, as well as the RE-AIM framework. ¹⁹ Young’s systematic review ¹ extracted implementation strategies and clinical outcomes. Given our rapid systematic review methodology and implementation science focus, we did not extract clinical outcomes, such as smoking cessation rates or shifting attitudes/self-efficacy variables. We extracted implementation strategies and implementation outcomes.

Methodological Quality Assessment

The quality of the included studies was assessed based on their study design using the Joanna Briggs Institute (JBI) critical appraisal tools for cohort studies, ²⁰ qualitative research, ²¹ quasi-experimental research, ²⁰ and randomized controlled trials. ²² For mixed methods studies, we used the Mixed Methods Appraisal Tool. ²³ For quality improvement studies, we used the Quality Improvement Minimum Quality Criteria Set. ²⁴ When program evaluations were encountered, tools specific to the initial study design were used. For studies using the JBI critical appraisal tools, questions were excluded from the overall score if “Not applicable.” The overall score for studies using the JBI critical appraisal tools, Mixed Methods Appraisal Tool, and Quality Improvement Minimum Quality Criteria Set were calculated based on the percentage of “Yes/Met”, “No/Not met”, and “Unclear/Can’t tell” answers. Studies with an overall score of 70% and above were deemed low risk of bias, studies with a score between 50% and 69% were deemed moderate risk of bias, and studies with a score of 49% and below were deemed high risk of bias. The assessment was completed by 1 reviewer (I.D.) and checked for correctness and completeness by a second reviewer (S.P.).

Data Synthesis

We used narrative synthesis to summarize the data extracted, including the implementation strategies and implementation outcomes. ¹⁴ We only reported statistically significant increases in asking, advising, and acting.

Results

A total of 3158 studies were identified through 3 databases, MEDLINE (n = 1288), Embase (n = 1132), and Cochrane Library (n = 738). Of these 3158 studies, 18 met our inclusion criteria.^8,25-41 The preferred reporting items for systematic reviews and meta-analyses flow diagram is housed in Figure 1.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Flow Diagram

Study Characteristics

Studies were conducted in the United States of America (n = 14),^{25-27,29,30,32-40} Canada (n = 2),^8,28 Japan (n = 1), ³¹ and Australia (n = 1). ⁴¹ Both Canadian studies^8,28 were conducted in Ontario regional cancer centres. The study characteristics are found in S3 Table.

Although we searched for studies published between September 8, 2020, and August 1, 2023, this did not guarantee that studies were completed within this timeframe. Overall, 9 studies^{25,26,28-33,36} were conducted before COVID-19 was declared a pandemic in March 2020, 7 studies^{27,34,35,37-39,41} spanned the time before and after March 2020, 1 study ⁴⁰ was undertaken after March 2020, and 1 study ⁸ did not specify. For the 1 study that did not specify when it was undertaken, ⁸ we contacted the corresponding author twice over 2 weeks seeking information but received no response.

Studies employed various study designs, including quasi-experimental research (n = 6),^{25,27,31,32,35,36} mixed methods (n = 4),^26,29,39,41 quality improvement (n = 3),^8,28,38 qualitative research (n = 2),^37,40 economic evaluations (n = 1), ³⁰ cohort studies (n = 1), ³⁴ and randomized controlled trials (n = 1). ³³

Methodological Quality Assessment

All studies had a low to moderate risk of bias (n = 18)^8,25-41; 15 had a low risk of bias^25-33,36-41 and 3 had a moderate risk of bias.^8,34,35

Healthcare Providers and Patient Characteristics

Of the 18 studies, 11 mentioned the type of healthcare providers who delivered smoking cessation.^{8,25-28,33-35,38,40,41} Of these, 9 studies^{25-28,34,35,38,40,41} reported multidisciplinary teams. These teams included physicians, nurses, or allied health professionals; also mentioned were pharmacists, tobacco treatment specialists, medical assistants, radiation therapists, and smoking cessation champions. One study had psychologists delivering smoking cessation ³³ and another study had nurses. ⁴⁰

Most studies (n = 12)^{8,26-29,31,32,34-36,38,39} did not specify whether smoking cessation was tailored to individuals with specific cancer types. Among the 6 studies^{25,30,33,37,40,41} that did report on cancer type, all noted that healthcare providers worked in clinics treating multiple cancer types. Only 1 study ³³ reported on the individuals' cancer stages. The participant and sociodemographic characteristics are outlined in S4 Table.

Intervention Characteristics

Of the 18 studies included in this rapid systematic review, only 8 cited the approach to smoking cessation employed.^{8,25,27,28,31,36,37,40} The most common approach to smoking cessation was the 5As (Ask, Advise, Assess, Assist, and Arrange), ²⁸ which was used in 6 studies.^{8,25,27,31,36,37} The other 2 studies used the 3As approach to smoking cessation ²⁸ or the Ask-Advise-Connect ⁴⁰ The Ask-Advise-Connect approach to smoking cessation shares similarities with other approaches but was designed to connect individuals who smoke with treatment via automated electronic health record integration. ⁴²

Implementation Strategies

The most commonly used ERIC implementation strategies ¹⁷ clustered into 9 domains were training and educating stakeholders (78%, n = 14),^{8,25,27-36,38,41} followed by providing interactive assistance (72%, n = 13),^{8,25-30,33,35,36,38-40} using evaluative and iterative strategies (67%, n = 12),^{25-29,31,32,34,36,38,39,41} supporting clinicians (61%, n = 11),^{26-29,33-38,41} utilizing financial strategies (61%, n = 11),^{8,26,29,30,33-35,37,38,40,41} and developing stakeholder interrelationships (56%, n = 10).^{25,26,29,31,32,34,35,38,40,41} Other implementation strategies used included engaging consumers (33%, n = 6),^{8,26,33,35,38,41} adapting and tailoring to context (33%, n = 6),^{25,28,33,34,38,40} and changing infrastructure (11%, n = 2).^26,27 S5 Table provides a complete list of implementation strategies. Studies employed an average of 8 ERIC implementation strategies ¹⁷ (Range: 3-14).^8,25-41 Of the 73 implementation strategies outlined in the ERIC framework, ¹⁷ 36 were used in the included studies. S6 Table presents a pictorial summary of implementation strategies.

Implementation Outcomes

Most studies (72%, n = 13)^{8,25,26,28-30,32,33,35-39} did not measure implementation outcomes. Notably, none of the studies reported implementation outcomes organized using the framework presented by Proctor et al.. ¹⁸ Five studies^{27,31,34,40,41} measured implementation outcomes using the RE-AIM framework. ¹⁹ Of these, only 2 studies^31,40 examined all components of the RE-AIM framework. ¹⁹ All studies (5 out of 5) measured reach,^{27,31,34,40,41} 4 measured effectiveness,^27,31,34,40 3 measured adoption^31,40,41 and implementation,^31,40,41 and 2 measured maintenance.^31,40

For context, reach is the scope of individuals willing to participate in an intervention, including the number, proportion, and representativeness. ⁴³ Effectiveness refers to the implications that an intervention has on the outcomes of interest. ⁴³ Adoption is the number, proportion, and representativeness of settings (eg, institutions) and intervention agents (eg, healthcare providers) inclined to participate in an intervention. ⁴³ At the setting level, implementation refers to the extent to which intervention agents adhere to the intervention. ⁴³ At the individual level, implementation refers to clients’ use of intervention strategies. ⁴³ Finally, maintenance refers to the lasting effects of an intervention, at the setting and individual level. ⁴³ Given broad definitions, the studies identified aspects of the RE-AIM framework as relevant to their specific aims but were not necessarily specific to smoking cessation implementation. ¹⁹

Associations Between Implementation Strategies and Increases in Asking, Advising, and Acting

Six studies^{27,28,31,32,35,36} aimed to increase asking, of which 3 (50%)^27,32,36 demonstrated a statistically significant increase in asking. Of these 3 studies:

• All^27,32,36 described training and educating stakeholders which included conducting ongoing training, ²⁷ developing educational materials,^32,36 distributing educational materials, ³² conducting educational meetings, ³² and creating a learning collaborative. ³²

• All^27,32,36 described using evaluative and iterative strategies which included purposefully re-examining the implementation, ²⁷ assessing for readiness and identifying barriers and facilitators, ³² and auditing and providing feedback.^32,36

• Two (66%)^27,36 described providing interactive assistance which included facilitating^27,36 and centralizing technical assistance. ³⁶

• Two (66%)^27,36 described supporting clinicians which included facilitating the relay of clinical data to providers ²⁷ and reminding clinicians.^27,36

• One (33%) ³² described developing stakeholder interrelationships, specifically, using advisory boards and workgroups. ³²

• One (33%) ²⁷ described changing infrastructure, specifically, changing record systems. ²⁷

Five studies^{25,27,31,32,36} aimed to increase advising, of which 3 (60%)^31,32,36 demonstrated a statistically significant increase in advising. Of these 3 studies:

• All (100%)^31,32,36 described training and educating stakeholders which included developing educational materials,^31,32,36 distributing educational materials, ³² conducting educational meetings, ³² and creating a learning collaborative. ³²

• Three (100%)^31,32,36 described using evaluative and iterative strategies which included developing and implementing tools for quality monitoring, ³¹ assessing for readiness and identifying barriers and facilitators, ³² and auditing and providing feedback.^32,36

• Two (66%)^31,32 described developing stakeholder interrelationships, specifically using advisory boards and workgroups.^31,32

• One (33%) ³⁶ described providing interactive assistance which included facilitating ³⁶ and centralizing technical assistance. ³⁶

• One (33%) ³⁶ described supporting clinicians, specifically reminding clinicians. ³⁶

Six studies^{27,28,31,32,35,36} aimed to increase acting, of which 3 (50%)^27,32,36 demonstrated a statistically significant increase in acting. Of these 3 studies:

• Three (100%)^27,32,36 described training and educating stakeholders which included conducting ongoing training, ²⁷ developing educational materials,^32,36 distributing educational materials, ³² conducting educational meetings, ³² and creating a learning collaborative. ³²

• Three (100%)^27,32,36 described using evaluative and iterative strategies which included purposefully re-examining the implementation, ²⁷ assessing for readiness and identifying barriers and facilitators, ³² and auditing and providing feedback.^32,36

• Two (66%)^27,36 described providing interactive assistance which included facilitating^27,36 and centralizing technical assistance ³⁶

• Two (66%)^27,36 described supporting clinicians which included facilitating the relay of clinical data to providers ²⁷ and reminding clinicians^27,36

• One (33%) ³² described developing stakeholder interrelationships, specifically, using advisory boards and workgroups ³²

• One (33%) ²⁷ described changing infrastructure, specifically, changing record systems ²⁷ .

Discussion

We conducted a rapid systematic review to update the systematic review by Young et al., ¹ exploring which strategies support the successful implementation of smoking cessation in oncology settings. We identified 18 studies^8,25-41 that met our inclusion criteria. Most studies were conducted in the United States of America (78%, n = 14),^{25-27,29,30,32-40} with 33% (n = 6)^{25,27,31,32,35,36} employing quasi-experimental research design, and 83% (n = 15)^25-33,36-41 demonstrating a low risk of bias. The preferred reporting items for systematic reviews and meta-analyses checklist is listed in S7 Table.

Although all 18 studies^8,25-41 were published following the declaration of COVID-19 as a pandemic in March 2020, their timeframes varied. Nine studies (50%)^{25,26,28-33,36} were conducted before the declaration, 7 (39%)^{27,34,35,37-39,41} spanned both before and after the pandemic’s onset, 1 (6%) ⁴⁰ was undertaken after the pandemic began, and 1 (6%) ⁸ did not specify the timeframe. This allowed us to capture a range of implementation strategies that have been employed since Young’s systematic review ¹ and explore some of the impact the COVID-19 pandemic had on healthcare delivery. However, implementation strategies used throughout the COVID-19 pandemic might be underrepresented in our rapid systematic review, due to variation in timeframes and publication delays.

Our rapid systematic review identified an average of 8 implementation strategies per study (Range: 3-14), higher than the estimate derived from the Young systematic review, ¹ which was approximately 4 implementation strategies per study (Range: 1-23). Although Young’s systematic review ¹ did not explicitly report the number of implementation strategies used, this estimate was derived by counting the individual implementation strategies listed in their supplemental materials. Our findings are similar to those of Ashcraft et al., ⁴⁴ whose systematic review of health and human services research reported an average of 7 implementation strategies per study (Range: 0-20).

Similar to Young et al., ¹ our rapid systematic review consisted mainly of studies from the United States of America (their 79% vs our 78%) and identified training and educating stakeholders, using evaluative and iterative strategies, and supporting clinicians as the most commonly used implementation strategies for delivering smoking cessation in oncology settings. ¹ The predominance of studies from the United States of America in both reviews might partially explain these similarities, as implementation efforts in the United States of America are often shaped by similar policy environments, healthcare delivery models, and national clinical guidelines. ⁴⁵ However, unlike Young et al., ¹ who did not find widespread use of providing interactive assistance or utilizing financial strategies, our rapid systematic review identified both as prevalent. Instead, Young et al. ¹ found changing infrastructure and developing stakeholder interrelationships to be frequently used implementation strategies. These differences may be attributed to the varying timeframes and sample sizes between the 2 reviews. In particular, our rapid systematic review included a substantial number of studies conducted during or shortly after the COVID-19 pandemic, a period marked by changes in healthcare delivery. ⁴⁶ During the COVID-19 pandemic, infrastructure changes were often constrained by infection control requirements, remote work mandates, and staffing limitations, which likely reduced the feasibility of testing other infrastructure changes. During this period, one major adaptation was the expanded use of telehealth services, which allowed individuals to receive healthcare remotely. ⁴⁷ We theorized this pandemic-related shift likely explains the increased use of providing interactive assistance and information technology support identified in our rapid systematic review, as oncology settings turned to telehealth to deliver smoking cessation. Two studies^35,38 in our rapid systematic review noted that the COVID-19 pandemic also accelerated the integration of information technology systems into clinical workflows, making it easier for clinicians to ask, advise, and act using digital tools.

Differences in coding methodology might have also contributed to the similarities and differences between our rapid systematic review’s findings and those from Young. Both reviews used the ERIC framework ¹⁷ to code implementation strategies, which likely contributed to convergence in identifying commonly used implementation strategies, such as training and educating stakeholders, using evaluative and iterative strategies, and supporting clinicians. However, differences in how individual implementation strategies were interpreted or categorized, especially in studies with limited reporting detail, might have led to discrepancies in the prevalence of certain implementation strategies over others.

Seven studies (39%)^{25,27,28,31,32,35,36} reported increases in asking, advising, and acting. The implementation strategies training and educating stakeholders, using evaluative and iterative strategies, providing interactive assistance, supporting clinicians, and developing stakeholder interrelationships were associated with increases in asking, advising, and acting. Young et al. ¹ found that supporting clinicians, training and educating stakeholders, changing infrastructure, and developing stakeholder interrelationships were associated with increases in asking, advising, and acting. Despite our reporting on 5 domains instead of the 4 reported in their systematic review, our results are similar. The difference is that we found using evaluative and iterative strategies and providing interactive assistance were associated with increases in asking, advising, and acting instead of changing infrastructure. ¹

Two systematic reviews^48,49 identified that insufficient knowledge, training, time, and confidence were major barriers to delivering smoking cessation in oncology settings.^48,49 Healthcare providers were concerned that smoking cessation might negatively affect an individual with cancer’s symptoms and recovery due to potential stress and guilt; some felt that smoking cessation was beyond their role.^48,49 On the other hand, facilitators included a willingness to undergo training and buy-in belief in the value of smoking cessation. ⁴⁸ A separate systematic review also noted the importance of taking workflows into consideration, including timing and frequency of quit conversations, in order to enhance the effective integration of smoking cessation in clinical settings. ⁵⁰ Altogether, this highlights the need for implementation strategies that address clinician hesitancy, improve workflows, and support behavioral change. Integrating health information technologies to improve workflows, such as utilizing reminders (e.g., best practice advisory alerts) and electronic health records could alleviate time constraints for healthcare providers but would require interactive assistance from information technology teams. Given the evolving nature of best practices, employing evaluative and iterative strategies, alongside collaboration with advisory boards and subject experts is crucial.

Limitations and Future Directions

Most studies were conducted in North America and might not reflect other jurisdictions and their oncology settings. Future studies should prioritize the examination of how smoking cessation is best integrated into oncology care within diverse global settings. This includes exploring how cultural factors and healthcare financing systems influence the implementation of smoking cessation. The scarcity of randomized controlled trials, 1 study (6%), ³³ also limits our ability to establish causality. Future studies might compare implementation strategies for smoking cessation in oncology settings before and after COVID-19. Finally, most studies (67%)^{8,26-29,31,32,34-36,38,39} did not specify whether smoking cessation was tailored to individuals with specific cancer types. Only 1 study (6%) ³³ reported on the individuals' cancer stages. The extent of cancer may influence the intensity of the healthcare provider’s efforts to encourage smoking cessation and the individual’s motivation to quit. Targeted recommendations for specific cancer types and cancer stages could not be made, but this could be explored in future studies. None of the studies in our rapid systematic review reported implementation outcomes using the framework presented by Proctor et al. ¹⁸ and only 5 studies captured implementation outcomes using the RE-AIM framework. ¹⁹ There was considerable heterogeneity in how these studies defined and applied the RE-AIM components, making it difficult to compare results across studies. Ultimately, while abundant data on implementation strategies was found, implementation outcomes were sparse and connections between both could not be made. When evaluating implementation, future studies should examine the relationship between implementation strategies and implementation outcomes, as this information is lacking in the current literature. A scoping review of implementation outcomes by Proctor et al. ⁵¹ found that less than a quarter of studies examined this relationship (14%). Without testing these relationships, we are ill-prepared to measure the extent of implementation success. ⁵¹ This finding is crucial for guiding future studies.

Conclusion

This rapid systematic review identified a range of implementation strategies used to support the implementation of smoking cessation in oncology settings. Specifically, training and educating stakeholders, using evaluative and iterative strategies, providing interactive assistance, supporting clinicians, and developing stakeholder interrelationships were associated with increased smoking cessation efforts, referred to as the 3As approach to smoking cessation. Although these implementation strategies were associated with the successful implementation of the 3As approach to smoking cessation, the relationships observed cannot be considered causal. Future studies should pilot these implementation strategies and measure their success in the delivery of smoking cessation, examining the impact of implementation strategies and implementation outcomes. Such efforts will help determine which implementation strategies are most effective in improving the integration of smoking cessation in routine cancer treatment.

This rapid systematic review, conducted as part of a larger study, identified implementation strategies that have been used in oncology settings. Together with interviews exploring barriers faced by healthcare providers and individuals with cancer and a two-phase Delphi study to build consensus on the most promising and feasible implementation plans for Ontario regional cancer centres, these findings will inform the development of tailored, context-specific implementation guidance to support smoking cessation in Ontario oncology settings.

Supplemental Material

Supplemental Material - Exploring Practices for Implementing Smoking Cessation in Oncology Settings: A Rapid Systematic Review Update

Supplemental Material for Exploring Practices for Implementing Smoking Cessation in Oncology Settings: A Rapid Systematic Review Update by Isabella R. DeVuono, BMSc, Stephanie Posa, MSc, Naomy M. C. Lafond BSc, Basilhea D. Woodley, MSc, Adina Coroiu, PhD, Michael O. Chaiton, PhD, William K. Evans, MD, Scott Veldhuizen, PhD, Laurie A. Zawertailo, PhD, Osnat C. Melamed, MD, MSc, Lawson Eng, MD, SM, Matthew M. George, MA, Michelle H. Halligan, MSc, Caroline B. Silverman, MSc, Archie Stewart, MSc, MBA, Lester Krames, PhD, MaryAnn. Bradley, Sarwar Hussain, MSc, Peter Selby MBBS, MHSc and Nadia Minian, PhD in Cancer Control.