Longitudinal Results from the Nationwide Just ASK Initiative to Promote Routine Smoking Assessment
Host Dr. Davide Soldato and guests Dr. Jessica Burris discuss the article "Longitudinal Results from the Nationwide Just ASK Initiative to Promote Routine Smoking Assessment in American College of Surgeons Accredited Cancer Programs" and how persistent smoking following cancer diagnosis causes adverse outcomes while smoking cessation can improve survival. TRANSCRIPT The guest on this podcast episode has no disclosures to declare. Dr. Davide SoldatoHello and welcome to JCO After Hours, the podcast where we sit down with authors from some of the latest articles published in the Journal of Clinical Oncology. I am your host, Dr. Davide Soldato, medical oncologist at Ospedale San Martino in Genoa, Italy. Today we are joined by JCO author Dr. Jessica Burris. Dr. Burris is an Associate professor of Psychology at the University of Kentucky and co leader of the Cancer Prevention and Control Research Program at the Markey Cancer Center. Her research focuses on smoking cessation among cancer survivors, health disparities, and behavioral interventions to promote health equity. She also leads the BIRDS Lab, which explores the intersection of smoking, social determinants of health, and cancer survivorship. Today I will be discussing with Dr. Burris on the article titled Longitudinal Results from the Nationwide Just Ask Initiative to Promote Routine Smoking Assessment in American College of Surgeons Accredited Cancer Program. So, thank you for Speaking with us, Dr. Burris. Dr. Jessica BurrisThank you for inviting me. Dr. Davide SoldatoSo today we'll be discussing an important study on the implementation of smoking assessment in cancer care and specifically through the Just Ask Initiative. So, we know that tobacco use is a critical factor in cancer treatment outcomes in general, and yet integrating systematic smoking assessment into oncology care has faced various challenges. So, Dr. Burris, to start off our interview, I would like to ask you to briefly introduce the Just Ask Initiative for those of our readers and listeners who may not be familiar with it. So, a little bit about the primary goals and why do you think that routine smoking assessment is such an important aspect of cancer care and why the Just Ask Initiative focuses on this specific issue? Dr. Jessica BurrisSure. So, as you mentioned before, smoking is a really critical factor in terms of cancer care and cancer outcomes. It impacts a lot of things, from complications after surgery up into cancer mortality, but it also impacts patient's quality of life. Their pain may be more severe, they're more tired, their distress levels are higher. So, there's just a lot of different reasons why we need to understand and address smoking in the context of cancer care. But like you said too, there's a lot of barriers as well. But in order to effectively treat nicotine dependence and tobacco use, we really need to know who is currently smoking. And so that was really the driver for Just Ask, wanting to make sure that we are asking every person with cancer at their diagnosis and as they go through treatment, what their smoking history is, if they are currently smoking, which we usually consider to be any smoking or other tobacco use in the past 30 days, so that once we can identify that person, then we know who we need to help. Dr. Davide SoldatoThank you very much. That was very clear. And in terms of methodology, Just Ask was really a quality improvement type of initiative that involved the programs that were contacted and approached to participate in this type of initiative. And the methodology is pretty standard for this type of implementation science, which is the Plan Do Study Act methodology. So just a little bit of background on this type of methodology and why do you think it might be so successful when implementing these types of changes at the structural level and when we are implementing these types of programs. Dr. Jessica BurrisRight. So, the American College of Surgeons requires all the accredited cancer programs, both Commission on Cancer and the NAPBC or the ones that focus on breast cancer, to do at least one quality improvement project annually. And most of the programs do use the evidence-based Plan Do Study Act approach. I think it's a great one. It has a lot of evidence behind it, but it also is very practical or pragmatic. So, you're using data from your local healthcare system or clinic or program to inform what it is that you do. And then you're constantly pulling data out to see how well you're addressing the clinical practice change that you're hoping to achieve. And so, data is going in and coming out and you're using that to inform exactly what it is that you're doing over time. So, it's an iterative approach to practice change and again, one that has proven successful time and time again. And so that's the program that these programs and Just Ask used in order to increase the frequency by which they ask patients about smoking. Dr. Davide SoldatoSo as you were saying, the main objective of the initiative was really to understand if we are asking patients diagnosed with cancer and survivors if they are smoking. And how can we better report this information inside of the medical chart of the patient. So, what was the primary endpoint or the objective that you had for this type of intervention? And can you give us a little bit of results? So, what did you find the implementation of this quality improvement? How did it change the percentages of patients that were asked about smoking habits? And a little bit, what is your opinion on the results that you obtain in the study? Dr. Jessica BurrisSure. So, the goal was simple and that was to have an ask rate that was at least 90%. The way that we defined an ask rate is among all newly diagnosed cancer patients, how many were asked about their smoking history and their current status at that initial visit? And so, we wanted all of the participating programs who opted in to Just Ask in 2022 to achieve that 90% ask rate by the end of this one-year quality improvement project. And again, using the Plan Do Study Act approach, it was a very pragmatic study in some ways. So, what we did was we provided an intervention change package that we made available online. And programs could access that whenever they needed to and pull-down educational resources, patient facing materials, practical tools for changing the EHR or pulling data out of the EHR, any of those number of things. And then we also hosted webinars over the course of the year. And those webinars were great because half the time they were in response to questions that programs were asking as they went through the Just Ask QI project. And the other half of time we were really just reminding programs of the rationale and the reason for making sure that they're asking. And then of course, letting them know that they don't have to stop there, they should be advising patients to quit and assisting them with cessation. Even though that wasn't the goal of Just Ask, the goal again of Just Ask was getting that 90% rate. And so, we had over 750 programs who opted in to Just Ask and did this QI study with us, and it was successful. So, we met the goal, or rather the programs met the goal of that 90% ask rate. And that was maintained over time. And that was just fantastic. So again, we know that the end goal is really to assist patients with quitting, but we can't do that unless we know who to help. And so, you have to ask first. And again, they were able to do that. Dr. Davide SoldatoSo thank you very much. The quality improvement program was absolutely successful. And to go a little bit in the numbers, by the end of the one-year implementation of the program, you report a 98% rate of asking patients who first approached the centers or over time if they were or not smokers. So, you said before that you targeted a 90% ask rate in terms of smoking habits. But when looking at the data, I noticed that you already had in the baseline survey where you asked the programs about what were the practice before the implementation of the Just Ask initiative, already something that was quite close to the 90%. And yet, despite starting from such a good point, which was basically your endpoint, you still observed a major change over the years of the implementation. So, I wanted to just underline a little bit what is the value of this type of programs. And still starting from such a very high standard still, we managed to further improve. And as you were saying, this is pivotal and I think it's fundamental to really understand and see who are the patients that we need to refer and then to help in the smoking cessation. So, I just wanted a little bit of a comment on these very important results, despite already starting from a very good background from the centers. Dr. Jessica BurrisYeah, I'm glad that you brought up the baseline. So, I think one thing that's important about this study is that we looked at our ask rate or the asking as a clinical practice in two different ways. So, the 98% that you referred to that we found at the final survey is based on a response to a question on the frequency of asking. So, it's a Likert type question. And essentially what we did was we combined programs that reported usually asking or almost always asking into one, and that's where we arrived at the 98%. And at baseline it was 92%. What's interesting though is that we also asked them to report the specific number of patients who were seen in their cancer program during the prior six months and the number of patients who were asked about smoking in the prior six months. And with that we could get a proportion. And in every case, the self-report Likert question had a higher outcome than the raw data based on the data that was pulled from the EHR. And so, we saw this increase significantly over time, both in the self-report Likert question, but also in the EHR based data. And so, it was a win in two ways. What I think is really interesting though is that at baseline, even though 92% of programs said that they regularly ask about their patient smoking status, 16% of programs could not provide data that would allow calculation of an ask rate. So, they were reporting that they were able to do so but then could not actually do so. So, I think what that means essentially is that there's a disconnect between what programs are doing regularly or they believe that they're doing regularly and what their data actually shows. And it could be an issue with the quality of the data that's going into the EHR, or it could be an issue with pulling the data out of the EHR. And so one of the things that we saw that I think is a second indicator of success of Just Ask is that the quality of the data that programs were inputting into the EHR related to their patients smoking history and smoking status did improve over time, which meant that by the end it really was the case that the vast majority of programs were asking. And not only that, but they were also documenting it in a way to where it could inform patient care. Does that make sense? Dr. Davide SoldatoAbsolutely. And I think that that explanation really is truly important because I think that it also connects a little bit to how the initiative was able also to change things at the structural level, to be sure that there was the best possible way of asking, but also of having that information readily available inside of the EHR. This also connects a little bit to my next question, which was a little bit about organizational structure and also implementation barriers, which you report also as a self-reported information by the specific programs. So, there was a little bit of implementation barriers that was reported by the programs and this was not a specific endpoint of the Just Ask initiative, but you kind of mentioned it a little bit. The difficulties in pulling data from the EHR in understanding whether the information was collected and how it was collected. This might be one of the implementation barrier when we are looking at initiatives like Just Ask. So, I just wanted a little bit of your opinion if you think that these implementational barriers are more on the organizational side or on the provider side. And how can we use these quality improvement programs to really tackle this type of barriers to improve overall the reach and the importance of our action regarding smoking cessation. Dr. Jessica BurrisThe devils in the details, right? So I think it's a “both and” situation and not either or I think for providers, for individual providers, oncologists, nurses, supportive care providers, the issue of feeling like they're not fully trained in tobacco use assessment and treatment, and also feeling because of a lack of training that they don't feel confident or competent or even comfortable having conversations with their patients about their smoking history or being in the position to where they can really help someone who wants to quit in choosing the best path and way forward to do that that really matters. And so organizational readiness, these programs that participated were pretty high even at baseline in terms of the organizational readiness. They understood that it's a problem and they wanted to do something about it. And they were really eager and chomping at the bit to do so. But that has to trickle down to individual providers. And so, I think one of the implementation strategies that was used was staff training and provider education. And a lot of the participating programs chose that strategy. And I think as staff and providers are trained in how to ask and how to do so in a way that is nonjudgmental and that doesn't lean into things like stigma or blame or making patients feel guilty that perhaps their behavior led to their cancer, but really just understanding tobacco history and understanding nicotine dependence and the best strategies that we have to address those things that helped and that made a difference but it also is things at the system level, like having good EHR data, being able to pull those data out at a regular interval every three months or every four months, or even every six months to make sure that you're tracking smoking and also quitting over time. Both of those things need to happen. And I think those were things that we saw change as a result of Just Ask participation. Dr. Davide SoldatoRelating to this, provider readiness also to counsel patients on how to stop smoking or what is the best strategy. Despite, as you said in the very beginning, this was not the objective of Just Ask because you just wanted to improve the rate of smoking assessment and the quality of reporting of smoking assessment. You still observed higher rates of patients and survivors that were actually referred to some kind of intervention for smoking cessation. So, I was just wondering, why do you think that even though that was not required, you still observe this type of improvement? Like, is it just inherent to the fact that we are improving and we are placing more interest and more attention on the fact that patients should quit smoking, or do you think that it relates to something else completely? Dr. Jessica BurrisI think there's probably multiple things going on. One is once you're fully aware of the fact of the impact of smoking after a cancer diagnosis, you're going to be compelled to do something, I think. And so just the simple fact of knowing now that the patient sitting in front of you has smoked in the past week or two, they may be under a lot of stress because they're coping with cancer and they're coping with the side effects of their treatment. They may even have increased their smoking since their cancer diagnosis. And now you have this information. I think people who are providing cancer care, they want to improve the health and the life of the person sitting in front of them. And if they understand that smoking is a detriment or a hurdle to their doing so, then they're also more inclined to try and help that person quit smoking. And so, I think the asking and the documenting likely led to an increase in assistance and referrals to tobacco treatment specialists or to a state quit line, which was also common, simply because that's part of providing quality care. I think also there's been a greater emphasis nationally, in part led by the National Cancer Institute and a cancer moonshot initiative that it led, they're really focused on getting more treatment to more patients with smoking and increasing the reach and the effectiveness of the treatments that we provide. And so, I think there has been a shift in oncology care broadly to put more attention on smoking and smoking cessation as part of standard cancer care. And so, I think this kind of shift in the field also informed things as well as, again, thinking about the patient and the individual who's in the room and wanting to do something about the problem that you've just identified. Dr. Davide SoldatoAnd one thing that I believe is truly exceptional about the Just Ask initiative is really also the diversity of the type of programs that you involved. Like, you went from community centers to more academic centers. And really, I did not have the impression reading the manuscript that there was any difference in the way this type of quality improvement initiative can really benefit all these programs and all these centers. So, I was just wanting to have your opinion or comment on how do you think this type of initiative could be transferable across the country and across different settings and different types of cancer care? Dr. Jessica BurrisYeah, I'm really glad that you brought that up, because I think most of the clinical trials that are done in this area are done at academic medical centers, which are admittedly kind of resource rich places to receive cancer care. And so, what works in academic medical center may not work in a small rural practice in the middle of Kansas, for example, or in Mississippi. And it may not work in other community-based practices, even if they're larger and set in an urban setting. And so, one of the things that frankly I loved about Just Ask is that it was very heterogeneous in terms of the sites and the participating groups. And so not only was it national and by far the largest initiative in this area, again with over 750 different programs, but the programs were diverse. So, we had large community-based programs, integrated networks, smaller community programs. And then the academic centers were actually the smallest. Only like 10 or 12 out of the 750 plus were academic. And so, it was very different than what is the norm in this research area and in this area generally in terms of clinical practice. And we were able to show that the type of program that participated had no bearing on their success. And so, when we think about initiatives that work and interventions that work, we also really have to think about what is scalable and what could be disseminated across different practices. And this is one of those things that can. It worked and it worked across different swaths of group, which was great. Dr. Davide SoldatoAbsolutely. And just one last comment about the intervention, and it's also a point that you raised in the manuscript. This initiative, like many others also at the national levels that have been reported previously, they rarely had really the participation or the perspective of the patients embodied inside of them. So, I was wondering, how do you see the field moving forward. Like you envision something that would implement sort of a co-creation with patients or cancer survivors in order to really create something that is more appealing and takes more into consideration what is the patient perspectives when we are approaching something like smoking cessation, which as you were mentioning before, it can have a lot of stigma or already some negative feelings by the patients and feelings of guilt regarding the fact that they smoked and that might have caused that cancer. So just a little bit of your opinion as to how you see the implementation science in smoking cessation moving forward while integrating also the patient perspectives. Dr. Jessica BurrisYeah, that's a great question. So, this is something that I've thought about a lot in my lab and at Market Cancer center, which I'll use as an example. But oftentimes what we see is that even when tobacco treatment is offered as part of standard cancer care, even when we try to remove barriers like the financial cost of treatment at Markey, we embed it within our psych oncology program. And so, all of those services are offered for free. The rate at which patients say, yes, they want to engage in treatment is much, much lower than what we would want. And so that means two things. One, we need to offer help repeatedly to patients and understand that their willingness to quit and their willingness to accept treatment likely would change over time. And so, we need to keep coming back to people. It's not a one and done situation. But then also we need to understand what the barriers are from a patient's perspective. So why are they saying no? That they're either not ready or that they don't want treatment. They want to, quote, unquote, go it alone. And oftentimes what we hear is that patients want to be able to do this by themselves. They want to feel like, I quit smoking and I did it all by myself. And this is this huge thing that I've overcome. Not too different from the perspective that a lot of patients have about fighting cancer. They want to fight this addiction, this dependence that they've had oftentimes for multiple decades. And so, I think one thing that might be beneficial is to think about having peer led tobacco treatment. So have a patient who was able to quit successfully and have them provide counseling alongside a trained provider so that patients see someone like them who's went through it in the context of cancer care and who was able to overcome and to fight and win against tobacco, essentially. I think the other thing is trying to make sure that when we're asking about smoking and when we're offering treatment that we are not accidentally harming patients by bringing up feelings of stigma or guilt or shame. And I think one way to make sure we don't do that is to really lean on clinicians who are trained in addressing social determinants of health and other supportive care. So, our social workers, I think would be great. They're oftentimes embedded within oncology care. They are surely able to be trained as tobacco treatment specialists. They're already working with patients; they're addressing other barriers to care. They're sensitive in how they ask questions oftentimes. And so, they're really an ideal partner for this work. And we have found in a lot of settings that social workers are great in terms of being tobacco treatment specialists, including what we saw in Just Ask. Dr. Davide SoldatoThank you very much. That was really very, very interesting. And so, last question, moving forward, we improved the rate of asking patients. We are able to document this addiction more clearly in the EHR. So how do you see the field moving forward? In the manuscript, you speak a little bit about the Beyond Ask initiative. So just a little bit of a background about what is this initiative, what you are planning to do, and what do you think would be the best way to really act on this information that we are starting to collect in a better way and more frequently. Dr. Jessica BurrisYeah. So Beyond Ask really took everything that we did in Just Ask and amplified it. So instead of focusing on asking, we really said to make a difference and to improve cancer outcomes, ultimately patients need to be able to quit smoking. It's not enough that we know who is smoking, but that we help that individual or those groups of people quit. And so Beyond Ask had the goal to increase cessation assistance. So, either prescribing medication to help with smoking cessation, referring to a quit line, or another evidence-based program, or personally providing cessation counseling on site at that cancer program and to try and improve again within assistance. It was another one-year study, but we increased the frequency of surveys. I think we ended up with five total surveys. So, we were capturing two to three months at a time instead of a six-month period. And the data that we were capturing was very similar to what we did in Just Ask. And I can say we're still doing the data analysis, but it was another major success. So, with Beyond Ask, we had about 350 participating programs, many of whom not all, but many did participate in Just Ask. So, I think Just Ask kind of energized people around addressing the issue of smoking in their patient population. And again, they were really chomping at the bit to do more. And so, we offered Beyond Ask just after Just Ask. So Just Ask was 2022. Beyond ask was 2023. It ended in the spring of 2024. And again, another success. Dr. Davide SoldatoThank you very much. So, we are eager to see the results of this study. So that leads us to the end of this interview. So, thank you again, Dr. Burris for joining us today and speaking about your work. Dr. Jessica BurrisThank you. Dr. Davide SoldatoSo we appreciate you sharing more on the JCO article titled Longitudinal Results from the Nationwide Just Ask Initiative to Promote Routine Smoking Assessment in American College of Surgeons Accredited Cancer Program. 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