Background: Quitting smoking after a cancer diagnosis improves survival and quality of life. Cessation counseling and medications increase quit rates, yet a minority of patients engage. We previously described factors aiding engagement with tobacco cessation treatment in the oncology setting among patients who engaged in services. The current study evaluated barriers to treatment engagement as perceived by patients who declined tobacco cessation services.
Methods: As part of the National Cancer Institute’s Moonshot Initiative, the Stanford Cancer Center offers a menu of telehealth services to all patients who report recent tobacco use (opt-out model). Services include cessation medication management, individual and group counseling, text-to-quit programs, and digital health apps. To optimize outreach efforts and enhance care delivery, we conducted in-depth, semi-structured interviews with 14 patients who declined treatment between 2020 and 2022. Patients shared their barriers to engagement, treatment preferences, and general recommendations; indicated their motivation to quit (1-10); and rated the importance of different treatment offerings (1-5). The interviews were audio-recorded, transcribed, and iteratively coded by two team members using a content analysis approach.
Results: The patient sample (M age=75, 64% female, 86% White, 7% Hispanic) reported cigarette (71%), vape (7%), smokeless tobacco (7%), and dual tobacco use (7%) beginning by a mean age of 19 (SD=11.5). A subset (7%) had quit. The mean motivation to quit was 4.69 (SD=3.55); the primary reason cited was a desire to improve health. Top identified barriers to engagement centered on a lack of readiness to quit, advanced illness, and a desire to quit independently. Recommendations included offering an inpatient tobacco treatment program and offering treatment after (rather than during) active cancer treatment. Most (64%) patients were open to follow-up by the Stanford team, while many (46%) were unsure how to contact the clinic. The highest-rated treatment components included the telehealth delivery (M=4.67, SD=.65), cost-coverage (M=4.62, SD=.76), and the individual counseling offering (M=4.62, SD=.65).
Conclusion: Findings suggest proactive and ongoing outreach throughout the care continuum may motivate tobacco cessation engagement. Future directions include improving clinic contact accessibility and exploring the impact of gain-frame messages for smoking cessation in the cancer context.