Improving Non-smoking Rate - Interventions

Introduction

This article suggests interventions to help improve non-smoking and smoking cessation counseling rates. This activity corresponds to the Plan section of the PDSA Worksheet. Interventions are suggested for addressing factors leading to performance gaps and demonstrating improved performance that you will record in the Do section of the PDSA Worksheet.

Consider using some of the tools for characterizing performance factors in the Set a Goal and Analyze Baseline Data section of the Performance Improvement Resources article.

Short-term Interventions (3-6 months)

1. Smoking Cessation Counseling

   A smoking cessation intervention includes documentation that a discussion about the benefits and harms of smoking and the means available to quit occurred, an offer to participate in a smoking cessation program was made, or resources related to smoking cessation were provided during the shared decision-making visit [1].

   1. Verify with all clinicians that engage with patients during the Lung Cancer Screening (LCS) process that smoking cessation counseling is being incorporated and reiterate its importance in an LCS program.

   2. Provide smoking cessation materials for them to distribute to those being screened (see section 1.c.ii).

   3. Train clinicians/screening personnel or dedicated coordinators/navigators to provide or refer evidence-based smoking cessation support.

   4. Use terms such as “currently smokes” vs “current smoker” and “person who smokes” instead of "smoker.” Shifting the terminology to be about the action vs who the patient is can help to reduce stigma and therefore increase patient willingness to participate in discussions of smoking cessation [2].

   5. Include reminders and resources at time of ordering screening to support clinicians with counseling and shared decision-making, such as a sidebar/template in the EHR (Integrating Tobacco Cessation Into Electronic Health Records (EHR template)). Resources could include:

      1. Local smoking cessation rates versus the ACR LCSR median (most pertinent in underperforming centers)

      2. Average cost of smoking based on local cigarette prices and by pack per day

      3. Past imaging of patient’s smoking-related lung disease, if applicable

      4. Smoking cessation programs (in-person and virtual) within the health system or local community

      5. Patient’s current and complete past smoking history. (Complete history may not be feasible depending on the capabilities of your EHR.)

   6. Smoking cessation counseling resources

      1. For clinicians

         • GO2 for Lung Cancer Motivational Interviewing for Tobacco Cessation: Use in the Lung Cancer Screening Context (Video)

         • CDC Clinical Education and Training on Smoking Cessation Counseling (Resource Collection) 

      2. For patients

         • GO2 for Lung Cancer Education Materials

         • ACR Lung Cancer Screening - Smoking Calculations (Video)

         • GO2 for Lung Cancer Why Quit: A resource for those at high risk for lung cancer (PDF)

         • 1-800-QUIT-NOW (National Network of Quit Lines) 

2. Patient Communications

   1. Incorporate smoking cessation resources and clinic information into imaging reports and/or communications to patients who are currently smoking. 

   2. Offer the patient interval financial incentives for meeting smoking cessation goals over a set intervention period. (Check with your legal department and/or Diversity, Equity, and Inclusion Committee if this is allowable at your organization and makes sense for your patient population.)

   3. Incorporate Episodic future thinking (EFT) tools into your LCS program. EFT as an intervention is an evidence-based, personalized behavioral tool that promotes prospective thinking about longer-term rewards [3]. Patients choose EFT cues that are specific, positive descriptions of future events that will be possible or improved by no longer smoking. While the patient is trying to quit, there should be multiple communications from the LCS program reminding them of their EFT cues. Effectiveness may be increased by pairing with financial incentives.  

      1. Comparing Smoking Cessation Interventions among Underserved Patients Referred for Lung Cancer Screening: A Pragmatic Trial Protocol (Study) 

3. On-site Services

   1. Smoking cessation support and services at the time of screening is when behavioral interventions are most effective. Incorporate health maintenance activities into the practice.

Long-term Interventions (1 year+)

1. Offer patients the opportunity to discuss their LCS imaging with a radiologist. The radiologist conducts a 5-10-minute consultation with the patient, viewing and talking through findings on the patient’s own LCS imaging, i.e., emphysema, lung nodules, assessment of lung health and damage, etc., as well as providing smoking cessation counseling alongside the imaging findings.

2. Media-rich Patient Imaging Reports

   1. Create a graphical or image-rich representation of patients' lung function or images of their smoking related lung disease over time (most applicable for those with long-term follow up at a single center).

   2. Sample smoking cessation patient report as used in a study on Personalized Smoking Cessation Tool Based on Patient Lung CT Images. (Used with permission from IMBIO, LLC, University of Michigan, University of Minnesota, Mayo Clinic and HealthPartners Institute.)

3. Clinician Performance Monitoring

   1. Create a local dashboard of individual clinicians’ non-smoking rates in their patients who are being evaluated for LCS and make this available to all participating clinicians. Include comparison data of their local peers, facility average, and/or at the national level (ACR LCSR). Set program goals to show clinicians how they are doing and provide supportive information and resources accessible from the dashboard. Social proof phenomenon can encourage underperformers to adopt strategies to improve their performance and top performers to share their techniques.

4. AI Automation

   1. Create AI algorithms to detect active, smoking-related lung changes on chest CT and automatically suggest smoking cessation strategies to the clinician via the EHR and directly to patients through the radiology report.

References

1. Mazzone PJ, White CS, Kazerooni EA, Smith RA, Carey C. Thomson CC. Proposed quality metrics for lung cancer screening programs. Chest. 2021 Jul;160(1):368-378. doi: 10.1016/j.chest.2021.01.063

2. Williamson TJ, Riley KE, Carter-Harris L, Ostroff JS. Changing the Language of How We Measure and Report Smoking Status: Implications for Reducing Stigma, Restoring Dignity, and Improving the Precision of Scientific Communication. Nicotine Tob Res. 2020; 22(12):2280-2282. doi: 10.1093/ntr/ntaa141

3. Lin H, Epstein LH. Living in the moment: effects of time perspective and emotional valence of episodic thinking on delay discounting. Behav Neurosci. 2014;128:12-19. doi: 10.1037/a0035705

4. Bellinger C, Foley KL, Dressle EV. Organizational characteristics and smoking cessation support in community-based lung cancer screening programs. J Am Coll Radiol. 2022;19(4):529-533. doi: 10.1016/j.jacr.2022.01.014