Key takeaways:

• An opt-out smoking cessation program referred hundreds of patients to counseling and medication.
• Many patients reported abstinence, an attempted quit or smoking reduction.

When a patient with cancer tells their clinician they smoke, Andrea C. King, PhD, wants alarm bells to ring inside the exam room — figuratively speaking.

“Helping patients to quit smoking should be a standard of care,” King, professor of psychiatry and behavioral neuroscience at The University of Chicago, told Healio.

The No Smoker Left Behind initiative at The University of Chicago Comprehensive Cancer Center aims to make that a reality.

The opt-out program proactively reaches out to all patients with cancer listed as current smokers in the electronic health record (EHR) and subsequently offers a variety of cessation options.

A retrospective analysis of the program’s first 6 years found almost 900 patients received counseling and/or medication referrals, and more than half who responded to follow-up indicated they made a smoking quit attempt in the past month with nearly one-third reporting at least 8 days of abstinence or a meaningful reduction in cigarettes smoked per day.

“We are going to help people,” King said. “We are going to repeatedly help you to try to find a way to reduce and quit smoking.”

Changing smoking habits ‘crucial’

Tobacco use causes 28% of all cancer deaths in the U.S., according to study background.

Among patients diagnosed with a malignancy in 2023, 14.7% reported being current smokers.

Healio previously reported tobacco to be the leading preventable cause of cancers globally, accounting for 15% of 7.1 million cases in 2022 attributed to modifiable risk factors.

Healio also has reported patients who quit smoking after a diagnosis halved their risk for death compared with those who continued to smoke.

Overall, reductions in cigarette smoking between 1970 and 2022 prevented nearly 4 million lung cancer deaths.

“Helping patients who have cancer to quit smoking and make a change in their smoking behavior is crucial, and yet it’s been ignored or sidelined far too long,” King said. “There are a variety of reasons why.”

More than 71% of American College of Surgeons’ Commission on Cancer–accredited cancer programs advise patients to stop smoking, but only 18.2% provide counseling and just 17.6% prescribe approved medications.

“There are many good reasons to help people to quit smoking, and yet there were few systematic programs in cancer centers across the country,” King said. “At University of Chicago, before we started this program, we were just like most other centers. It was a bit ‘catch as catch can’ in terms of action steps to help cancer patients connect to approved treatments to help them quit smoking.” If there was a moment during a provider visit, and enough time to even engage in the conversation, the patient might have been provided a prescription or referral to our group-based program, but it wasn’t done across the board.”

King and colleagues wanted to develop a “bigger, more sustainable” program to reach a larger group of people, which led to the No Smoker Left Behind initiative.

Patients receive emails, phone calls and text messages about treatment options, and to select as many as they want, including referrals to discuss medications, and referrals to King’s in-house telehealth group program, as well as state telephone quitline resources and/or a text-messaging program by the National Cancer Institute.

“This program is automatically delivered to every patient with cancer who is listed in the EHR as a smoker,” King said. “We also offer repeated enrollments. If you were enrolled the first time, and you didn’t quit for a variety of reasons, if 6 months later you had another outpatient visit, the system would automatically re-enroll you as we know quitting smoking is a process and may require repeated attempts for some.

“This is an addiction like any other addiction,” she added. “People can relapse or may not meet their goals. We want to offer a menu of options repeatedly. We want to say we’re not giving up on you; don’t give up on yourself. We’re going to continue to offer a variety of options as part of your cancer care.”

King and colleagues retrospectively analyzed the effectiveness of the program, for which 3,706 patients (mean age 62.1 years; standard deviation, 12; 57% men; 46.6% Black; 38.5% white) treated at The University of Chicago between 2019 and 2024 were eligible.

‘Terrific’ response

Overall, 2,024 patients (54.6% of those attempted) were reached, meaning they responded to at least one contact attempt.

Of those, 10.7% engaged with the program but did not select a treatment option, and 43.1% selected and were referred to one or more treatment options.

“To get about half of patients to respond in this opt-out program is terrific,” King said.

The most common patient-selected cessation options included medication with counseling (70.6%), medication alone (14.8%) and a text-only program (8.8%).

Among those referred for treatment, the most common referrals included counseling services (58%), medications alone (20.8%), and medications with counseling (11.5%).

Black patients had higher referral rates than white patients (31.8% vs. 16.4%), but white patients had higher rates of self-reported abstinence (25.7% vs. 14.4%).

Among 327 respondents to final, 6-month follow-up, 16.2% abstained from smoking for at least 8 days, 58.7% reported attempting to quit within the previous month, and 15% said they smoked less than at program enrollment.

“Even reducing the number of cigarettes smoked is a step in the right direction, but we don’t want to stop there because we know there’s no safe level of smoking,” King said.

Patients with smoking-related malignancies had significantly higher abstinence rates than those with non-smoking-related cancers (23.7% vs. 14.7%; P = .022).

The program had a median annual cost of $64,279. Each person reached cost $183, each referred patient cost $415, and the cost per quit was $6,067.

Researchers acknowledged program limitations, including using smoking status as documented in the EHR to determine eligibility, which may not capture all patients who currently use tobacco and underreport their smoking due to stigma.

King and colleagues continue to investigate how to “sustain and grow” the program, including partnering with other affiliates and trying to reach individuals who smoke who may be at high risk for cancer, but not diagnosed yet.

Additionally, researchers are evaluating who did not respond to the initiative, and if there are other ways to connect with them.

“There’s so much more we want to do to continue to innovate and improve from this starting point,” King said. “I hope more cancer centers can implement something like this program to ensure sustainability. I hope that can be the future.”

In fact, the No Smoker Left Behind initiative may serve as a model for other centers to meet the benchmarks for the new standard introduced by the American College of Surgeons Commission on Cancer in January 2026. The standard requires accredited cancer centers implement a process for screening all new cancer patients for smoking status and refer those who currently smoke to evidence-based smoking cessation services.

Focusing on positives could help achieve that.

“We can’t help every patient, but we can try to use these kinds of systems and the EHR to invite them in a nonjudgmental way,” King said. “People can sometimes get down on themselves and feel bad that they engage in tobacco smoking. But we want to focus more on the benefits of quitting. If we can change the narrative a bit, and we can be here to help, I think that will go a long way.”

For more information:

Andrea C. King, PhD, can be reached at aking@bsd.uchicago.edu.