New Study Expands Lifesaving Smoking Cessation Efforts to Rural, Underserved Communities

Michael Cummings, PhD

MUSC Hollings Cancer Center researchers hope to save lives by expanding the Tobacco Treatment Program, first implemented at MUSC Health in 2014, to rural and underserved communities to improve overall patient health, save patients money and reduce the number of premature deaths.

Cigarette smoking causes about 18% of all deaths in the U.S. and is responsible for 33% of cancer deaths, according to a U.S. Department of Health and Human Services Report of the Surgeon General. Given the success of the Tobacco Treatment Program at MUSC Health, two Hollings researchers will be studying the impact of replicating it at the MUSC Institute of Psychiatry and MUSC Health’s regional hospitals in Florence, Marion, Lancaster and Chester.

The study, led by Michael Cummings, PhD, and Benjamin Toll, PhD, began enrolling patients in March. They will be using a randomized model in which 75% of patients will receive enhanced care consisting of in-person or telehealth consults while hospitalized, followed by post-discharge interactive voice calls made seven days after discharge to connect patients to the South Carolina Quitline. The basic care group, comprising 25% of the patients, will only receive the post-discharge call.

Since 2014, MUSC Health has used an opt-out model in its Tobacco Treatment Program in which hospitalized patients who smoke are identified and provided smoking cessation support and follow-up calls, if they agree. Since beginning the program, Cummings said that 85% of patients have accepted the service.

“I wasn’t surprised by this,” he said. “It is a teachable moment for patients who have a condition that has led them to be hospitalized. That makes a big difference in them accepting the service.”

Toll said they have found that the enhanced care intervention improves smoking cessation efforts, and they will see the impact it has in the new study. The personal consult is an important part of the program.

“If you are identified as a current cigarette smoker, our trained bedside smoking cessation counselor will show up in your hospital room and say, ‘Hi, I’m from the Tobacco Treatment Program. Your medical records indicate that you smoke, and we want to discuss options for changing your tobacco use, if you wish. May we speak with you for a few minutes?’” Toll explained. “If they are interested, we will do a proper diagnostic review of their smoking history. How long have they smoked? How much do they smoke? When do they smoke? After which, we develop a treatment plan, if they wish, to reduce or quit smoking.”

Cummings said that previous research on smoking cessation efforts at MUSC has shown patients exposed to the program are roughly 2.5 times more likely to use Food and Drug Administration-approved medications to stop smoking and twice as likely to quit smoking for at least a week. Cummings said that the program increased post-discharge nonsmoking rates from 10% to 20%.

The Tobacco Treatment Program also is offering an opt-out service for Hollings outpatients, according to Toll.

Graham Warren, MD, vice chairman for research in radiation oncology and one of the Hollings researchers affiliated with the Tobacco Treatment Program, said that getting cancer patients to quit smoking is critical. The 2014 Report of the Surgeon General identified 13 different cancers causally linked with cigarette smoking, including lung, oropharynx, larynx, esophagus, stomach, pancreas, kidney, cervix, bladder, colon and rectum, liver and acute myeloid leukemia.

Not only does smoking cause certain cancers, it also hampers cancer treatment, with research showing a decrease in efficacy of those treatments in patients who smoke.

“Smoking after a cancer diagnosis increases the risk of treatment failure, toxicity from cancer treatment and risk of death by 50% to 60% or more. We estimate that for every three patients that we get to quit smoking, we improve survival and increase the effectiveness of cancer treatment,” Warren said. “Furthermore, we have shown that the program at MUSC can reduce risk for readmission across all patients, which is also a huge benefit for our patients and their quality of life.”

Since March 2021, the inpatient Tobacco Treatment Program has screened more than 18,000 patients and identified over 3,300 current smokers at MUSC Health, MUSC Health Florence Medical Center, MUSC Health Marion Medical Center, MUSC Health Lancaster Medical Center and MUSC Health Chester Medical Center. Cummings said that the smoking prevalence rates of patients at the rural sites are more than double the rates seen at MUSC Health. Rates are 12% at MUSC Health in Charleston, compared with Florence at 25%; Lancaster, 28%; Marion, 27%; and Chester, 32%. He said that this makes it that much more important to expand the Tobacco Treatment Program to all four of MUSC’s regional hospitals.

“The Tobacco Treatment Program has been well-received in the more rural regional hospitals because nobody has offered patients a service like this before,” Cummings said. “Now patients are seeing that there is help available and getting an education, which is the first part in the journey to quit smoking.”

Edward McCutcheon, MD, chief medical officer for MUSC Health Lancaster and Chester medical centers, said Lancaster and Chester counties have some of the highest adult smoking rates in all of South Carolina. He believes that the Tobacco Treatment Program will save lives.

“We feel that this program is vital to the public health initiative to care for the community and offering this will definitely make an impact for our patients who are smokers,” McCutcheon said. “We’re excited to have this program in place.”

Rami Zebian, MD, chief medical officer for MUSC Health Florence Division, said that the Tobacco Treatment Program has enabled providers to reach and treat patients who smoke. He also said that the educational aspect of the program is critical.

“The Florence area has a lot of tobacco farms. A lot of people here began smoking at 8 years old. Many people did not know any better, and so they smoked at a very young age,” explained Zebian. “Whatever we can do to prevent diseases is the way to go and getting people to quit smoking is key.”

In addition to saving lives, the study also hopes to prove the financial benefits of smoking cessation efforts. Previous research published in the Journal of Smoking Cessation showed that smokers exposed to an inpatient Tobacco Treatment Program, such as the one at MUSC, were less likely to experience an unplanned hospital readmission, resulting in lower health care expenditures over the next year by an average of $7,299.

According to Cummings, the current study comparing enhanced versus basic care will require following up with 500 patients to test the impact of the two intervention arms.

One of the goals of the study, Cummings explained, is to offer a practical solution to smoking cessation that is highly scalable. He also believes that improving education and access to smoking cessation treatments will increase the number of successful quit attempts. The study also extends Hollings’ ongoing mission to disseminate evidence-based smoking cessation treatments to high-risk populations.

“Smoking is the leading cause of preventable premature death, with one out of two smokers dying prematurely,” Cummings said. “It’s an economic drain on our state and economy, and in the 21st century, South Carolina needs to move beyond its historical roots in tobacco and give the citizens a chance to live healthier lives.”

Patients will continue being enrolled in the study until December. Researchers plan to have a final report published by September of 2022.