Integrating Diversity, Equity, and Inclusion Approaches Into Treatment of Commercial Tobacco Use for Optimal Cancer Care Delivery

Tobacco-related cancer incidence and mortality and commercial tobacco use have decreased steadily in recent decades, but improvements have not been equitably experienced across population subgroups. A complex interaction across socioecological domains of individual, interpersonal, community/organization, and societal/policy factors influence disparities in tobacco use, treatment, and related health outcomes. NCI’s Cancer Center Cessation Initiative (C3I) provides an ideal platform to examine and intervene on multilevel influences across the cancer control continuum to reduce any disproportionate tobacco-related burden and eliminate tobacco-related disparities. The C3I Diversity, Equity, and Inclusion (DEI) Working Group encourages cancer centers to develop, evaluate, and adopt evidence-based practices regarding DEI for prevention and treatment of commercial tobacco use across the cancer control continuum. This paper highlights how 3 C3I sites intervene to address socioecological influences on tobacco use among racially, ethnically, socioeconomically, and geographically diverse patient subgroups. It then outlines ways in which DEI considerations could be integrated into research with patients with cancer who use tobacco and practices related to standards of cancer care. Incorporating DEI considerations in the pursuit of optimal tobacco treatment could facilitate elimination of inequities in population-level cancer outcomes, spanning the full continuum of cancer care from prevention to survivorship.

Background

Nearly one-third of all cancer-related deaths are attributable to commercial tobacco use. Improvements in tobacco-related cancer incidence, mortality and tobacco cessation, however, have not been equitably experienced across all population subgroups.1 In particular, Black/African Americans, individuals of low socioeconomic status, and those living in rural areas experience a disproportionate burden of tobacco-related cancer incidence and mortality.1 Black/African Americans and Native Hawaiians also have a higher smoking-associated risk for lung cancer than other racial/ethnic groups.2 Additionally, other racial and ethnic minoritized groups, sexual and gender minorities, and people with behavioral health and/or comorbid substance use conditions are more likely to be exposed to tobacco marketing and price promotions, and are less likely to receive advice to quit tobacco and use pharmacotherapy.3 A complex interaction across socioecological domains of individual, interpersonal, community/organizational, and societal/policy factors influence these disparities in tobacco use and treatment, and ultimately within cancer care.46

The Cancer Center Cessation Initiative (C3I), which was launched in 2017, includes 52 NCI-designated Cancer Centers that work to integrate high-quality tobacco treatment into routine cancer care.7 Although NCI has previously funded tobacco-related disparities research in community networks,8 C3I is integrated into the cancer center infrastructure, thereby providing an ideal platform to examine and intervene on multilevel influences across the entire cancer control continuum, from prevention to palliation.9 Thoughtful design and implementation of tobacco treatment that prioritizes and integrates diversity, equity, and inclusivity (DEI)6,10 is critical if C3I programs are to reduce cancer disparities at the population level.

Members from 22 C3I sites comprise the current DEI workgroup, whose mission is to encourage cancer centers to develop, evaluate, and adopt evidenced-based practices with regard to DEI for the prevention and treatment of commercial tobacco use across the cancer control continuum. Here, we showcase how 3 C3I sites integrate DEI efforts into tobacco treatment at multiple socioecological levels of influence. We then propose ways in which cancer centers could embed DEI considerations into patient-oriented tobacco-related research and practice implementation.

Fred Hutchinson Cancer Research Center

Seattle Cancer Care Alliance (SCCA) is the primary site for patient care at the Fred Hutchinson Comprehensive Cancer Center. SCCA serves people from all over Washington State and beyond, but community-based efforts focus on King, Pierce, and Snohomish counties, where 52% of SCCA’s patient population and 3.7 million people reside. SCCA’s Living Tobacco Free Services Program, established in 2008, includes counseling by certified tobacco treatment specialists (TTSs), pharmacotherapy, and referral to external resources like a quitline. Patients are followed in various ways, tailored to patient preferences (eg, calls with a TTS, written resources, and free download and support for the Quit2Heal smartphone app). In 2019, a community health needs assessment found 4 major cancer-related health needs: (1) cancer prevention and screening, (2) culturally and linguistically appropriate outreach, (3) access to care, and (4) Indigenous health.

Simultaneously, in 2019, SCCA launched həliʔil (haa lee (ʔ) eel, Coast Salish for “become well/heal”), an Indigenous-specific Health Promotion program. həliʔil engages the Indigenous community in cancer care and provides treatment for commercial, nonceremonial tobacco cessation. The program supports a tribal liaison, a patient navigator specifically for Indigenous populations, a community health worker, and a medical director. The program applies culturally and linguistically appropriate methods to provide outreach, patient navigation, and advocacy. The program team is conducting focus groups and interviews with American Indian/Alaska Native community members to elucidate facilitators and barriers to nonceremonial tobacco cessation and lung cancer screening. As the program matures, SCCA plans to expand its reach by facilitating health fairs, powwows and other community gatherings, and offering routine training to SCCA staff and providers to build capacity and responsiveness to patients who identify as Indigenous.

University of Maryland Greenebaum Comprehensive Cancer Center

University of Maryland Greenebaum Comprehensive Cancer Center (UMGCCC) serves a catchment area of 5.4 million people living in Baltimore City plus a 10-county region in central Maryland. Baltimore City has a predominately Black/African American population (62%), with a sizeable percentage of Black/African American residents in the UMGCCC 10-county catchment area as well (32%). In 2020, the UMGCCC Community Outreach and Engagement leadership organized a Tobacco Taskforce for key stakeholders to strategize on tobacco and cancer. The resultant UMGCCC tobacco treatment program places patients at the center and builds options around their preferences and needs, including virtual or in-person visits with a certified TTS, SmokefreeTXT text messaging support, free nicotine replacement therapy samples, lung cancer screening enrollment, and a closed-loop referral to the Maryland Quitline. The program also resulted in treatment of tobacco use as the “fifth” vital sign and facilitated the electronic referral process for tobacco treatment.

To increase patient reach, tobacco cessation advice is provided at multiple touchpoints throughout the patients’ care by staff who act as patient navigators. Using a DEI lens, when possible, patients are paired with patient navigators of the same race and/or language. Additionally, in response to patients’ described preferences during focus groups, the UMGCCC team created patient education and communication media that is inclusive of patients and providers of different genders and skin tones. Community members and patients will provide input into these materials to bolster acceptance, reach, and engagement with the final products, and improve cessation among traditionally underrepresented patient groups.

University of California Davis Comprehensive Cancer Center

The University of California Davis Comprehensive Cancer Center’s (UCDCCC’s) catchment area of 19 inland northern California counties (42% rural) is home to 5 million people who comprise a diverse majority-minority population (particularly Latinx, Asian American, Native Hawaiian, and Pacific Islander) with nearly 30% speaking a non-English language at home. The UCDCCC Stop Tobacco Program was established in 2017, housed under UCDCCC’s Office of Community Outreach and Engagement and in partnership with the health system’s TTS in Health Management and Education.11 UCDCCC partners with local county tobacco control coalitions, conducts tobacco treatment trainings for safety-net clinics that serve diverse populations (eg, Asian American, Native American), and hosts community tobacco education events that include partners serving sexual and gender minority and rural populations.

UCDCCC community outreach and education has been the basis for supporting policy change at the local and state level. UCDCCC member, Dr. David Cooke, and Dr. Phil Gardiner, Co-Chair of the African American Tobacco Control Leadership Council, described in a local op-ed how menthol cigarettes were cheaper in a local predominantly African American neighborhood,12 demonstrating a community-level variable that put African Americans at a disadvantage. In a 2019 educational roundtable forum hosted by UCDCCC, academic and community partners discussed key issues related to flavored tobacco products, and a subsequent resource document13 was shared with local policymakers. The City of Sacramento later implemented a retail ban on all flavored tobacco products, including menthol.14 Subsequent education was requested by and provided to the state assembly. A statewide law for a retail ban on flavored tobacco products, including menthol, was to take effect in 2021, but implementation has been delayed due to a referendum sponsored by the tobacco industry.14

DEI-Specific Research and Implementation Approaches in Cancer Center Tobacco Treatment Programming

These 3 C3I sites each considered their community’s and patients’ unique needs and tailored their tobacco treatment program in response. As more cancer centers investigate tobacco-related inequities and implement tobacco treatment programs, it will be important to consider DEI-related research and implementation strategies across the socioecological levels of influence, and equally important to consider specifically what investigators, clinicians, and administrators can practice and implement. Table 1 presents some recommendations for such DEI-oriented research and practice activities.

Table 1.

Considerations for Future DEI-Related Research and Practice/Implementation Strategies by Socioecological Level of Influence

Table 1.

Our hope is that as cancer centers develop and continue to implement evidence-based tobacco treatment programs, DEI considerations will be routinely and mindfully incorporated at each level of socioecological influence to optimize tobacco treatment and eliminate inequities for population-level cancer and tobacco treatment outcomes.

References

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The Cancer Center Cessation Initiative Diversity, Equity, and Inclusion Working Group Members

Rashelle B. Hayes PhD1, Jessica L. Burris PhD2, Elisa K. Tong MD, MA3, Niharika Khanna MBBS, MD, DGO4, Ursula Tsosie MS5, Sarah D. Hohl PhD6, Kimlin Ashing PhD7, Gleneara E. Bates-Pappas LMSW8, Lisa Sanderson Cox PhD9, Stephanie Craven Bunch MPH, TTS10, Adam Gaynor MPH, CHES4, Mercy Laurino MS, CGC, PhD5, Katie L. Lenhoff MPH11, Christine E. Sheffer PhD12, Matthew Triplette MD, MPH13, Sophia Yeung MHA, CTTS7, Robert Adsit MEd14, Mara Minion MA6, Danielle Pauk BS6, and Betsy Rolland PhD, MLIS, MPH6,15

1 Department of Psychiatry and Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia; | 2 Department of Psychology and Markey Cancer Center, University of Kentucky, Lexington, Kentucky; | 3 Department of Internal Medicine, University of California Davis Comprehensive Cancer Center, Sacramento, California; | 4 Department of Family Medicine, University of Maryland School of Medicine, Baltimore, Maryland; | 5 Cancer Genetics and Prevention, Seattle Cancer Care Alliance, Seattle, Washington; | 6 Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin; | 7 Department of Population Sciences, City of Hope National Medical Center, Duarte, California; | 8 Department of Psychiatry and Behavioral Science, Memorial Sloan Kettering Cancer Center, New York, New York; | 9 Department of Population Health, University of Kansas School of Medicine, Kansas City, Kansas; | 10 Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, North Carolina; | 11 Dartmouth-Hitchcock Norris Cotton Cancer Center, Lebanon, New Hampshire; | 12 Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York; | 13 Clinical Research Division, Fred Hutchinson Cancer Research Center; Department of Medicine, University of Washington, Seattle, Washington; | 14 Department of Medicine, Center for Tobacco Research and Intervention, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin; and | 15 Institute for Clinical and Translational Research, University of Wisconsin-Madison, Madison, Wisconsin.

Submitted July 26, 2021; final revision received September 14, 2021; accepted for publication September 16, 2021.

Disclosures: E.K. Tong has disclosed participating research for the California Tobacco Control Program (Principal Investigator). S.C. Bunch has disclosed receiving research support from Wake Forest School of Medicine. The remaining individuals have disclosed no relevant financial relationships.

Funding: This supplement was funded by the C3I Coordinating Center contract from the National Cancer Institute (CRDF Award #66590). In addition, authors received funding for their C3I participation via a supplement to their NCI P30 cancer center support grant during the period 2017–2021.

Correspondence: Rashelle B. Hayes, PhD, Department of Psychiatry, Virginia Commonwealth University, 501 North 2nd Street, Suite 400A, Richmond, VA 23298. Email: rashelle.hayes@vcuhealth.org
  • 1.

    Henley SJ, Thomas CC, Sharapova SR, et al. Vital signs: disparities in tobacco-related cancer incidence and mortality—United States, 2004–2013. MMWR Morb Mortal Wkly Rep 2016;65:12121218.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Haiman CA, Stram DO, Wilkens LR, et al. Ethnic and racial differences in the smoking-related risk of lung cancer. N Engl J Med 2006;354:333342.

  • 3.

    US Department of Health and Human Services. Smoking cessation: a report of the Surgeon General. Accessed September 6, 2021. Available at: https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf

    • Search Google Scholar
    • Export Citation
  • 4.

    Babb S, Malarcher A, Schauer G, et al. Quitting smoking among adults—United States, 2000–2015. MMWR Morb Mortal Wkly Rep 2017;65:14571464.

  • 5.

    Dahne J, Wahlquist AE, Smith TT, et al. The differential impact of nicotine replacement therapy sampling on cessation outcomes across established tobacco disparities groups. Prev Med 2020;136:106096.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Webb Hooper M. Editorial: preventing tobacco-related cancer disparities: a focus on racial/ethnic minority populations. Ethn Dis 2018;28:129132.

  • 7.

    Croyle R, Morgan G, Fiore M. Addressing a core gap in cancer care: the NCI Cancer Moonshot program to help oncology patients stop smoking. N Engl J Med 2019;380:512515.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Tong EK, Fagan P, Cooper L, et al. Working to eliminate cancer health disparities from tobacco: a review of the National Cancer Institute’s Community Networks Program. Nicotine Tob Res 2015;17:908923.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Simmons VN, Piñeiro B, Hooper MW, et al. Tobacco-related health disparities across the cancer care continuum. Cancer Contr 2016;23:434441.

  • 10.

    Sheffer CE, Webb Hooper M, Ostroff JS. Commentary: educational and clinical training for addressing tobacco-related cancer health disparities. Ethn Dis 2018;28:187192.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Tong EK, Wolf T, Cooke DT, et al. The emergence of a sustainable tobacco treatment program across the cancer care continuum: a systems approach for implementation at the University of California Davis Comprehensive Cancer Center. Int J Environ Res Public Health 2020;17:E3241.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Cooke DT, Gardiner P. To save African American lives, flavored tobacco ban must include menthol cigarettes. Sacramento Bee. March 12, 2019.

    • Search Google Scholar
    • Export Citation
  • 13.

    Lara P, Chen M, Homer K, et al. Flavored Tobacco Products: An Educational Roundtable. Accessed September 6, 2021. Available at: https://health.ucdavis.edu/cancer/support/pdf/FlavoredTobaccoProducts_UCDavisComprehensiveCancerCenter.pdf

    • Search Google Scholar
    • Export Citation
  • 14.

    Clift T. Sacramento City Council approves ban on sale of flavored tobacco products. Sacramento Bee. April 16, 2019.

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