Design, implementation, and evaluation of an intervention to improve referral to smoking cessation services in breast cancer patients

  • Margaret NolanEmail author
  • Jennifer L. Ridgeway
  • Karthik Ghosh
  • David Martin
  • David O. Warner
Original Article



Smoking is a risk factor for poor outcomes following breast reconstructive surgery. This project aimed to design and implement an intervention to consistently refer all breast cancer patients to tobacco treatment services.


In formative work, a set of processes for providers to consistently refer patients to a tobacco treatment specialist at the Nicotine Dependence Center (NDC) was designed. Elements included consistent documentation of smoking status, provider advice specific to the benefits of quitting to cancer care, referral to NDC using an “opt-out” strategy that emphasized smoking cessation as a standard part of breast cancer treatment, and reinforcement of the importance of the referral by multiple personnel. The number of referrals to the NDC and number of patients who attended their scheduled NDC appointment were measured before and 1 year after implementation. Qualitative evaluation was performed using semi-structured interviews with participating providers and patients regarding acceptability.


The proportion of smoking patients referred to the NDC increased from 29% (22/75) before the intervention to 74% (20/27) afterward. Among those referred, attendance at the consultation increased from 41% (9/22) to 75% (15/20). This occurred despite provider interviews revealing knowledge gaps about the referral process and evidence of provider adaptation to accommodate personal practice. Feasibility and acceptability of the intervention were high.


These findings suggest that similar referral interventions for all cancer patients should be pursued with the aim of embedding tobacco dependence treatment seamlessly and consistently into the cancer treatment plan of every patient who smokes cigarettes.


Standards of care Breast cancer Health services research Quality improvement 


Funding information

This work was funded directly by Mayo Clinic.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


The authors have full control of all primary data and will agree to allow the journal to review this data if requested.

Supplementary material

520_2018_4486_MOESM1_ESM.docx (21 kb)
ESM 1 (DOCX 20 kb)
520_2018_4486_MOESM2_ESM.docx (17 kb)
ESM 2 (DOCX 16 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterUSA
  2. 2.Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterUSA
  3. 3.Breast Clinic, Division of General Internal MedicineMayo ClinicRochesterUSA

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