52 Barriers and Facilitators to Implementing a Motivational Self-Help Intervention for Smoking Cessation in Oncology

Faculty Mentor: Ursula Martinez (Family & Preventative Medicine, University of Utah)

Research Question: What are the barriers and facilitators to integrating a self-help intervention to increase motivation to quit smoking among patients with cancers that are not typically associated with smoking in oncology settings?

Introduction

Smoking cessation after cancer diagnosis improves treatment outcomes, lowers recurrence, and enhances quality of life across cancer types.^[1] Patients with smoking-related cancers (e.g., throat, lung) often recognize smoking risks and are more motivated to quit, while those with cancers not typically linked to smoking are less likely to see it as a factor and less inclined to stop.^[2] Despite its importance, smoking cessation in oncology care remains fragmented, limited by time constraints and insufficient provider training.^[3] This study examined barriers and facilitators to using a brief, self- help booklet to boost quitting motivation in patients with cancers not typically linked to smoking (e.g., breast, bladder, colorectal, gynecological, melanoma). Based on the Teachable Moment Model (TMM)^[4], each booklet is tailored to a cancer type, showing how smoking harms treatment and prognosis—even if not the cause. Written at a 5th–6th grade reading level, content includes facts, cancer-specific statistics, and testimonials.^[5]

Methods

In the present study we conducted semi-structured in-depth qualitative interviews with stakeholders at the Huntsman Cancer Institute that could play a role in delivering this recently created self-help intervention. Potential participants were contacted via email and invited to participate in the study.

Interested individuals completed a brief online questionnaire and received PDF versions of the booklets. After completing the online survey, participants were scheduled to complete a 30-minute interview. Interviews were conducted via Zoom and were recorded and transcribed verbatim. All participants received a $20 gift card after completing all study procedures.

Our interview guide followed the Consolidated Framework for Implementation Research (CFIR) Model, which includes the following factors^[6]:

• Characteristics of Individuals: Roles, tobacco cessation experience, emotional reactions.
• Intervention Characteristics: Benefits, comparisons, adaptability.
• Outer Setting: Patient needs, likely responses, participation barriers.
• Inner Setting: Clinic receptivity, infrastructure, required approvals.
• Implementation Process: Potential leaders, communication plans (posters, portals, & emails).

Results

The sample included 26 participants with a variety of roles at the Huntsman Cancer Institute (e.g., oncologists, nurses, social workers, psychologists, medical assistants). They were mainly female (84.6%) and White (80.8%), with Asian (11.5%) and Hispanic (11.5%) participants also represented. Participants had an average of 14.08 years of experience in their respective roles (SD = 8.44). Most held a professional degree (61.5%), while others had an associate/technical degree (15.4%), a bachelor’s degree (15.4%), or education beyond four years (3.8%). In terms of patient interaction, 43% reported seeing patients every day, 19% most days, 23% some days, and 15% never. Most staff shared that while they interact with patients daily or nearly every day, they rarely ask about smoking cessation. Many also expressed that the self-help booklets would be easy to use, accessible, feasible, and welcoming for both patients and staff. During the qualitative analysis, themes around barriers and facilitators of intervention implementation emerged. Common barriers included limited time during appointments, lack of clarity around roles and responsibilities, variability in patient engagement, and uncertainty about introducing smoking cessation materials to patients who may not expect them. Other challenges to implementation included patients’ emotional readiness, unclear staff responsibilities, insufficient training in introducing the booklet, and limited cultural or linguistic adaptability of the materials. Facilitators that could help successfully implement the intervention included clearly defined workflows, early expectation setting, support from social workers or medical assistants, digital options for delivery, and alignment with clinic values and existing patient education strategies. Participants also mentioned delivering the intervention at emotionally appropriate times, offering materials in both print and digital formats, ensuring cultural relevance, and assigning a dedicated staff member to oversee consistent distribution.

Conclusion and Next Steps

Findings from this study suggest that while a self-help intervention to address patients smoking behavior is both appropriate and acceptable, successful implementation depends on thoughtful integration into clinical workflows, culturally and linguistically relevant materials, and team-based communication strategies. Future steps in the systematic development of this intervention include modifications to increase cultural diversity and accessibility as well as workflow restructure to ensure its systematic implementation as part of routine care. Future efforts will focus on staff training, expanding access to translated content, and evaluating the intervention’s impact in more diverse clinical settings. This study underscores the importance of offering tailored, accessible, and proactive smoking cessation support to all cancer patients, regardless of whether their diagnosis is traditionally linked to tobacco use.

Reflection

Participating in Project IMPACT under the mentorship of Dr. Ursula Martinez was a transformative experience that provided me with valuable insight into the field of implementation science and, more importantly, into myself. This was my first formal research experience, and my project centered on identifying the barriers and facilitators to implementing a motivational self-help intervention for smoking cessation among patients diagnosed with cancers not traditionally associated with smoking. Through this work, I learned about a range of factors and nuances that influence the implementation of new practices in healthcare, such as provider attitudes, institutional priorities, patient perceptions, and timing of intervention delivery. I came to understand how complex healthcare implementation can be, and how successful integration often depends on more than just evidence; it requires adaptability, communication, and sustained support.

During this internship, I also learned technical and procedural skills that will benefit me far beyond this experience. I became familiar with research platforms such as REDCap for data collection, Box for file storage and organization, Microsoft Teams for interdepartmental communication, and EPIC, the electronic medical records system widely used in hospital settings. I also had the opportunity of getting exposed to participant screening and enrollment in research studies.

Throughout my time as an intern, I deepened my knowledge about cancers not typically linked to smoking, specifically breast, bladder, colorectal, gynecological, and cutaneous melanoma cancers. Before this experience, I had not fully understood how patients with these types of cancers might view smoking differently than those with cancers traditionally associated with smoking, such as lung or throat cancer. Before this project, I did not realize that smoking is a major cause of bladder cancer. Many patients do not see smoking as connected to their illness and therefore do not feel the same urgency to quit, even though research shows that cessation improves outcomes across all cancer types. Through reviewing interviews with healthcare staff at the Huntsman Cancer Institute, I gained insight into how providers perceive patient behavior around smoking. These conversations helped me understand how emotions, timing, and the way information is delivered all play a role in whether a patient is open to change.

Beyond academic and technical learning, this internship allowed me to grow as a professional. One of the most meaningful aspects was learning how to network in a way that was truly enhanced by the environment, the culture, and the willingness of mentors to engage with and support us. I had the privilege of meeting and connecting with successful African American professionals, from physicians to business leaders who served as both mentors and sources of motivation. These connections helped me reach several personal and academic goals and reminded me that relationships can be just as critical as knowledge in navigating a career in healthcare. I also built a community in Utah that felt like family, providing me with professional and emotional support during my time away from home.

Another way I grew professionally during this internship was through learning and applying the ABCD model: Appearance, Behavior, Communication, and Digital Footprint. Wearing professional clothing each day helped me present myself with the level of professionalism expected in healthcare environments. I became more intentional in how I engaged during conversations, in meetings, and even online. Learning how to code-switch appropriately while staying true to myself taught me to be adaptable and confident in a variety of settings.

However, this journey was not without challenges. Reviewing and correcting transcriptions of qualitative interviews was particularly difficult. Every “um,” “mhm,” laugh, pause, stutter, and moment of hesitation had to be accurately documented, requiring a high level of attention to detail and focus. I often had to replay recordings multiple times and revise transcripts that did not meet the required standard. Although frustrating at times, this task taught me the importance of thoroughness and patience in research.

Another challenge was adjusting to a quiet, isolated work environment. As someone who is naturally bubbly and extroverted, spending 4 to 8 hours a day in front of a screen, often with limited interaction, was mentally exhausting. Over time, I learned how to stay focused and self- motivated, and I found creative ways to stay connected with others despite the physical distance. This challenge complemented another eye-opening opportunity I had during the internship: shadowing a pediatric orthopedic surgeon. This experience was a major highlight for me. I learned about children with cerebral palsy, chronic foot conditions, and hip disorders. I enjoyed reviewing spine and hip X-rays, observing patient visits, and discussing treatment plans. These experiences confirmed that I thrive most in clinical environments where I can interact directly with patients and provide compassionate, hands-on care, rather than in purely academic or corporate research settings.

In conclusion, working with Dr. Martinez on Project IMPACT was not only my introduction to research but also a pivotal experience in my personal and professional development. It provided me with technical skills, more insight into patient-centered care, a powerful network of mentors, and clarity about my career goals. I leave this experience with greater confidence, a renewed sense of purpose, and the assurance that the lessons I have learned about research, people, and myself will shape my journey in healthcare moving forward.