Expanding Access to Smoking Cessation Treatment among Cancer Survivors in Appalachia: A Demonstration Trail with Community Health Workers

Smoking after cancer diagnosis is causally linked to increased mortality and second primary cancer in addition to increased risk of cancer recurrence, poor treatment effectiveness, greater treatment complications, and worse quality of life. Thus, it is imperative that cancer survivors quit smoking as soon as possible and remain abstinent for the rest of their lives. Encouragingly, many cancer survivors are motivated to quit and are able to do so during cancer treatment. For those who quit, however, the risk of relapse is high, and some begin smoking again once they leave the cancer care system and return to their communities. Indeed, the prevalence of smoking among US adult cancer survivors (20-30%) is typically higher than what is found in the general population of US adults. Importantly, the risk of smoking is not evenly distributed in the US population, with the highest rates concentrated among those who are socioeconomically disadvantaged and underserved. Appalachian Kentucky unfortunately serves as an exemplar of this public health problem, with rates of smoking and other tobacco use as well as cancer mortality among the highest in the nation. These two inequities–the unacceptably high rates of smoking and cancer mortality–exist in tandem alongside a litany of institutional and social barriers to smoking cessation (e.g., weak tobacco control policy, permissive norms about smoking, practical barriers to tobacco treatment). To address the critical problem of smoking among cancer survivors in Appalachia, evidence-based smoking cessation treatment must be accessible and acceptable to the target population. Community health workers (CHW) are primed to meet this need for many reasons: 1) they are certified to serve as facilitators of health and wellbeing; 2) they are trained to navigate through systemic obstacles to healthcare utilization; and perhaps most important, 3) being from the same community as those they serve, they are sensitive to and uniquely suited to help mitigate social impediments to smoking cessation. The proposed study will address a significant gap in the evidence base about how to best provide smoking cessation treatment to cancer survivors who live in underserved communities. In Appalachian Kentucky, I will partner with a wellestablished network of CHW (Kentucky Homeplace) to train three CHW as tobacco treatment specialists via an online program accredited by the Council for Tobacco Treatment Training Programs. Next, in a demonstration trial that relies heavily on a type 1 hybrid effectiveness-implementation design, I will: 1) describe the effectiveness of smoking cessation treatment that is delivered by CHW and complemented by free nicotine replacement therapy samples and 2) investigate implementation outcomes and associated factors. This study will be the first to leverage the strengths of CHW to address the undeniable problem of smoking after cancer diagnosis, with significance greatly enhanced by our focus on the socioeconomically disadvantaged and underserved region of Appalachian Kentucky. If effectiveness is shown in this pilot trial and a subsequent larger RCT, then findings concerning implementation will promote more rapid translation of an evidence-based smoking cessation strategy into community practice, with the ultimate goal of reducing cancer mortality.