For patients with cancer who smoke tobacco, quitting may be one of the most impactful interventions available. Quitting smoking after a cancer diagnosis has been linked to better treatment response and improved overall survival.

Quitting is so effective that “my colleagues have called tobacco treatment the ‘fourth pillar of cancer care’ alongside surgery, radiation, and chemo/immunotherapy,” said clinical psychologist Jesse Kaye, PhD, assistant professor at the University of Wisconsin-Madison (UW) Department of Family Medicine and Community Health and the UW Center for Tobacco Research and Intervention.

Yet, despite decades of evidence and guideline recommendations, tobacco cessation treatment remains underused. Most patients never receive it, and survey data suggest that more than half of people who smoke continue after a cancer diagnosis.

The disconnect reflects a persistent gap in oncology: Effective strategies to improve quit rates and outcomes exist, but they are not routinely embedded into cancer care.

Why does that gap exist? And what can realistically be done to close it?

The Evidence and the Gap

The evidence supporting tobacco treatment is remarkably consistent. Continuing to smoke has been linked to worse survival, while quitting improves outcomes across multiple cancer types.

A 2025 analysis, for instance, found that patients who continued smoking had an almost twofold higher risk for all-cause mortality than those who quit smoking within 6 months of their cancer diagnosis. At 2 years, 85% of patients who quit were alive compared with nearly 75% of those who continued smoking. These patterns held across studies assessing smoking cessation and cancer survival for a range of cancer types, including head and neck, lung, colorectal, and bladder cancer.

With this body of evidence that smoking undermines the effectiveness of cancer treatment and reduces patient survival, “smoking should be assessed, documented, and treated with a sense of urgency,” said Jessica L. Burris, PhD, professor in the department of psychology and co-leader of the Cancer Prevention and Control Research Program at the University of Kentucky in Lexington.

The National Comprehensive Cancer Network has developed tobacco treatment guidelines for patients with cancer, and leading oncology organizations, including the American Society of Clinical Oncology and the American Association for Cancer Research, recommend screening for and treating tobacco use. The National Cancer Institute (NCI) also established the Cancer Center Cessation Initiative to provide grant funding dedicated to implementing tobacco use treatment programs at 52 NCI-Designated Cancer Centers. The initiative has helped dozens of cancer centers implement cessation programs, many of which remained in place after federal funding ended. Additionally, many community and academic programs outside the network also offer cessation clinics or referrals to quit lines and other support services.

Still, “tobacco treatment has not been integrated into routine cancer care,” said Li-Shiun Chen, MD, MPH, ScD, professor of psychiatry at the Washington University School of Medicine and director of the Tobacco Treatment Program at Siteman Cancer Center, both in St. Louis.

If the evidence is so strong, why isn’t tobacco treatment routine oncology care?

Experts say the problem is not lack of evidence — it’s implementation.

A recent survey from Burris and colleagues found that many cancer programs accredited by the American College of Surgeons’ Commission on Cancer still were not routinely documenting smoking cessation treatment plans, providing counseling, prescribing cessation medications, or referring patients to tobacco treatment programs.

The reasons were largely practical. Programs cited inadequate staff training (68.8%), lack of tobacco treatment specialists (61.9%), perceived patient resistance (58.3%), insufficient staff time (42.4%), as well as inadequate funding (40.6%) and reimbursement (31%).

Even when cancer centers have a dedicated smoking cessation program, clinicians still need to identify patients and initiate referrals, which can create a potential bottleneck.

“The biggest barrier that I’ve witnessed in our Tobacco Treatment Program is the dissemination of information of its existence,” said Ashley Charles, a tobacco treatment specialist at Moffitt Cancer Center, Tampa, Florida. “We rely heavily on our providers to send in tobacco treatment referrals, and some are proactive in referring patients to our department.”

She noted that most patients are reluctant to refer themselves to the smoking cessation program at Moffitt, which means the onus is on providers to “advocate for patients and educate them about our services.”

A Path Forward

Can these implementation barriers realistically be overcome?

Experts hope to turn the tide with a new standard implemented earlier this year by the Commission on Cancer. The Commission on Cancer accredited programs are now required to provide tobacco screening and cessation assistance to all newly diagnosed cancer patients. All patients reporting current smoking during screening must be referred to or receive access to evidence-based smoking cessation treatment within 30 days.

Kaye called this standard “a gamechanger” because “it highlights that tobacco treatment is an essential part of routine cancer care.”

The standard, however, does not address the financial and workflow challenges that cancer centers may face.

Chen said overcoming those barriers requires redesigning the care workflow rather than expecting oncologists to shoulder the full responsibility.

At Siteman Cancer Center, for instance, tobacco treatment is distributed across the care team rather than left solely to oncologists. During e-check-in, patients complete a brief screener about their smoking status and interest in tobacco treatment for providers to review before the appointment. Medical assistants provide script-based advice to quit smoking and pend referral orders for free cessation resources, while nurses review patient-reported interest in tobacco treatment and pend orders for medication, such as nicotine replacement therapy or varenicline. Physicians then approve the orders for treatment.

Experts said explaining the effect of smoking on cancer outcomes — not simply advising patients to quit — can be one of the strongest motivators for cessation.

“It makes a huge difference when the clinician caring for them explains how much of an impact it could have if they quit smoking,” said psychiatrist Maher A. Karam Hage, MD, also medical director of the Tobacco Research and Treatment Program at the University of Texas MD Anderson Cancer Center, Houston. 

A multiprong approach to cessation, involving counseling and pharmacotherapy, can be key to kicking the habit because it addresses other smoking triggers, such as stress.

But because relapse is common, experts recommend assessing tobacco use at every oncology visit rather than treating cessation as a one-time discussion.

“Quitting smoking and then restarting is part of the cessation progress, so ongoing attention is required,” said Lisa Sloan, a tobacco cessation specialist at Moffitt.

Although there are many tools in the toolbox, personalizing the treatment plan for each patient is essential.

“Just like cancer treatment is not one-size-fits-all, it’s important to meet the patient where they are and design a quit plan that fits them,” said Sloan.

Importantly, institutions do not have to build programs from scratch. Kaye pointed to the NCI’s Cancer Center Cessation Initiative Tobacco Treatment Implementation Roadmap, which provides guidance on developing workflows, EHR integration, and population-based approaches to ensure every patient who smokes is identified and offered treatment.

The bottom line is: Smoking cessation is one of the few interventions shown to consistently improve outcomes across multiple cancer types but is often treated as supportive care rather than a core component of cancer treatment.

The new Commission on Cancer standards signal that the field has moved beyond debating whether tobacco treatment belongs in oncology. The challenge now is ensuring that every patient who smokes is identified, offered evidence-based treatment, and supported throughout cancer care.

“Many barriers that contribute to undertreatment of smoking are challenges in all health care contexts, such as lack of clinician time or inefficient workflows,” said Kaye. “Supporting cancer care teams to consistently ask about smoking and provide cessation treatment is incredibly important for treatment delivery at the point of care.”

The experts in the piece did not report any relevant disclosures.