No Smoker Left Behind: Research-backed smoking cessation as cancer care

Receiving a cancer diagnosis sometimes makes people think there is no point in quitting smoking, or that quitting will be too stressful to attempt during or after difficult cancer treatment. In reality, quitting is linked to better survival and fewer side effects, and although quitting can is difficult, it’s never too late to make a change.

New research from the University of Chicago Medicine indicates that a simple opt-out, technology-based outreach program is an effective and efficient way for cancer centers to make smoking cessation a routine part of patient care.

Through the No Smoker Left Behind program, healthcare professionals identify cancer patients who smoke and use an opt-out approach to repeatedly offer a menu of free or low-cost treatment and support options for quitting. According to the new analysis, more than half of eligible cancer patients responded to automated outreach, and of those who chose treatment, most selected a combination of counseling and medication, which is considered the “gold standard” for smoking cessation.

“Adults who have cancer and who smoke have worse outcomes across the board: poorer treatment response and higher likelihood of complications, relapse, and secondary cancers,” said senior author Andrea King, PhD, director of UChicago Medicine’s Courage to Quit and No Smoker Left Behind programs. “Tobacco cessation for cancer patients should be a medical priority right alongside treatments like chemotherapy.”

A place for smoking cessation in cancer care

Despite the statistics about the adverse effects of continued tobacco use after a cancer diagnosis, the authors said smoking has too often remained an afterthought in oncology.

“There’s a tendency to assume that smoking cessation is something that falls outside the realm of cancer care,” said first author Michael Wakeman, an MD candidate at the University of Chicago Pritzker School of Medicine. “And when we talked to healthcare professionals across multiple cancer centers, we repeatedly heard that people don’t feel like they have time to add tobacco cessation programs to their routine practice.”

The Cancer Moonshot-funded Cancer Center Cessation Initiative (C3I) was created in 2017 to change that by providing support for National Cancer Institute-designated cancer centers integrating tobacco treatment into routine care. The UChicago Medicine Comprehensive Cancer Center was one of just 22 cancer centers across the country to receive the first wave of funding to develop and sustain smoking cessation programs.

A persistent, efficient intervention that retains patient agency

No Smoker Left Behind was UChicago’s C3I result: an “opt-out” program that uses technology instead of relying on already overburdened clinicians to initiate the conversation.

The system uses the electronic health record to identify adult cancer patients who currently smoke. After an outpatient visit, those patients are automatically contacted for up to six months through text messages, emails, and short, interactive phone calls with pre-recorded messages from King.

The opt-out model means that every eligible patient is invited to participate rather than having to reach out for help on their own, and the contact messages are designed to be warm and welcoming. This strategy helps lower barriers to participation and avoids making patients feel singled out or shamed, and makes the program sustainable from a labor and cost perspective since the initial enrollment doesn’t need to be triggered by additional actions from a healthcare team member.

“I’m old school: I would love to meet with every patient and have a warm, 30-minute conversation. But I know I’d only reach a fraction of patients that way, and there are financial constraints at the institutional level,” King said. “But we can’t let excuses get in the way of providing state-of-the-art care and offering all patients a range of options. Technology is the way to do that.”

Patients who engage with the No Smoker Left Behind communications answer a few questions about their smoking behaviors and can then choose from a menu of treatment options, including:

• Individual virtual counseling from a dedicated UChicago Medicine specialist
• Group-based virtual counseling through the Courage to Quit program
• FDA-approved medications that can aid cessation
• The Illinois Tobacco Quitline, which offers free phone-based counseling and nicotine replacement patches
• A free intensive text-messaging program sponsored by SmokeFree.gov and the National Cancer Institute

Patients can select counseling, medications, both, or decline altogether, and they are offered these options multiple times over the course of 180 days. Patients who don’t quit within six months or who don’t respond to the first set of outreach attempts can be invited again after another outpatient visit.

King said that both the repeated contact and the offering of multiple options are deliberate.

“We had many people re-enroll over and over again. It’s about finding a moment when someone’s ready to receive the information and support,” she said. “Providing options lets patients retain agency, which should be made a standard of care.”

High referral rates, relatively low cost

During the study period (2019–2024), No Smoker Left Behind contacted 3,706 eligible cancer patients who smoked. Nearly half were Black, and almost two-thirds were publicly insured — groups that often face greater tobacco-related harms and have less access to community resources and other cessation support.

More than half of those contacted responded to at least one message from the program, and about one in four of all eligible patients went on to receive referrals to cessation treatment. Over 70% of those who selected treatment chose to combine medication and counseling, which is considered the “gold standard” treatment plan for smoking cessation.

The researchers calculated that the program costs are lower than the estimated cost of cancer treatments failing because patients continue to smoke, which has been estimated at more than $10,000 per patient in some analyses.

‘Quitting smoking is cancer care’

“We want patients and their loved ones to know that it's never too late to make a change when it comes to smoking,” Wakeman said. “Millions have quit — it’s okay that for some people it takes longer or requires more support. We recognize that it’s a journey: if you're not ready to quit yet, we talk about reducing to get to the point of quitting. There’s a lot of flexibility.”

In the future, the researchers hope to expand the program to hospitalized patients and eventually to people with other serious conditions linked to smoking, such as chronic obstructive pulmonary disease (COPD), cardiovascular disease, and diabetes. With the current paper and ongoing efforts, they hope to shift how patients and healthcare professionals alike think about smoking in the context of cancer.

“Quitting smoking is cancer care,” King said. “If we could start changing our thinking about that, it would be so important. It's all about support, not blame.”

 

“No Smoker Left Behind: Evaluation of a Population-Based, Opt-Out Smoking Cessation Program for Cancer Patients Who Smoke” was published in the Journal of Clinical Oncology in May 2026. Co-authors are Michael Wakeman, Yasmin Asvat, Raymond A. Ruiz, Emma I. Brett, Vincent Talbot, Jasmin Tiro and Andrea C. King.