Prioritizing implementation strategies to enhance smoking cessation delivery in cancer care in Ontario, Canada: a modified Delphi study

Smoking cessation is considered the "fourth pillar" of cancer care due to its impact on treatment outcomes, survival, and quality of life. In Ontario, a provincial framework promotes systematic smoking status screening and referrals across Regional Cancer Centers (RCCs), yet integration of evidence-based supports remains inconsistent.

To identify and prioritize strategies to improve smoking cessation delivery within Ontario RCCs.

A two-round modified Delphi study engaged health care providers, smoking cessation champions, and patients with lived experience of cancer and tobacco use. In Round 1, 14 panelists rated 13 evidence-informed strategies on a five-point Likert scale; consensus was defined as ≥70% rating of "high" or "very high" likelihood of success. Qualitative feedback informed revisions to six strategies with partial consensus. In Round 2, 12 panelists reassessed the revised strategies.

Four strategies achieved consensus: (i) distributing free cessation medications onsite, (ii) mailing medications to patients, (iii) revising clinical roles to mandate referrals, and (iv) expanding the number of smoking cessation champions. These strategies addressed patient-level barriers (cost, access) and system-level barriers (role clarity, institutional support). Other strategies, including automatic referrals and quality-monitoring systems, had partial or low consensus due to feasibility concerns.

Panelists prioritized strategies that enhance accessibility, affordability, and integration into RCC workflows. Implementing free medication distribution, mandated referrals, and expanded champions can strengthen cessation delivery and normalize cessation as standard cancer care.