Qualitative Review of a Dialectical Behavior Therapy – Skills Training Intervention for Cigarette Smoking by Patients with Cancer

A Dialectical Behavior Therapy – Skills Training Intervention for Cigarette Smoking by Patients with Cancer: Focused Qualitative Inquiry Prior to Feasibility Trial | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search A Dialectical Behavior Therapy – Skills Training Intervention for Cigarette Smoking by Patients with Cancer: Focused Qualitative Inquiry Prior to Feasibility Trial View ORCID Profile Marcia H. McCall , View ORCID Profile Charlotte T. Boyd , View ORCID Profile Nicole D. Kerr , View ORCID Profile Ellen A. Nicola , View ORCID Profile Sherona R. Sirkisoon , View ORCID Profile Erica Fox , View ORCID Profile Lindsay K. Seigenthaler , View ORCID Profile Stephanie S. Daniel , View ORCID Profile Erin L. Sutfin doi: https://doi.org/10.1101/2025.08.19.25334013 Marcia H. McCall 1 Department of Psychiatry and Behavior Medicine, Wake Forest University School of Medicine Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Marcia H. McCall For correspondence: marcia.mccall{at}wfusm.edu Charlotte T. Boyd 2 Department of Family and Community Medicine, Wake Forest University School of Medicine Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Charlotte T. Boyd Nicole D. Kerr 1 Department of Psychiatry and Behavior Medicine, Wake Forest University School of Medicine Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Nicole D. Kerr Ellen A. Nicola 3 Behavioral Medicine, Atrium Health Wake Forest Baptist, Advocate Health Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Ellen A. Nicola Sherona R. Sirkisoon 4 Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Advocate Health Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Sherona R. Sirkisoon Erica Fox 5 Psychosocial Oncology Program, Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Advocate Health Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Erica Fox Lindsay K. Seigenthaler 5 Psychosocial Oncology Program, Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Advocate Health Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Lindsay K. Seigenthaler Stephanie S. Daniel 2 Department of Family and Community Medicine, Wake Forest University School of Medicine Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Stephanie S. Daniel Erin L. Sutfin 6 Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Erin L. Sutfin Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Background Despite evidence that quitting smoking improves cancer treatment and outcomes, about one in eight patients with cancer smokes cigarettes. Barriers to quitting for patients with cancer include psychological distress such as anxiety and hopelessness and difficulties with emotion regulation. Patients who continue to smoke may benefit from targeted therapies beyond motivational and cognitive approaches common to standard-of-care smoking cessation treatment. To improve patient self-efficacy for quitting, we developed an eight-session virtual group intervention to teach patients skills in mindfulness, emotion regulation, and distress tolerance. Our intervention uses Dialectical Behavior Therapy – Skills Training (DBT-ST), a psychotherapy that has been applied successfully to improve coping skills and outcomes for patients with substance use disorders and patients with breast cancer but has not been applied to smoking among cancer populations. Aim To improve our intervention prior to testing with a feasibility clinical trial, we performed a focused qualitative inquiry of patients with cancer who had smoking histories and of their clinicians. Methods We conducted semi-structured qualitative interviews with patients with cancer who smoked or had quit ( n =8) and oncology physicians, psychotherapists, and nurses ( n =9). After reaching data saturation within each participant group, we analyzed interviews using thematic analysis and compared findings within and across participant groups. Results Patients and clinicians strongly supported the intervention for smoking cessation, especially the group format and teaching DBT-ST skills for being present, managing emotions, and handling stress. They shared conflicting opinions on other components such as the virtual setting and whether to include patients not ready to quit. Additional perceived benefits were improved quality of life, decreased anxiety and depression, and acquisition of universal skills for managing life’s challenges. Conclusions These results indicate early enthusiasm and promise for our DBT-ST intervention for patients with cancer who smoke cigarettes, while suggesting modifications prior to the feasibility trial. Highlights People with cancer who continue to smoke cigarettes – about one in eight patients – are more likely to have worse outcomes and shorter lifespans than patients who quit or have never smoked. We designed an innovative program to help people with cancer learn new skills to manage intense stress, calm intense emotions, and be more present to their experiences rather than using smoking to cope. To improve the program in advance of a clinical trial, we described it to patients with cancer and cancer clinicians for their reactions and opinions. Overall, our participants were enthusiastic about our program, especially the skills we were planning to teach, while also offering many helpful suggestions that we will use to modify the program. Introduction Patients who continue smoking cigarettes after their cancer diagnosis are at increased risk of death, failed treatment, treatment complications, and secondary tumor development compared to patients who stop smoking. 1 – 3 Succeeding disease site and stage, continued smoking is the strongest predictor of adverse cancer survival outcomes. 4 In contrast, the benefits of quitting smoking after diagnosis are well established, among them improved survival, better surgical outcomes, lower likelihood of recurrence or new tumor sites, less fatigue, and increased psychosocial well-being compared to continuing to smoke. 3 , 5 – 8 Although a cancer diagnosis can be a catalyst for cessation, 12.7% of patients with cancer currently smoke cigarettes. 9 The recommended standard-of-care smoking cessation treatment, counseling using motivational or cognitive therapy plus medication, helps patients manage withdrawal, plan for situations triggering a desire to smoke, connect motivation to quit with values and goals, and build confidence to quit. 10 The standard treatment is effective for many patients with cancer, particularly more intensive treatment, with one study reporting 43.7% abstinence at nine months after six to eight standard-of-care counseling sessions plus medication. 11 However, this treatment appears to be less effective for patients with cancer who have long-term smoking histories and repeated failures to quit, for reasons not well understood. 12 – 15 Research into novel smoking cessation interventions for patients with cancer is a national priority. 14 For people with long-term smoking histories, cigarette use is usually their primary mechanism for coping with negative experiences. 13 , 16 Cancer diagnosis and treatment can induce or worsen these negative experiences, including distress, anxiety, depression, hopelessness, and interpersonal conflict. 5 , 13 , 16 , 17 These conditions predict fewer quit attempts and higher rates of relapse in the cancer population. 13 , 17 , 18 Difficulties with tolerating distressing experiences and regulating emotions are transdiagnostic psychosocial mechanisms implicated in smoking persistence in the general population. 18 – 21 A possible explanation for continued smoking by patients with cancer is a lack of skills for managing stress and emotions without relying on smoking to cope. Learning and reinforcing these psychosocial skills may help patients gain self-efficacy for quitting and preventing relapse. Dialectical Behavior Therapy A counseling approach developed for improving these psychosocial skills is Dialectical Behavior Therapy (DBT), a mindfulness-based psychotherapy. Dialectic means the synthesis of opposites; in DBT, the dialectic is the synthesis of change in emotions and relationships and acceptance of distress and self. 22 DBT helps people gain proficiency in mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness through skills training. A guiding principle of DBT is for people to construct a “life worth living” instead of giving in to fatalism and hopelessness. 23 DBT is effective with populations from varied cultural backgrounds. 23 – 25 However, the time commitment for the comprehensive DBT program (at least a year) is not feasible for most people. To improve access, researchers have adapted and tested content from DBT’s principal component, Skills Training (DBT-ST), as brief interventions. In the only known study of DBT-ST as a brief intervention for smoking, a small trial of women in a methadone clinic who smoked, the treatment was found feasible, with participants reducing cigarette use by 83%. 26 In similar populations, such as people with substance use problems and patients with breast cancer in psychological distress, DBT-ST interventions have demonstrated positive effects. 27 To our knowledge, despite its potential benefits, DBT-ST has not been adapted as a smoking intervention for patients with cancer. DBT-ST Intervention Development Given the need for effective treatment approaches for cigarette smoking by patients with cancer, we initiated development of a novel DBT-ST intervention for this population, guided by the NIH Stage Model for behavioral intervention development. 28 Per the Stage Model, behavioral interventions progress through stages of design and evaluation, culminating in one or more randomized controlled trials to establish effectiveness. 28 In Stage 1A of the Model, researchers 1) identify promising scientific findings to support intervention development, 2) design the new intervention, and 3) refine or modify the intervention for real-world settings. 28 To identify promising scientific findings, McCall et.al. 27 conducted a scoping review of DBT-ST as a brief intervention for difficult-to-treat populations: people with alcohol and drug use disorders and people in severe psychological distress, including patients with cancer. 27 The authors found that DBT-ST demonstrated preliminary efficacy as a brief intervention for these populations. 27 Accordingly, we designed an eight-session DBT-ST intervention consisting of introduction and conclusion sessions, two sessions on mindfulness, two sessions on emotion regulation, and two sessions on distress tolerance. We planned the intervention as a virtual group, with 6-10 patients meeting via videoconference once per week for 90 minutes, led by a facilitator with DBT-ST training. The patients could be from any stage of the cancer journey, with interest in quitting smoking ranging from ready to not ready. During intervention design, we collaborated with a multi-disciplinary advisory board of oncology and family medicine physicians, nurses, behavioral health clinicians, and a patient with cancer who had quit tobacco use, meeting six times for intervention feedback and revision. Focused Qualitative Inquiry of DBT-ST Intervention For this focused qualitative inquiry, which completes Stage 1A of the NIH Stage Model to refine the intervention for testing, we sought patient and clinician feedback on our proposed DBT-ST intervention. Our goal was to improve it prior to a feasibility clinical trial. During semi-structured interviews, we presented our intervention to patients with cancer who smoked or had quit and to oncology clinicians. Our primary goal was to obtain feedback to improve the intervention’s content and structure. Our secondary goals were to obtain input on optimizing patient recruitment and engagement for the feasibility trial and on outcome measures being considered for use in the trial. We obtained regulatory approval from our Institutional Review Board to conduct this study. Methods In the methods section, we report how we determined our sample size, all data exclusions (if any), all manipulations, and all measures in the study. We followed Journal Article Reporting Standards for Qualitative Research 29 and the Standards for Reporting Qualitative Research. 30 This study’s design and its analysis were not pre-registered. Setting The setting for this focused qualitative inquiry was a large comprehensive cancer center in the southeastern United States. Participants The study team recruited participants from the patient and clinician populations of the cancer center, seeking a sample that was racially and ethnically representative of the cancer center’s population of patients who smoked, and a clinician sample that included diverse professional backgrounds. Patients Potential patient participants were identified by medical and radiation oncologists, psychosocial oncology therapists, and cancer center study coordinators and referred to the research team for screening. Included were English-speaking adult patients aged 18 years or older with cancer, active or in remission, who were currently smoking or had quit. We excluded patients with cognitive impairment or altered cognition due to psychiatric illness or psychoactive drug use. We prioritized recruiting a patient sample aligned with the self-reported race and ethnicity of our cancer center population of patients who smoke, which is approximately 22% non-Hispanic Black (hereafter, Black) and 76% non-Hispanic White (hereafter, White). Patients satisfying screening criteria were contacted either in person at their oncology visit or by phone to learn about the study and complete the consent and enrollment process. Patients were compensated for their participation with $10 gift cards. Clinicians The team contacted clinicians from diverse specialties and professions who were known to the team or suggested by other clinicians. All clinicians of the cancer center were eligible to participate, including oncology physicians, advanced practice providers, nurses, and psychotherapists. Clinicians who responded affirmatively were consented via phone. Potential participants were informed the purpose of the study was to provide feedback on an intervention being developed to help patients with cancer who smoke cigarettes to reduce or quit smoking, as well as suggestions for clinical trial recruitment and engagement strategies and feedback on surveys being considered for future trials. The sample size was not predetermined but was set when data saturation was reached for each participant group. Data saturation is defined as the point in data collection when all important issues or insights are exhausted from data (typically 9 to 17 participants). 31 , 32 Interviews Using a semi-structured interview format, participants were interviewed about the DBT-ST intervention structure and content, study recruitment and engagement, and patient-reported outcome measures under consideration for future studies. Prior to their interviews, patient participants completed the outcome measures while clinician participants reviewed the measures. During the interviews, participants were sufficiently informed about the intervention to provide knowledgeable feedback. Questions about interview structure focused on the appropriateness of the group format, number of sessions, and session length for patients with cancer as well as whether to include patients at all stages of treatment and readiness to quit smoking. Questions about interview content sought feedback on DBT-ST skills. Mindfulness skills were described as allowing a patient with cancer to “press the pause button” when upset and regain the ability to make healthy behavior choices. Emotion regulation skills were presented as helping patients during emotionally intense moments and restoring healthy functioning. Distress tolerance skills were described as helping patients make stressful or painful situations more tolerable, making it possible to refrain from behaviors that could make situations worse. Recruitment and engagement questions focused on likelihood of patients with cancer who smoke cigarettes enrolling in, engaging with, and completing the intervention program, and how to best recruit this patient population to clinical trials. Patient-reported outcome measures completed by patients and reviewed by clinicians included assessments of tobacco use, emotion regulation, distress tolerance, depression, anxiety, stress, and mental adjustment to cancer. Table1 outlines the interview approach for each of these topic areas. View this table: View inline View popup Table 1. Interview Topic Areas and Approaches The interviewers were four female members of the research team with master’s level training, including a health educator in family medicine and the study coordinator for this qualitative study, two psychosocial oncology therapists in the comprehensive cancer center, and a community-based mental health counselor. They received two hours of qualitative interview training from an in-house shared service staffed by experienced qualitative researchers. Data Collection Individual interviews were conducted over the phone or via video call by one of the four interviewers. Field notes were recorded by each interviewer immediately following interviews. Interviews were audio-recorded and transcribed by a professional transcription service. Transcripts were reviewed and compared to the audio files by a study team member to ensure accuracy. No follow-up interviews or transcript clarification with participants were needed. Data Analysis The patient and clinician data were analyzed separately using the following procedures for each participant group, then compared for common and disparate themes. Interview transcripts were imported and coded in ATLAS.ti version 24 software. 33 Transcripts were reviewed and a codebook was developed. Both deductive and inductive coding strategies were used to develop the codebook, creating a framework from the interview guide and research questions and adding codes emerging from the participant discussions. An in-house expert qualitative researcher and a study team member independently coded the textual data and met weekly to compare coding. Discrepancies in coding were discussed and resolved. The codebook was adjusted as needed based on discussions of code meanings and application. Text segments were reviewed by code and summarized. Code summaries were synthesized into themes and organized using principles of thematic analysis by two in-house expert qualitative researchers and the study team member. 34 Themes were selected using a combination of the following criteria: (1) prevalence, or the frequency with which an idea is shared across participants; (2) strength, or the emphasis participants give to a point; and (3) valence, or how relevant the point is to the research question or context. 34 The themes arising from each participant group (patient and clinician) were examined to discover similarities and differences within each group and across groups. Transparency and Openness Comprehensive reports of patient and clinician thematic analyses are available from the corresponding author upon request. Results Study Sample and Interviews Data saturation was met through interviews of eight patient and nine clinician participants and emergence of alignment between participant responses in each group, at which point additional data no longer yielded new analytic insights. 31 Given that we sought focused, specific-purpose qualitative data, reaching data saturation with our relatively small sample sizes was expected and justified. 32 Eight patient participants agreed, consented, and completed the interviews. Two additional patients consented then declined to be interviewed for personal reasons, and another consenting patient was lost to contact. Of patients completing interviews, two patients were Black and six were White. No patient participants were Asian or of Hispanic or Latino ethnicity. This race and ethnicity distribution matched the cancer center’s population of patients who smoke cigarettes. Two participants were female and six were male. The average age of patient participants was 60.6 years, with ages ranging from 51 to 80 years. Interviews lasted about 30 to 70 minutes, with an average of 47 minutes. The study team emailed 13 clinicians from diverse professions to recruit them to the study, nine of whom completed the study and four who did not respond to recruitment efforts. The clinician sample included three medical oncologists, two radiation oncologists, an advanced practice provider, an oncology nurse, and two psychosocial oncology therapists. One clinician was Asian and eight were White. (Race and ethnicity statistics for cancer center clinicians are not available for comparison.) Seven clinicians were female, while two were male. The average age of clinician participants was 44.0 years, with ages ranging from 37 to 62 years. Interviews lasted from 27 to 58 minutes, with an average of 40 minutes. See Table 2 for complete demographic data. View this table: View inline View popup Download powerpoint Table 2. Sociodemographic Characteristics of Participants The following qualitative results are summarized in Table 3 by topic area. View this table: View inline View popup Table 3. Summary of Qualitative Results by Topic Area Intervention Structure Patient and clinician participants thought the group format offered social support and validation of personal struggles, making the experience “more personable” (PA13), allowing group members to “support each other as far as people giving suggestions on what they’re doing versus others” (PA17), and “very helpful” (PA15). According to a clinician, “It’s a great thought to bring people who are going through similar experiences together to have each other weigh in. If one is down, the other can lift, and vice versa” (C09). One patient stated, “I have had people close to me fuss at me. I have never had any kind of support” (PA13). Patients who described themselves as “shy” (PA04) or “introverted” (PA 10) felt reluctant to participate but were willing to do so “if it’s gonna help me reach that final goal” (PA10). However, a few clinicians felt individual therapy might be preferred by some patients (C08, C12). All patients favored the virtual setting for saving travel time and for ease of scheduling, especially for patients living far away or amid treatment. Clinician opinions on the virtual setting were mixed, with some citing potential technological barriers to virtual sessions for older, rural, or lower-income adults, while also recognizing that in-person session attendance could be hampered by transportation barriers. A few clinicians were concerned about reduced engagement and distractions during virtual sessions (C03, C06). Including patients in later stages of cancer was favored because they could offer perspective, advice, solace, and solidarity to those in earlier stages, as well as encourage accountability, as those further along in treatment could prompt the “earlier-stage people to take it more seriously” (C01), and for patients to see how motivations to quit smoking can vary by stage (C11). The inclusion of patients not ready to quit smoking had mixed reactions from participants, with a patient doubting whether they would “commit to the program” (PA14) while a clinician believed being with patients committed to quitting would help such patients gain motivation to quit: “It can be helpful to be with other people who are more committed. That can help tip them over the edge to make that commitment” (C05). Both patient and clinician participants had concerns about the 90-minute session length as too burdensome due to patient time constraints, with 60-minute sessions recommended. The number of sessions, eight, was deemed appropriate by most participants. Intervention Content Patient and clinician participants responded positively to the DBT-ST skills, noting their potential to support smoking cessation by helping patients understand emotions and triggers, manage stress and anxiety related to diagnosis and treatment, and make health-promoting decisions. They spoke well about breathing practices and learning to be more present in life. Overall, participants thought DBT-ST skills were practical, helpful, and transferable to other life situations. One clinician summarized DBT-ST skills as being “helpful for literally everyone,” particularly those going through “stressful cancer treatment” (C03). Distress tolerance skills were especially well-received, with one clinician stating, “I think giving them [patients] these detailed instructions of ‘when you have cravings, these are physical things that you can try to reduce that craving.’ I really liked that. I thought that that could be very effective” (C11). Participants thought that patients regulating their emotions and breathing would help them as they try to change their smoking behaviors (PA15, PA19). One clinician stressed the importance of “being able to deal with your emotions in a separate way instead of reaching for a cigarette. How do you deal with those emotions? How do you face this new reality?” (C07). However, some patients did not associate emotions with smoking (PA14) or needed to put emotions aside to deal with cancer (PA10). A specific clinician concern was the potentially abstract nature of mindfulness or that some patients might see mindfulness as a “religious thing” crossing their ethical and religious boundaries “rather than a ‘mental health thing’” (C05). Clinicians also suggested more accessible language for individuals with lower literacy. Participants believed the DBT-ST intervention could enhance patient outcomes such as decreasing anxiety and depression and improving quality of life. Patients thought the skills were inclusive of their experiences with depression and anxiety, sharing specific examples and noting how helpful and practical the DBT-ST skills would be in helping them cope. Clinicians anticipated that using DBT-ST skills could lower dependence on medications or nicotine patches, with one clinician postulating this intervention could spur “lower rates of urgent visits or calls” as well as “lower rates of frantic calls about cancer recurrence or worry about recurrence” because patients will gain a “general better sense for their own body and for when things are going wrong and whatnot” (C03). Patients spontaneously offered barriers to quitting including stress caused by cancer diagnoses, general distressing emotions, being around cigarette smoking, and switching from environments where they could not smoke to environments in which they could. Patients suggested incorporating these triggers for smoking into the skills aspect of the intervention. Patients also mentioned incentives to quit including the wake-up call of a cancer diagnosis, knowing the effects of smoking on their health, the cost of smoking on top of the financial stress of cancer treatment, feelings of guilt, and the assistance of nicotine replacement. Recruitment and Participation Patient and clinician participants shared recruitment suggestions including flyers in waiting areas and clinic spaces, social media advertising, and clinician referral. They also suggested advertising the overall benefits of DBT-ST skills as life skills, rather than being solely for smoking cessation. Most supported having the patient’s healthcare team introduce the intervention, especially trusted figures like oncologists, nurses and other clinic staff. Clinicians suggested advertisement framing the intervention as patient-centered rather than research-focused due to stigma associated with being involved in research, especially for “patients from minority groups [because] they have less trust [in the healthcare field],” and “don’t enroll in trials as often” as a result (C07; C09). Participants discussed specific barriers to engagement and completion such as dislike for the group setting, time constraints, concerns about the program being prescriptive/judgmental, and patients feeling unwell from treatment or illness. Internet, computer, and other technology issues were mentioned as access barriers. Suggestions to facilitate engagement included interesting content, appropriately sized groups, and personable group leaders. Patients shared personal motivators for wanting to participate in an intervention like the one proposed, with one patient stating, “If my final goal is to live, there’s gotta be something there to help me. I’d probably go wrestle a bear if it could help me, you know what I mean?” (PA10). Patient-Reported Outcome Measures Participants found the patient-reported outcome measures relevant, easy to understand, and valid for measuring intervention outcomes. Patients thought the measures did a decent job at capturing their feelings of depression and anxiety, and the way they cope with these conditions. The measures prompted them to reflect on and understand their experiences. Clinicians raised concerns about patient comprehension, noting repetitive or related questions could be confusing, and the time burden of the surveys. Clinician suggestions regarding the assessments included using clear, simple language, shortening the surveys, reducing the number of related questions to avoid confusion, and sharing with patients how their data is being used to benefit them and other patients with cancer who smoke. Discussion This focused qualitative inquiry of our proposed DBT-ST intervention for cigarette smoking by patients with cancer resulted in valuable feedback from participants. They strongly supported aspects of the intervention, such as teaching patients DBT-ST skills for being more present, managing emotions, and dealing with stress, while sharing mixed opinions on other intervention components, such as its virtual format and inclusion of patients not ready to quit. Perceived benefits extended beyond smoking cessation to improved quality of life, enhanced social support, decreased anxiety and depression, and acquisition of skills universally applicable to managing life’s challenges, including cancer. A cross-cutting theme is that patients felt more capable and less burdened regarding virtual technology and outcome measures than clinicians perceived they would. Patients were uniformly supportive of virtual sessions for accessibility and ease of scheduling. Clinicians were concerned their older, rural, and lower-income patients would struggle with video technology or that patients would become disengaged during sessions; however, no patients spoke of technology or disengagement during sessions as concerns. Regarding outcome measures, patients had positive feedback and expressed no concerns, while clinicians thought patients might find them confusing, repetitive, or too much of a time burden. Our results are supported by recent qualitative research into cessation interventions for patients with cancer. Shenton, et al. 35 interviewed patients, clinicians, and cessation program staff to discover barriers and facilitators to smoking cessation in a single cancer center. They found that patients endorsed interventions focused on stress management to enable quitting, and they recommended that cessation services tailored to patients with cancer be offered throughout treatment and survivorship. Charlot, et al. 36 conducted a mindfulness-based group cessation intervention for patients with cancer from low socioeconomic and minority populations. The authors reported that participants reduced cigarette use by 41% on average, were satisfied with the program, and made positive lifestyle changes. Intervention Implications Given the results of this focused qualitative inquiry, several modifications to the intervention will be made in preparation for Stage 1B of the NIH Stage Model, 28 intervention testing for preliminary efficacy. Resulting modifications to our intervention will include the following: Reducing session length to 60 minutes each (while retaining eight sessions) Offering sessions in late afternoons or evenings to accommodate complex patient schedules Offering session materials to participants who must miss due to emergencies or illness Having a staff member at each session dedicated to helping participants successfully join the virtual group online Taking care with language, framing of concepts, and instructions to make the intervention concrete, value-neutral, and easy to understand Ensuring skills training incorporates smoking cessation barriers and facilitators identified by patients Limitations Despite reaching qualitative data saturation, 31 with the final interviews not yielding new data, the study’s sample size and composition limited the diversity of perspectives and generalizability to other cancer populations with respect to Hispanic or Latino ethnicity and Asian racial identity, despite matching our cancer center’s patient population who smokes for race and ethnicity. Conclusion These results suggest our DBT-ST intervention has potential to provide an effective smoking cessation intervention for patients diagnosed with cancer and serves as an important addition to the literature. We will continue to develop this DBT-ST intervention for the oncological patient population using the NIH Stage Model 28 to determine further its feasibility, efficacy, effectiveness, and sustainability, with a feasibility clinical trial as the next step. Data Availability All data produced in the present study are available upon reasonable request to the authors Statements and Declarations Ethical Considerations This study was approved by the Institutional Review Board of Advocate Health – Wake Forest University School of Medicine on March 23, 2024. Consent to Participate All participants provided verbal informed consent prior to enrollment in the study. Consent for Publication not applicable Declaration of Conflicting Interest We have no known conflicts of interest to disclose. Funding Statement Research supported in part by the Qualitative and Patient-Reported Outcomes Shared Resource, the Tobacco Control Center of Excellence, and the Cancer Prevention and Control Program of the Atrium Health Wake Forest Baptist Comprehensive Cancer Center’s NCI Cancer Center Support Grant P30CA012197. Data Availability Comprehensive reports of patient and clinician thematic analyses are available from the corresponding author upon request. Acknowledgments The authors would like to acknowledge and thank James Morgan, Thomas Lycan, Jr., DO, Michael Farris, MD, Ryan Hughes, MD, William J. Petty, MD, and the Psychosocial Oncology Program therapists for recruiting patients to this study. Footnotes Title Abstract Introduction Methods Results Discussion References 1. ↵ US Office on Smoking and Health . 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