1. Externally led, one-off training programs (10) Implementation strategy was solely related to training and predominantly involved academics providing training for nurses on smoking-cessation interventions; one-off engagement of frontline staff lasted 30-60 min in the majority of studies. Adoption (10) Limited evidence for increased adoption of smoking-cessation strategies: One study that had a control group showed no difference for the 5As (Sarna 201286), whereas others showed minimal improvements (eg, improved asking from 67% to 78% [Bialous 201742] or improved assisting 17% to 21% of the time) (Gonzalez 201860). The most promising adoption result was an 86% delivery of smoking-cessation services at 15 mo; however, there were no baseline data (Fore 201458). Appropriateness (2) Mixed evidence, with one study showing that nurses felt smoking-cessation support was important (NHS 201031), whereas another found that most nurses (75%) reported barriers to implementation, such as lack of interest from patients (Fore 201458) Feasibility (1) There was limited evidence because nurses described a lack of time (Fore 201458). Fidelity (1) One study demonstrated moderate compliance with an online webinar, however, it had a low response rate (Sarna 201286). Penetration (1) Varying penetration; eg, brochures provided (73%) versus shown DVD (2%) Sustainability (1) Found that use of the study was reducing over time (NHS 201031) 2. Externally led, one-off training programs with reinforcement (10) Most studies involved academics providing training to health care professionals, including nurses. Several forms of reinforcement supported this training, including reminder systems, promotional material, adaptations of electronic record systems, providing feedback, and supervision. All studies involved leading activities; there was also evidence of planning, organizing, and monitoring activities. All studies engaged frontline staff or volunteers, sometimes with additional support/supervision as needed. Engagement typically lasted ≤60 min. Acceptability (4) There was evidence that these interventions were not acceptable, with 3 of the 4 studies identifying disruption to the therapeutic relationship (Malone 201973) and resistance from patients (Katz 2014,65 201666) or staff (Castaldelli-Maia 201750). Conversely, one paper reported that patients were comfortable discussing smoking (Duffy 201551). Adoption (8) There was limited evidence, with improvements to the delivery of smoking interventions being either unsuccessful (Hughes 201861), modest (Blok 2019,44 Duffy 201551; Katz 2013,64 2014,65 201666), or mixed (Malone 2019,73 Raupach 201482). Appropriateness (6) There were concerns about suitability or ambivalence from staff (Campbell 201949; Castaldelli-Maia 201750; Katz 2013,64 2014,65 201666; Malone 201973; Raupach 201482); eg, concerns that smoking-cessation discussions would duplicate efforts of primary health staff (Castaldelli-Maia 201750) or noting tensions with other priorities (Malone 201973). Cost (2) One study counted resources only and did not include staff time (Blok 201944), and the other study calculated costs per quitter at $147USD (including costs associated with volunteer time) (Duffy 201051). Feasibility (4) Poor evidence of feasibility; 2 studies showed insufficient staff time (Katz 2014,65 201666; Raupach 201482), one had limited feasibility because of extensive patient exclusion criteria (Mbata 201976), and the other was inconclusive (Katz 201864). Fidelity (3) Adherence to the intervention was shown in one study (Duffy 201051); and 2 other studies noted selective implementation and skills (Katz 2014,65 201666; Raupach 201482). Penetration (1) Penetration was demonstrated through reporting of the booked appointments (n = 6613) and the number of opt-in forms distributed for the smoking intervention (n = 1800; 27%) (Campbell 201949). Sustainability (2) Sustainability was low, with one study showing that the intervention was discontinued (Duffy 201551) and the other showed reduced sustainability of the intervention (Blok 201944). 3. Internally-led, one-off training programs with reinforcement (7) These studies engaged nurses, physicians, and other health care staff in training. Reinforcement mainly took the form of providing feedback. Most studies included leading activities, planning, and monitoring; principally auditing/data collection. Engagement of frontline staff varied between one-off to ongoing. Adoption (4) Adoption was modest (Jose 2020,62 Kisuule 2010,70 Matten 201175); eg, an increase in asking about smoking from 51% to 80% (Jose 202062) or an increase in documentation of tobacco-dependence counselling in progress notes from 36% to 44%; and nicotine-replacement therapy dosing increased from 26% to 64% (Kisuule 202070). One study noted a substantial improvement in the number of nicotine-replacement therapy units used, from 768 in the year before implementation to 1418 12 mo later (Vega & Stolare 201094). Appropriateness (1) One study found that nurses often did not regard smoking-cessation interventions as their responsibility; similarly, for feasibility, staff noted insufficient time (Jose 202062). Cost (2) One study calculated intervention (nicotine-replacement therapy) costs (Vega & Stolare 201094), and the other provided a financial incentive to 13 residents (Singer 201989). Feasibility (1) One study stated that staff reported insufficient time to deliver intervention (Jose 202062). Penetration (4) Three studies showed that the intervention was still integrated after 12 mo (Bickerstaffe 2013,43 Jose 2020,62 Slattery 201691). One article indicated that penetration reduced over time (from 76% to 52%), potentially because of a financial incentive already being provided to radiation oncology residents (Saxony 201789). Sustainability (1) One study demonstrated ongoing implementation efforts with new workflows being developed (Saxony 201789). 4. Prompts for clinicians in charts or electronic medical records (EMRs) with training/notification (6) Prompts to perform smoking-cessation interventions were inserted in patient charts or EMR. Implementation was by academics or internal staff. In addition to leading activities, monitoring activities were common, especially auditing/data and providing feedback. Engagement of staff—mainly nurses and physicians—was generally undertaken using one-off training. Engagement varied (from ≤30 min up to >60 min to ≤2 h) Acceptability (1), appropriateness (1), feasibility (1) One study assessed these outcomes with qualitative data, showing staff believed that smoking-cessation counselling was not practical and met with resistance from patients; staff also expressed ambivalence toward the implementation of the smoking-cessation guidelines and indicated delivery could be difficult in some settings, such as an emergency department (acceptability, appropriateness, and feasibility) (Katz 2012,67 2013,68 201469). Adoption (5) A 2-y cluster RCT (Bernstein 2017,39 201940; Grau 201941) showed improved delivery of smoking cessation in several areas (eg, referrals to quitline: 29% in the intervention arm and 0% in the control arm). Another controlled before-after study found that advice to quit increased in the charts of patients who underwent elective surgery (from 1.8% to 18.7%), and no change was evident in the charts of those who underwent nonelective surgery but did not receive the intervention (Webb & Wilson 201796). Other studies found mixed or minimal success for adoption (Katz 2012,67 2013,68 201469), lacked baseline data (Simerson & Hackbarth 201888), or demonstrated modest improvements (Vick 201395). Fidelity (1) One study reported that it was not clear whether the protocol was being implemented as specified (poor fidelity) (Simerson & Hackbarth 201888). Penetration (1) One study found solid uptake, with 62% of 13,617 new patients screened for smoking (Abdelmutti 201936). Sustainability (1) One 2-y study revealed that a more sustained strategy was needed, and the researchers were developing e-learning modules to try to improve maintenance over time (Abdelmutti 201936). 5. Increasing staff dedicated to smoking-cessation interventions (10) Predominant strategy was to employ additional staff or dedicate existing staff time to undertake smoking cessation interventions. All studies involved planning, organizing, and leading activities, with one-half also using monitoring activities. In some, interventions were piloted and implementation was rolled out in stages. Adapting electronic record systems to facilitate the delivery of interventions, the development of promotional material, and the redevelopment of assessment, treatment, and referral was also common. External influences included government funding. Staff and volunteers were engaged with training and, in one-half of the studies, training was ongoing. Acceptability (1) One study found that the intervention was well received (Campbell 2016,47 201748). Adoption (3) There were moderate increases; eg, self-report of smoking-cessation practices increased from 57% to 86% (Duffy 201052); and 72% of tobacco users were visited by volunteers as required (Taylor 202092). Appropriateness (1) One study was unable to demonstrate that the intervention was appropriate, with staff reporting barriers and a lack of interest from patients (Duffy 201052). Cost (5) Cost considerations included additional staff but often not the whole implementation effort (Balmford 2014,37 Bruce 2018,46 Evison 2020,56 Lappin 2020,71 Saxony 201787). Feasibility (3) Results for feasibility were mixed: One study found referrals were easier than expected (Campbell 2016,47 201748), another noted insufficient time (Duffy 201052), and another found resource limitations (Taylor 202092). Penetration (8) There was evidence of penetration; eg, screening for tobacco use increased over an 18-mo period (from 50% to 89%) (Saxony 201787); 92% of people were screened and 96% were given advice to quit (Evison 202056). Sustainability (4) Two studies appeared to have achieved this with ongoing, dedicated staff (Bruce 2018,46 Saxony 201787); 2 other studies revealed that implementation efforts were ongoing (Balmford 2014,37 Saxony 201787). 6. External resourcing for smoking-cessation interventions (9) Provision of funding or in-kind support, principally from government, for hospitals to implement smoking-cessation interventions: Implementation was by internal staff, external academics, cancer organizations or hospitals. Most involved planning, organizing, leading, and monitoring activities. Planning involved steering group guidance, executive/senior leadership support, and multidisciplinary implementation team, as well as stakeholder engagement. One-half of the studies involved monitoring and auditing/data collection. A wide range of staff received training, which was often ongoing. Acceptability (1) One study found that patients were comfortable with the intervention (Bowden 201045). Adoption (4) One study showed evidence of adoption with an increase in referrals to smoking services (incident rate ratio = 2.47) (Bell 201838); the others showed some improvements, eg, an increase in medication prescription from 3% to 17% (Ramsey 202081) or an increase in new patient referrals to tobacco services by 100% (Meyer 202077). Appropriateness (1) In one study, clinicians reported that smoking cessation may not be suitable for advanced disease (Evans 2017,54 201955). Cost (3) Costs for additional staff to implement were estimated for 2 studies (Bowden 2019,45 Gali 202059), whereas another study assessed full costs (training of staff, investments in equipment and consumables, changes to workload) at £572,009 per NHS trust over a 5-y period (Bell 201838). Feasibility (3) Feasibility outcomes were mixed. In one study, clinicians thought the intervention was well integrated into their work (Bowden 201945); one study identified clinician concern about workload, incomplete data, and difficulties in motivation (Bowden 201945); and another study had extensive eligibility criteria, restricting the number of smokers who could receive the intervention (Taylor 202093). Fidelity (2) There was mixed support for fidelity, with one study reporting adherence (Karn 201663) but another noting variability in practices (Evans 2017,54 201955). Penetration (6) One study with 8-y follow-up found that most centers achieved a target of 75% screening for smoking status (Evans 2017,54 201955), and another study had 1254 patients referred to the quitline, compared with just 7 before implementation (Karn 201663). Other penetration outcomes were relatively strong; eg, 70% of patients assessed (Taylor 202093) or 65% of current smokers received advice (Bowden 201945). Sustainability (5) Results were mixed, with 2 studies noting that the intervention was reducing at 90 d (Meyer 202077) and 4 mo (Bell 201838), whereas 2 studies appeared to have secured funding to support the implementation (Bowden 201045; Evans 2017,54 201955), and one noted continuation and expansion of the program (Gali 202059). 7. Internally resourced development of systems and structures (4) Internally funded/supported strategies aimed to make significant changes to existing systems and structures: Most studies involved planning, multidisciplinary implementation teams, internal environment/practices/needs reviews, and stakeholder engagement. Organizing most commonly involved delegating new tasks to existing staff and upskilling/certification of key staff. Leading activities included training, developing/adapting paper-based forms/systems, and redeveloping assessment, treatment, and referral practices. All implementations involved auditing/data collection. Staff engagement focused on physicians and nurses. Acceptability (2) There was evidence for acceptability, with patients satisfied with the intervention (Sisler 201790), and another study reported that patients were not surprised about smoking discussions (Nolan 201979). Adoption (1) One study reported there appeared to be an increase in assessment of nicotine dependence (Ziedonis 201298). Feasibility (1) One study found that a reasonable proportion of patients (45 of 209) did not receive the smoking intervention for reasons that included cognitive impairment, not speaking English, or refusal (Sisler 201790). Fidelity (1) One study found a lack of knowledge of, or forgetting, processes by clinical staff, suggesting poor fidelity (Nolan 201979). Penetration (3) There was evidence of successful penetration: One study found substantial increases in documentation of tobacco status from 1% up to 80%-90% over a 3-y period (Liu 201072); whereas authors of 2 other studies reported solid increases in uptake in the longer term (eg, referrals increased from 32% to 62% and follow-up phone calls increased from 1.5 to 31 per mo) (Taylor 202090) or an increase in consultation attendance from 41% to 75% (Nolan 201979). Sustainability (3) There was evidence of sustainability: One study reported putting structures in place to sustain implementation efforts (Ziedonis 201298), another noted ongoing implementation efforts (Taylor 202090), and another study appeared to have ongoing funding (Liu 201072).