The findings show an extensive but largely early-stage research base: 12 of 20 empirical studies were feasibility studies, while eight were efficacy trials. The researchers defined adolescent and young adult childhood cancer survivors as people aged 13 to 39 who had been diagnosed with childhood cancer, meaning a diagnosis before age 21 or a typical childhood cancer arising before age 30. The imbalance was pronounced: 13 of the 17 interventions included a physical-activity component, compared with four addressing tobacco use and two each targeting nutrition and alcohol.

Only three programs crossed behavioral domains, combining physical activity with alcohol and tobacco, tobacco with alcohol, or physical activity with nutrition. The review authors said this distribution is consequential because survivors of childhood cancer face elevated risks of chronic disease and premature death, while physical inactivity, poor diet, risky drinking and tobacco use can compound treatment-related toxicities. They also noted that adolescent and young adult survivors may engage in risk-taking behaviors at rates similar to those of their peers, despite their medical vulnerability.

However, the evidence was too heterogeneous and methodologically uneven to support conclusions about comparative effectiveness or clinical benefit. The physical-activity programs used varied delivery modes, including supervised exercise sessions, university facilities, telehealth consultations, web-based counseling, mobile applications, social-media groups and wearable activity trackers. StepByStep used Fitbits, individualized goals, an Instagram peer group and staff messages over 48 weeks.

Making Moves was designed as an eight-week, self-paced online program with exercise-physiologist consultations, while the SURFit trial offered physiotherapist coaching, pedometers and web-based activity diaries over 12 months. Some interventions delivered skills directly, such as resistance, aerobic and flexibility training, whereas others relied more heavily on self-monitoring, planning and digital feedback. Results from individual studies illustrate why feasibility and efficacy must be interpreted separately.

A 10-participant theory-based program reported initial improvements in physical activity, fitness and quality of life, but activity levels were not maintained at three- or 12-month follow-up. In the 151-participant SURFit trial, the intervention significantly affected a composite cardiovascular-risk score, yet accelerometer and pedometer data showed no effect on physical activity. A counseling trial in 89 survivors found no significant improvement in vigorous activity, although favorable trends emerged during follow-up.

The Fitbit-and-Facebook pilot was feasible and acceptable but produced no significant group differences in activity or sedentary time. By contrast, a six-month home tracker study found a modest, statistically nonsignificant rise in moderate-to-vigorous activity, while a wearable-only observational study recorded adherence falling below one-third within 12 weeks and nearly disappearing by one year. These findings suggest that trackers can support self-monitoring but are not consistently sufficient as stand-alone behavior-change tools.

Nutrition was represented by only two interventions. ENHANCE combined individual telehealth sessions of motivational interviewing, education, problem-solving, goal setting and skills training for nutrition and physical activity. In a pilot randomized trial involving 58 survivors, 96.7% completed all sessions, the intervention was highly feasible, and interventionists demonstrated expert-level proficiency in motivational interviewing on 97% of coded sessions; the publication focused largely on feasibility, acceptability and fidelity rather than establishing efficacy.

The INAYA pilot provided individualized counseling based on German Nutrition Society recommendations to 23 survivors. Twelve participants, or 52.2%, improved their Healthy Eating Index score by 20 points, but the uncontrolled design, small sample and 30% attrition limit causal interpretation. Both nutrition programs emphasized psychological capacity and reflective motivation, yet neither addressed physical capacity or physical and social opportunity.

Alcohol-focused research was equally sparse, and no intervention exclusively targeted alcohol. A six-week web program offered young adult survivors modules, check-ins and tailored information about exercise, drinking and smoking; the pilot was feasible and acceptable, with 85.7% satisfaction, but documented no significant pre-to-post improvements in physical activity, alcohol consumption or tobacco use. Decision KEYS used a 12-month cognitive-behavioral decision-aid program with CD-ROM modules, tailored counseling, booster contacts and videos portraying positive role models and refusal strategies.

The review interpreted this evidence as descriptive and preliminary, not as proof that either program could reduce drinking. Smoking cessation had the largest body of intervention research after physical activity, encompassing four distinct programs and seven publications. The Partnership for Health trials compared proactive telephone counseling by trained childhood cancer survivors with self-help materials.

In a trial of 796 participants, proactive counseling increased quit rates, with benefits sustained at 12 months; participants receiving more calls were more likely to quit, and high self-efficacy strongly predicted cessation, although the intervention cost more than self-help. Long-term follow-up found continued advantages for proactive counseling, with nicotine replacement therapy mediating part of the effect. By contrast, a quit-line trial of 519 survivors produced self-reported abstinence that proved misleading: biochemical testing found that 80% of those claiming abstinence were still using tobacco, and biochemically adjusted cessation rates were below 2%.

The contrast demonstrates why outcome measurement and intervention delivery must be considered alongside self-reported findings. Mapping the programs through the Behavior Change Wheel revealed that they typically used about four of nine intervention functions and addressed about four of six sources of behavior change. All physical-activity programs included enablement, usually through trackers or fitness platforms, and targeted physical opportunity and reflective motivation.

Common functions included education, training, environmental restructuring, incentives and peer modelling; none used coercion or restriction. Every tobacco program addressed psychological capacity and reflective motivation, while most also supported physical or social opportunity, often by providing nicotine replacement therapy or social support. Nutrition and alcohol programs were more dependent on education, knowledge and reflective planning.

Across domains, interventions favored supportive strategies consistent with the value that adolescent and young adults place on autonomy, but physical capacity and automatic motivation were underused, despite the role of conditioned cues in addiction and the importance of sustained habit formation. Major reporting gaps complicate replication and interpretation. Most studies described modes, schedules and procedures clearly enough to outline general delivery, but intervention materials, curricula, message scripts and contextual details were often incomplete.

Only one of the 17 programs publicly provided a provider training manual. Four reported explicit plans for monitoring fidelity, and only one subsequently reported an actual fidelity percentage; many others used attendance, retention or engagement as a proxy for whether the intervention was delivered as intended. Participant characteristics were also reported inconsistently, including age at diagnosis, age at intervention, cancer type and treatment history.

The evidence was geographically concentrated, with 14 of 23 publications coming from the United States, and much of the smoking-cessation research predated widespread vaping. The review therefore supports stronger manualization, standardized reporting, clearer links between theory and techniques, and larger trials with longer follow-up, while its own findings remain a descriptive map rather than a verdict on which programs work.

Subject of Research: Behavior-change interventions for physical activity, nutrition, alcohol use and tobacco cessation among adolescent and young adult childhood cancer survivors

Article Title: Behavior Change Interventions to Promote Healthy Lifestyles Among Adolescent and Young Adult Childhood Cancer Survivors: A Scoping Review

Article References: Gélinas‐Gagné, C., Bilodeau, K., Guarascio, N., Caru, M., Coltin, H., Curnier, D., Desjardins, L., Laverdière, C., Marcil, V., Santiago, R., Vairy, S., & Sultan, S. (2026). Behavior Change Interventions to Promote Healthy Lifestyles Among Adolescent and Young Adult Childhood Cancer Survivors: A Scoping Review. Cancer Reports, 9(10), Article e70721. https://doi.org/10.1002/cnr2.70721

Image Credits: AI Generated

DOI: 10.1002/cnr2.70721

Keywords: childhood cancer survivors, adolescent and young adults, scoping review, physical activity, nutrition, alcohol use, tobacco cessation, behavior change, digital health, survivorship care, Behavior, Change

The rationale behind EXIT begins with a candid assessment of why conventional cessation programs fail this population. The researchers identify structural inequities as central barriers: the lack of stable housing, limited access to treatment services, and the fragmentation of care that forces people to navigate multiple disconnected systems. Layered on top of these structural obstacles are high rates of serious mental illness and substance use disorders among homeless smokers, which compound the physiological grip of nicotine dependence. Existing cessation treatments, the authors note, are often brief in duration, rarely integrated into community service settings, and short on the kind of ongoing behavioral support that sustained quitting demands. A single counseling session and a starter pack of patches, in other words, is poorly matched to the realities of life without a home.

EXIT was engineered around two design principles that distinguish it from prior efforts. The first is duration: rather than offering weeks of support, the intervention extends pharmacotherapy and coaching across a full six months, reflecting evidence that longer treatment courses improve cessation odds. The second is accessibility: the intervention routes treatment through community pharmacies and delivers behavioral support by telephone, so participants do not need to travel to clinics, keep rigid appointments, or negotiate unfamiliar healthcare bureaucracies. Community pharmacies have long been recognized as a promising venue for expanding access to evidence-based tobacco treatment, because pharmacists are numerous, trusted, geographically distributed, and empowered in many states to prescribe or recommend nicotine replacement products. Until now, however, pharmacy-based approaches have mostly been tested in short-duration interventions, leaving open the question of whether they can sustain quitting over the long term.

The trial itself is a two-arm, parallel-group randomized controlled trial conducted in transitional shelters in Los Angeles and San Francisco, two cities where homelessness has reached crisis scale. The investigators plan to enroll 150 adults experiencing homelessness who smoke at least five cigarettes per day, whose tobacco exposure is confirmed objectively by an expired carbon monoxide reading of at least 8 parts per million, and who report an intention to quit within six months. That carbon monoxide threshold is an important methodological safeguard, ensuring that self-reported smoking status is corroborated by a biochemical marker before randomization. Participants will then be allocated, in equal numbers, either to the full EXIT intervention or to a pharmacist-only comparator condition, allowing the trial to isolate the added value of extended pharmacotherapy and wellness coaching.

The comparator arm is deliberately pragmatic. Dubbed the pharm-only condition, it consists of a single pharmacist-delivered telephone session structured around the 5As framework, the established clinical sequence of asking about tobacco use, advising cessation, assessing readiness, assisting with a quit plan, and arranging follow-up, plus three months of nicotine replacement therapy. This condition represents a reasonable standard of care that a person might receive through a well-functioning pharmacy-based service, making it a meaningful benchmark against which to measure EXIT’s incremental benefits. Any advantage observed for the full intervention can therefore be attributed with some confidence to the additional months of medication and the intensive coaching component, rather than to mere contact with the healthcare system.

EXIT builds on that foundation in two decisive ways. Participants in the intervention arm receive the same initial 5As session, but their nicotine replacement therapy extends to a full six months, doubling the comparator’s treatment duration. More distinctive still is the behavioral component: 14 wellness-focused telephone coaching sessions delivered over six months by trained health coaches. The framing of these sessions as wellness-focused rather than narrowly cessation-focused is a deliberate design choice. Coaching conversations encompass broader health behaviors, including diet and physical activity, alongside smoking cessation goals. The investigators anticipate that this holistic approach may improve engagement and retention among participants for whom smoking is only one of many competing health and survival concerns, and for whom a single-issue intervention may feel disconnected from their priorities.

The trial’s primary outcome is adherence itself, an unusually honest choice for a feasibility-stage study. Adherence will be measured by the number of coaching sessions attended and by participants’ adherence to the nicotine replacement regimen, since an intervention only works if people actually use it. Secondary outcomes include biochemically verified seven-day point prevalence abstinence at three and six months, again confirmed by carbon monoxide readings of 5 parts per million or below. Assessment visits occur at baseline and at one, three, and six months, capturing a rich panel of measures: tobacco use and nicotine dependence, health behaviors such as diet and physical activity, mental health, substance use, and adherence to nicotine replacement therapy. This longitudinal design allows the team to track not only whether people quit, but how the intervention reshapes the broader health landscape that sustains addiction.

Methodologically, the protocol reflects the iterative logic of modern behavioral intervention science. Rather than leaping directly to a large, fully powered effectiveness trial, the EXIT team is first testing feasibility, acceptability, and preliminary efficacy in the very settings where a scalable program would ultimately operate. This staged approach guards against the familiar failure mode of cessation interventions that perform well in controlled academic clinics but collapse when transplanted into community environments with high participant mobility, competing survival needs, and limited staffing. By embedding the trial within transitional shelters and partnering with pharmacy infrastructure from the outset, the investigators are stress-testing the delivery model under real-world conditions. The findings are explicitly intended to inform a future fully powered trial that could establish a scalable model for delivering tobacco cessation treatment to people experiencing homelessness nationwide.

The scientific significance of the trial extends beyond its immediate population. Smoking among homeless adults is a major driver of the stark mortality gap between housed and unhoused populations, contributing to cardiovascular disease, respiratory illness, and cancer at rates that dwarf the risks posed by many problems that receive far more public attention. Yet tobacco is frequently deprioritized in homeless services, treated as a concern to be addressed only after housing, addiction, and mental health needs are met. EXIT challenges that triage logic by demonstrating that evidence-based tobacco treatment can be woven directly into homeless services and pharmacy systems rather than deferred. The trial is funded by the California Tobacco-Related Disease Research Program, with additional support to the first author from the National Institute on Drug Abuse, and it is registered at ClinicalTrials.gov under identifier NCT07148232.

If EXIT proves feasible, acceptable, and even preliminarily effective, the implications could ripple across public health practice. A model that pairs six months of nicotine replacement with sustained telephone coaching, initiated through a pharmacist visit and anchored in transitional shelters, could be replicated in cities across the country at comparatively low cost, since it relies on existing pharmacy networks and remote coaching rather than new clinics. The trial also contributes a methodological template for studying cessation in transient populations, combining biochemical verification, extended follow-up, and outcome measures that respect participants’ full health context. For the roughly seven in ten homeless adults who smoke, most of whom express a desire to quit but lack access to sustained treatment, EXIT represents a rigorous test of whether the healthcare system can finally meet them where they are, for as long as quitting truly takes.

Subject of Research: A randomized controlled trial testing an extended pharmacy-linked tobacco cessation intervention with telephone coaching for adults experiencing homelessness.

Article Title: Extended Intervention for Tobacco Use (EXIT) for people experiencing homelessness: study protocol for a randomized controlled trial

Article References: Hawes, M. R., Gelberg, L., McCarthy, W. J., George, T. P., Strong, D., Cheng, J., Chakravarty, D., Alway, J., Escober, J., Giannola, J., Figueroa, I., Akabike, W., & Vijayaraghavan, M. (2026). Extended Intervention for Tobacco Use (EXIT) for people experiencing homelessness: study protocol for a randomized controlled trial. Addiction Science & Clinical Practice. https://doi.org/10.1186/s13722-026-00720-z

Image Credits: AI Generated

DOI: 10.1186/s13722-026-00720-z

Keywords: tobacco cessation, homelessness, nicotine replacement therapy, randomized controlled trial, community pharmacies, telephone coaching, health inequity, smoking prevalence, transitional shelters, public health, clinical trial protocol, addiction science