The Ask-Advise-Connect approach for smokers in a safety net healthcare system: a group-randomized trial

A multi-component intervention increased access to smoking cessation treatment after hospitalization for atherosclerotic cardiovascular disease: a randomized trial

Aims

To evaluate the effects of a multi-component intervention for smokers hospitalized for atherosclerotic cardiovascular disease (ASCVD) on the participation rate in community-based cessation programmes and the use of cessation drugs. Additionally, to explore the impact on the cessation rates at 6 months.

Methods and results

A randomized parallel-group study was conducted at a Norwegian secondary care hospital in 2021. The intervention group was: (i) counselled using motivational interviewing techniques during hospitalization; (ii) given an information leaflet, detailing the cessation programme; and (iii) referred to the community-based smoking cessation treatment including a post-discharge pro-active telephone invitation. The control group received usual care and the same information leaflet containing clear contact details for initiating participation. Data were collected at baseline, 1, 3, and 6 months. Among 99 smokers hospitalized with ASCVD, 40 were excluded. Of 59 randomized patients, 4 were lost to follow-up and 55 completed the study. The mean age was 65.1 (standard deviation 9.3) years, 35% were female, and 88% had smoked >20 years. Co-morbidity was prevalent (mean Charlson score 4.8). The intervention group was more likely to participate in the smoking cessation treatment {48 vs. 7%, difference: 41% [95% confidence interval (CI): 14%, 63%]} and used cessation drugs more frequently [59 vs. 21%, difference: 38% (95% CI: 17%, 59%)]. At the 6 months point prevalence, we observed notable between-group differences in self-reported cessation rate (48 vs. 25%).

Conclusion

The intervention significantly increased the participation rate at community-based smoking cessation programmes and the use of cessation drugs among multi-morbid smokers hospitalized for ASCVD.

A Systematic Review of Electronic Community Resource Referral Systems

INTRODUCTION

Community Resource Referral Systems delivered electronically through healthcare information technology systems (e.g., electronic medical records) have become more common in efforts to address patients' unmet health-related social needs. Community Resource Referral System connects patients with social supports such as food assistance, utility support, transportation, and housing. This systematic review identifies barriers and facilitators that influence the Community Resource Referral System's implementation in the U.S. by identifying and synthesizing peer-reviewed literature over a 15-year period.

METHODS

This systematic review was conducted following PRISMA guidelines. A search was conducted on five scientific databases to capture the literature published between January 2005 and December 2020. Data analysis was conducted from August 2021 to July 2022.

RESULTS

This review includes 41 articles of the 2,473 initial search results. Included literature revealed that Community Resource Referral Systems functioned to address a variety of health-related social needs and were delivered in different ways. Integrating the Community Resource Referral Systems into clinic workflows, maintenance of community-based organization inventories, and strong partnerships between clinics and community-based organizations facilitated implementation. The sensitivity of health-related social needs, technical challenges, and associated costs presented as barriers. Overall, electronic medical records-integration and automation of the referral process was reported as advantageous for the stakeholders.

DISCUSSION

This review provides information and guidance for healthcare administrators, clinicians, and researchers designing or implementing electronic Community Resource Referral Systems in the U.S. Future studies would benefit from stronger implementation science methodological approaches. Sustainable funding mechanisms for community-based organizations, clear stipulations regarding how healthcare funds can be spent on health-related social needs, and innovative governance structures that facilitate collaboration between clinics and community-based organizations are needed to promote the growth and sustainability of Community Resource Referral Systems in the U.S.

Texas tobacco quitline knowledge, attitudes, and practices within healthcare agencies serving individuals with behavioral health needs: A multimethod study

Patients with behavioral health conditions have disproportionately high tobacco use rates and face significant barriers to accessing evidence-based tobacco cessation services. Tobacco quitlines are an effective and accessible resource, yet they are often underutilized. We identify knowledge, practices, and attitudes towards the Texas Tobacco Quitline (TTQL) within behavioral healthcare settings in Texas. Quantitative and qualitative data were collected in 2021 as part of a statewide needs assessment in behavioral healthcare settings. Survey respondents (n = 125) represented 23 Federally Qualified Health Centers, 29 local mental health authorities (LMHAs), 12 substance use treatment programs in LMHAs, and 61 standalone substance use treatment centers (26 people participated in qualitative interviews). Over half of respondents indicated familiarity with the TTQL and believed that the TTQL was helpful for quitting. Qualitative findings reveal potential concerns about inconsistency of services, long wait time, and the format of the quitline. About half of respondents indicated that their center promoted patient referral to TTQL, and few indicated that their center had an electronic referral system with direct TTQL referral capacity. Interview respondents reported overall lack of systematic follow up with patients regarding their use of the TTQL services. Findings suggest the need for (1) increased TTQL service awareness among healthcare providers; (2) further investigation into any changes needed to better serve patients with behavioral health conditions who use tobacco; and (3) electronic health record integration supporting direct referrals and enhanced protocols to support patient follow up after TTQL referral.

The implementation of ask-advise-connect in a federally qualified health center: a mixed methods evaluation using the re-aim framework

Ask-Advise-Connect (AAC) efficiently links smokers in healthcare settings with evidence-based Quitline-delivered tobacco treatment through training clinic staff to systematically ask patients about smoking status, advise smokers to quit, and connect patients with state Quitlines using the electronic health record. This study utilized a mixed-methods approach, guided by the RE-AIM framework, to evaluate the implementation of AAC in a Federally Qualified Health Center (FQHC). AAC was implemented for 18 months at a FQHC serving primarily low-socioeconomic status (SES) Latinos and Latinas. Results are presented within the RE-AIM conceptual framework which includes dimensions of reach, effectiveness, adoption, implementation, and maintenance. Quantitative patient-level outcomes of reach, effectiveness, and Impact were calculated. Post-implementation, in-depth interviews were conducted with clinic leadership and staff (N = 9) to gather perceptions and inform future implementation efforts. During the implementation period, 12.0% of GNHC patients who reported current smoking both agreed to have their information sent to the Quitline and were successfully contacted by the Quitline (Reach), 94.8% of patients who spoke with the Quitline enrolled in treatment (Effectiveness), and 11.4% of all identified smokers enrolled in Quitline treatment (Impact). In post-implementation interviews assessing RE-AIM dimensions, clinic staff and leadership identified facilitators and advantages of AAC and reported that AAC was easy to learn and implement, streamlined existing procedures, and had a positive impact on patients. Staff and leadership reported enthusiasm about AAC implementation and believed AAC fit well in the clinic. Staff were interested in AAC becoming the standard of care and made suggestions for future implementation. Clinic staff at a FQHC serving primarily low-SES Latinos and Latinas viewed the ACC implementation process positively. Findings have implications for streamlining clinical smoking cessation procedures and the potential to reduce tobacco-related disparities.

Implementation of ask-advise-connect for smoking cessation in Dutch general practice during the COVID-19 pandemic: a mixed-methods evaluation using the CFIR framework

BACKGROUND

The Ask-Advise-Connect (AAC) approach can help primary care providers to increase the number of people who attempt to quit smoking and enrol into cessation counselling. We implemented AAC in Dutch general practice during the COVID-19 pandemic. In this study we describe how AAC was received in Dutch general practice and assess which factors played a role in the implementation.

METHODS

A mixed-methods approach was used to evaluate the implementation of AAC. Implementation took place between late 2020 and early 2022 among 106 Dutch primary care providers (general practitioners (GPs), practice nurses and doctor's assistants). Quantitative and qualitative data were collected through four online questionnaires. A descriptive analysis was conducted on the quantitative data. The qualitative data (consisting of answers to open-ended questions) were inductively analysed using axial codes. The Consolidated Framework for Implementation Research was used to structure and interpret findings.

RESULTS

During the study, most participants felt motivated (84-92%) and able (80-94%) to apply AAC. At the end of the study, most participants reported that the AAC approach is easy to apply (89%) and provides advantages (74%). Routine implementation of the approach was, however, experienced to be difficult. More GPs (30-48%) experienced barriers in the implementation compared to practice nurses and doctor's assistants (7-9%). The qualitative analysis showed that especially external factors, such as a lack of time or priority to discuss smoking due to the COVID-19 pandemic, negatively influenced implementation of AAC.

CONCLUSIONS

Although AAC was mostly positively received in Dutch general practice, implementation turned out to be challenging, especially for GPs. Lack of time to discuss smoking was a major barrier in the implementation. Future efforts should focus on providing additional implementation support to GPs, for example with the use of e-health.

A Clinical Decision Support System for Motivational Messaging and Tobacco Cessation Treatment for Parents: Pilot Evaluation of Use and Acceptance

BACKGROUND

Research is needed to identify how clinical decision support (CDS) systems can support communication about and engagement with tobacco use treatment in pediatric settings for parents who smoke. We developed a CDS system that identifies parents who smoke, delivers motivational messages to start treatment, connects parents to treatment, and supports pediatrician-parent discussion.

OBJECTIVE

The objective of this study is to assess the performance of this system in clinical practice, including receipt of motivational messages and tobacco use treatment acceptance rates.

METHODS

The system was evaluated at one large pediatric practice through a single-arm pilot study from June to November 2021. We collected data on the performance of the CDS system for all parents. Additionally, we surveyed a sample of parents immediately after the clinical encounter who used the system and reported smoking. Measures were: (1) the parent remembered the motivational message, (2) the pediatrician reinforced the message, and (3) treatment acceptance rates. Treatments included nicotine replacement therapy, quitline referral (phone counseling), and/or SmokefreeTXT referral (text message counseling). We described survey response rates overall and with 95% confidence intervals (CIs).

RESULTS

During the entire study period, 8,488 parents completed use of the CDS: 9.3% (n = 786) reported smoking and 48.2% (n = 379) accepted at least one treatment. A total of 102 parents who smoke who used the system were approached to survey 100 parents (98% response rate). Most parents self-identified as female (84%), aged 25 to 34 years (56%), and Black/African American (94%), and had children with Medicaid insurance (95%). Of parents surveyed, 54% accepted at least one treatment option. Most parents recalled the motivational message (79%; 95% CI: 71-87%), and 31% (95% CI: 19-44%) reported that the pediatrician reinforced the motivational message.

CONCLUSION

A CDS system to support parental tobacco use treatment in pediatric primary care enhanced motivational messaging about smoking cessation and evidence-based treatment initiation.

Influence of Provider and Leader Perspectives about Concurrent Tobacco-Use Care during Substance-Use Treatment on Their Tobacco Intervention Provision with Clients: A Mixed-Methods Study

People with substance-use disorders have elevated rates of tobacco use compared with the general population, yet rarely receive tobacco-dependence treatment within substance-use treatment settings (SUTS). One barrier to delivering evidence-based interventions in SUTS is providers' misconception that treating tobacco use and non-nicotine substance use concurrently jeopardizes clients' substance-use recovery, although research indicates that it enhances support for recovery and relapse prevention. A total of 86 treatment providers employed in SUTS (i.e., 9 Federally Qualified Health Centers, 16 Local Mental Health Authorities (LMHAs), 6 substance-use treatment programs in LMHAs, and 55 stand-alone substance-use treatment centers) in Texas, USA, answered survey questions about their (1) thoughts about treating tobacco during substance-use treatment, and (2) delivery of the 5A's tobacco-use intervention (Ask, Advise, Assess, Assist, Arrange). Twenty-six providers and leaders were interviewed about attitudes toward tobacco-free workplace policies and tobacco dependence and the relative importance of treating tobacco (vs. other substance-use disorders) at their center. Providers who did not believe tobacco use should be addressed as soon as clients begin treatment (i.e., endorsed responses of after 1 year, it depends on the client, or never) had lower odds of Asking clients about their tobacco use (OR = 0.195), Advising clients to quit smoking (OR = 0.176), and Assessing interest in quitting smoking (OR = 0.322). Qualitative results revealed barriers including beliefs that clients need to smoke to relieve the stress of substance-use recovery, are disinterested in quitting, fears that concurrent treatment would jeopardize substance use, and limited resources; additional training and education resources was the key facilitator theme. The results demonstrate a critical need to eliminate barriers to tobacco-treatment provision for clients in SUTS through education to correct misperceptions, specialized training to equip providers with knowledge and skills, and resources to build center capacity. Integrating evidence-based smoking interventions into routine care is key to support the recovery efforts of clients in SUTS.

Sustained Effects of a Systems-Based Strategy for Tobacco Cessation Assistance

INTRODUCTION

Primary care settings that serve lower-income patients are critical for reducing tobacco-related disparities; however, tobacco-related care in these settings remains low. This study examined whether processes for the provision of tobacco cessation care are sustained 18 and 24 months after implementing a health system-level intervention consisting of electronic health record functionality changes and expansion of rooming staff roles.

METHODS

This nonrandomized stepped-wedge study included electronic health record data from adults with ≥1 primary care visit to 1 of 8 community-based clinics between August 2016 and September 2019. Generalized estimating equations methods were used to compute ORs of asking about tobacco use and among those who use tobacco, providing brief advice to quit and assessing readiness to quit, contrasting 18 and 24 months after implementation to both preimplementation (baseline) and 12 months after implementation. Using a 2-level model of patients clustered in clinics, outcomes were examined over time by clinic site. Analyses were conducted in 2022.

RESULTS

A total of 305,665 patient visits were evaluated. Significantly higher odds of all 3 outcomes were observed at 18 and 24 months than at baseline. The odds of asking about tobacco use increased, whereas the odds of advising to quit were similar at 18 and 24 months to those at 12 months. Odds of assessing readiness to quit decreased at 18 months (OR=0.71; 95% CI=0.63, 0.80) and 24 months (OR=0.46; 95% CI=0.40, 0.52). Performance varied significantly by clinical site.

CONCLUSIONS

Health system changes can have a sustained impact on tobacco assessment and the provision of brief advice among lower-income patients. Strategies to sustain assessment of readiness to quit are warranted.

Patient Engagement by the Tobacco Quitline After Electronic Referrals

INTRODUCTION

Referrals through the electronic health record (EHR) system provide an efficient evidence-based method to connect patients to the Tobacco Quitline. However, patients frequently do not respond to Quitline phone calls or accept services. The goal of this study was to characterize factors associated with successful engagement with Quitline following e-referrals by physicians in Maryland.

AIMS AND METHODS

This is a cross-sectional study with hierarchical data modeling. Data for 1790 patients e-referred in 2018-2019 by the University of Maryland Medical System (UMMS) were analyzed. Patients' engagement was assessed using a generalized estimating equation multivariable regression model for ordinal outcomes at two levels: Picking up a phone call from Quitline (1-800-QUIT-NOW) and enrollment in tobacco cessation programs.

RESULTS

Older age, female gender, black race, low socioeconomic status, and provider's skills were significantly associated with successful outcomes of Quitline referral. The engagement with Quitline was higher in black non-Hispanic patients compared to other racial/ethnic groups (phone call response odds ratio [OR] = 1.99, 95% confidence interval [CI] = 1.35% to 2.93% and service acceptance OR = 1.89, 95% CI = 1.28% to 2.79%). Patients residing in socioeconomically deprived areas were more likely to respond to Quitline phone calls compared to those from affluent neighborhoods (OR = 1.52, 95% CI = 1.03% to 2.25%). Patients referred by faculty or attending physicians were more likely to respond compared to those referred by residents (OR = 1.23, 95% CI 1.04, 1.44, p = .0141).

CONCLUSIONS

Multiple factors impact successful engagement with Quitline. Additional means to improve Quitline engagement success may include focused messaging on tobacco cessation benefits to patients, and skillful counseling by the provider.

IMPLICATIONS

Implementation of the clinical decision support (CDS) tool for electronic referrals to the Tobacco Quitline at the UMMS was successful in providing evidence-based free service to elderly patients and socioeconomically disadvantaged racial and ethnic minorities. The CDS also served to engage physicians in conversation about tobacco use and cessation with every tobacco-using patient. Curricular content for physicians in training should be enriched to expand tobacco use and treatment.

Ask-Advise-Connect: Differential Enrollment and Smoking Cessation Outcomes Between Primary Care Patients Who Received Quitline-Delivered Treatment in Spanish vs English

PURPOSE

This study examined differences in Quitline treatment enrollment, engagement, and smoking cessation outcomes among primary care patients preferring Spanish and English using the evidence-based tobacco treatment Ask-Advise-Connect.

METHODS

Ask-Advise-Connect was implemented April 2013 through February 2016 in a large safety-net health system to connect smokers with treatment via a link in the electronic health record. Rates of treatment enrollment, engagement, acceptance of nicotine replacement therapy, and smoking abstinence (self-reported and biochemically confirmed) were compared at 6 months among patients who received treatment in Spanish and English using χ ² tests. Logistic regression examined language and nicotine replacement therapy and their interaction as predictors of abstinence.

RESULTS

The smoking status of 218,915 patients was assessed and recorded in the electronic health record. Smoking prevalence was 8.4% among patients preferring Spanish and 27.0% among those preferring English. Spanish-preferring patients were less likely to enroll in treatment (10.7% vs 12.0%, χ ² = 12.06, P = .001) yet completed more counseling calls when enrolled (median = 2 vs 1, P <.001). Patients who received treatment in Spanish (vs English) were twice as likely to be abstinent at 6 months (self-reported: 25.1% vs 14.5%, odds ratio [OR] = 1.98, 95% CI, 1.62-2.40; biochemically confirmed: 7.6% vs 3.7%, OR = 2.13, 95% CI, 1.52-2.97). Receipt of nicotine replacement therapy increased abstinence for all patients and language did not interact with nicotine replacement therapy to predict abstinence.

CONCLUSIONS

Automated point-of-care approaches such as Ask-Advise-Connect have great potential to reach Spanish-preferring smokers. Those who received tobacco treatment in Spanish (vs English) demonstrated better engagement and cessation outcomes.

Adapting a tobacco cessation treatment intervention and implementation strategies to enhance implementation effectiveness and clinical outcomes in the context of HIV care in Vietnam: a case study

BACKGROUND

Smoking rates remain high in Vietnam, particularly among people living with HIV/AIDS (PLWH), but tobacco cessation services are not available in outpatient HIV clinics (OPCs). The research team is conducting a type II hybrid randomized controlled trial (RCT) comparing the cost-effectiveness of three tobacco cessation interventions among PLWH receiving care in HIV clinics in Vietnam. The study is simultaneously evaluating the implementation processes and outcomes of strategies aimed at increasing the implementation of tobacco dependence treatment (TDT) in the context of HIV care. This paper describes the systematic, theory-driven process of adapting intervention components and implementation strategies with demonstrated effectiveness in high-income countries, and more recently in Vietnam, to a new population (i.e., PLWH) and new clinical setting, prior to launching the trial.

METHODS

Data collection and analyses were guided by two implementation science frameworks and the socio-ecological model. Qualitative interviews were conducted with 13 health care providers and 24 patients in three OPCs. Workflow analyses were conducted in each OPC. Qualitative data were analyzed using rapid qualitative analysis procedures. Based on findings, components of the intervention and implementation strategies were adapted, followed by a 3-month pilot study in one OPC with 16 patients randomized to one of two intervention arms.

RESULTS

The primary adaptations included modifying the TDT intervention counseling content to address barriers to quitting among PLWH and Vietnamese sociocultural norms that support smoking cessation. Implementation strategies (i.e., training and system changes) were adapted to respond to provider- and clinic-level determinants of implementation effectiveness (e.g., knowledge gaps, OPC resource constraints, staffing structure, compatibility).

CONCLUSIONS

Adaptations were facilitated through a mixed method, stakeholder (patient and health care provider, district health leader)-engaged evaluation of context-specific influences on intervention and implementation effectiveness. This data-driven approach to refining and adapting components aimed to optimize intervention effectiveness and implementation in the context of HIV care. Balancing pragmatism with rigor through the use of rapid analysis procedures and multiple methods increased the feasibility of the adaptation process.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05162911 . Registered on December 16, 2021.

An EHR-automated and theory-based population health management intervention for smoking cessation in diverse low-income patients of safety-net health centers: a pilot randomized controlled trial

This study tested the preliminary effectiveness of an electronic health record (EHR)-automated population health management (PHM) intervention for smoking cessation among adult patients of a federally qualified health center in Chicago. Participants (N = 190; 64.7% women, 82.1% African American/Black, 8.4% Hispanic/Latino) were self-identified as smokers, as documented in the EHR, who completed the baseline survey of a longitudinal "needs assessment of health behaviors to strengthen health programs and services." Four weeks later, participants were randomly assigned to the PHM intervention (N = 97) or enhanced usual care (EUC; N = 93). PHM participants were mailed a single-page self-determination theory (SDT)-informed letter that encouraged smoking cessation or reduction as an initial step. The letter also addressed low health literacy and low income. PHM participants also received automated text messages on days 1, 5, 8, 11, and 20 after the mailed letter. Two weeks after mailing, participants were called by the Illinois Tobacco Quitline. EUC participants were e-referred following a usual practice. Participants reached by the quitline were offered behavioral counseling and nicotine replacement therapy. Outcome assessments were conducted at weeks 6, 14, and 28 after the mailed letter. Primary outcomes were treatment engagement, utilization, and self-reported smoking cessation. In the PHM arm, 25.8% of participants engaged in treatment, 21.6% used treatment, and 16.3% were abstinent at 28 weeks. This contrasts with no quitline engagement among EUC participants, and a 6.4% abstinence rate. A PHM approach that can reach all patients who smoke and address unique barriers for low-income individuals may be a critical supplement to clinic-based care.

Electronic Health Record-Embedded, Behavioral Science-Informed System for Smoking Cessation for the Parents of Pediatric Patients

BACKGROUND

 Helping parents quit smoking is a public health priority. However, parents are rarely, if ever, offered tobacco use treatment through pediatric settings. Clinical decision support (CDS) systems developed for the workflows of pediatric primary care may support consistent screening, treatment, and referral.

OBJECTIVES

 This study aimed to develop a CDS system by using human-centered design (HCD) that identifies parents who smoke, provides motivational messages to quit smoking (informed by behavioral science), and supports delivery of evidence-based tobacco treatment.

METHODS

 Our multidisciplinary team applied a rigorous HCD process involving analysis of the work environment, user involvement in formative design, iterative improvements, and evaluation of the system's use in context with the following three cohorts: (1) parents who smoke, (2) pediatric clinicians, and (3) clinic staff. Participants from each cohort were presented with scenario-based, high-fidelity mockups of system components and then provided input related to their role in using the CDS system.

RESULTS

 We engaged 70 representative participants including 30 parents, 30 clinicians, and 10 clinic staff. A key theme of the design review sessions across all cohorts was the need to automate functions of the system. Parents emphasized a system that presented information in a simple way, highlighted benefits of quitting smoking, and allowed direct connection to treatment. Pediatric clinicians emphasized automating tobacco treatment. Clinical staff emphasized screening for parent smoking via several modalities prior to the patient's visit. Once the system was developed, most parents (80%) reported that it was easy to use, and the majority of pediatricians reported that they would use the system (97%) and were satisfied with it (97%).

CONCLUSION

 A CDS system to support parental tobacco cessation in pediatric primary care, developed through an HCD process, proved easy to use and acceptable to parents, clinicians, and office staff. This preliminary work justifies evaluating the impact of the system on helping parents quit smoking.

Smoking cessation strategy in the national cervical cancer screening program (SUCCESS): study protocol for a pragmatic cluster randomised trial and process evaluation in Dutch general practice

INTRODUCTION

Cervical cancer screening in general practice could be a routine moment to provide female smokers with stop smoking advice and support. The aim of this study is to assess the effect of a stop smoking strategy delivered by trained practice assistants after the cervical smear, and to evaluate the implementation process.

METHODS AND ANALYSIS

The study is a two-arm, pragmatic cluster randomised trial, in Dutch general practice. Randomisation takes place 1:1 at the level of the general practice. Practices either deliver the SUCCESS stop smoking strategy or the usual care condition. The strategy consists of brief stop smoking advice based on the Ask-Advise-Connect method and is conducted by trained practice assistants after routine cervical cancer screening. The primary outcome is the performance of a serious quit attempt in the 6 months after screening. Secondary outcomes are 7-day point prevalence abstinence, reduction in the number of cigarettes per day and transition in motivation to quit smoking. Follow-up for these measurements takes place after 6 months. Analysis on the primary outcome aims to detect a 10% difference between treatment arms (0.80 power, p=0.05, using a one-sided test), and will be performed according to the intention to treat principle. The process evaluation will assess feasibility, acceptability and barriers or enablers to the strategy's implementation. For this purpose, both qualitative and quantitative data will be collected via questionnaires and in-depth interviews, respectively, in both individual study participants and involved staff.

ETHICS AND DISSEMINATION

The Dutch Ministry of Health, Welfare and Sport approved of the trial after an advisory report from the Health Council (Nr. 2018/17). A licence was provided to conduct the study under the Population Screening Act. Study results will be disseminated through publications in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

NL5052 (NTR7451).

Comparison of an automated smartphone-based smoking cessation intervention versus standard quitline-delivered treatment among underserved smokers: protocol for a randomized controlled trial

BACKGROUND

Smoking is the leading cause of preventable morbidity and mortality in the United States. Individuals with low socioeconomic status have disproportionately high smoking rates and greater difficulty quitting smoking. Efficiently connecting underserved smokers to effective tobacco cessation programs is crucial for disease prevention and the elimination of health disparities. Smartphone-based interventions have the potential to enhance the reach and efficacy of smoking cessation treatments targeting underserved smokers, but there is little efficacy data for these interventions. In this study, we will partner with a large, local hunger-relief organization to evaluate the efficacy and economic impact of a theoretically-based, fully-automated, and interactive smartphone-based smoking cessation intervention.

METHODS

This study will consist of a 2-group randomized controlled trial. Participants (N = 500) will be recruited from a network of food distribution centers in West Central Florida and randomized to receive either Standard Treatment (ST, n = 250) or Automated Treatment (AT, n = 250). ST participants will be connected to the Florida Quitline for telephone-based treatment and will receive a 10-week supply of nicotine replacement therapy (NRT; transdermal patches and lozenges). AT participants will receive 10 weeks of NRT and a fully-automated smartphone-based intervention consisting of interactive messaging, images, and audiovisual clips. The AT intervention period will span 26 weeks, with 12 weeks of proactive content and 26 weeks of on-demand access. ST and AT participants will complete weekly 4-item assessments for 26 weeks and 3-, 6-, and 12-month follow-up assessments. Our primary aim is to evaluate the efficacy of AT in facilitating smoking abstinence. As secondary aims, we will explore potential mediators and conduct economic evaluations to assess the cost and/or cost-effectiveness of ST vs. AT.

DISCUSSION

The overall goal of this project is to determine if AT is better at facilitating long-term smoking abstinence than ST, the more resource-intensive approach. If efficacy is established, the AT approach will be relatively easy to disseminate and for community-based organizations to scale and implement, thus helping to reduce tobacco-related health disparities.

TRIAL REGISTRATION

Clinical Trials Registry NCT05004662 . Registered August 13, 2021.

Application of community - engaged dissemination and implementation science to improve health equity

Community engagement is critical to accelerate and improve implementation of evidence-based interventions to reduce health inequities. Community-engaged dissemination and implementation research (CEDI) emphasizes engaging stakeholders (e.g., community members, practitioners, community organizations, etc.) with diverse perspectives, experience, and expertise to provide tacit community knowledge regarding the local context, priorities, needs, and assets. Importantly, CEDI can help improve health inequities through incorporating unique perspectives from communities experiencing health inequities that have historically been left out of the research process. The community-engagement process that exists in practice can be highly variable, and characteristics of the process are often underreported, making it difficult to discern how engagement of community partners was used to improve implementation. This paper describes the community-engagement process for a multilevel, pragmatic randomized trial to increase the reach and impact of evidence-based tobacco cessation treatment among Community Health Center patients; describes how engagement activities and the resulting partnership informed the development of implementation strategies and improved the research process; and presents lessons learned to inform future CEDI research.

Implementation and Outcomes of a Comprehensive Tobacco Free Workplace Program in Opioid Treatment Centers

Tobacco use is exceedingly high among individuals receiving care for opioid addiction, but not commonly addressed by clinicians in treatment settings. Taking Texas Tobacco Free (TTTF) is a comprehensive tobacco-free workplace (TFW) program that builds treatment centers' capacity to address tobacco use with evidence-based tobacco cessation policies and practices. Here, we examine the process and outcomes of TTTF's implementation within 7 opioid addiction centers. Program goals were structured according to the RE-AIM framework. Pre- and post-implementation data were collected from client facing and non-client facing employees to assess changes in education, training receipt, knowledge, and intervention behaviors, relative to program goals. Centers reported tobacco screenings conducted and nicotine replacement therapy (NRT) delivered through 6 months post-implementation. Overall, 64.56% of employees participated in TTTF-delivered tobacco education, with a 54.9% gain in tobacco control and treatment knowledge (p < 0.0001), and significant increases in exposure to education about tobacco use and harms among individuals with opioid use disorder (p = 0.0401). There were significant gains in clinicians' receipt of training in 9/9 tobacco education areas (ps ≤ 0.0118). From pre- to post-implementation, there were mean increases in the use of the 5A's (ask, advise, assess, assist, and arrange) and other evidence-based interventions for tobacco cessation, with statistically significant gains seen in NRT provision/referral (p < 0.0001). Several program goals were achieved or exceeded; however, 100% center participation in specialized clinical trainings was among notable exceptions. One program withdrew due to competing pandemic concerns; all others implemented comprehensive TFW policies. Overall, TTTF may have improved participating opioid treatment centers' capacity to address tobacco use, although study limitations, including lower post-implementation evaluation response rates, suggest that results require replication in other opioid addiction treatment settings.

A Study Protocol for Increasing Access to Smoking Cessation Treatments for Low-Income Minority Smokers

Background: Smoking rates among low-income patients are double those of the general population. Access to health care is an essential social determinant of health. Federally qualified health care centers (FQHC) are government-supported and community-based centers to increase access to health care for non-insured and underinsured patients. However, barriers to implementation impact adherence and sustainability of evidence-based smoking cessation within FQHC settings. To address this implementation barrier, our multi-disciplinary team proposes Mi QUIT CARE (Mile Square QUIT Community-Access-Referral-Expansion) to establish the acceptability, feasibility, and capacity of an FQHC system to deliver an evidence-based and multi-level intervention to increase patient engagement with a state tobacco quitline. Methods: A mixed-method approach, rooted in an implementation science framework of RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance), will be used in this hybrid effectiveness-implementation design. We aim to evaluate the efficacy of a novel delivery system (patient portal) for increasing access to smoking cessation treatment. In preparation for a future randomized clinical trial of Mi QUIT CARE, we will conduct the following developmental research: (1) Examine the burden of tobacco among patient populations served by our partner FQHC, (2) Evaluate among FQHC patients and health care providers, knowledge, attitudes, barriers, and facilitators related to smoking cessation and our intervention components, (3) Evaluate the use of tailored communication strategies and patient navigation to increase patient portal uptake among patients, and (4) To test the acceptability, feasibility, and capacity of the partner FQHC to deliver Mi QUIT CARE. Discussion: This study provides a model for developing and implementing smoking and other health promotion interventions for low-income patients delivered via patient health portals. If successful, the intervention has important implications for addressing a critical social determinant of cancer and other tobacco-related morbidities. Trial Registration: U.S. National Institutes of Health Clinical Trials, NCT04827420, https://clinicaltrials.gov/ct2/show/NCT04827420.

Evaluating the Efficacy of Automated Smoking Treatment for People With HIV: Protocol for a Randomized Controlled Trial

Background

Smoking prevalence rates among people with HIV are nearly 3 times higher than those in the general population. Nevertheless, few smoking cessation trials targeting smokers with HIV have been reported in the literature. Efforts to develop and evaluate sustainable, low-cost, and evidence-based cessation interventions for people with HIV are needed. Given the widespread proliferation of mobile phones, the potential of using mobile health apps to improve the reach and efficacy of cessation interventions is promising, but evidence of efficacy is lacking, particularly among people with HIV.

Objective

This study will consist of a 2-group randomized controlled trial to evaluate a fully automated smartphone intervention for people with HIV seeking cessation treatment.

Methods

Participants (N=500) will be randomized to receive either standard treatment (ST; 250/500, 50%) or automated treatment (AT; 250/500, 50%). ST participants will be connected to the Florida Quitline and will receive nicotine replacement therapy in the form of transdermal patches and lozenges. This approach, referred to as Ask Advise Connect, was developed by our team and has been implemented in numerous health systems. ST will be compared with AT, a fully automated behavioral treatment approach. AT participants will receive nicotine replacement therapy and an interactive smartphone-based intervention that comprises individually tailored audiovisual and text content. The major goal is to determine whether AT performs better in terms of facilitating long-term smoking abstinence than the more resource-intensive ST approach. Our primary aim is to evaluate the efficacy of AT in facilitating smoking cessation among people with HIV. As a secondary aim, we will explore potential mediators and moderators and conduct economic evaluations to assess the cost and cost-effectiveness of AT compared with ST.

Results

The intervention content has been developed and finalized. Recruitment and enrollment will begin in the fall of 2021.

Conclusions

There is a critical need for efficacious, cost-effective, and sustainable cessation treatments for people with HIV who smoke. The AT intervention was designed to help fill this need. If efficacy is established, the AT approach will be readily adoptable by HIV clinics and community-based organizations, and it will offer an efficient way to allocate limited public health resources to tobacco control interventions.

Trial Registration

ClinicalTrials.gov NCT05014282; https://clinicaltrials.gov/ct2/show/NCT05014282

International Registered Report Identifier (IRRID)

PRR1-10.2196/33183

Implementation and Outcomes of a Train-the-Trainer Program at Behavioral Health Treatment Centers as a Mechanism to Maintain Organizational Capacity to Address Tobacco Use Disorder

Despite prior successful implementation of Taking Texas Tobacco Free (TTTF), an evidence-based tobacco-free workplace program, in local mental health authorities (LMHAs), post-implementation employee attrition necessitated continuing education on tobacco-free policies and tobacco treatment practices. Here, we report on the outcomes of a train-the-trainer program which trained "champions" to deliver tobacco cessation education at their LMHAs. Three LMHAs participated in program implementation via 10 champions, iteratively trained and coached by TTTF. Measures administered evaluated four goals: (1) increase champions' self-efficacy in delivering trainings, (2) achieve program fidelity via TTTF staff evaluation of trainer effectiveness and knowledge increases among attending employees, (3) achieve stakeholder program acceptability, and (4) achieve program adoption via an increase in follow-up trainings. Champions' self-efficacy increased throughout TTTF training. TTTF staff ratings of champion-led trainings met the targeted range for trainer effectiveness; employees had a 28.71% knowledge increase over baseline post-training (p < 0.001). Employees rated champions' training delivery "very good" to "excellent", on average; both champions and employees were, on average, "satisfied" to "extremely satisfied" with the curriculum and training received. There was an increase over baseline in trainings delivered during follow-up, and trainings increased in length and topic coverage. Ultimately, the train-the-trainer program achieved the intended goals, although not all changes were statistically significant, likely at least partially attributable to small sample sizes. Overall, these results suggest that TTTF's train-the-trainer program was successful in its delivery and intention to build capacity for the provision of in-house tobacco education trainings to behavioral health employees/providers. However, further evaluation in additional settings, with more champions, et cetera, is necessary to validate these findings, ensure their replicability, link program implementation with reduced patient tobacco use rates, and assess long-term sustainability.

Time to put it out - nurse-facilitated tobacco treatment in a comprehensive cancer center

Few cancer patients receive guideline-concordant care for treatment of tobacco dependence. The purpose of this pilot trial was to obtain preliminary estimates of effectiveness of an evidence-based practice intervention on the delivery of tobacco treatment and cessation outcomes in cancer patients. We conducted a pragmatic implementation trial with a before-after design in 119 current or recently quit adult smokers with cancer who met with a clinician at a single National Cancer Institute designated comprehensive cancer center (CCC) (n = 61 pre-implementation, n = 58 post-implementation). We used a multi-component strategy based on the Chronic Care Model to implement National Comprehensive Cancer Network (NCCN) guidelines for smoking cessation. Smoking cessation counseling during the index visit was assessed by exit interview and patients were interviewed by phone to assess cessation outcomes at 3-month follow-up. Performance of cessation counseling and 7-day point prevalence abstinence (PPA) were compared across the pre- and post-implementation periods using log-logistic regression, accounting for clustering by nursing staff. More patients had received assistance in quitting at the index visit during the post-implementation period compared to the pre-implementation period (30 vs. 10%, p < .01). At 3-month follow-up, 38 and 14% of participants had discussed smoking cessation medication with a CCC healthcare professional and 57 and 27% of participants had used pharmacotherapy, respectively (p < .01 for both comparisons). Seven-day PPA at 3-month follow-up was similar in both periods, however (14 vs. 12%, respectively). A multi-component tobacco treatment intervention increased the proportion of smokers who received assistance in quitting smoking during usual cancer care but did not improve cessation outcomes.

Strategies to improve smoking cessation rates in primary care

BACKGROUND

Primary care is an important setting in which to treat tobacco addiction. However, the rates at which providers address smoking cessation and the success of that support vary. Strategies can be implemented to improve and increase the delivery of smoking cessation support (e.g. through provider training), and to increase the amount and breadth of support given to people who smoke (e.g. through additional counseling or tailored printed materials).

OBJECTIVES

To assess the effectiveness of strategies intended to increase the success of smoking cessation interventions in primary care settings. To assess whether any effect that these interventions have on smoking cessation may be due to increased implementation by healthcare providers.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries to 10 September 2020.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and cluster-RCTs (cRCTs) carried out in primary care, including non-pregnant adults. Studies investigated a strategy or strategies to improve the implementation or success of smoking cessation treatment in primary care. These strategies could include interventions designed to increase or enhance the quality of existing support, or smoking cessation interventions offered in addition to standard care (adjunctive interventions). Intervention strategies had to be tested in addition to and in comparison with standard care, or in addition to other active intervention strategies if the effect of an individual strategy could be isolated. Standard care typically incorporates physician-delivered brief behavioral support, and an offer of smoking cessation medication, but differs across studies. Studies had to measure smoking abstinence at six months' follow-up or longer.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Our primary outcome - smoking abstinence - was measured using the most rigorous intention-to-treat definition available. We also extracted outcome data for quit attempts, and the following markers of healthcare provider performance: asking about smoking status; advising on cessation; assessment of participant readiness to quit; assisting with cessation; arranging follow-up for smoking participants. Where more than one study investigated the same strategy or set of strategies, and measured the same outcome, we conducted meta-analyses using Mantel-Haenszel random-effects methods to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs).

MAIN RESULTS

We included 81 RCTs and cRCTs, involving 112,159 participants. Fourteen were rated at low risk of bias, 44 at high risk, and the remainder at unclear risk. We identified moderate-certainty evidence, limited by inconsistency, that the provision of adjunctive counseling by a health professional other than the physician (RR 1.31, 95% CI 1.10 to 1.55; I2 = 44%; 22 studies, 18,150 participants), and provision of cost-free medications (RR 1.36, 95% CI 1.05 to 1.76; I2 = 63%; 10 studies,7560 participants) increased smoking quit rates in primary care. There was also moderate-certainty evidence, limited by risk of bias, that the addition of tailored print materials to standard smoking cessation treatment increased the number of people who had successfully stopped smoking at six months' follow-up or more (RR 1.29, 95% CI 1.04 to 1.59; I2 = 37%; 6 studies, 15,978 participants). There was no clear evidence that providing participants who smoked with biomedical risk feedback increased their likelihood of quitting (RR 1.07, 95% CI 0.81 to 1.41; I2 = 40%; 7 studies, 3491 participants), or that provider smoking cessation training (RR 1.10, 95% CI 0.85 to 1.41; I2 = 66%; 7 studies, 13,685 participants) or provider incentives (RR 1.14, 95% CI 0.97 to 1.34; I2 = 0%; 2 studies, 2454 participants) increased smoking abstinence rates. However, in assessing the former two strategies we judged the evidence to be of low certainty and in assessing the latter strategies it was of very low certainty. We downgraded the evidence due to imprecision, inconsistency and risk of bias across these comparisons. There was some indication that provider training increased the delivery of smoking cessation support, along with the provision of adjunctive counseling and cost-free medications. However, our secondary outcomes were not measured consistently, and in many cases analyses were subject to substantial statistical heterogeneity, imprecision, or both, making it difficult to draw conclusions. Thirty-four studies investigated multicomponent interventions to improve smoking cessation rates. There was substantial variation in the combinations of strategies tested, and the resulting individual study effect estimates, precluding meta-analyses in most cases. Meta-analyses provided some evidence that adjunctive counseling combined with either cost-free medications or provider training enhanced quit rates when compared with standard care alone. However, analyses were limited by small numbers of events, high statistical heterogeneity, and studies at high risk of bias. Analyses looking at the effects of combining provider training with flow sheets to aid physician decision-making, and with outreach facilitation, found no clear evidence that these combinations increased quit rates; however, analyses were limited by imprecision, and there was some indication that these approaches did improve some forms of provider implementation.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that providing adjunctive counseling by an allied health professional, cost-free smoking cessation medications, and tailored printed materials as part of smoking cessation support in primary care can increase the number of people who achieve smoking cessation. There is no clear evidence that providing participants with biomedical risk feedback, or primary care providers with training or incentives to provide smoking cessation support enhance quit rates. However, we rated this evidence as of low or very low certainty, and so conclusions are likely to change as further evidence becomes available. Most of the studies in this review evaluated smoking cessation interventions that had already been extensively tested in the general population. Further studies should assess strategies designed to optimize the delivery of those interventions already known to be effective within the primary care setting. Such studies should be cluster-randomized to account for the implications of implementation in this particular setting. Due to substantial variation between studies in this review, identifying optimal characteristics of multicomponent interventions to improve the delivery of smoking cessation treatment was challenging. Future research could use component network meta-analysis to investigate this further.

Implementation of Ask-Advise-Connect in a safety net healthcare system: quitline treatment engagement and smoking cessation outcomes

Ask-Advise-Connect (AAC) was designed to link smokers in primary care settings with evidence-based tobacco treatment delivered via state quitlines. AAC involves training medical staff to Ask about smoking status, Advise smokers to quit, and offer to immediately Connect smokers with quitlines through an automated link within the electronic health record. We evaluated the efficacy of AAC in facilitating treatment engagement and smoking abstinence in a 34 month implementation trial conducted in a large, safety-net health care system. AAC was implemented from April 2013 through February 2016 in 13 community clinics that provided care to low-income, predominantly racial/ethnic minority smokers. Licensed vocational nurses were trained to implement AAC as part of standard care. Outcomes included (a) treatment engagement (i.e., proportion of identified smokers that enrolled in treatment) and (b) self-reported and biochemically confirmed abstinence at 6 months. Smoking status was recorded for 218,915 unique patients, and 40,888 reported current smoking. The proportion of all identified smokers who enrolled in treatment was 11.8%. Self-reported abstinence at 6 months was 16.6%, and biochemically confirmed abstinence was 4.5%. AAC was successfully implemented as part of standard care. Treatment engagement was high compared with rates of engagement for more traditional referral-based approaches reported in the literature. Although self-reported abstinence was in line with other quitline-delivered treatment studies, biochemically confirmed abstinence, which is not routinely captured in quitline studies, was dramatically lower. This discrepancy challenges the adequacy of self-report for large, population-based studies. A more detailed and comprehensive investigation is warranted.

Workflow analysis for design of an electronic health record-based tobacco cessation intervention in community health centers

OBJECTIVE

Tobacco use is the leading cause of preventable morbidity and mortality in the United States. Quitlines are effective telephone-based tobacco cessation services but are underutilized. The goal of this project was to describe current clinical workflows for Quitline referral and design an optimal electronic health record (EHR)-based workflow for Ask-Advice-Connect (AAC), an evidence-based intervention to increase Quitline referrals.

MATERIALS AND METHODS

Ten Community Health Center systems (CHC), which use three different EHRs, participated in this study. Methods included: 9 group discussions with CHC leaders; 33 observations/interviews of clinical teams' workflow; surveys with 57 clinical staff; and assessment of the EHR ecosystem in each CHC. Data across these methods were integrated and coded according to the Fit between Individual, Task, Technology and Environment (FITTE) framework. The current and optimal workflow were notated using Business Process Modelling Notation. We compared the requirements of the optimal workflow with EHR capabilities.

RESULTS

Current workflows are inefficient in data collection, variable in who, how, and when tobacco cessation advice and referral are enacted, and lack communication between referring clinics and the Quitline. In the optimal workflow, medical assistants deliver a standardized AAC intervention during the visit intake. Referrals are submitted electronically, and there is bidirectional communication between the clinic and Quitline. We implemented AAC within all three EHRs; however, deviations from the optimal workflow were necessary.

CONCLUSION

Current workflows for Quitline referral are inefficient and ineffective. We propose an optimal workflow and discuss improvements in EHR capabilities that would improve the implementation of AAC.

A cluster randomized trial evaluating a teachable moment communication process for tobacco cessation support

Introduction

This study examines the uptake of a clinician-focused teachable moment communication process (TMCP) and its impact on patient receipt of tobacco cessation support. The TMCP is a counseling method that uses patient concerns to help clinicians guide behavior change discussions about tobacco. We evaluate the added value of the TMCP training in a health system that implemented an Ask-Advise-Connect (AAC) systems-based approach.

Methods

A stepped wedge cluster randomized trial included eight community health centers. Training involved a web module and onsite skill development with standardized patients and coaching. Main outcome measures included contact and enrollment in cessation services among patients referred for counseling, prescription of cessation medications and quit attempts.

Results

Forty-four of 60 eligible clinicians received the TMCP training. Among TMCP-trained clinicians 68% used a TMCP approach (documented by flowsheet use) one or more times, with the median number of uses being 15 (IQR 2–33). Overall, the TMCP was used in 661 out of 8198 visits by smokers (8%). There was no improvement in any of the tobacco cessation assistance outcomes for the AAC + TMCP vs. the AAC only period. Visits where clinicians used the TMCP approach were associated with increased ordering of tobacco cessation medications, (OR = 2.6; 95% CI = 1.9, 3.5) and providing advice to quit OR 3.2 (95% CI 2.2, 4.7).

Conclusions

Despite high fidelity to the training, uptake of the TMCP approach in routine practice was poor, making it difficult to evaluate the impact on patient outcomes. When the TMCP approach was used, ordering tobacco cessation medications increased.

Implications

Tobacco cessation strategies in primary care have the potential to reach a large portion of the population and deliver advice tailored to the patient. The poor uptake of the approach despite high training fidelity suggests that additional implementation support strategies, are needed to increase sustainable adoption of the TMCP approach.

Trial Registration

clinicaltrials.gov #NCT02764385, registration date 06/05/2016.

Organizational Characteristics and Readiness for Tobacco-Free Workplace Program Implementation Moderates Changes in Clinician's Delivery of Smoking Interventions within Behavioral Health Treatment Clinics

BACKGROUND

Smoking is elevated amongst individuals with behavioral health disorders, but not commonly addressed. Taking Texas Tobacco Free is an evidence-based, tobacco-free workplace program that addresses this, in-part, by providing clinician training to treat tobacco use in local mental health authorities (LMHAs). This study examined organizational moderators of change in intervention delivery from pre- to post-program implementation.

METHODS

LMHA leaders completed the Organizational Readiness for Implementing Change (ORIC) and provided organization demographics pre-implementation. Clinicians (N = 1237) were anonymously surveyed about their consistent use of the 5As (Asking about smoking; Advising clientele to quit; Assessing willingness to quit; Assisting them to quit; Arranging follow-up) pre- and post-program implementation. Adjusted generalized linear mixed models were used for analyses (responses nested within LMHAs), with interaction terms used to assess moderation effects.

RESULTS

Clinician delivery of 5As increased pre- to post-implementation (p < .001). LMHAs with fewer employees (ref = ≤300) demonstrated greater increases in Asking, Assessing, and Assisting over time. LMHAs with fewer patients (ref = ≤10 000) evinced greater changes in Asking over time. Less initial ORIC Change Efficacy, Change Commitment, and Task Knowledge were each associated with greater pre- to post-implementation changes in Asking. Less initial Task Knowledge was associated with greater increases in Advising, Assessing, and Assisting. Finally, less initial Resource Availability was associated with greater increases in Assisting (all moderation term ps < .025).

CONCLUSION

The smallest and least ready LMHAs showed the largest gains in tobacco cessation intervention delivery; thus, low initial readiness was not a barrier for program implementation, particularly when efficacy-building training and resources are provided.

IMPLICATIONS

This study examined organizational moderators of increases in tobacco cessation treatment delivery over time following the implementation of a comprehensive tobacco-free workplace program within 20 of 39 LMHAs across Texas (hundreds of clinics; servicing >50% of the state) from 2013 to 2018. Overall, LMHAs with fewer employees and patients, and that demonstrated the least initial readiness for change, evinced greater gains in intervention delivery. Findings add to dissemination and implementation science by supporting that low initial readiness was not a barrier for this aspect of tobacco-free workplace program implementation when resources and clinician training sessions were provided.

The Emerging Global Tobacco Treatment Workforce: Characteristics of Tobacco Treatment Specialists Trained in Council-Accredited Training Programs from 2017 to 2019

Tobacco use is projected to kill 1 billion people in the 21st century. Tobacco Use Disorder (TUD) is one of the most common substance use disorders in the world. Evidence-based treatment of TUD is effective, but treatment accessibility remains very low. A dearth of specially trained clinicians is a significant barrier to treatment accessibility, even within systems of care that implement brief intervention models. The treatment of TUD is becoming more complex and tailoring treatment to address new and traditional tobacco products is needed. The Council for Tobacco Treatment Training Programs (Council) is the accrediting body for Tobacco Treatment Specialist (TTS) training programs. Between 2016 and 2019, n = 7761 trainees completed Council-accredited TTS training programs. Trainees were primarily from North America (92.6%) and the Eastern Mediterranean (6.1%) and were trained via in-person group workshops in medical and academic settings. From 2016 to 2019, the number of Council-accredited training programs increased from 14 to 22 and annual number of trainees increased by 28.5%. Trainees have diverse professional backgrounds and work in diverse settings but were primarily White (69.1%) and female (78.7%) located in North America. Nearly two-thirds intended to implement tobacco treatment services in their setting; two-thirds had been providing tobacco treatment for 1 year or less; and 20% were sent to training by their employers. These findings suggest that the training programs are contributing to the development of a new workforce of TTSs as well as the development of new programmatic tobacco treatment services in diverse settings. Developing strategies to support attendance from demographically and geographically diverse professionals might increase the proportion of trainees from marginalized groups and regions of the world with significant tobacco-related inequities.

Quitline Treatment Enrollment and Cessation Outcomes Among Smokers Linked With Treatment via Ask-Advise-Connect: Comparisons Among Smokers With and Without HIV

INTRODUCTION

Given that people living with HIV (PLWH) are disproportionately burdened by tobacco-related morbidity and mortality, it is critically important to understand the degree to which evidence-based cessation interventions are utilized by and are effective among PLWH.

AIMS AND METHODS

This secondary data analysis aimed to examine differences in Quitline treatment enrollment and 6-month cessation outcomes among smokers seeking care at 1 HIV clinic and 12 non-HIV clinics that were part of a large healthcare system in the greater Houston, Texas metropolitan area, United States. Data were from a 34-month (April 2013-February 2016) one-group implementation trial that evaluated the Ask-Advise-Connect (AAC) approach to linking smokers with Quitline treatment. Primary outcomes included (1) treatment enrollment and (2) 6-month self-reported and biochemically confirmed abstinence.

RESULTS

The smoking status of 218 915 unique patients was recorded in the electronic health record; 5285 (2.7%) of these patients were seen at the HIV clinic where the smoking prevalence was 45.9%; smoking prevalence at the non-HIV clinics was 17.9%. The proportion of identified smokers who enrolled in treatment was 10.8% at the HIV clinic and 11.8% at the non-HIV clinics. The self-reported abstinence rate was 18.7% among HIV clinic patients and 16.5% among non-HIV clinic patients. Biochemically confirmed abstinence was lower at 4.2% and 4.5%, respectively (all ps > .05).

CONCLUSIONS

AAC resulted in rates of Quitline treatment enrollment and abstinence rates that were comparable among patients seen at an HIV clinic and non-HIV clinics. Findings suggest that AAC should be considered for widespread implementation in HIV clinics.

IMPLICATIONS

PLWH were as likely as other patients to enroll in evidence-based tobacco cessation treatment when it was offered in the context of a primary care visit. Cessation outcomes were also comparable. Therefore, standard care for PLWH should include routine screening for smoking status and referrals to cessation treatment.

12-Month Evaluation of an EHR-Supported Staff Role Change for Provision of Tobacco Cessation Care in 8 Primary Care Safety-Net Clinics

SIGNIFICANCE

Guidelines urge primary care practices to routinely provide tobacco cessation care (i.e., assess tobacco use, provide brief cessation advice, and refer to cessation support). This study evaluates the impact of a systems-based strategy to provide tobacco cessation care in eight primary care clinics serving low-income patients.

METHODS

A non-randomized stepped wedge study design was used to implement an intervention consisting of (1) changes to the electronic health record (EHR) referral functionality and (2) expansion of staff roles to provide brief advice to quit; assess readiness to quit; offer a referral to tobacco cessation counseling; and sign the referral order. Outcomes assessed from the EHR include performance of tobacco cessation care tasks, referral contact, and enrollment rates for the quitline (QL) and in-house Freedom from Smoking (FFS) program. Generalized estimating equations (GEE) methods were used to compute odds ratios contrasting the pre-implementation vs. 1-, 3-, 6-, and 12-month post-implementation periods.

RESULTS

Of the 176,061 visits, 26.1% were by identified tobacco users. All indicators significantly increased at each time period evaluated post-implementation. In comparison with the pre-intervention period, assessing smoking status (26.6% vs. 55.7%; OR = 3.7, CI = 3.6-3.9), providing advice (44.8% vs. 88.7%; OR = 7.8, CI = 6.6-9.1), assessing readiness to quit (15.8% vs. 55.0%; OR = 6.2, CI = 5.4-7.0), and acceptance of a referral to tobacco cessation counseling (0.5% vs. 30.9%; OR = 81.0, CI = 11.4-575.8) remained significantly higher 12 months post-intervention. For the QL and FFS, respectively, there were 1223 and 532 referrals; 324 (31.1%) and 103 (24.7%) were contacted; 241 (74.4%) and 72 (69.6%) enrolled; and 195 (80.9%) and 14 (19.4%) received at least one counseling session.

CONCLUSIONS

This system change intervention that includes an EHR-supported role expansion substantially increased the provision of tobacco cessation care and improvements were sustained beyond 1 year. This approach has the potential to greatly increase the number of individuals referred for tobacco cessation counseling.

Factors Associated with Cigarette Smoking Cessation in Lao People's Democratic Republic: Results from the 2015 National Adult Tobacco Survey

Cigarette smoking represents a major public health problem in Lao People's Democratic Republic (Lao PDR). This study aims to examine factors associated with cigarette smoking cessation attempts and intention to quit. Data were from the Lao National Adult Tobacco Survey that consisted of 7562 participants ≥15 years old. Multivariable logistic regression models were used to evaluate the associations, adjusted for sex, age groups, education level, income per day, and smoking frequency. Results show that past quit attempts were associated with visiting a healthcare provider in the past year (adjusted odds ratio [AOR]: 1.74, 95% confidence intervals [CI]: 1.28-2.35), home smoking bans (AOR: 5.52, 95% CI: 2.13-14.33), noticing media-based messages informing the dangers of smoking or encouraging quitting (AOR: 3.25, 95% CI: 2.28-4.63), noticing health warnings on cigarette packages in the past 30 days (AOR: 3.33, 95% CI: 2.21-5.03), and believing that smoking is seriously harmful to their health (AOR: 3.45, 95% CI: 1.24-9.57). The Lao PDR government should continue implementing tobacco control policies that demonstrated associations with cessation attempts or intention to quit, such as smoke-free environments and required health warnings on cigarette packages. Tobacco cessation treatment programs are pressingly needed in Lao PDR.

Quitting the quitline: a qualitative study of patient experience of electronic referrals to quitlines

BACKGROUND

The use of electronic referrals (eReferrals) to state quitlines (QLs) for tobacco-using patients is a promising approach for addressing smoking cessation on a large scale. However, QL contact, enrollment, and completion rates are low. The purpose of this study was to examine the eReferral to QL process from the patient's perspective in order to inform strategies for improving QL engagement.

METHODS

We conducted interviews with 55 patients who agreed to an eReferral at a primary care visit to 1 of 8 safety-net community health centers in Cuyahoga County, Ohio (September 2017-August 2018). Interviews were designed to explore the experiences of three subgroups of patients who subsequently: 1) declined participation in the QL; 2) were unreachable by the QL; or 3) were enrolled in or had completed the QL program. Analysis was guided by a phenomenological approach designed to identify emergent themes.

RESULTS

Reasons for QL program non-completion included changing life circumstances and events making cessation unviable; misunderstandings about the QL; discomfort with telephonic counseling; perceived lack of time for counseling; cell phone barriers; and having already quit smoking. We found that some individuals who were no longer engaged with the QL still desired continued support from the QL.

CONCLUSIONS

Participants intentionally and unintentionally disengage from the QL for a wide variety of reasons, several of which are mediated by low socioeconomic status. Integrating QL care with community-based resources that address these mediators could be a promising strategy.

Variation in Patient Smoking Cessation Rates Among Health-Care Providers: An Observational Study

BACKGROUND

Physicians play a crucial role in providing smoking cessation counseling and medications. However, it is unknown whether individual physicians' approaches affect whether patients quit.

RESEARCH QUESTION

This study assessed patient quit rates within a national quality-improvement learning collaborative to document variation in quit rates at the physician, practice, and health system levels.

STUDY DESIGN AND METHODS

A retrospective cohort study was conducted of primary care patients identified from the Optum analytics database containing longitudinal ambulatory data for patients from 22 health-care organizations between January 2012 and December 2018. The study included smokers aged ≥ 18 years who attended at least three ambulatory visits, with two visits at least 1 year apart. The primary study outcome was abstinence for ≥ 1 year. A mixed effects logistic regression model was used to predict the probability of quitting as a function of patient variables. Quit rates were then adjusted by patient factors and calculated at the level of clinician, clinic/practice, and health system.

RESULTS

Across all systems, 56% of patients had a documented smoking status in 2017. Among nearly 1 million smokers, 24% quit smoking. In the regression model, patient characteristics associated with quitting included older age, Hispanic ethnicity, being married, urban residence, commercial insurance, pregnancy, and a diagnosis of pneumonia, myocardial infarction, ischemic heart disease, cataract, or asthma. Medicaid insurance, low income, high BMI, peripheral vascular disease, alcohol-related diagnosis, and COPD were negatively associated with smoking cessation. Adjusted quit rates ranged from 14.3% to 34.5% across 20 health systems, 5% to 66% among 1,399 practice sites, and 4% to 87% among 3,803 health-care providers. Of smokers, 10.2% were prescribed smoking deterrents, and 3.9% were referred for counseling.

INTERPRETATION

Smoking cessation rates varied substantially at the practitioner, practice site, and health system levels. It is likely that individual physician approaches to smoking cessation influence patients' likelihood of quitting.

Tobacco Dependence Treatment in Oncology: Initial Patient Clinical Characteristics and Outcomes from Roswell Park Comprehensive Cancer Center

Despite the importance of smoking cessation to cancer care treatment, historically, few cancer centers have provided treatment for tobacco dependence. To address this gap, the National Cancer Institute (NCI) launched the Cancer Center Cessation Initiative (C3i). As part of this effort, this study examined implementation outcomes in a cohort of cancer survivors (CSs) who smoked cigarettes in the first year of an ongoing process to develop and implement a robust Tobacco Treatment Service at Roswell Park Comprehensive Cancer Center. We provide a comprehensive description of the new tobacco use assessment and referral process, and of the characteristics of cancer survivors who agreed to treatment including traditional tobacco-related psychosocial and cancer treatment-related characteristics and novel characteristics such as delay discounting rates. We also examine characteristic differences among those who agreed to treatment between those who attended and those who did not attend treatment. As the new tobacco assessment was implemented, the number of referrals increased dramatically. The mean number of treatment sessions attended was 4.45 (SD = 2.98) and the six-month point prevalence intention to treat abstinence rate among those who attended was 22.7%. However, only 6.4% agreed to treatment and 4% attended at least one treatment session. A large proportion of cancer survivors who agreed to treatment were women, of older age, of lower socioeconomic status (SES), and who had high levels of depressive symptomology. The findings demonstrate that the implementation of system changes can significantly improve the identification of cancer survivors who use tobacco and are referred to tobacco use treatment. Among those who attend, treatment is effective. However, the findings also suggest that a systematic assessment of barriers to engagement is needed and that cancer survivors may benefit from additional treatment tailoring. We present plans to address these implementation challenges. Systematic electronic medical record (EMR)-sourced referral to tobacco treatment is a powerful tool for reaching cancer survivors who smoke, but more research is needed to determine how to enhance engagement and tailor treatment processes.

QuitSMART Utah: an implementation study protocol for a cluster-randomized, multi-level Sequential Multiple Assignment Randomized Trial to increase Reach and Impact of tobacco cessation treatment in Community Health Centers

BACKGROUND

Tobacco use remains the leading cause of death and disability in the USA and is disproportionately concentrated among low socioeconomic status (SES) populations. Community Health Centers (CHCs) are a key venue for reaching low SES populations with evidence-based tobacco cessation treatment such as Quitlines. Electronic health record (EHR)-based interventions at the point-of-care, text messaging (TM), and phone counseling have the potential to increase Quitline reach and are feasible to implement within CHCs. However, there is a lack of data to inform how, when, and in what combination these strategies should be implemented. The aims of this cluster-randomized trial are to evaluate multi-level implementation strategies to increase the Reach (i.e., proportion of tobacco-using patients who enroll in the Quitline) and Impact (i.e., Reach × Efficacy [efficacy is defined as the proportion of tobacco-using patients who enroll in Quitline treatment that successfully quit]) and to evaluate characteristics of healthcare system, providers, and patients that may influence tobacco-use outcomes.

METHODS

This study is a multilevel, three-phase, Sequential Multiple Assignment Randomized Trial (SMART), conducted in CHCs (N = 33 clinics; N = 6000 patients). In the first phase, clinics will be randomized to two different EHR conditions. The second and third phases are patient-level randomizations based on prior treatment response. Patients who enroll in the Quitline receive no further interventions. In phase two, patients who are non-responders (i.e., patients who do not enroll in Quitline) will be randomized to receive either TM or continued-EHR. In phase three, patients in the TM condition who are non-responders will be randomized to receive either continued-TM or TM + phone coaching.

DISCUSSION

This project will evaluate scalable, multi-level interventions to directly address strategic national priorities for reducing tobacco use and related disparities by increasing the Reach and Impact of evidence-based tobacco cessation interventions in low SES populations.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov (NCT03900767) on April 4th, 2019.

Cost-effectiveness of population-level proactive tobacco cessation outreach among socio-economically disadvantaged smokers: evaluation of a randomized control trial

AIMS

To estimate the cost-effectiveness at population-level of the OPT-IN proactive tobacco cessation outreach program for adult smokers enrolled in publicly funded health insurance plans for low-income persons (e.g. Medicaid).

DESIGN

Cost-effectiveness analysis using a state transition model based on data from the Offering Proactive Treatment Intervention (OPT-IN) randomized control trial.

SETTING

The trial was conducted in Minnesota, USA, and the economic analysis was conducted from the Medicaid program perspective.

PARTICIPANTS

Data were used from 2406 smokers who were randomized into the intervention or comparator groups.

INTERVENTION AND COMPARATOR

The intervention was comprised of proactive outreach (mailed invitation and telephone calls) and free cessation treatment (nicotine replacement therapy and intensive telephone counseling). The comparator was usual care, which comprised access to a primary care physician, insurance coverage of Food and Drug Administration (FDA)-approved smoking cessation medications and the state's telephone quitline.

MEASUREMENTS

Smoking status, quality of life and health-care use at varying times, including at baseline and 1 year.

FINDINGS

The OPT-IN program cost an average of $84 per participant greater than the comparator. One year after randomization, the population-level, 6-month prolonged smoking abstinence rate was 16.5% in the proactive outreach intervention group and 12.1% in the usual care group (P < 0.05). The model projected that the proactive outreach intervention added $78 in life-time cost and generated 0.005 additional quality-adjusted life-years (QALYs), with an expected incremental cost-effectiveness ratio of $4231 per QALY. Probabilistic sensitivity analysis found that the proactive outreach intervention would be cost-effective against a willingness-to-pay threshold of $50 000/QALY approximately 68% of the time.

CONCLUSIONS

Population-level proactive tobacco treatment with personal telephone outreach was effective in achieving higher population-level quit rates and was cost-effective at various willingness-to-pay thresholds, compared with usual care (i.e. reactive treatment). Taken together with prior research, population-level proactive tobacco cessation outreach programs are judged to be highly cost-effective over the long term.

Evaluation of a Dedicated Tobacco Cessation Support Service for Thoracic Cancer Center Patients

CONTEXT

Cancer patients' continued tobacco use results in poorer therapeutic outcomes including decreased quality of life and survival.

OBJECTIVE

To assess reach and impact of a free, opt-out, telephone-based tobacco cessation program for thoracic cancer center patients.

DESIGN

Observational study.

SETTING

Comprehensive Cancer Center in Western New York.

PARTICIPANTS

Current or recent (within past 30 days) tobacco-using thoracic cancer center patients referred to a tobacco cessation support service between October 2010 and October 2012 at a Comprehensive Cancer Center (n = 942/1313 referrals were eligible for cessation support).

INTERVENTION

A free, opt-out, telephone-based cessation service that was implemented as standard of care. Cessation specialists had patient-guided conversations that assessed readiness to quit; methods used in the past provided cessation strategies and worked to set up a quit date. There was an average of 35.9 days between referral and first contact.

MAIN OUTCOME MEASURES

Program reach (referral and participation rates) and impact (as self-reported cessation outcomes measured twice after referral).

RESULTS

Of 942 patients, 730 (77.5%) referred to and called by a tobacco cessation service participated in at least 1 cessation support call, of which 440 of 730 (60.3%) were called for follow-up and 89.5% (394/440) participated. In total, 20.2% (69/342) of current smokers at referral reported at least 7-day abstinence at follow-up. Among current smokers at referral and first contact, being married (odds ratio [OR] = 2.05; 95% confidence interval [CI], 1.01-4.18) and having a lower Eastern Cooperative Oncology Group (ECOG) performance score (OR = 4.05; 95% CI, 1.58-10.39) were associated with quitting at follow-up, after controlling for demographic, clinical, and health behavior characteristics.

CONCLUSIONS

Our results demonstrate that 78% of thoracic cancer center patients, if contacted, participated at least once in this cessation support service; for current smokers at referral and first contact, being married and having a lower ECOG performance score were associated with self-reported quitting at follow-up. Other organizations may find our results useful while implementing a systematic way to identify tobacco-using patients as part of routine care and to improve available cessation support services.

Current advances in research in treatment and recovery: Nicotine addiction

The health harms of combusted tobacco use are undeniable. With market and regulatory pressures to reduce the harms of nicotine delivery by combustion, the tobacco product landscape has diversified to include smokeless, heated, and electronic nicotine vaping products. Products of tobacco combustion are the main cause of smoking-induced disease, and nicotine addiction sustains tobacco use. An understanding of the biology and clinical features of nicotine addiction and the conditioning of behavior that occurs via stimuli paired with frequent nicotine dosing, as with a smoked cigarette, is important for informing pharmacologic and behavioral treatment targets. We review current advances in research on nicotine addiction treatment and recovery, with a focus on conventional combustible cigarette use. Our review covers evidence-based methods to treat smoking in adults and policy approaches to prevent nicotine product initiation in youth. In closing, we discuss emerging areas of evidence and consider new directions for advancing the field.

Health System Implementation of a Tobacco Quitline eReferral

BACKGROUND

Proactive referrals through electronic orders (eReferrals) can increase patient connection with tobacco quitlines. More information is needed on "real-world" implementation of electronic health record tools to promote tobacco cessation while minimizing provider burden.

OBJECTIVES

This paper examines the health system implementation of an eReferral to a tobacco quitline without best practice alerts in primary care, specialty, and hospital settings in an academic health system.

METHODS

This is a prospective implementation study of a health system tobacco eReferral to a state quitline that was completed with an approach to minimize provider cognitive burden. Data are drawn from electronic health record data at University of California, Davis Health Systems (March 2013-February 2016).

RESULTS

Over 3 years, 16,083 encounters with smokers resulted in 1,137 eReferral orders (7.1%). Treatment reach was 1.6% for quitline services and 2.3% for outpatient group classes. While the group classes were offered to outpatient smokers, the eReferral order was included in an outpatient order set and eventually an automated inpatient discharge order set; no provider alerts were implemented. Referrals were sustained and doubled after inpatient order set implementation. Among all first time eReferral patients, 12.2% had a 6 to 12 month follow-up visit at which they were documented as nonsmoking.

CONCLUSION

This study demonstrates a quitline eReferral order can be successfully implemented and sustained with minimal promotion, without provider alerts and in conjunction with group classes. Reach and effectiveness were similar to previously described literature.

Parent eReferral to Tobacco Quitline: A Pragmatic Randomized Trial in Pediatric Primary Care

INTRODUCTION

Quitlines are effective in helping smokers quit, but pediatrician quitline referral rates are low, and few parents who smoke use the service. This study compared enrollment of parents who smoke in the quitline using electronic referral with that using manual referral.

STUDY DESIGN

The study was designed as a pragmatic RCT.

SETTING/PARTICIPANTS

Participants were recruited from one large, urban pediatric primary care site in Philadelphia, Pennsylvania with a high percentage of low-income families. Participants included adult parents who smoked and were present at their child's healthcare visit.

INTERVENTION

Pediatricians screened for tobacco use; smokers were given brief advice to quit and, if interested in quitting, were referred to the quitline. The eReferral ("warm handoff") involved electronically sending parent information to the quitline (parent received a call within 24-48 hours). Control group procedures were identical to eReferral, except the quitline number was provided to the parent. Data were collected between March 2017 and February 2018 and analyzed in 2018.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of parents enrolled in quitline treatment. Secondary outcomes included parent factors (e.g., demographics, nicotine dependence, and quitting motivation) associated with successful enrollment. Number of quitline contacts was also explored.

RESULTS

During the study period, in the eReferral group, 10.3% (24 of 233) of parents who smoked and were interested in quitting enrolled in the quitline, whereas only 2.0% (5 of 251) of them in the control group enrolled in the quitline-a difference of 8.3% (95% CI=4.0, 12.6). Parents aged ≥50 years enrolled in the quitline more frequently. Although more parents in the eReferral group connected to the quitline, among parents who had at least one quitline contact, there was no significant difference in the mean number of quitline contacts between eReferral and control groups (mean, 2.04 vs 2.40 calls; difference, 0.36 [95% CI=0.35, 1.06]).

CONCLUSIONS

Smoking parent eReferral from pediatric primary care may increase quitline enrollment and could be adopted by practices interested in increasing rates of parent treatment.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02997735.

Quitline treatment dose predicts cessation outcomes among safety net patients linked with treatment via Ask-Advise-Connect

The efficacy of tobacco treatment delivered by state quitlines in diverse populations is well-supported, yet little is known about associations between treatment dose and cessation outcomes following the implementation of Ask-Advise-Connect (AAC), an electronic health record-based systematic referral process that generates a high volume of proactive calls from the state quitline to smokers. The current study is a secondary analysis of a 34-month implementation trial evaluating ACC in 13 safety-net clinics in Houston, TX. Treatment was delivered by a quitline and comprised up to five proactive, telephone-delivered multi-component cognitive-behavioral treatment sessions. Associations between treatment dose and abstinence were examined. Abstinence was assessed by phone six months after treatment enrollment, and biochemically confirmed via mailed saliva cotinine. Among smokers who enrolled in treatment and agreed to follow-up (n = 3704), 29.2% completed no treatment sessions, 35.5% completed one session, 16.4% completed two sessions, and 19.0% completed ≥three sessions. Those who completed one (vs. no) sessions were no more likely to report abstinence (OR: 0.98). Those who completed two (vs. no) sessions were nearly twice as likely to report abstinence (OR: 1.83). Those who completed ≥three (vs. no) sessions were nearly four times as likely to report abstinence (OR: 3.70). Biochemically-confirmed cessation outcomes were similar. Most smokers received minimal or no treatment, and treatment dose had a large impact on abstinence. Results highlight the importance of improving engagement in evidence-based treatment protocols following enrollment. Given that motivation to quit fluctuates, systematically offering enrollment to all smokers at all visits is important.

•

The majority of smokers received minimal or no evidence-based tobacco treatment.

•

Smokers who completed 0 or 1 treatment sessions were unlikely to achieve abstinence.

•

Completion of 2 calls doubled the likelihood of abstinence at 6 months.

•

Completion of ≥3 calls was associated with a near quadrupling of abstinence rates.

•

Improving engagement in evidence-based treatment protocols is a research priority.

Identifying Differences in Rates of Invitation to Participate in Tobacco Treatment in Primary Care

INTRODUCTION

The progress achieved in reducing tobacco use has not been consistent across groups of smokers, and health systems are inconsistently implementing best practice guidelines. Guideline implementation could be associated with improved treatment invitation rates.

AIMS

To evaluate differences in tobacco treatment invitation rates based on patient characteristics in primary care clinics implementing best practice guidelines.

METHODS

A secondary analysis of patients presenting to 11 primary care clinics from 2 Wisconsin health systems from June 2010 to February 2013. The main outcome was whether patients received an invitation to participate in tobacco treatment. Invitation rates were examined by sex, age group (≤ 24 years, 25-44, 45-64, ≥ 64), race (white, black, other), insurance status (private, Medicare, Medicaid, none), and visit diagnosis ("high-risk" [cardiovascular and pulmonary disease, malignancy, pregnancy] vs "low-risk" [all other ICD-9 categories]). Moderation effects of health systems also were examined.

RESULTS

Of the 95,471 patients seen, 84,668 (89%) were screened for smoking. Among the 15,193 smokers, 10,242 (67%) were invited to participate. Invited patients were older, white or black, and carried low-risk diagnoses. Invitation rates and patient-level differences varied between the health systems.

CONCLUSIONS

Variable treatment invitation rates and health system differences remain evident in the primary care setting employing robust clinical practice guideline recommendations.

Patient Cessation Activity after Automatic Referral to a Dedicated Cessation Support Service

Introduction

We characterized tobacco use, cessation patterns, and patient satisfaction with a cessation support program at an NCI Designated Comprehensive Cancer Center following a mandatory tobacco assessment and automatic referral.

Methods

A 3-month follow-up survey (via web, paper, or telephone) was administered between March 2013 and November 2013 for all patients referred to and contacted by a cessation support service, and who consented to participation three months prior to administration. Patients were asked about their perceived importance and self-efficacy to quit smoking, quit attempts, and satisfaction with the cessation service.

Results

Fifty-two percent (257/499) of patients who participated in the cessation support service, and consented to be contacted again, completed a follow-up survey. Of those who participated, 9.7% were referred to the service as having recently quit tobacco (in the past 30 days) and 23.6% reported having quit at the time of first contact. At the 3-month follow-up, 48.1% reported being smoke-free for the previous seven days. When patients were asked about their experience with the cessation service, 86.4% reported being very or mostly satisfied with the service, and 64.3% reported that their experience with the service increased their satisfaction with the care received at the cancer centre.

Conclusions

Our findings suggest that recently diagnosed cancer patients are aware that quitting tobacco is important, are making attempts to quit, and are amenable to an opt-out automatic referral cessation support service as part of their cancer care.

The effects of framed messages for engaging adolescents with online smoking prevention interventions

Messages emphasizing the harms of smoking (loss-framed) or the benefits of not smoking (gain-framed) may be effective for engaging adolescents with tobacco prevention resources. This novel approach could help to close a gap in tobacco prevention intervention delivery in the pediatric primary care setting. To examine the effects of framed messages for engaging adolescents with an evidence-based smoking prevention website, adolescents ages 12 to 17 presenting for primary care well-visits were recruited for a three-arm experiment. Participants completed baseline measures including demographics, smoking behavior, and smoking susceptibility and were randomized to view 1 of 3 messages introducing an evidence-based smoking prevention website: (1) gain-framed communicating the benefits of avoiding smoking, (2) loss-framed communicating the harms of smoking, or (3) neutral. Self-reported website engagement was assessed at 1-month follow-up. Participants (279) (87% of those enrolled) completed a follow-up (M age 14.9 years, 66% female, 32% non-white race, 47% non-susceptible never smokers, 53% susceptible never smokers/ever smokers). Overall, 26% of participants reported website engagement. After adjusting for baseline intentions to visit the website, engagement was significantly greater in response to the loss-framed message than the gain-framed (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.51, 6.15) and neutral (OR 2.31, 95% CI 1.15, 4.63) messages. The message framing effects did not differ by baseline smoking risk. Loss-framed messages emphasizing the harms of smoking may be effective for engaging adolescents with smoking prevention resources.

Evaluation of a population-level strategy to promote tobacco treatment use among insured smokers: a pragmatic, randomized trial

Background

Most smokers do not use evidence-based smoking cessation treatment. Increasing utilization of these services is an important public health goal. Health care systems and insurers are well positioned to support this goal within their patient populations. We tested whether a brief, mail-based intervention increased utilization of tobacco cessation services among insured smokers.

Methods

Adult smokers were identified via automated health plan data and randomized to one of five treatment arms (n = 4767). Randomization was stratified by gender, age, and type of health plan coverage. Three arms received a letter containing motivational content and treatment referral information. Motivational content emphasized either the financial, health, or values-based benefits of quitting. One arm received a referral letter with no motivational content, and one arm received no letter. Enrollment in the referred tobacco cessation program was monitored for 5 months. Treatment was available to all participants through their insurance.

Results

Across all four letter conditions, 0.8% of participants enrolled in tobacco treatment compared to 0.9% in the no letter reference group (p = .69). No single letter condition was superior to the others (p = .71), but treatment uptake was greater among participants who received their care and coverage from the health plan versus those with insurance coverage only (1.2% vs. 0.3%, p < .01).

Conclusions

A one-time, mailed letter is not a cost-effective strategy for promoting use of covered smoking cessation treatment within large health plan populations, particularly when the message source is an insurance provider only and does not also provide clinical care. Health plans and insurers should consider alternative outreach efforts to promote treatment uptake among smokers.

Trial registrations

TRN registered retrospectively with ISRCTN registry (www.isrctn.com). Registered on 11/01/2018. Registration number: ISRCTN32311137.

Outcomes for a Public Hospital Tobacco Cessation Program: The Cook County Health and Hospitals System Experience

The objective of this study is to determine the rate and predictors of sustained smoking cessation for a cohort of smokers exposed to a guideline-based health education program delivered during routine clinical care at an urban public hospital. This is a retrospective analysis of 755 public hospital system patients who had at least two health educator contacts embedded in routine clinical care, with the latter contact 12-18 months after the baseline. The education occurred during visits to primary care, specialty clinics, urgent/episodic care, or during hospitalization. The assessment of smoking status is determined by the health educators as part of their routine assessment and recorded in the program's database. The primary outcomes are self-reported 12-month sustained smoking cessation at the 12-18 month contact and predictors of cessation. The cohort is predominantly minority smokers (African American 69 % and Latino 15 %) and uninsured (70 %) or on Medicaid (13 %). The sustained cessation rate was 9.3 %. Latino ethnicity, smoking 1-9 cigarettes/day at baseline, reporting smoke-free home, and additional educator contact in the year after the baseline were independent predictors of sustained cessation in the multivariate analysis. Smokers with multiple risks for poor cessation outcomes exposed to a guideline-based program of health education during routine healthcare encounters had sustained smoking cessation rates that compare favorably with published National Health Interview Study population cessation rates. An additional educator contact after the baseline was a predictor of cessation. The findings support development of cessation programs in which health educators are integrated into clinical care settings.

Quit Outcomes and Program Utilization by Mode of Entry Among Clients Enrolling in a Quitline

PURPOSE

To investigate how mode of entry into a quitline influences program utilization and quit outcomes among clients seeking cessation services.

DESIGN

This is a retrospective analysis of clients receiving quitline services from January 2011 to June 2016.

SETTING

The study was conducted at the Arizona Smokers' Helpline.

PARTICIPANTS

Enrolled clients completed a 7-month follow-up (N = 18 650).

MEASURES

The independent variable was referral mode of entry (ie, proactive, passive, and self-referral). Outcome variables included tobacco cessation medication use, number of coaching sessions completed, and 30-day tobacco abstinence at 7 months.

ANALYSIS

Logistic regression was used to analyze tobacco abstinence after controlling for potential confounders.

RESULTS

Compared to self-referred clients, proactively referred clients were least likely (odds ratio [OR]: 0.88; 95% confidence interval [CI]: 0.81-0.97), whereas passively referred clients were most likely (OR: 1.14; 95% CI: 1.00-1.30) to report tobacco abstinence. Proactively referred (OR: 0.79; 95% CI: 0.70-0.88), but not passively referred, clients were 21% less likely to report tobacco cessation medication use than self-referred clients.

CONCLUSION

Proactive referrals are associated with lower utilization of tobacco cessation medication and less successful quit outcomes; however, provider referrals are critical to reaching tobacco users who may have more significant health risks and barriers to quitting. Examining potential barriers among both providers and provider-referred clients is needed to inform improvements in training providers on brief interventions for tobacco cessation.

Weight management and physical activity throughout the cancer care continuum

Mounting evidence suggests that weight management and physical activity (PA) improve overall health and well being, and reduce the risk of morbidity and mortality among cancer survivors. Although many opportunities exist to include weight management and PA in routine cancer care, several barriers remain. This review summarizes key topics addressed in a recent National Academies of Science, Engineering, and Medicine workshop entitled, "Incorporating Weight Management and Physical Activity Throughout the Cancer Care Continuum." Discussions related to body weight and PA among cancer survivors included: 1) current knowledge and gaps related to health outcomes; 2) effective intervention approaches; 3) addressing the needs of diverse populations of cancer survivors; 4) opportunities and challenges of workforce, care coordination, and technologies for program implementation; 5) models of care; and 6) program coverage. While more discoveries are still needed for the provision of optimal weight-management and PA programs for cancer survivors, obesity and inactivity currently jeopardize their overall health and quality of life. Actionable future directions are presented for research; practice and policy changes required to assure the availability of effective, affordable, and feasible weight management; and PA services for all cancer survivors as a part of their routine cancer care. CA Cancer J Clin 2018;68:64-89. © 2017 American Cancer Society.

An integrated digital/clinical approach to smoking cessation in lung cancer screening: study protocol for a randomized controlled trial

Background

Delivering effective tobacco dependence treatment that is feasible within lung cancer screening (LCS) programs is crucial for realizing the health benefits and cost savings of screening. Large-scale trials and systematic reviews have demonstrated that digital cessation interventions (i.e. web-based and text message) are effective, sustainable over the long-term, scalable, and cost-efficient. Use of digital technologies is commonplace among older adults, making this a feasible approach within LCS programs. Use of cessation treatment has been improved with models that proactively connect smokers to treatment rather than passive referrals. Proactive referral to cessation treatment has been advanced through healthcare systems changes such as modifying the electronic health record to automatically link smokers to treatment.

Methods

This study evaluates the impact of a proactive enrollment strategy that links LCS-eligible smokers with an evidence-based intervention comprised of a web-based (WEB) program and integrated text messaging (TXT) in a three-arm randomized trial with repeated measures at one, three, six, and 12 months post randomization. The primary outcome is biochemically confirmed abstinence at 12 months post randomization. We will randomize 1650 smokers who present for a clinical LCS to: (1) a usual care control condition (UC) which consists of Ask–Advise–Refer; (2) a digital (WEB + TXT) cessation intervention; or (3) a digital cessation intervention combined with tobacco treatment specialist (TTS) counseling (WEB + TXT + TTS).

Discussion

The scalability and sustainability of a digital intervention may represent the most cost-effective and feasible approach for LCS programs to proactively engage large numbers of smokers in effective cessation treatment. We will also evaluate the impact and cost-effectiveness of adding proven clinical intervention provided by a TTS. We expect that a combined digital/clinical intervention will yield higher quit rates than digital alone, but that it may not be as cost-effective or feasible for LCS programs to implement. This study is innovative in its use of interoperable, digital technologies to deliver a sustainable, scalable, high-impact cessation intervention and to facilitate its integration within clinical practice. It will add to the growing knowledge base about the overall effectiveness of digital interventions and their role in the healthcare delivery system.

Trial registration

ClinicalTrials.gov, NCT03084835. Registered on 9 March 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2312-x) contains supplementary material, which is available to authorized users.