Proposing a Model of Proactive Outreach to Advance Clinical Research and Care Delivery for Patients Who Use Tobacco (original) (raw)
Proactive Tobacco Treatment and Population-Level Cessation
JAMA Internal Medicine, 2014
IMPORTANCE Current tobacco use treatment approaches require smokers to request treatment or depend on the provider to initiate smoking cessation care and are therefore reactive. Most smokers do not receive evidence-based treatments for tobacco use that include both behavioral counseling and pharmacotherapy. OBJECTIVE To assess the effect of a proactive, population-based tobacco cessation care model on use of evidence-based tobacco cessation treatments and on population-level smoking cessation rates (ie, abstinence among all smokers including those who use and do not use treatment) compared with usual care among a diverse population of current smokers. DESIGN, SETTING, AND PARTICIPANTS The Veterans Victory Over Tobacco Study, a pragmatic randomized clinical trial involving a population-based registry of current smokers aged 18 to 80 years. A total of 6400 current smokers, identified using the Department of Veterans Affairs (VA) electronic medical record, were randomized prior to contact to evaluate both the reach and effectiveness of the proactive care intervention. INTERVENTIONS Current smokers were randomized to usual care or proactive care. Proactive care combined (1) proactive outreach and (2) offer of choice of smoking cessation services (telephone or in-person). Proactive outreach included mailed invitations followed by telephone outreach to motivate smokers to seek treatment with choice of services. MAIN OUTCOMES AND MEASURES The primary outcome was 6-month prolonged smoking abstinence at 1 year and was assessed by a follow-up survey among all current smokers regardless of interest in quitting or treatment utilization. RESULTS A total of 5123 participants were included in the primary analysis. The follow-up survey response rate was 66%. The population-level, 6-month prolonged smoking abstinence rate at 1 year was 13.5% for proactive care compared with 10.9% for usual care (P = .02). Logistic regression mixed model analysis showed a significant effect of the proactive care intervention on 6-month prolonged abstinence (odds ratio [OR], 1.27 [95% CI, 1.03-1.57]). In analyses accounting for nonresponse using likelihood-based not-missing-atrandom models, the effect of proactive care on 6-month prolonged abstinence persisted (OR, 1.33 [95% CI, 1.17-1.51]). CONCLUSIONS AND RELEVANCE Proactive, population-based tobacco cessation care using proactive outreach to connect smokers to evidence-based telephone or in-person smoking cessation services is effective for increasing long-term population-level cessation rates. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00608426
Proactive Tobacco Cessation Outreach to Smokers of Low Socioeconomic Status
JAMA Internal Medicine, 2014
IMPORTANCE Widening socioeconomic disparities in mortality in the United States are largely explained by slower declines in tobacco use among smokers of low socioeconomic status (SES) than among those of higher SES, which points to the need for targeted tobacco cessation interventions. Documentation of smoking status in electronic health records (EHRs) provides the tools for health systems to proactively offer tobacco treatment to socioeconomically disadvantaged smokers. OBJECTIVE To evaluate a proactive tobacco cessation strategy that addresses sociocontextual mediators of tobacco use for low-SES smokers. DESIGN, SETTING, AND PARTICIPANTS This prospective, randomized clinical trial included low-SES adult smokers who described their race and/or ethnicity as black, Hispanic, or white and received primary care at 1 of 13 practices in the greater Boston area (intervention group, n = 399; control group, n = 308). INTERVENTIONS We analyzed EHRs to identify potentially eligible participants and then used interactive voice response (IVR) techniques to reach out to them. Consenting patients were randomized to either receive usual care from their own health care team or enter an intervention program that included (1) telephone-based motivational counseling, (2) free nicotine replacement therapy (NRT) for 6 weeks, (3) access to community-based referrals to address sociocontextual mediators of tobacco use, and (4) integration of all these components into their normal health care through the EHR system. MAIN OUTCOMES AND MEASURES Self-reported past-7-day tobacco abstinence 9 months after randomization ("quitting"), assessed by automated caller or blinded study staff. RESULTS The intervention group had a higher quit rate than the usual care group (17.8% vs 8.1%; odds ratio, 2.5; 95% CI, 1.5-4.0; number needed to treat, 10). We examined whether use of intervention components was associated with quitting among individuals in the intervention group: individuals who participated in the telephone counseling were more likely to quit than those who did not (21.2% vs 10.4%; P < .001). There was no difference in quitting by use of NRT. Quitting did not differ by a request for a community referral, but individuals who used their referral were more likely to quit than those who did not (43.6% vs 15.3%; P < .001).
Population-based tobacco treatment: study design of a randomized controlled trial
BMC Public Health, 2012
Background: Most smokers do not receive comprehensive, evidence-based treatment for tobacco use that includes intensive behavioral counseling along with pharmacotherapy. Further, the use of proven, tobacco treatments is lower among minorities than among Whites. The primary objectives of this study are to: (1) Assess the effect of a proactive care intervention (PRO) on population-level smoking abstinence rates (i.e., abstinence among all smokers including those who use and do not utilize treatment) and on utilization of tobacco treatment compared to reactive/usual care (UC) among a diverse population of smokers, (2) Compare the effect of PRO on population-level smoking abstinence rates and utilization of tobacco treatments between African American and White smokers, and (3) Determine the cost-effectiveness of the proactive care intervention. Methods/Design: This prospective randomized controlled trial identifies a population-based sample of current smokers from the Department of Veterans Affairs (VA) electronic medical record health factor dataset. The proactive care intervention combines: (1) proactive outreach and (2) offer of choice of smoking cessation services (telephone or face-to-face). Proactive outreach includes mailed invitation materials followed by an outreach call that encourages smokers to seek treatment with choice of services. Proactive care participants who choose telephone care receive VA telephone counseling and access to pharmacotherapy. Proactive care participants who choose face-to-face care are referred to their VA facility's smoking cessation clinic. Usual care participants have access to standard smoking cessation services from their VA facility (e.g., pharmacotherapy, smoking cessation clinic) and from their state telephone quitline. Baseline data is collected from VA administrative databases and participant surveys. Outcomes from both groups are collected 12 months post-randomization from participant surveys and from VA administrative databases. The primary outcome is self-reported smoking abstinence, which is assessed at the population-level (i.e., among those who utilize and those who do not utilize tobacco treatment). Primary analyses will follow intention-to-treat methodology. Discussion: This randomized trial is testing proactive outreach strategies offering choice of smoking cessation services, an innovation that if proven effective and cost-effective, will transform the way tobacco treatment is delivered. National dissemination of proactive treatment strategies could dramatically reduce tobacco-related morbidity, mortality, and health care costs. Clinical trials registration: ClinicalTrials.gov: NCT00608426.
Offering Population-Based Tobacco Treatment in a Healthcare Setting
American Journal of Preventive Medicine, 2011
Background-The healthcare system is a key channel for delivering treatment to tobacco users. Brief clinic-based interventions are effective but not reliably offered. Population management strategies might improve tobacco treatment delivery in a healthcare system.
Thorax, 2016
Evidenced-based tobacco cessation treatments are underused, especially by socioeconomically disadvantaged smokers. This contributes to widening socioeconomic disparities in tobacco-related morbidity and mortality. The Offering Proactive Treatment Intervention trial tested the effects of a proactive outreach tobacco treatment intervention on population-level smoking abstinence and tobacco treatment use among a population-based sample of socioeconomically disadvantaged smokers. Current smokers (n=2406), regardless of interest in quitting, who were enrolled in the Minnesota Health Care Programs, the state's publicly funded healthcare programmes for low-income populations, were randomly assigned to proactive outreach or usual care. The intervention comprised proactive outreach (tailored mailings and telephone calls) and free cessation treatment (nicotine replacement therapy and intensive, telephone counselling). Usual care comprised access to a primary care physician, insurance cove...
Proactive tobacco treatment for low income smokers: study protocol of a randomized controlled trial
BMC Public Health, 2014
Background: There is a high prevalence of smoking and high burden of tobacco-related diseases among low-income populations. Effective, evidenced-based smoking cessation treatments are available, but low-income smokers are less likely than higher-income smokers to use these treatments, especially the most comprehensive forms that include a combination of pharmacotherapy and intensive behavioral counseling. Methods/Design: The primary objectives of this randomized controlled trial are to compare the effects of a proactive tobacco treatment intervention compared to usual care on population-level smoking abstinence rates and tobacco treatment utilization rates among a diverse population of low-income smokers, and to determine the cost-effectiveness of proactive tobacco treatment intervention. The proactive care intervention systematically offers low-income smokers free and easy access to evidence-based treatments and has two primary components:
Health System Changes to Facilitate the Delivery of Tobacco-Dependence Treatment
American Journal of Preventive Medicine, 2007
In 1996, the Agency for Health Care Policy and Research (AHCPR, now AHRQ, the Agency for Healthcare Research and Quality) released the first federal clinical practice guideline for smoking cessation that was updated in 2000 by the United States Public Health Service (USPHS). The innovative guideline identified six evidence-based strategies for healthcare systems to facilitate the institutionalization of tobacco dependence treatment so that smokers received evidence-based treatments as a routine part of health care.
Journal of Evaluation in Clinical Practice, 2018
Objectives: The high prevalence of tobacco use at primary care safety-net clinics represents an opportunity to offer assistance with cessation. Documentation of smoking status, offering advice and medications, and referral to cessation services are important steps in supporting cessation attempts and are required elements by payors and accrediting agencies to demonstrate care quality. This study examines tobacco cessation support rates and patient characteristics using electronic medical record (EMR) data. Methods: This cross-sectional study engaged eight community health centers affiliated with a county hospital system in NE Ohio where adult tobacco use rates exceed 30%. EMR data from June 2014 through May 2016 were analysed to assess rates of tobacco cessation counselling, order of cessation medications, or both. The association of tobacco cessation support with patient characteristics and quit attempts was assessed using multivariable logistic regression models. Results: Among 21 702 current tobacco users, 74% had no intervention documented; 15.4% had counselling documented, 6.4% were prescribed tobacco cessation medication, and 4.2% had both documented. Males, those aged 18 to 34, and African Americans were more likely to have no documented intervention. Of current tobacco users with at least two visits, 5.6% had a quit attempt. Medication alone was associated with a greater likelihood of a quit attempt (AOR: 1.72 [95% CI: 1.36-2.17]) as well as counselling and medication combined (AOR: 1.95 [95% CI: 1.48-2.56]). Conclusions: Tobacco cessation support was lacking for 74% of current smokers and was less likely in subgroups including males, younger adults, and African Americans. Ordering tobacco cessation medication combined with counselling nearly doubled the likelihood of a quit attempt.
Tobacco cessation interventions in health care settings: Rationale, model, outcomes
Addictive Behaviors, 1996
Health care settings provide opportunities to reach populations of tobacco users with personalized cessation assistance. We describe a model for doing so which emphasizes a team approach, minimizes the burden on clinicians, and uses brief counseling by allied professionals, videos, written materials, and telephone calls to augment clinician advice. The model has been implemented in several diverse settings including outpatient, inpatient, and dental clinic managed care: fee-for-service dentistry and pediatric practices; and planned parenthood clinics. Data from several randomized trials support the effectiveness of the approach. The brief, low-intensity interventions derived from the model appear to be sustainable on a routine basis in many settings.
Closing Tobacco-Related Disparities
American Journal of Preventive Medicine, 2010
Background: Individuals living in poverty are more likely to smoke, and they suffer disproportionately from tobacco use. Strategies used to deliver tobacco-cessation interventions often fail to reach smokers living in poverty. Providing tobacco interventions to smokers when they present to community organizations is a potential strategy, but the acceptability and effectiveness of such interventions is unknown.
A Safety Net Tobacco Use Cessation Resource: Quitline Service Usage, 2019
Preventing Chronic Disease, 2023
Introduction Quitlines are free, accessible evidence-based services that may provide an important resource for people facing barriers to clinical treatment for cessation of tobacco use. Methods Using 2019 intake data from the National Quitline Data Warehouse, we examined quitline service usage, stratified by sociodemographic characteristics. Only US quitlines reporting service type data were included (n = 40 [of 51]). Callers (aged ≥12 years) who registered with a quitline, reported current use of a tobacco product, and received at least 1 service comprised the analytic data. Chi-square tests examined differences in quitline services received by participant characteristics. Results In 2019, 182,544 people reporting current use of a tobacco product received at least 1 service from a quitline in 39 states and the District of Columbia. Among them, 80.4% had attained less than a college or university degree and 70.4% were uninsured or enrolled in Medicaid or in Medicare (aged <65 years). By educational attainment (aged ≥25 years), receipt of cessation medications ranged from 59.4% of callers with a college or university degree to 65.0% of callers with a high school diploma (P < .001). The range by insurance coverage was 59.3% of callers with private insurance to 74.7% of callers with Medicare (aged <65 years) (P < .001). Conclusion Quitlines served as a resource for low-SES populations in 2019, providing cessation services to many people who may face barriers to clinical cessation treatment. Strengthening and expanding quitlines may help to increase cessation among populations with a disproportionately high prevalence of tobacco product use and improve the health and well-being of people in the US.
Tobacco treatment and prevention: what works and why
Respiratory care, 2009
Tobacco abuse is one of the main reasons that chronic obstructive pulmonary disease is the fourth leading cause of death in the United States. Many people kick the habit easily, while others struggle through a difficult cycle of addiction. Respiratory therapists often have contact with patients with chronic lung disease who want to quit smoking but do not know where to begin. Smoking bans and clean air laws are in place across the United States, but this is not enough for a complete tobacco treatment and prevention program. For any successful disease-management program, tobacco-control education and support must be included. Studies show that when pharmacologic interventions are used along with the appropriate counseling and other resources, the success of tobacco cessation increases. This must be understood, because if the regulatory efforts of our governing bodies are not enough and if patients do not receive the care that is essential for disease management and rehabilitation, th...
Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, 2017
Disparities in receiving advice to quit smoking and other tobacco use from health professionals may contribute to the continuing gap in smoking prevalence among priority populations. Under the Affordable Care Act (ACA), beginning in 2010, tobacco cessation services are currently covered in private and public health insurance plans. Providers and hospitals are also incentivized through the Meaningful Use of Electronic Health Records (EHRs) to screen and document patients' tobacco use and deliver brief cessation counseling. This study analyzes trends and correlates of receiving health professionals' advice to quit and potential disparities among US adult smokers from 2010 to 2015. Data were from the National Health Interview Survey in 2010 and 2015. We analyzed the weighted prevalence of smokers' receipt of advice to quit smoking and other tobacco use from a health professional in 2010 and 2015 and correlates of receiving advice to quit. Prevalence of receiving advice to q...
Journal of Addiction Research & Therapy, 2015
abstinence once they begin smoking [7-15]. Standard evidence-based treatments for tobacco dependence attract lower SES smokers [16-20]; however, there are significant socioeconomic disparities in treatment retention and long-term treatment outcomes even when treatment adherence, clinical, environmental, and demographic factors are accounted for [17-24]. Estimates indicate that the highest SES smokers are at least twice as likely to achieve long-term abstinence as the lowest SES smokers after treatment regardless of treatment modality [18,20].
Tobacco use: prevention, cessation, and control
2006
OBJECTIVES The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) systematically reviewed the evidence on (a) the effectiveness of community- and population-based interventions to prevent tobacco use and to increase consumer demand for and implementation of effective cessation interventions; (b) the impacts of smokeless tobacco marketing on smoking, use of those products, and population harm; and (c) the directions for future research. DATA SOURCES We searched MEDLINE, Cumulative Index to Nursing and Applied Health (CINAHL), Cochrane libraries, Cochrane Clinical Trials Register, Psychological Abstracts, and Sociological Abstracts from January 1980 through June 10, 2005. We included English-language randomized controlled trials, other trials, and observational studies, with sample size and follow-up restrictions. We used 13 Cochrane Collaboration systematic reviews, 5 prior systematic reviews, and 2 meta-analyses as the foundati...
Under-use of smoking-cessation treatments
American Journal of Preventive Medicine, 2005
To describe the use of treatment for tobacco dependence in relation to insurance status and advice from a healthcare provider in a population-based national sample interviewed in 2000. Methods: Analyses are based on 3996 adult smokers who participated in the National Health Interview Survey in 2000, and who provided information on tobacco-cessation treatments used at their most recent quit attempt occurring in the last year. Age-adjusted and weighted categorical analysis was used to compute prevalence estimates of self-reported treatments (pharmacotherapy and behavioral counseling) for tobacco dependence. Multivariate logistic regression analyses were used to examine factors associated with use of treatments. Results: Overall, 22.4% of smokers who tried to quit in the previous year used one or more types of cessation aid compared to 15% in 1986. Treatment usually involved pharmacotherapy (21.7%) rather than behavioral counseling (1.3%). Smokers attempting to quit were more likely to use cessation aids if covered by private (25.4%) or military (25.0%) insurance than by Medicare (17.8%), Medicaid (15.5%), or no insurance (13.2%). In a multivariate analysis of factors related to use of cessation aids, advice from a healthcare provider to quit smoking and the number of cigarettes smoked per day were significant predictors of treatment use, regardless of insurance status. Conclusions: Cessation aids are under-used across insurance categories. Advice by a healthcare provider to quit is associated with increased use of effective therapies for tobacco dependence. Systematic efforts are needed to eliminate barriers to appropriate treatment.
Tobacco Induced Diseases, 2018
Tobacco Induced Diseases encompasses all aspects of research related to the prevention and control of tobacco use at a global level. Preventing diseases attributable to tobacco is only one aspect of the journal, whose overall scope is to provide a forum for the publication of research articles that can contribute to reducing the burden of tobacco induced diseases globally. To address this epidemic we believe that there must be an avenue for the publication of research/ policy activities on tobacco control initiatives that may be very important at a regional and national level. This approach provides a very important "hands on" service to the tobacco control community at a global scale -as common problems have common solutions. Hence, we see ourselves as "connectors" within this global community. The journal hence encourages the submission of articles from all medical, biological and psychosocial disciplines, ranging from medical and dental clinicians, through health professionals to basic biomedical and clinical scientists.