Research article
Promoting Primary Care Smoking-Cessation Support with Quitlines: The QuitLink Randomized Controlled Trial

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Background

Counseling by clinicians promotes smoking cessation, but in most U.S. primary care practices, it is difficult to provide more than brief advice to quit in the course of routine work. Telephone quitlines can deliver effective intensive counseling, but few collaborate closely with clinicians.

Purpose

This study aimed to determine whether cessation support in practices is enhanced by a systems approach, in partnership with quitlines.

Design

A cluster RCT was used.

Setting/participants

Participants included 1817 adult smokers from 16 primary care practices in the Virginia Ambulatory Care Outcomes Research Network.

Intervention

An expanded tobacco-use “vital sign” intervention (identify smokers, advise cessation, and assess readiness to quit) that was combined with fax referral of preparation-stage smokers to a quitline providing feedback to practices was compared to a traditional tobacco-use vital sign alone.

Main outcome measures

The frequency of cessation support (in-office discussion of methods to quit or quitline referral) reported by patients in an exit survey (September 2005–July 2006, analyzed in 2008) was measured.

Results

The adjusted percentage of smokers who reported receiving cessation support differed by 12.5% in intervention and control practices (40.7% vs 28.2%, respectively; p<0.001). Both in-office discussion of methods to quit and quitline referral increased significantly with the intervention. Post hoc analysis revealed that the increase in cessation was stable for both patient gender and visit type and was more pronounced with patients aged 35–54 years and with male and more experienced clinicians.

Conclusions

A systems approach to identifying smokers, advising and assessing readiness to quit, combined with a partnership with a quitline, increases delivery of cessation support for primary care patients beyond that accomplished by traditional tobacco-use vital sign screening alone.

Clinical trial registration

NCT00112268.

Introduction

Few interventions provide greater health benefit than smoking cessation. Tobacco use is the leading cause of death in the U.S.1 and is a major risk factor for a number of chronic diseases.2 Clinicians have long been viewed as important catalysts for promoting smoking cessation. At least 70% of smokers see a physician each year,3 and smokers cite physician advice as a major determinant in quitting.4, 5

Clinicians find it difficult to offer additional counseling, however, because of lack of time, skills, staff, and reimbursement.6, 7 These missed opportunities are important because half of all clinical encounters occur8 in the primary care setting, in which short office visits and competing demands impede delivery of more than brief advice to quit. Treating tobacco use as a “vital sign” can increase delivery of brief advice to quit,9 which helps some smokers,10 but it does not increase the frequency with which clinicians provide the additional assistance that many smokers need.11 Reconfiguring practices to enable physicians or other staff to offer intensive cessation counseling is feasible in exceptional settings only.12

Clinicians unable to provide intensive counseling themselves can refer patients to telephone quitlines, an evidence-based intervention13, 14 explicitly recommended in the USDHHS smoking-cessation guideline.3 Quitlines are available in all states, and clinicians can refer patients by advising smokers to call themselves or in many states by faxing/emailing a referral directly from the practice.15 Smokers who call directly may be more likely to enroll than those referred, but the infrequency with which patients place such calls may ultimately make referral more effective.16 By either means, quitline services in the U.S. remain substantially underutilized.

Clinician enthusiasm for referral is more likely if the process is easy to accomplish during busy clinical operations, with available infrastructure and office procedures to expedite referrals. Clinicians also want counseling programs to collaborate as partners by keeping clinicians informed of patients' progress and coordinating logistics. Few quitlines routinely provide feedback to clinicians about the results of intensive counseling or request that the physician provide prescriptions for medications; some arrange classes and nonprescription medication but do so independently of the physician.

Elements of this partnership model exist in some states,16, 17 where clinicians can refer patients for counseling and pharmacotherapy, sometimes with clinician feedback, or vouchers or direct mailings for medications. An Oregon health system16 uses an electronic medical record to systematize counseling and generate fax referrals to the quitline. Practices in Michigan18 used clinician feedback to promote quitline referrals. A trial in Minnesota19 made quitline referrals a feature of its pay-for-performance program. These experiments reported an effect on referrals, but few studies have documented effects on in-office cessation support. An Australian study20 found that access to a quitline was helpful to smokers but was not associated with more-intensive clinician advice to quit. The Oregon study21 reported increased documentation of counseling when clinicians received performance feedback. A Massachusetts study22 of an electronic health record–based intervention that included availability of fax referral found that patients were more often referred, predominantly via email to a health system counselor, and overall made more contacts with any cessation counselor.

Few of these models combine all of the ideal features for implementation in primary care. Some rely on electronic prompts, but most primary care practices remain paper-based. Some require counseling to be delivered by physicians, who face competing demands.

We report a cluster RCT of the “QuitLink” intervention, designed to address the above deficiencies, in which practices used a paper-based, systems approach to identify smokers, provide advice to quit, and assess willingness to quit (A1–3 of the 5A's framework, see Table 1). For smokers ready to attempt quitting and willing to work with a quitline, the system also accommodated fax referral for free proactive telephone counseling and feedback from the quitline to the practices. This study examined whether such a system increased the delivery of in-office cessation support (a proxy for A4–5), defined as a discussion of methods to quit (e.g., medications, quit date) or referral to a quitline.

Section snippets

Methods

The study was approved by the IRBs of Virginia Commonwealth University and Bon Secours Richmond Health System.

Pre-Intervention Period

The exit survey was administered for 3 months to 3203 patients (581 smokers) at the 16 practices. The frequency with which practices offered in-office cessation support was divided into six ranges that defined the strata (see Appendix A, available online at www.ajpm-online.net). The QuitLink intervention was assigned randomly to eight practices, and there was no attrition of intervention or control practices before or after randomization. The one practice with an EMR was randomized to the

Discussion

Current guidelines3, 26, 27, 28, 29, 30 emphasize the need for the medical community and quitlines to promote smoking cessation, but both are underperforming. According to one analysis,31 physicians offer cessation counseling at only 20% of visits by smokers. Quitlines are used on average by less than 1% of smokers in their general populations.15

The QuitLink intervention was designed to enhance both efforts by providing a model for collaboration between clinicians and quitlines that is

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