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Author(s): Coral Gartner 1, Wayne D. Hall 2,* Progress has been made in reducing the global burden of tobacco-related disease and disability but the implementation of tobacco control measures recommended [...]

Presenters Susan Flocke, PhD, Steffani Bailey, PhD, Eileen Seeholzer, Elizabeth Albert, Steven [...], Context: Primary care has an important role in identifying individuals that use tobacco, providing advice to quit and assisting cessation by referring to evidence-based resources such as state tobacco quitlines (QL). Objective: To evaluate the degree to which provision of tobacco cessation care is sustained 24 months after implementation of an Ask-Advise-Refer strategy with an electronic referral to the QL for patients ready to quit tobacco. Setting: Eight community primary care clinics in a Midwest safety-net health system. 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 rooming staff roles to include performing tobacco cessation care tasks. Outcomes assessed from the EHR included asking about tobacco use, providing brief advice to quit and assessing readiness to quit. Generalized estimating equations (GEE) methods were used to compute odds ratios contrasting the pre-implementation (Pre-I) vs. 12, 18 and 24-month post-implementation (Post-I). Results: A total of 305,665 patient visits were evaluated. Significantly higher odds of asking and advising were observed for all three Post-I periods compared to Pre-I rates, with rates either remaining steady or increasing over time. Asking about tobacco use Pre-I was 27.5% vs. 63.3% 24-months, OR 5.1 (95% CI 4.8-5.4). Advising tobacco users to quit at Pre-I was 45.0% vs. 79.0% 24- months, OR 3.6 (95% CI 3.1-4.1). Odds of assessing readiness to quit were higher across all three Post-I periods compared with Pre-I but declined after 12 months. Assessing readiness to quit Pre-I was 15.9% vs 35.4% at 24 months, OR 2.7 (95% CI 2.4-3.1). There was substantial variability across each outcome by clinical site with the greatest variability for assessing readiness; site-level performance at 24 months range was 9%-74%. Conclusions: Embedding a new process in the rooming workflow can result in substantial and sustained impact on tobacco assessment and provision of brief advice. Improvement in assessing patient readiness to quit was less successfully sustained and highly variable across clinical sites. EHR upgrade changes and staff and clinician turnover are disruptions that may negatively impact performance and additional implementation support strategies to reinforce positive performance and mitigate disruptions should be deployed and tested.

Presenters Marlon Mundt, PhD, Larissa Zakletskaia, MS, Mark Zehner, [...], CONTEXT: Primary care offers a unique opportunity to deliver chronic- illness care management to patients who smoke. This real-world pragmatic trial implemented electronic health record (EHR) prompts to facilitate proactive, repeated outreach and smoking cessation treatment to all adult patients who smoked cigarettes. Certified tobacco treatment specialists sent annual invitations to engage with cessation support to patients listed in the clinic's smoking registry, offered aid in smoking cessation within a week after a primary care clinic visit to patients who neither addressed nor endorsed a willingness to quit, and provided ongoing support to patients who were making a quit attempt or attempting to reduce their smoking. OBJECTIVE: This research examines the relative health care costs and benefits of a smoking cessation intervention that involves EHR-guided outreach and intervention by certified tobacco treatment specialists. STUDY DESIGN: The intervention was implemented in 3 steps at 6 primary care clinics located in the Midwest using a stepped-wedge design. ANALYSIS: Pre-post analysis compared intervention costs with benefits of increased treatment engagement, quit attempts, and successful smoking cessation, as well as acute health care use, including emergency department visits and hospitalization. Incremental cost-effectiveness was calculated based on staff time and resources used (including medications) relative to weighted individual pathways of pre-post smoking rates and health care costs for patients who smoked. RESULTS: A total of 10,683 adults were on the smoking registry at the 6 participating clinics from January 2017 to February 2020. Cessation treatment rates increased from 12.9% pre-implementation to 24.0% post-implementation. Smoking cessation rates increased from 2.1% pre-implementation to 10.5% post-implementation. Total intervention cost was $11.28 per patient on the smoking registry per month post-implementation. Acute health care costs decreased from pre- to post-implementation by an average $42.65 per patient on the smoking registry per month. The incremental cost-effectiveness ratio was $1,853 per person who quit smoking. CONCLUSIONS: Implementation of a comprehensive and proactive EHR-enabled smoking cessation outreach and treatment program with certified tobacco treatment specialists is cost-effective in real- world primary care clinics. Reductions in acute health care cost could offset the smoking cessation intervention costs.

Researchers in Birmingham undertook a systematic review and meta-analysis of randomised controlled trials to investigate the effectiveness and safety of smoking cessation programmes involving nicotine replacement therapy (NRT). Seven placebo [...]