Reducing Tobacco Use Disparities Among Adults in Safety Net Community Health Centers

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An estimated 26 million smokers still receive no treatment for their smoking during their primary care visits. Given the persistent clinical system, provider, and patient barriers to addressing smoking, especially among poor populations, an EHR-automated population health management approach that links a healthcare system with community services both clinically and electronically to engage all smokers may increase access to effective treatment. Increased access is especially significant for low-income smokers who are underserved and carry a disproportionate burden of tobacco-related disease. While 90% of smokers are not ready to quit, many are interested in cutting down, and smoking reduction increases the likelihood of future quit attempts and smoking cessation. Based on self-determination theory, person-centered population outreach that targets low- income smokers and offers them the choice to either quit or cut down as a first step towards cessation may increase their engagement in and utilization of treatment and likelihood of achieving abstinence. This 2-group randomized controlled trial will evaluate the effectiveness of a person-centered population health management intervention for smoking cessation in low-income smokers. Participants will be 530 diverse, low-income smokers of a large Federally Qualified Health Center (FQHC) in Chicago identified using its electronic health record (EHR) system. Automated via the EHR system, participants will be mailed a letter on behalf of their providers that encourages smoking cessation or smoking reduction as a first step to cessation if not ready to set a quit date (Choose to Change; N=265). The letter will be paired with two automated text/voices messages three days apart that are designed to reinforce the central messaging of the letter (“Choose to change and make your own goal”). Two weeks after letter mailing, participants will receive a call from the Illinois Tobacco Quitline and be offered free person-centered behavioral counseling and free nicotine replacement therapy (NRT; patch, gum, or lozenge). Treatment will continue as either accepted or initiated by participants for 26 weeks. Treatment outcomes will be transmitted directly from the Quitline server to the EHR system. Choose to Change will be compared with Usual Care (N=265), in which a referral for proactive Quitline treatment is made during a clinic visit. The primary study outcomes will be treatment engagement (initial counseling call completed) at 6 weeks, utilization (one or more additional counseling calls completed) at 12 weeks, and smoking cessation (bioverified 7-day point-prevalence abstinence) at 26 weeks. An exploratory study aim will be to examine moderators of intervention effects. We hypothesize that Choose to Change will increase the proportion of smokers who engage in and utilize treatment and who achieve cessation, as compared with Usual Care. An EHR-automated, person-centered, population health management intervention that is informed by both theory and patient feedback and targeted to low-income smokers could reduce critical disparities in treatment access, utilization, and cessation. If determined to be effective, the Choose to Change intervention could be disseminated to FQHCs and state quitlines throughout the United States.