Multi-level interventions for addressing tobacco cessation and SDOH in Community Health Centers (CHCs)

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PROJECT 1: PROJECT SUMMARY Tobacco use is the leading cause of death and disability in the United States, and is associated with at least 16 different types of cancers. Though nationwide rates have declined, tobacco use has become concentrated in populations that have been historically marginalized and plays a critical role in health inequities, accounting for 34% of the socioeconomic gradient in all-cause mortality and 62% in smoking related diseases, including cancers of the lip/oral cavity/pharynx, esophagus, larynx, trachea, and lung. These populations also experience adverse Social Determinants of Health (SDOH), which frequently co-occur with tobacco use, and contribute to limited access and engagement with evidenced-based interventions (EBIs) for tobacco cessation. Consequently, addressing SDOH and tobacco use concurrently may address barriers to engaging in EBIs for tobacco cessation and ultimately reduce the impact of tobacco use among individuals living in poverty. However, the effectiveness and cost effectiveness of strategies to concurrently increase the reach of EBIs for tobacco cessation and mitigate the effects of SDOH among individuals living in persistent poverty areas is unknown. The proposed project, Reach through Equitable Implementation in Utah (REI-UT), is a pragmatic, multilevel Type III Hybrid Effectiveness-Implementation trial with a 2x2 factorial experimental design. REI-UT will be conducted with 6 Community Health Center (CHC) systems and 14 primary care clinics across Utah that serve ~1560 patients who use tobacco and live in persistent poverty census tracts. REI-UT utilizes an innovative bundled approach to address adverse SDOH and tobacco use concurrently, and leverages ubiquitous health information technology/telehealth for both the evidence-based intervention (EBI) delivery modality (i.e., the Utah Tobacco Quit Line) and for dissemination and implementation (D&I) strategies. The clinic and patient- level D&I strategies utilize widely adopted Electronic Health Record (EHR) capabilities, mobile phone—based conversational agents (CA), and telephone–based patient navigation (PN) approaches to address adverse SDOH and increase the reach of the Quit Line. Sustainability is enhanced by utilizing an existing, free, nationally available EBI for tobacco cessation. The aims are to 1) Test the ability of patient level (CA & PN) dissemination strategies to increase the Reach (primary outcome) of evidence-based tobacco cessation treatment delivered via the Quit Line among CHC patients who use tobacco and live in persistent poverty census tracts. Secondary analyses will examine the outcome of Reach of services for SDOH among these patients, and will evaluate both (1) patient level CA and PN strategies, and (2) clinic level strategy (Ask – Advise – Connect [AAC] for SDOH) using a pre-post design; 2) Explore contextual factors related to the Reach, Adoption, Implementation, and potential Maintenance of strategies; and 3) Determine cost-effectiveness of clinic and patient level strategies based on Quit Line enrollment and receipt of services for SDOH.