BACKGROUND Tobacco use remains the leading cause of preventable premature death and illness in Denver (Denver Health, 2015a). Specifically, tobacco is a major contributor to four of the top 10 leading causes of death in Denver: cardiovascular disease, cancer, chronic lung disease, and influenza/pneumonia (Denver Public Health, 2012). Regarding exposure to secondhand smoke, the Denver Health website (2015b) describes it as a contributor to pediatric asthma, a major problem among Denver's children. Because of the frequency of tobacco use, exposure to secondhand smoke, and the resulting serious health problems, decreasing tobacco use and exposure is the single most powerful tool to improve health in Denver. Denver Health is a comprehensive, integrated health care system providing care for all, regardless of ability to pay, and it serves as a model for other safety-net institutions across the nation. Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care at Denver Health, including one in three children in Denver who are cared for by Denver Health physicians (Denver Health, 2015c). Denver Public Health (DPH) is part of the integrated Denver Health system, and stands at the forefront of public health activities in the City and County of Denver. The overarching mission of Denver Public Health is to promote, improve, and protect the health and well-being of the residents of the City and County of Denver and beyond. Like other urban core areas, Denver County has high numbers of people living in poverty, with low educational levels, from racial and ethnic minorities, and with limited English proficiency. The Ask, Advise, and Refer (AAR) intervention was initiated in DPH's Sexual Health and Family Planning Clinic in late 2012 and revealed that approximately 37 percent of patients reported smoking (Mickiewicz, 2013). The initiation of this program in the clinic provided the groundwork for continued implementation in Denver Health's Community Health Service (CHS). The CHS clinics are Denver's largest federally qualified health centers (FQHC). CHS clinics manage more than 365,000 outpatient visits annually. The clinics and outreach services serve as the safety-net health care provider for Denver's most vulnerable populations often at risk for tobacco use. In 2010, approximately 11,000 (28 percent) of adult outpatients at Denver Health CHS clinics reported being a current smoker, compared to 21 percent of Denver adults as a whole, thus making these clinics an ideal site for intervention (BRFSS, 2010). Although current tobacco use was recorded in the electronic health record (EHR) system, provider advice and referrals were not documented, thus disallowing program staff to determine if the AAR components of a comprehensive cessation treatment were being offered. Based on these factors, the AAR program was initiated at Denver Health CHS clinics in order to address the high smoking rates and inconsistency in advising patients to quit and referring patients to cessation services.
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