Background: Tobacco users receiving behavioural and pharmacological assistance are more likely to quit. Although telephone quitlines provide population access to counselling, few offer pharmacotherapy. Objective: To assess change in cessation rates and programme impact after the addition of free nicotine replacement therapy (NRT) to statewide quitline services. Design, setting, participants: An observational study of cohorts of callers to the Minnesota QUITPLAN SM Helpline before (n = 380) and after (n = 373) the addition of access to free NRT. Intervention: Mailing of NRT (patch or gum) to callers enrolling in multi-session counselling. Main outcome measure: Thirty-day abstinence six months after programme registration. Results: The number of callers increased from 155 (SD 75) to 679 (180) per month pre-NRT to post-NRT (difference 524, 95% confidence interval (CI) 323 to 725). Post-NRT, the proportion of callers enrolling in multi-session counselling (23.4% v 90.1%, difference 66.6%, 95% CI 60.8% to 71.6%) and using pharmacotherapy (46.8% v 86.8%, difference 40.0%, 95% CI 31.3% to 47.9%) increased. Thirty-day abstinence at six months increased from 10.0% pre-NRT to 18.2% post-NRT (difference 8.2%, 95% CI 3.1% to 13.4%). Post-NRT the average number of new ex-smokers per month among registrants increased from 15.5 to 123.6 (difference 108.1, 95% CI 61.1 to 155.0).

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BackgroundHealth systems play key roles in identifying tobacco users and providing evidence-based care to help them quit. Health systems change – changes to health care processes, policies and financing – has potential to build capacity within these systems to address tobacco use. In 2010, ClearWay MinnesotaSM piloted a health systems change funding initiative, providing resources and technical assistance to four health care systems. This paper presents findings from a process evaluation, describing key stakeholders’ views on whether changes to how health systems treat tobacco use resulted from this initiative and what may have facilitated those changes.MethodsA process evaluation was conducted by an independent evaluation firm. A qualitative case study approach provided understanding of systems change efforts. Interviews were conducted with key informants representing the health systems, funder and technical assistance providers. Core documents were reviewed and compared to thematic analysis from the interviews. Results were triangulated with existing literature to check for convergence or divergence. A cross-case analysis of the findings was conducted in which themes were compared and contrasted.ResultsAll systems created and implemented well-defined written tobacco use screening, documentation and treatment referral protocols for every patient at every visit. Three implemented systematic follow-up procedures for patients referred to treatment, and three also implemented changes to electronic health records systems to facilitate screening, referral and reporting. Fax referral to quitline services was implemented or enhanced by two systems. Elements that facilitated successful systems changes included capitalizing on environmental changes, ensuring participation and support at all organizational levels, using technology, establishing ongoing training and continuous quality improvement mechanisms and leveraging external funding and technical assistance.ConclusionsThis evaluation demonstrates that health systems can implement substantial changes to facilitate routine treatment of tobacco dependence in a relatively short timeframe. Implementing best practices like these, including increased emphasis on the implementation and use of electronic health record systems and healthcare quality measures, is increasingly important given the changing health care environment. Lessons learned from this project can be resources for states and health systems likely to implement similar systems changes.

Background: Partnerships can expand the reach and effectiveness of quitlines while conserving limited tobacco control dollars. Objective: To describe how the addition of free nicotine replacement therapy (NRT) to the ''QUITPLAN Helpline'' in Minnesota influenced triage and transfer to health plan quitlines and how efforts taken to reestablish balance in the partnership expanded population based access to NRT. Results: Following the addition of NRT to the QUITPLAN Helpline, the percentage of health plan members transferred to their health plans decreased because callers were resisting transfer to their health plans for telephone counselling that did not include NRT. Transfer rates eventually returned to pre-NRT levels following sequential implementation of scripting changes, transfer requirements and collection of health plan identification numbers. These changes reduced ClearWay Minnesota dollars spent on providing services to insured Minnesotans. Through the partnership, all Minnesotans currently have access to both telephone counselling and NRT either at no or low cost. Conclusions: Minnesota's partnership has effectively expanded access to NRT through quitlines. The increased use of partnerships for providing quitline services may be effective in broadening population access while conserving limited tobacco control dollars for those without cessation benefits.

An NRT starter kit brought more tobacco users to QUITPLAN services, demonstrating interest in cessation services separate from phone counseling. The starter kit produced high quit rates, comparable to the quit line in the same time period. Cessation service providers may want to consider introducing starter kits to reach more tobacco users and ultimately improve population health.