Delivery of Smoking Cessation Services and Cessation Attempts Across a Public, Safety-Net Primary Care System

Abstract

Background: Smoking cessation rates are low in safety-net settings, contributing to high smoking-related morbidity and mortality. Understanding factors associated with cessation attempts can inform interventions. Objective: To evaluate factors associated with smoking cessation attempts. Design: Retrospective analysis using electronic health record (EHR) data on individuals with at least three primary care encounters from 2016 to 2019 in the San Francisco Health Network (SFHN), a network of clinics serving publicly insured and uninsured residents in San Francisco.Participants: Patients engaged in primary care in the San Francisco Health Network.Main Measures: The outcome was recent cessation attempt, defined as change in smoking status from “current smoker” at the index visit to “former smoker” at visit 2 or 3. We measured demographics, tobacco-related comorbidities, and cessation treatment characteristics (i.e., counseling and pharmacotherapy). To better characterize subpopulations that may benefit from targeted interventions, we described characteristics of smokers with hypertension, depression, diabetes, or HIV.Key Results: Of the 51,554 adults identified across 15 SFHN primary care clinics, 11,622 (22.7%) were current smokers. Approximately 26% of smokers made a recent cessation attempt. Medical assistant (90%) and provider counseling (73%) rates were high, while behavioral assistant counseling rate (17%) was low. All counseling types had lower odds of cessation attempts in multivariable analysis. Smokers with depression (AOR 1.18, 95%CI 1.05-1.33) and ischemic heart disease (AOR 1.36, 95%CI 1.06-1.74) had higher odds of attempts. Among comorbidity groups, cessation attempts ranged from 21-26%, and smokers with HIV received the lowest rates of cessation counseling. Conclusions: Although rates of basic cessation counseling were high, efforts were associated with lower odds of making a cessation attempt. Using intensive interventions to target populations with comorbidities could be opportunities to increase cessation engagement.