Implementation of Ask-Advise-Connect in a safety net healthcare system: quitline treatment engagement and smoking cessation outcomes

Abstract

Ask-Advise-Connect (AAC) was designed to link smokers in primary care settings with evidence-based tobacco treatment delivered via state quitlines. AAC involves training medical staff to Ask about smoking status, Advise smokers to quit, and offer to immediately Connect smokers with quitlines through an automated link within the electronic health record. We evaluated the efficacy of AAC in facilitating treatment engagement and smoking abstinence in a 34 month implementation trial conducted in a large, safety-net health care system. AAC was implemented from April 2013 through February 2016 in 13 community clinics that provided care to low-income, predominantly racial/ethnic minority smokers. Licensed vocational nurses were trained to implement AAC as part of standard care. Outcomes included (a) treatment engagement (i.e., proportion of identified smokers that enrolled in treatment) and (b) self-reported and biochemically confirmed abstinence at 6 months. Smoking status was recorded for 218,915 unique patients, and 40,888 reported current smoking. The proportion of all identified smokers who enrolled in treatment was 11.8%. Self-reported abstinence at 6 months was 16.6%, and biochemically confirmed abstinence was 4.5%. AAC was successfully implemented as part of standard care. Treatment engagement was high compared with rates of engagement for more traditional referral-based approaches reported in the literature. Although self-reported abstinence was in line with other quitline-delivered treatment studies, biochemically confirmed abstinence, which is not routinely captured in quitline studies, was dramatically lower. This discrepancy challenges the adequacy of self-report for large, population-based studies. A more detailed and comprehensive investigation is warranted.

A Digital Smoking Cessation Program for Heavy Drinkers: Pilot Randomized Controlled Trial

“…Additional methods to enhance completion of follow-up assessment, such as offering an additional bonus incentive for survey completion within 24 hours [ 39 ] or providing more frequent brief communications from the study between follow-up visits, would be important to utilize in a future trial. Consistent with prior research [ 41 , 42 ], there were large discrepancies between self-reported and biochemically verified smoking abstinence due to missing data rather than misreported smoking status. We agree with previous recommendations on the verification of smoking status, which suggest that using biochemical verification in large-scale web-based cessation trials is of limited value and is not feasible [ 43 ].…”

Increasing access to smoking cessation treatment among Latino smokers using case management

“…In addition, text message interventions are similar to quitlines regarding their potential for scalability and costeffectiveness -given that notably less human resources are needed to interact with smokers. Lastly, study outcome measures relied on self-report, which may increase the threat of social desirability bias 37 . Caution should thus be made when interpreting findings.…”

Quitting the quitline: a qualitative study of patient experience of electronic referrals to quitlines

“…"Yes, I would (like to talk to the QL), because it was just a misunderstanding and the wrong moment. (15,17,18). This study expands our understanding of why so many smokers, having accepted a referral during their primary care office visit, later disengage with the QL.…”

“…They found that at the non-HIV clinics, 54.5% of referred smokers were later unreachable, and of those reached, 24% then declined services; similarly, among those seen at the HIV clinic, 55.6% of referred patients were unreachable and 24.9% of those reached declined services (15). In addition to being unreachable or declining QL participation, many smokers do not complete the multiple (3)(4)(5) counseling sessions offered by most QLs (17,18). This is significant because research has found that those who complete more of the calls offered in QL programs have higher quit rates than those who complete fewer calls (7,18,19).…”

“…In addition to being unreachable or declining QL participation, many smokers do not complete the multiple (3)(4)(5) counseling sessions offered by most QLs (17,18). This is significant because research has found that those who complete more of the calls offered in QL programs have higher quit rates than those who complete fewer calls (7,18,19).…”