Offering population-based tobacco treatment in a healthcare setting: a randomized controlled trial

Abstract

Background: The healthcare system is a key channel for delivering treatment to tobacco users. Brief clinic-based interventions are effective but not reliably offered. Population management strategies might improve tobacco treatment delivery in a healthcare system.

Purpose: To test the effectiveness of supplementing clinic-based care with a population-based direct-to-smoker (DTS) outreach offering easily accessible free tobacco treatment.

Design: Randomized controlled trial, conducted in 2009-2010, comparing usual clinical care to usual care plus DTS outreach.

Setting/participants: A total of 590 smokers registered for primary care at a community health center in Revere MA.

Interventions: Three monthly letters offering a free telephone consultation with a tobacco coordinator who provided free treatment including up to 8 weeks of nicotine patches (NRT) and proactive referral to the state quitline for multisession counseling.

Main outcome measures: Use of any tobacco treatment (primary outcome) and tobacco abstinence at the 3-month follow-up; cost per quit.

Results: Of 413 eligible smokers, 43 (10.4%) in the DTS group accepted the treatment offer; 42 (98%) requested NRT and 30 (70%) requested counseling. In intention-to-treat analyses adjusted by logistic regression for age, gender, race, insurance, diabetes, and coronary heart disease, a higher proportion of the DTS group, compared to controls, had used NRT (11.6% vs 3.9%, OR=3.47; 95% CI=1.52, 7.92) or any tobacco treatment (14.5% vs 7.3%, OR=1.95, 95% CI=1.04, 3.65) and reported being tobacco abstinent for the past 7 days (5.3% vs 1.1%, OR=5.35, 95% CI=1.23, 22.32) and past 30 days (4.1% vs 0.6%, OR=8.25, 95% CI=1.08, 63.01). The intervention did not increase smokers' use of counseling (1.7% vs 1.1%) or non-NRT medication (3.6% vs 3.9%). Estimated incremental cost per quit was $464.

Conclusions: A population-based outreach offering free tobacco treatment to smokers in a health center was a feasible, cost-effective way to increase the reach of treatment (primarily NRT) and to increase short-term quit rates.

Trial registration: This study is registered at Clinicaltrials.govNCT01321944.

Figure 1

Flow diagram Note: Intervention Plus consists of the standard intervention (three mailed letters offering treatment) plus two proactive telephone calls offering the same treatment options. DTS, direct to smoker; HC, health center; PCP, primary care provider