California has one of the most demographically, ethnically, and culturally diverse populations in the United States. That means that when it comes to evidence-based tobacco cessation services, they must take this diversity into account and meet patients where they are. Enter, community practice-based research, which seeks to bridge the gap between scientific research and the practice of healthcare. The TRDRP Community Practice-Based Research Initiative (CPBRI) funded projects that partnered with clinics serving Medi-Cal recipients, which have disproportionately high rates of tobacco use and tobacco-related diseases. In addition to producing relevant findings to support these interventions, the CPBRI sought to develop long-term partnerships between academic and healthcare practitioner researchers.
On September 28th, 2023, three teams of TRDRP-funded CPBRI researchers highlighted their project results during a TRDRP dissemination webinar.
Connecting Patients to Quitlines
UC Davis Professor of Medicine, Elisa Tong, and doctoral student Cindy Valencia’s project expanded the Los Angeles Department of Health Services (LA DHS) eConsult system to connect providers, and ultimately patients, to California’s free telephone-based commercial tobacco cessation services (quitlines); studied factors that influenced the effectiveness of outreach attempts to connect smoking patients; and researched disparities among Latino and non-Latino whites in access to tobacco cessation services.
Originally designed to connect doctors with specialists, the team expanded the LA DHS eConsult system to connect healthcare providers to a quitline (then California Smokers Helpline, now Kick It California), which then contacted smoking patients. The team evaluated the system’s effectiveness and suggested ways to improve provider workflow and contact rates.
“Quit lines are an important resource for time-constrained providers to conduct evidence-based tobacco counseling,” says Valencia. “Proactive outreach — offering tobacco treatment — is a promising strategy outside of clinical settings, but little was known around the factors of engagement.”
In one study[i], they assessed how a 213 area code number versus a toll-free 888 number affected consent to receive tobacco cessation services. Volunteers called smoking patients to request consent to refer them to a quitline. Kick It California then contacted 52% of consenting patients to offer tobacco cessation services. “We found a higher consent rate among those patients who were called from the local area code, who were older, and who were Spanish speakers,” says Valencia.
The team also developed a proactive outreach strategy during COVID, sending tobacco cessation mailings to more than 7.5 million Californians. “The [CDPH] California Tobacco Control Program was already doing quarterly household mailings; we turned it into a 2x2 randomized trial,” says Tong.[ii] “We tested two health messages: ‘Quit for COVID’ versus ‘Stop smoking, live your life’.” Each of these was combined with alternative incentive messages: Get a free nicotine patch or access a free Quit Service.
“The free nicotine patch was almost seven times more effective in terms of generating calls,” says Tong. “That incentive message was something that really drove people to pick up the phone and make that call.” More than 13,000 Californians received free nicotine patches mailed during stay-at-home orders.
Racial/Ethnic Differences in Tobacco Use and Cessation Services
Valencia’s doctoral research involved identifying racial/ethnic differences associated with receiving cessation services. One study compared Latino and non-Latino white smokers; [iii] Latinos are the most likely to be light and nondaily smokers. “Nationally, research shows that Latino smokers are advised [about cessation] and assisted less by health professionals,” says Valencia. “While California Medi-Cal expansion increased access for many, including access to comprehensive tobacco cessation benefits, it was unknown if expanded coverage helped resolve this disparity.”
Using California Health Interview Survey data, 1,861 Latino and non-Latino smokers were asked two questions: “In the past 12 months, did a doctor or other health professional advise you to quit smoking?” and “In the past 12 months, did a doctor or other health professional refer you to, or give you information about, a cessation program?”
Latino smokers reported less provider advice and ‘assistance to quit’ than non-Latino white counterparts, but after adjusting for sociodemographic factors, smoking behavior, measures of acculturation, and health care factors, race/ethnicity was no longer a strong factor. Factors associated with provider advice were having a chronic disease and more office visits, while the main factor associated with provider assistance was smoking behavior - if the patient was a daily smoker they were more likely to receive assistance with tobacco cessation from their provider.
Substance Use Disorder and Tobacco Use
A second project focused on smoking among people with substance use disorder. While smoking rates are decreasing in the general population and among people with substance use disorder, “we're not seeing the same decline for people who use illicit substances,” says Caravella McCuistian, Assistant Professor of Psychiatry at the University of California, San Francisco (UCSF), who co-led this project with UCSF Associate Professor of Medicine and Director of the UCSF Smoking Cessation Leadership Center Maya Vijayaraghavan. Excluding cannabis use, smoking prevalence among people with substance use disorder (SUD) actually increased from 2002 to 2014; it's now almost six times that of the statewide average (10.1% versus 68.9%).[iv]
Therefore, targeting SUD treatment facilities is a natural place to implement tobacco cessation interventions. Yet, in California, only 52% of the SUD treatment programs screen for tobacco, says McCuistian, and less than 20% offer cessation medication or pharmacotherapy.
Working with community partner Health Right 360 (HR360), which runs substance use disorder treatment programs in San Francisco, the team created three with support developing an individual quit plan. All sessions were ran weekly by a UCSF clinician and HR360 staff, who were trained to facilitate the intervention.
From before the Readiness Group to the end of the Readiness Group, the team observed a significant increase in use of nicotine replacement therapy (NRT), a significant decrease in people reporting that they were daily smokers, and a trend towards more 24-hour quit attempts, explains McCuistian. Additionally, by the end of the whole intervention, 24-hour quit attempts increased significantly from 42% to 60% in participants that completed the Readiness Group and the Tobacco Cessation Group.
“This project informed legislation resulting in the passage of ,” says McCuistian. This bill requires all licensed and certified California SUD treatment programs to assess clients for tobacco use, educate them on the harms of tobacco, include tobacco cessation in their treatment plans, and offer treatment or referral to services for tobacco cessation. “So this is a big win for us.”
Tobacco Cessation in the San Francisco Health Network Primary Care Clinics
In a second project by the team, Dr. Vijayaraghavan partnered with San Francisco Health Network primary care clinics and SF Department of Public Health to increase access to tobacco treatment in primary care clinics within the San Francisco Health Network[v]. The San Francisco Health Network is the largest network of primary safety net clinics serving San Francisco’s racially/ethnically and linguistically diverse low-income populations. The goals of the project were to increase cessation attempts by building a registry of patients who smoke, and training staff how to use the registry to make practice improvements in delivering cessation services and addressing racial/ethnic gaps in the delivery of services database.
In the first study, Dr. Vijayaraghavan conducted an analysis of electronic health record data of patients in 13 primary care clinics to measure cessation attempts and factors associated with cessation. At the outset, they identified 7,388 adults currently smoking; 17.6% of whom made any cessation attempt, and 9% who made a sustained cessation attempt. Patients who were older, who had Medicaid insurance, and who had limited English proficiency had lower odds of cessation[vi]. Their project found that after providing training and making the tobacco registry available to staff, attempts to quit smoking increased from 17.6% to 26%. They also found that racial and ethnic minorities were less likely to receive services. Thus, while the research results are promising, it is important to address the disparities that remain.
Tobacco Cessation in LA Clinics
In a final presentation, UCLA Professor of Medicine Thomas Friedman reported on outcomes from embedding smoking tobacco cessation programs into LA County clinics. The project started with 18 sites that were randomly assigned either to continue “treatment as usual” or were assigned to the intervention arm, which involved embedding a comprehensive smoking cessation program into the clinic where smokers could select counseling, medications (Bupropion or Varenicline), or nicotine-replacement therapy (NRT).[vii],[viii]
Smoker-chosen interventions were divided somewhat equally between the three types. The intervention group showed modest but significant improvements in outcomes. For example, 23% received medicines in the intervention group versus 15% in treatment-as-usual. Additionally, the number of cigarettes smoked dropped more in the intervention arm, and about 18% of participants stopped smoking entirely in the intervention versus 10% in the control. The project found that smokers in the intervention group who received more counseling sessions had increased success quitting smoking. Finally, the team found that medicines, NRT, and counseling were equally effective at leading to smoking cessation.
Friedman’s team partnered with community engagement consultant Norma Mtume to ensure project sustainability. “We developed a training manual for facilitators and participants, and those have been made available to the clinics,” explains Mtume. “We also trained the behavioral health specialists that are facilitating the groups now. We tried to make sure that we put those things in place so that they would be more capable to continue the services.” All the clinics still exist even though the grant funding ended.
Summary
Overall, the projects have proven quite successful. Despite all teams experiencing some setbacks and challenges due to the COVID pandemic, all were able to overcome or pivot to produce outstanding projects with insightful scientific findings, and perhaps more importantly, sustainable results from these innovative partnerships that will continue to have long-lasting impact.
Community Practice-Based Research Initiative (One Pager)
MEDIA CONTACT
Wendee Nicole Holtcamp, wendeenicole@gmail.com
References
[i] Valencia CV, Dove MS, Cummins SE, et al. A Proactive Outreach Strategy Using a Local Area Code to Refer Unassisted Smokers in a Safety Net Health System to a Quitline: A Pragmatic Randomized Trial. Nicotine Tob Res. 2023; 25(1): 43–49. doi:10.1093/ntr/ntac156. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9717369/
[ii] Tong EK, Cummins SE, Anderson CM, et al. Quitline Promotion to Medicaid Members Who Smoke: Effects of COVID-19–Specific Messaging and a Free Patch Offer. Am J Prev Med. 2023;64(3):343-351. doi:10.1016/j.amepre.2022.09.009. https://pubmed.ncbi.nlm.nih.gov/36319510/.
[iii] McCuistian C, Le T, Delucchi K, et al. Racial/Ethnic Differences in Tobacco Use and Cessation Services among Individuals in Substance Use Treatment. J Psychoactive Drugs. 2021;53(5):483-490. doi:10.1080/02791072.2021.1977874. https://pubmed.ncbi.nlm.nih.gov/34672862/.
[iv] Guydish J, Kapiteni K, Le T, et al. 2020. Tobacco Use and Tobacco Services in California Substance Use Treatment Programs. Drug Alcohol Depend. 2020 Sep 1:214:108173. doi:10.1016/j.drugalcdep. 2020.108173. https://pubmed.ncbi.nlm.nih.gov/32693199/
[v] Gubner NR, Williams DD, Chen E, Silven D, Tsoh JY, Guydish J, Vijayaraghavan M. Recent cessation attempts and receipt of cessation services among a diverse primary care population - A mixed methods study. Prev Med Rep. 2019 May 22;15:100907. doi: 10.1016/j.pmedr.2019.100907. PMID: 31193606; PMCID: PMC6536779.
[vi] Suen LW, Rafferty H, Le T, Chung K, Straus E, Chen E, Vijayaraghavan M. Factors associated with smoking cessation attempts in a public, safety-net primary care system. Prev Med Rep. 2022 Jan 19;26:101699. doi: 10.1016/j.pmedr.2022.101699. PMID: 35145838; PMCID: PMC8802046.
[vii] Baskerville W, Friedman TC, Hurley B, et al. Embedding Comprehensive Smoking Cessation Programs into Community Clinics: Study Protocol for a Randomized Controlled Trial. Trials. 2022;23(1):109. doi:10.1186/s13063-022-06023-3. https://pubmed.ncbi.nlm.nih.gov/35115017/.
[viii] Meredith LR, Hurley, B Friedman TC. Implementation of Specialty Tobacco Use Disorder Services in a Community Health Setting: Support for Enhanced Prescription Practices. J Addict Med. 2023;17(6):677-684. doi:10.1097/ADM.000000000000121. https://pubmed.ncbi.nlm.nih.gov/37934530/.
