Tobacco Cessation: Ask, Advise, Connect

The eReferral & Teachable Moment research project was a collaborative effort between Case Western Reserve University  and MetroHealth that focused on tobacco cessation assistance for primary care patients. The project was funded by the Patient-Centered Outcomes Research Institute (PCORI) and tested the combined effect of a systems change initiative and a communication strategy for providing smoking cessation assistance in the primary health care setting. This work was led by previous PRCHN faculty, Sue Flocke and Eileen Seeholzer at MetroHealth. 

Tobacco use

In greater Cleveland, more than 30% of adults use tobacco; this is substantially higher than the national average of 18%. Based on data from adult patient visits in the past 2 years, the rate of tobacco use for patients seen in primary care clinics at the MetroHealth System is 30% overall and 29% for Internal Medicine, 35% for Family Medicine and 26% for OB/GYN. Given the high prevalence of tobacco use and the connection of tobacco with multiple chronic disease, focusing on interventions to support tobacco cessation has the potential to have a substantial impact.

Possible solutions

Others have found that while all states have a Quitline that offers effective tobacco cessation services, the uptake and use of those services remains low. Clinician recommendation increases Quitline contacts slightly. A strategy that shows marked success is an Ask-Advise-Connect approach that uses a systematic approach to asking about smoking status and assessing interest in quitting. For those patients that are interested in quitting in the next month, an eReferral is sent to the Ohio Quitline. Once referred, the Quitline contacts the patient to initiate enrollment in the telephonic counseling program. Use of this strategy by Medical Technical Assistants and Nurses has shown a 12 to 30 fold increase in the enrollment of patients in Quitline counseling and substantially increases key quality indicators.

The Teachable Moment Communication Process (TMCP) is a communication strategy for brief tobacco advice that builds on the established clinician – patient relationship and works with the natural flow of the primary care visit. The approach has been developed and refined by this study team and for this project we are modifying and adapting the skill-based curriculum. The curriculum is designed for primary care clinicians and consists of two parts: a web-based module and in person coaching sessions.

Overall, our project will test the effect of adding this clinician approach to the systems focused Ask-Advise-Connect on patient report, Quitline referrals and smoking outcomes. Our work is guided by a diverse team of co-investigators and staff and is also guided by a Stakeholder Group including patients, clinicians, medical technical assistants, nurses and others.

For more information about the project contact Erika Trapl