Reducing Tobacco Use Disparities Among Low-Income Adults

An estimated 26 million smokers still receive no treatment for their smoking during their
primary care visits. Given the persistent clinical system, provider, and patient barriers to
addressing smoking in primary care, especially for poor populations, an electronic health
record (EHR)-automated population health management approach that directly links the
healthcare system with public health services to engage all smokers may increase access to
effective treatment. Increased access is especially significant for low-income smokers who
are underserved and who carry a disproportionate burden of tobacco-related disease. While 90%
of smokers are not ready to quit, many are interested in cutting down, and smoking reduction
increases the likelihood of future quit attempts and smoking cessation. Based on
self-determination theory, population outreach targeted to low-income smokers that offers
them the choice to either quit or cut down as a first step towards cessation may increase
their engagement in and utilization of smoking cessation treatment and likelihood of
achieving abstinence. This 2-group randomized controlled trial will evaluate the
effectiveness of a population health management intervention for smoking cessation in
low-income smokers. Participants will be 530 diverse, low-income smokers of a large Federally
Qualified Health Center (FQHC) in Chicago identified using its EHR system. Automated via the
EHR system, participants will be mailed a letter on behalf of their providers that encourages
smoking cessation or smoking reduction as a first step to quitting (Choose to Change; N=265).
The letter will be paired with 5 text messages 2-3 days apart that are designed to reinforce
the central messaging of the letter ("Choose to change and make your own goal"). All
components of the Choose to Change intervention will be offered in English and Spanish. Two
weeks after letter mailing and automated electronic referral, participants will receive a
call from the Illinois Tobacco Quitline and offered free behavioral counseling and free
nicotine replacement therapy (NRT; patch, gum, or lozenge) for smoking cessation or
reduction. Treatment will continue as either accepted or initiated by participants for 28
weeks. Treatment outcomes will be transmitted directly from the Quitline server to the EHR
system. Choose to Change will be compared with Enhanced Usual Care (N=265), in which an
electronic referral for proactive Quitline treatment is made during a clinic visit. The
primary study outcomes will be treatment engagement (initial counseling call completed) at 6
weeks, utilization (one or more additional counseling calls completed) at 14 weeks, and
smoking cessation (bioverified 7-day point-prevalence abstinence) at 28 weeks. An exploratory
aim is to examine moderators of intervention effects. An EHR-automated population health
management intervention targeted to low-income smokers could reduce critical disparities in
treatment access, utilization, and cessation. If determined to be effective, the Choose to
Change intervention could be readily disseminated to 11 other FQHCs in Chicago, comprising 85
clinical sites that care for almost 500,000 low-income patients.

Inclusion criteria

1. Men and women who are 18 years of age or older

2. A patient who receives healthcare at one of the seven Near North Health Service
Corporation community health centers in Chicago

3. Daily or weekly cigarette smoker

4. One or more healthcare visits within the past 12 months

Exclusion criteria

1. Language preference other than English or Spanish for their healthcare

2. No telephone number or address listed in the EHR system

3. Lives with another patient who is already enrolled in the study