Text Messaging to Engage and Retain Veterans in Smoking Cessation Counseling

Tobacco use remains the number one cause of premature death and morbidity in the United
States, and tobacco-related diseases account for 24% of all VA healthcare costs. The VA has
been a leader in addressing tobacco use, having implemented annual tobacco screening and made
pharmacotherapy readily available. However, one of the most cost-effective services -
telephone quit lines - remain highly underused. Few Veterans enroll in telephone counseling
to help them quit smoking, and among Veterans who begin telephone counseling, few complete a
full course. The advent of electronic health records (EHRs) has enabled new strategies for
ensuring that patients receive preventive services. These methods can reduce provider burden
and close gaps in systems of care. The investigators' research team has conducted numerous
studies using EHRs to identify smokers and proactively reach out to coordinate telephone
tobacco treatment. While the investigators have successfully implemented this approach, the
overall enrollment rates for counseling remain low and the majority of smokers complete only
one counseling session. Therefore, the investigators propose to test novel mHealth strategies
for promoting enrollment in and adherence to telephone counseling. The Specific Aims are to:
1) Conduct a sequentially randomized trail to estimate the effectiveness of text messaging
for increasing enrollment in and adherence to telephone tobacco treatment, 2) Compare rates
of tobacco cessation between patients who received and did not receive text messaging during
treatment, and 3) Evaluate patient experiences with these interventions. Using the VA EHR,
the investigators will identify N=3,600 smokers at three VA sites. All identified smokers
will be mailed an introductory packet with information about the study. Patients who mail
back a consent will be randomized to standard telephone outreach for counseling or to receive
8 educational texts to counter barriers of participating in counseling prior to telephone
outreach. Patients who enroll in tobacco treatment will then be randomized to receive
standard telephone counseling or to also receive appointment reminders and supportive texts
throughout the 8-week counseling period. The investigators hypothesize that these approaches
will increase the rate of enrollment in telephone tobacco cessation and 12-month
biochemically validated abstinence (primary outcomes) over standard telephone counseling
approaches. The investigators will also assess patient experiences with each texting
protocol. The investigators' overarching goal is to investigative innovative mHealth
strategies for increasing Veteran use of telephone-based tobacco cessation counseling and to
improve quit rates. This research, exploring both population-based outreach and text
messaging, advances multiple goals set forth by the VA's Blueprint for Excellence. Results
will have direct implications to inform decision-making and population-based care models for
tobacco treatment.

Inclusion Criteria:

- Current smoker (i.e., positive tobacco use in past 6 months)

- Veteran 18 years or older

- Cell phone number listed the medical record

Exclusion Criteria:

- ICD 9 diagnosis of dementia (excluded during data abstraction process)

- Does not speak English

- No mailing address (necessary to mail out initial study materials)