Tobacco quitlines

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) has identified the availability of free tobacco quitlines as one of several strategies for reducing global morbidity and mortality from tobacco use. In the US, federal programs have sought to address barriers to receiving smoking cessation services among low-income and other population groups by providing access to free or low-cost smoking cessation services. In 2004, a single nationwide 1-800 portal (1-800-QUIT-NOW) was developed to give smokers uniform access to state quitlines⁶. In all 50 states, quitlines are telephone-based tobacco cessation services that help tobacco users quit or decrease their smoking by providing counseling, nicotine replacement, referrals to local cessation programs, and self-help materials sent via mail or online^7,8. Approximately 500000 smokers contact a state tobacco quitline yearly, with over 126000 callers quitting because of treatment⁶.

In 2008, the Public Health Service (PHS) Clinical Practice Guideline, Treating Tobacco Use and Dependence, listed state tobacco quitlines as effective and recommended⁹. The potential impact of quitlines comes from their capacity to deliver evidence-based treatment for smokers at scale cost-effectively⁶. Further, quitline services are free to most smokers and are offered over the phone, which reduces substantial barriers to treatment for low-income smokers⁶. Despite the benefits of state quitlines, utilization rates are modest, especially among low-income individuals. According to the North American Quitline Consortium’s annual survey of quitlines, just under 1% of adults who smoke in the US used a quitline in 2019¹⁰.

Health providers serving low-income patients are essential in linking high-risk smokers to effective treatments such as state tobacco quitlines. For example, Federally Qualified Health Centers (FQHCs) provide comprehensive health services to economically disadvantaged populations in rural and urban communities across the US¹¹. In the US, more than 28 million – one in three low-income persons who live below 200% of the federal poverty level – receive medical care at an FQHC¹². Studies show an estimated median prevalence rate of 29.3% tobacco use among FQHC patient populations¹².

Several barriers exist to consistently delivering smoking cessation treatments, including referrals to state quitlines by providers in high-burden clinics. For example, Gonzales et al.13 identified barriers to providing smokers in FQHC clinics with tobacco cessation assessment and interventions, including the Nebraska Tobacco Quitline. These authors found that providers and non-provider clinical staff reported a lack of awareness, time, competing demands, electronic health records (EHR) that do not facilitate recommendations/referrals, insufficient training, and limited staff as primary barriers to treatment at the FQHC setting¹³.

Research examining interventions to improve patient linkage to state tobacco quitlines is emerging. For example, the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework was used in a study to assess the implementation of a healthcare system change carried out across 30 primary care clinics within the University of Wisconsin Health system to address unmet needs of smokers in obtaining tobacco cessation treatments, including a linkage to the Wisconsin Tobacco Quitline (WTQL)¹⁴. The healthcare system employed standard, computer-based training to implement EHR and clinic workflow changes to facilitate electronic referrals, whereas previously, they faxed patient referrals to the WTQL. The EHR data captured assessment rates of patients’ readiness to quit and quitline referral 4 months before and 8 months after implementation. Results showed an increase in assessment in readiness to quit (24.8% to 93.2%) and an increase in quitline referrals (1.7% to 11.3%), with 3.6% of those patients connecting with the WTQL after implementation¹⁴.

This study sought to understand providers’ attitudes and behaviors concerning quitline services and referrals in a large urban FQHC. Specifically, we assessed providers’ knowledge about the Illinois state tobacco quitline (ITQL) services in the FQHC context, examined typical referral patterns to the ITQL among FQHC providers, and identified and explored barriers providers encounter when referring patients to the ITQL. The findings can inform targeted implementation strategies to improve quitline utilization and support smoking cessation efforts in this vulnerable population.

Study design

The study used a descriptive-qualitative design^15,16. Recruitment and data collection took place between August and October 2021. The Institutional Review Board of the University of Illinois Chicago (IRB # 2021-0578) approved the study.

Setting

The study was conducted at Mile Square Health Center (MSHC), a federally qualified health center (FQHC) affiliated with the University of Illinois Hospital in Chicago, Illinois. MSHC consists of six primary care clinics in high-poverty neighborhoods with documented health inequalities associated with chronic disease. Annually, the clinic serves more than 40000 patients, most living at or below the federal poverty level (98%)¹⁷.

Recruitment and enrollment

A volunteer convenience sample of providers was recruited from all six MSHCs using posted flyers and outreach via the clinic listserv. Eligibility requirements were: 1) aged ≥21 years, 2) a healthcare provider at MSHC, 3) English-speaking, and 4) able to provide informed consent. Interested individuals contacted the study team directly, and eligible individuals were scheduled for an interview. Recruitment and enrollment occurred continuously until the total sample size was achieved.

Data collection procedures

All participants (n=25) completed the informed consent document and a brief (5–10 minute) demographic survey in REDCap before their interview. Semi-structured in-depth interviews were conducted in person (n=15), over the phone (n=9), or via Zoom (n=1). A standardized moderator’s guide was developed based on primary objectives and study research questions. Sample questions/items included: ‘How often do you refer your patients who smoke to the state quitline?’, ‘Please describe the procedures used by providers in your practice to refer patients to the quitline.’, and ‘How does the typical patient respond to your recommendation for a quitline referral?’. The interviews took 30–45 minutes (mean=40 minutes). Consistent with recommended approaches¹⁸, trained interviewers conducted and audio-recorded each interview and participated in a post-session debriefing to highlight significant themes. Next, audio recordings were transcribed verbatim by an independent transcriber and reviewed by two team members for accuracy. Audio recordings were destroyed after transcription was completed and verified. Participants received a $50 gift card for completing the study.

Data analysis

Data analysis for this study used descriptive statistics to summarize the responses to the demographic questionnaire. Frequencies, means, and standard deviations were computed using SPSS, version 19 (IBM Corporation, Armonk, NY). We used deductive thematic analysis to analyze the interviews¹⁸. Codes were created based on the moderator’s guide and the Consolidated Framework for Implementation Research (CFIR)¹⁹. The CFIR is a widely recognized framework that provides a comprehensive approach to understanding barriers and facilitators to implementation processes. It encompasses five domains: intervention characteristics, outer setting, inner setting, characteristics of individuals, and the process of implementation. To ensure the validity and reliability of qualitative data, we used the Lincoln and Guba²⁰ four criteria: credibility, dependability, confirmability, and transferability. The authors conducted an iterative process, individually reviewing the codes, categories, and themes. Subsequently, the authors met to discuss and document analytic insights, assumptions, and decisions related to the data analysis process. Thematic saturation (i.e. when no additional themes are generated in subsequent rounds of data collection)²¹ was reached with our sample.

Participant characteristics

Participants’ demographic characteristics are summarized in Table 1. Among the 25 participants, 92% were female, 44% were Black, 52% were medical providers, and 60% worked at the largest of the FQHC’s six primary care locations. Participants’ age and work experience averaged 41.5 (SD=9.4) and 5.25 (SD=5.9) years, respectively. Over two-thirds of participants (68%) had not received specialty training in smoking cessation or other addiction counseling. Furthermore, more than half (52%) reported never or rarely referring patients who smoked to the state tobacco quitline.

Qualitative results

The section below summarizes the qualitative findings related to provider attitudes, referral patterns, barriers to patient referral, patient-level factors influencing referral, and recommendations for improving the use of the ITQL among providers. Below, we describe each primary theme and subthemes, with illustrative quotations from the interviewees (coded for anonymity as I#), as appropriate.

Characteristics of individuals: Providers

Provider knowledge and attitudes

Providers generally expressed positive attitudes about the ITQL as a smoking cessation resource for patients receiving care at MSHC. They reported receiving positive information about the ITQL from other clinicians and patients who have used the service. When providers were asked to identify the perceived benefits of the ITQL, they noted the expertise of quitline counselors, the availability of free counseling and nicotine replacement therapies, and the availability and flexibility of the services offered. Further, providers noted the value of having quitline information to share with patients who were not yet ready to quit smoking but might benefit from it:

Patterns of patient referral to ITQL

Despite positive attitudes about the quitline, most providers reported infrequently referring patients to the ITQL. Those who referred patients reported their most common practice was to advise the patient to quit smoking and give them ITQL-related materials (such as business cards, flyers, or handouts). However, patients were responsible for calling the quitline directly after their clinic appointment:

In addition to providing patients with the ITQL information and materials, a few providers completed the required paperwork for direct referral and faxed it to the ITQL:

Characteristics of individuals: Patients

Low-patient motivation to quit

Providers identified patient characteristics impeding patients’ ITQL use. The first was low motivation among patients to engage in smoking cessation:

Difficulties reaching patients

Providers noted the failure of the quitline counselor to reach the patient after a referral. Providers stated that patients often did not recognize the ITQL counselor’s telephone number, missed their telephone calls, or did not check their voicemail:

Language and literacy levels

Patient language skills were listed as barriers to patients’ ITQL use. FQHC settings serve patients with low SES and diverse backgrounds, so some patients need help reading and understanding English. One participant stated that having Spanish-language resources and staff would ease this barrier for patients:

Inner setting

Provider knowledge gaps

When asked why they did not refer patients to the ITQL, providers indicated a lack of knowledge about the quitline, namely when and how to refer patients, what services were available, what patients could expect from the ITQL (its processes or procedures), or how effective the ITQL would be. Also, some providers preferred referring patients to smoking cessation services in their clinic rather than to the ITQL:

Provider time constraints

Time constraints were cited as barriers to educating and referring patients to the ITQL. These constraints often resulted from heavy workloads, patients’ complex needs, and an overall clinic workflow that diverted their attention away from activities related to smoking cessation:

Outer setting

Referral processes

Providers described the referral procedure to the ITQL as cumbersome, especially the complex paperwork and process. One participant reported insufficient system linkage between the clinical setting and the ITQL. Several participants expressed the need for a more efficient process:

Communication and follow-up

Providers also identified the need for more communication between the ITQL and MSHC. Provider-initiated follow-up is optional at MSHC, and no formal data-sharing system has been established between the two systems. As a result, providers expressed a desire for better communication about whether patients accessed quitline services and patient outcomes such as quit status:

One participant shared a positive experience contacting the ITQL to follow up on a patient referral:

Process of implementation: Provider recommendations

Integration of referral processes into usual care

Providers offered recommendations for promoting ITQL linkage for patients. For example, they suggested integrating referrals to the quitline during the clinical appointment or having someone on site who can provide cessation services. Integrating quitline referral processes into usual care would allow providers and quitline staff to establish relationships and trust with patients, increasing the likelihood that patients engage with quitline services:

Bi-directional information exchange

Providers suggested establishing efficient communication and information exchange systems between the ITQL and MSHC. Improved communication would permit providers to stay informed about their patients’ smoking status. Providers felt that access to this information would help them facilitate patients’ connection to and ongoing engagement with the quitline:

Better understanding of patient preferences

Finally, providers recommended considering patient preference when referring them to the ITQL. Some patients preferred to be called directly from the ITQL. However, others prefer to initiate the phone call themselves and perceive the ITQL phone calls as intrusive. Given their differing experiences with patients, the providers disagreed on whether the best approach was for patients to call or for the quitline to contact them:

Strategies for addressing barriers to quitline referral

Strategies to strengthen patients’ quitline use will require attention to multi-level targets. Four are suggested below: provider education, streamlining referral processes, information exchange and data sharing between providers and quitlines, and leveraging the patient portal to provide patient education and monitor referral uptake.

Comprehensive provider education about the services and advantages of quitlines is a crucial first step to increasing patient referrals. Our study findings suggest that healthcare providers would benefit from greater awareness of available resources and training on referring patients to quitlines. Providers often have limited time during patient visits, impeding discussions of smoking cessation options and referrals to tobacco quitlines. However, state tobacco quitlines could collaborate with FQHCs to create concise, evidence-based materials for providers to facilitate patient linkage and referral. These educational materials should highlight the benefits of tobacco quitlines and explain the referral process in a simple and easily understandable format.

A second strategy should establish more streamlined referral processes. Current practices are overly complex and time-consuming. Simplifying and streamlining the process can overcome these barriers, particularly by incorporating tobacco quitline referral options within EHR systems. Referral materials should describe standardized guidelines and steps to ensure efficient referral procedures and specify eligibility criteria, contact information, and necessary documentation. Alternatively, dedicated support staff, such as tobacco cessation coordinators or nurses, can work directly with patients to facilitate the referral process, assist with paperwork, provide patient information, and follow up on referrals. Dedicated staff would reduce the administrative burden on providers and enable referrals with minimal effort and time.

Thirdly, study participants recommended strengthening communication between FQHC providers and quitline counselors using a formal feedback mechanism, information exchange system, and data sharing. More effective communication would alert providers to their patients’ smoking status and progress toward cessation, thereby improving providers’ ability to encourage patient persistence in cessation efforts and engagement with the quitline. One method to improve information exchange and communication across settings is to use the EHR and eReferrals. EHR-supported eReferrals will help maintain smooth clinic workflows in healthcare settings and minimize providers’ cognitive burden²⁶. For example, in a study using data from the EHR at the University of California, Davis Health Systems to send a tobacco eReferral to state quitline²⁶, results showed that over 3 years, 16083 encounters with smokers resulted in 1137 (7.1%) eReferral orders. Treatment reach was 1.6% for quitline services, and referrals doubled after inpatient eReferral order sets were implemented. Among first-time eReferral patients, 12.2% had a 6- to 12-month follow-up visit at which they were documented as non-smoking²⁶.

Finally, time constraints are repeatedly reported as barriers to providers addressing patient’s smoking cessation needs. FQHCs could leverage patients’ health portals to address issues related to time constraints. For example, providers should continue to advise patients to quit smoking and to refer patients to the ITQL. Also, with the referral to the ITQL, an automated message could be sent to the patients’ health portal that serves as a reminder that their provider has referred them to the quitline, provides standardized information about the quitline’s procedures and services, and lists the quitline’s telephone number so patients can recognize it when the quitline calls or they can phone the ITQL directly, based on preferences. Further, the electronic health record could be programmed to send the referral to the state tobacco quitlines and send automated messages to the patient’s portal as a reminder. The sent referral could also trigger a message to patients within a specified timeframe (e.g. two weeks after the referral) to determine whether a connection was made and if barriers were encountered. A community health worker or smoking cessation counselor could monitor patient messages and provide information and resources as needed.

Limitations

It is essential to acknowledge the following limitations. Firstly, data are limited to a single healthcare system in a large urban area with providers from multiple clinic locations within the FQHC. Data from one healthcare system may limit the generalizability of the findings to FQHCs in different geographical locations, particularly those in rural or suburban areas. Providers in these areas may face distinct barriers and require different strategies to facilitate patient referrals to quitline services. Replication of the study in diverse FQHC settings is necessary to identify additional barriers or facilitators.

This study examined provider perspectives only – other factors, such as patient-reported preferences and organizational policies, likely influence quitline referrals. Future research could explore additional factors and patient perspectives to better understand the complex influences on quitline referrals. Research is also needed to expand the understanding of quitline referral practices and optimize their integration into FQHC services. Nevertheless, this study underscores much-needed provider views on utilizing state tobacco quitlines within FQHCs.