Among 51,554 individuals across 15 safety-net primary care clinics, we found 23% were current smokers, and 26% made a recent cessation attempt. Safety-net clinics delivered medical assistant and provider counseling at high rates, though rates were much lower for behavioral assistant counseling and pharmacotherapy. Contrary to our hypothesis, individuals receiving any type of cessation counseling were less likely to make a cessation attempt. This was dissimilar to our prior work, which found higher odds of making a cessation attempt in those who received medical assistant counseling and provider counseling, albeit the prior study was limited to only four clinic sites with a much smaller study sample.7
Our results highlight how safety-net clinics are able to adequately deliver basic cessation interventions such as provider and medical assistant counseling, and that enhancements in EHR functions allowed demonstration of cessation service delivery. However, delivery of cessation services may not always correlate with cessation attempts, especially in the context of large health systems with diverse subpopulations. For subpopulations with high burden of comorbidities, basic cessation services may be insufficient, highlighting a need for more intensive efforts.8,16 Such efforts may include counseling from care providers of multiple disciplines, combining referrals from different encounters or providers, and streamlined infrastructure to ensure efficient delivery of cessation resources.
Several opportunities for interventions among subgroups exist. Although members of Black/African American, Latinx, and Asian communities are less likely to ever smoke and are more likely to be lighter smokers than their White counterparts, they also face disproportionately worse smoking-related health outcomes.17–19 And despite higher interest in quitting than White individuals and past-year quit attempts, Black/African American individuals have lower rates of sustained cessation. These racial disparities can be attributed to structures of systemic racism, including barriers to accessing care, lower receipt of cessation counseling and pharmacotherapy, and increased targeted marketing of tobacco products to racial/ethnic minorities, making sustained cessation more challenging among these communities.20–23
We found communities of color were well represented across comorbidity groups, with Asian smokers well represented among groups with hypertension and diabetes, Latinx smokers represented among those with diabetes, depression, and HIV, and Black/African American represented across all comorbidity groups, especially hypertension. As efforts in addressing diabetes, hypertension, depression, and HIV have all displayed success in improving health outcomes by using a chronic disease management framework, pairing smoking cessation with other chronic disease management efforts may help address racial/ethnic disparities in smoking outcomes.20,24,25 Such interventions include telephone or in-person outreach to targeted populations, linking cessation counseling with efforts to improve blood pressure or diabetes care targets, or community engagement practices to inform cessation interventions. Latinx and Non-English speaking patients also had higher odds of recent cessation attempts, highlighting the importance of culturally informed and language concordant cessation counseling and resources.26 More intensive efforts would align with equity goals to reduce racial disparities across health systems.
Our findings demonstrate how EHRs can be an effective tool for identifying smokers and delivering basic smoking cessation services within the context of rapid cycle quality improvement work. In the past decade, financial incentive programs for meaningful use of EHRs have increased tobacco screening, documentation of smoking status, and delivery of cessation services in safety-net settings.11,27−29 Additionally, the EHR has shown to be effective in rapidly identifying factors associated with cessation attempts and the receipt of referral services, which could be used to drive quality improvement activities to improve health outcomes.7,13
In the face of many competing priorities, health systems are required to meet minimum criteria to obtain reimbursement and incentives from public insurers. For example, The Public Hospital Redesign and Incentives in Medi-Cal program (PRIME) requires evidence-based quality improvement goals for clinics, including screening for smoking status and counseling every two years.30 However best practices guidelines recommend assessments at every clinical encounter to optimize chances of cessation,31 highlighting how more intensive interventions than those required by public insurers may be needed to improve patient outcomes. Therefore, clinics should acknowledge the need to meet minimum requirements for reimbursement, but also to take measures to strive for best practice recommendations. Health systems can do so by streamlining efforts, including assigning responsibilities to each health team member for providing smoking cessation services or providing guidance on how frequently these services should be provided to avoid redundancy and waste of resources. The EHR is also advantageous in identifying populations that need these intensive interventions, and the PRECEDE-PROCEED model can be used to develop interventions in these contexts. For example, the SFHN implemented an EPIC Enterprise EHR in August 2020. Our evaluation using the PRECEDE-PROCEED is therefore timely in providing critical information to developing system-level approaches to support cessation efforts throughout the network. Already, efforts from this work have led to creation of a tobacco registry that includes a better screening tool for tobacco use embedded within the new EHR and templates to document counseling interventions. The registry can be used to track receipt of cessation services and drive practice changes in delivery of cessation care.
In our study, we found that only a quarter of current smokers made a recent cessation attempt, and of those who made a smoking cessation attempt at visit 2, about half of them relapsed by visit 3. These rates of cessation attempts were lower than the estimated 44% of smoking cessation attempts in the past year made by the general US population.32 Little is known about the rates of cessation attempts in primary care settings, with few studies estimating roughly 36–39% of patients making a recent cessation attempt and 15–20% of patients maintain cessation at one year.24,25,33,34 Ours was one of the few studies evaluating cessation attempts and relapse rates at clinic or system levels within a safety-net system. Because most smokers who attempt cessation are likely to relapse with high average lifetime number of quit attempts before sustained cessation,35,36 program initiatives should pay increasing attention toward sustaining cessation attempts and streamlining interventions to determine which groups require more intensive efforts.
There are several limitations to our study. EHR data relied on patient self-report, and smoking status was not biochemically verified, leading to a potential misclassification bias. However, our repeated assessments of smoking status over time may have reduced potential misclassifications. By excluding people with missing smoking status in the analysis, we may have also introduced some bias.7 Still, our large sample size may have protected against this and allows our data to be generalizable, as the inclusion of a diverse array of patients and clinics may be representative of other safety-net settings. The quality of smoking status data collection could have varied across clinic sites, though all clinics had the same EHR with a structured format for data collection.28 Finally, for some clinics especially those serving young adult populations, the actual numbers of patients who attempted recent cessation were small, leading to inflated percentages of relapse in these clinics.
In conclusion, the EHR can be used to efficiently understand and identify opportunities for improvement in delivering smoking cessation services, especially in subpopulations that may require more intensive, directed efforts to achieve sustained cessation.37–39 Safety-net providers and clinic leaders could consider using the EHR to enhance the reach and efficacy of smoking cessation services, and target subpopulations with high needs in order to reduce racial and health disparities in safety-net settings.