Short-term impact of a randomized, clinic-based trial to improve tobacco cessation services in free clinics

Background: Limited access to cessation programs among the uninsured who use tobacco may contribute to their excess disease burden and poorer survival. Methods: A pilot study to test the impact of evidence-based tobacco cessation strategies in 6 free clinics for the uninsured was undertaken. Six clinics were randomized to receive onsite education by a physician cessation expert or a training director of a free clinic advocacy organization. Systems-level and provider strategies were used to improve patient cessation and provider behavior. Repeated cross-sectional patient exit interviews assessed tobacco use (n=304), provider behavior regarding asking about tobacco (n=301) and, among users, advice and assistance with quitting (n=156) at baseline and 1-month after the intervention. Results: 73% of all patients were asked about tobacco use before and after the intervention. Patients were more likely to be advised to quit (61% vs. 76%, p=.05) and provided with quit assistance (33% to 61%, p<.001) after the intervention. In the multivariable model controlling for patient demographics, the odds of being advised to quit after intervention was not statistically significant (OR=1.68, 95%CI 0.84-3.38), while the odds of being assisted to quit was marginally significant (OR=2.74, 95%CI 0.96-7.85). The percentage of patients who use tobacco declined from 58% to 45%, p=.02 one month after the intervention. Trends are in the desired direction. Conclusions: This intervention appears to improve tobacco cessation and provider behavior related to advice and assistance with quitting, at least in the short-run. Follow-up to assess sustainability of the intervention is underway.