Sustained Effects of a Systems-Based Strategy for Tobacco Cessation Assistance

Introduction: Primary care settings that serve lower-income patients are critical for reducing tobacco-related disparities; however, tobacco-related care in these settings remains low. This study examined whether processes for the provision of tobacco cessation care are sustained 18 and 24 months after implementing a health system-level intervention consisting of electronic health record functionality changes and expansion of rooming staff roles. Methods: This nonrandomized stepped-wedge study included electronic health record data from adults with ≥1 primary care visit to 1 of 8 community-based clinics between August 2016 and September 2019. Generalized estimating equations methods were used to compute ORs of asking about tobacco use and among those who use tobacco, providing brief advice to quit and assessing readiness to quit, contrasting 18 and 24 months after implementation to both preimplementation (baseline) and 12 months after implementation. Using a 2-level model of patients clustered in clinics, outcomes were examined over time by clinic site. Analyses were conducted in 2022. Results: A total of 305,665 patient visits were evaluated. Significantly higher odds of all 3 outcomes were observed at 18 and 24 months than at baseline. The odds of asking about tobacco use increased, whereas the odds of advising to quit were similar at 18 and 24 months to those at 12 months. Odds of assessing readiness to quit decreased at 18 months (OR=0.71; 95% CI=0.63, 0.80) and 24 months (OR=0.46; 95% CI=0.40, 0.52). Performance varied significantly by clinical site. Conclusions: Health system changes can have a sustained impact on tobacco assessment and the provision of brief advice among lower-income patients. Strategies to sustain assessment of readiness to quit are warranted.