The Ask-Advise-Connect approach for smokers in a safety net healthcare system: a group-randomized trial.

BACKGROUND: Because smoking has a profound impact on socioeconomic disparities in illness and death, it is crucial that vulnerable populations of smokers be targeted with treatment. The U.S. Public Health Service recommends that all patients be asked about their smoking at every visit and that smokers be given brief advice to quit and referred to treatment. PURPOSE: Initiatives to facilitate these practices include the 5A's (ask, advise, assess, assist, arrange) and Ask-Advise-Refer (AAR). Unfortunately, primary care referrals are low, and most smokers referred fail to enroll. This study evaluated the efficacy of the Ask-Advise-Connect (AAC) approach to linking smokers with treatment in a large, safety net public healthcare system. DESIGN: The study design was a pair-matched group-randomized trial with two treatment arms. SETTING/PARTICIPANTS: Ten safety net clinics in Houston TX. INTERVENTION: Clinics were randomized to AAC (n=5; intervention) or AAR (n=5; control). Licensed vocational nurses (LVNs) were trained to assess and record the smoking status of all patients at all visits in the electronic health record. Smokers were given brief advice to quit. In AAC, the names and phone numbers of smokers who agreed to be connected were sent electronically to the Texas quitline daily, and patients were proactively called by the quitline within 48 hours. In AAR, smokers were offered a quitline referral card and encouraged to call on their own. Data were collected between June 2010 and March 2012 and analyzed in 2012. MAIN OUTCOME MEASURES: The primary outcome was impact, defined here as the proportion of identified smokers that enrolled in treatment. RESULTS: The impact (proportion of identified smokers who enrolled in treatment) of AAC (14.7%) was significantly greater than the impact of AAR (0.5%), t(4)=14.61, p=0.0001, OR=32.10 (95% CI=16.60, 62.06). CONCLUSIONS: The AAC approach to aiding smoking cessation has tremendous potential to reduce tobacco-related health disparities.

Ask-Advise-Connect: a new approach to smoking treatment delivery in health care settings.

IMPORTANCE: Several national health care-based smoking cessation initiatives have been recommended to facilitate the delivery of evidence-based treatments, such as quitline (telephone-based tobacco cessation services) assistance. The most notable examples are the 5 As (Ask, Advise, Assess, Assist, Arrange) and Ask. Advise. Refer. (AAR) programs. Unfortunately, rates of primary care referrals to quitlines are low, and most referred smokers fail to call for assistance. OBJECTIVE: To evaluate a new approach--Ask-Advise-Connect (AAC)--designed to address barriers to linking smokers with treatment. DESIGN: A pair-matched, 2-treatment-arm, group-randomized design in 10 family practice clinics in a single metropolitan area. Five clinics were randomized to the AAC (intervention) and 5 to the AAR (control) conditions. In both conditions, clinic staff were trained to assess and record the smoking status of all patients at all visits in the electronic health record, and smokers were given brief advice to quit. In the AAC clinics, the names and telephone numbers of smokers who agreed to be connected were sent electronically to the quitline daily, and patients were called proactively by the quitline within 48 hours. In the AAR clinics, smokers were offered a quitline referral card and encouraged to call on their own. All data were collected from February 8 through December 27, 2011. SETTING: Ten clinics in Houston, Texas. PARTICIPANTS: Smoking status assessments were completed for 42,277 patients; 2052 unique smokers were identified at AAC clinics, and 1611 smokers were identified at AAR clinics. INTERVENTIONS: Linking smokers with quitline-delivered treatment. MAIN OUTCOME MEASURE: Impact was based on the RE-AIM (Reach, Efficacy, Adoption, Implementation, and Maintenance) conceptual framework and defined as the proportion of all identified smokers who enrolled in treatment. RESULTS: In the AAC clinics, 7.8% of all identified smokers enrolled in treatment vs 0.6% in the AAR clinics (t4 = 9.19 [P < .001]; odds ratio, 11.60 [95% CI, 5.53-24.32]), a 13-fold increase in the proportion of smokers enrolling in treatment. CONCLUSIONS AND RELEVANCE: The system changes implemented in the AAC approach could be adopted broadly by other health care systems and have tremendous potential to reduce tobacco-related morbidity and mortality.