BUILDING A TOBACCO INTERVENTION SYSTEM IN MANAGED CARE Implementing tobacco interventions in the real world of managed care

Over the years we have been working to develop, test, and implement tobacco control interventions as a part of routine care within Kaiser Permanente. Most of our work has been in Kaiser Permanente’s northwest division, based in Portland, Oregon, but we have also implemented similar approaches in several other divisions, including Ohio, Hawaii, and Georgia. I will first describe our general approach, which we call the TRAC model (“tobacco reduction, assessment, and care”), and then share both our progress and some very real diYculties we have encountered in trying to implement the program throughout the health care system. The rationale for delivering brief tobacco intervention during routine care is familiar to those who work in cessation. Tobacco remains the most important cause of preventable disease. We know that most smokers see clinicians frequently, and that these visits create teachable moments when patients are receptive to advice and intervention. When we routinely ignore these intervention opportunities, we are, in eVect, failing our patients. Indeed, metaanalyses from the Agency for Health Care Policy and Research (AHCPR) clinical guideline show that brief advice and support lead to modest but consistent long term eVects on smoking cessation. We also know that brief tobacco interventions are among the most cost eVective of all medical care procedures we routinely oVer. 4 It is for these reasons that the Health Plan Employer Data Information Set (HEDIS) and other quality monitoring groups are holding health care systems accountable for addressing tobacco during clinical care. For me, however, the most important reasons to oVer cessation advice and assistance are that our patients want, need, and expect this kind of support. How are we doing as a nation in delivering cessation advice during medical care visits? Figure 1 displays time trend data from the National Household Interview Survey and the Current Population Survey from the US Bureau of Labor Statistics. Both surveys use national probability samples to estimate the percent of smokers with visits in the preceding year who report that a physician has ever advised them to quit smoking. Back in 1974, few smokers reported ever receiving cessation advice. Advice rates rose sharply by 1986 and have continued to slowly improve up through the mid 1990s. Elsewhere, I have projected what impact our current clinician advice rate might have on smoking cessation rates among the 35 million smokers who see a clinician each year. I assumed a 3% spontaneous quit rate and that primary care interventions, when they are delivered at all, largely consist of simple advice to quit. We might call this the 2A model (“ask and advise”), as opposed to the 4A model (“ask, advise, assist, and arrange”) recommended by the National Cancer Institute (NCI) and the AHCPR. Meta-analyses from the AHCPR clinical guideline estimate that the cessation odds ratio for one to three minutes of simple brief advice is 1.2. Delivering brief advice to 60% of the smokers who see a clinician each year across the country might generate about 126 000 additional quitters over and above the spontaneous rate. If we increase the simple advice rate to 90%, we would produce something like 189 000 additional clinician generated quitters, which would be a substantial achievement. But suppose, once each year, clinicians advised 90% of smokers and that, for the half of these smokers who are at least considering quitting at any given time (“contemplators” in Prochaska’s model), clinicians or their staV also provided 10 minutes of actual cessation counselling and assistance. The AHCPR metaanalyses estimate that 10 minutes of cessation assistance yields a much higher 2.4 odds ratio. This would yield about 756 000 additional quitters per year or a sixfold increase in the number of clinician generated quitters over current practice. My point here is that the third and fourth As in the 4A model really do matter, and we need to overcome the very real barriers that are preventing the delivery of