Characteristics of Patients Engaging in Quitline Counseling After an Electronic Referral


      Proactive, electronic referral of primary care patients to quitlines has great potential to provide evidence-based tobacco-cessation assistance to tobacco users. However, the quitline contact rates and engagement of individuals beyond 1 counseling call are poor. This study examines the characteristics of electronically referred patients who engage with the quitline.


      This cross-sectional study included 2,407 primary care patients who reported using tobacco and accepted an electronic referral to the quitline. Outcomes included contact, enrollment, and receipt of ≥2 counseling sessions from the quitline. All measures were assessed from the electronic health record. The association of patient characteristics and outcomes was evaluated using logistic regression modeling with generalized estimating equation methods. Data were collected in 2016‒2018 and were analyzed in 2020.


      Among 2,407 referred patients, 794 (33.0%) were contacted; of those, 571 enrolled (71.9%); and of those, 240 (42.0%) engaged in ≥2 quitline counseling sessions. In multivariable analyses, older adults (aged 50–64 and ≥65 years) were significantly more likely to be contacted (OR=2.32, 95% CI=1.6, 3.4) and to receive ≥2 counseling sessions (OR=2.34, 95% CI=1.2, 4.7) than those aged 18–34 years. Those with both Medicare and Medicaid insurance coverage were more likely than those with Medicaid only to be contacted (OR=1.71, 95% CI=1.4, 2.2), to enroll (OR=1.84, 95% CI=1.2, 2.9), and to receive ≥2 counseling sessions (OR=1.83, 95% CI=1.2, 2.9).


      The current quitline phone-based approach is less likely to engage younger adults and those with Medicaid coverage; however, there is a need to improve quitline engagement across all patients. Identification and testing of alternative engagement approaches are needed.
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        • Stead LF
        • Hartmann-Boyce J
        • Perera R
        • Lancaster T
        Telephone counselling for smoking cessation.
        Cochrane Database Syst Rev. 2013; CD002850
        • Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff
        A clinical practice guideline for treating tobacco use and dependence: 2008 update: a U.S. Public Health Service Report.
        Am J Prev Med. 2008; 35 ( 158-176
        • Fiore M
        • Adsit R
        • Zehner M
        • et al.
        An electronic health record–based interoperable eReferral system to enhance smoking Quitline treatment in primary care [published correction appears in J Am Med Inform Assoc. 2019;26(10):1159].
        J Am Med Inform Assoc. 2019; 26: 778-786
        • Adsit RT
        • Fox BM
        • Tsiolis T
        • et al.
        Using the electronic health record to connect primary care patients to evidence-based telephonic tobacco quitline services: a closed-loop demonstration project.
        Transl Behav Med. 2014; 4: 324-332
        • Flocke SA
        • Seeholzer E
        • Lewis SA
        • et al.
        12-Month evaluation of an EHR-supported staff role change for provision of tobacco cessation care in 8 primary care safety-net clinics.
        J Gen Intern Med. 2020; 35: 3234-3242
        • Piñeiro B
        • Vidrine DJ
        • Wetter DW
        • et al.
        Implementation of Ask-Advise-Connect in a safety net healthcare system: quitline treatment engagement and smoking cessation outcomes.
        Transl Behav Med. 2020; 10: 163-167
        • Bernstein SL
        • Weiss JM
        • Toll B
        • Zbikowski SM
        Association between utilization of quitline services and probability of tobacco abstinence in low-income smokers.
        J Subst Abuse Treat. 2016; 71: 58-62
        • Piñeiro B
        • Wetter DW
        • Vidrine DJ
        • et al.
        Quitline treatment dose predicts cessation outcomes among safety net patients linked with treatment via Ask-Advise-Connect.
        Prev Med Rep. 2019; 13: 262-267
        • Burns EK
        • Deaton EA
        • Levinson AH
        Rates and reasons: disparities in low intentions to use a state smoking cessation quitline.
        Am J Health Promot. 2011; 25: S59-S65
        • Lien RK
        • Schillo BA
        • Mast JL
        • et al.
        Tobacco user characteristics and outcomes related to intensity of quitline program use: results from Minnesota and Pennsylvania.
        J Public Health Manag Pract. 2016; 22: E36-E46
        • Nair US
        • Rabe B
        • Brady BR
        • Bell ML
        Predictors of client retention in a state-based tobacco quitline.
        J Smok Cessat. 2020; 15: 67-75
        • Warlick C
        • Richter KP
        • Mussulman LM
        • Nazir N
        • Patel V
        Prevalence and predictors of quitline enrollment following hospital referral in real-world clinical practice.
        J Subst Abuse Treat. 2019; 101: 25-28
        • Scheuermann TS
        • Preacher KJ
        • Carlini BH
        • et al.
        Predictors of engagement in post-discharge quitline counseling among hospitalized smokers.
        J Behav Med. 2019; 42: 139-149
        • Flocke SA
        • Seeholzer E
        • Lewis SA
        • et al.
        Designing for sustainability: an approach to integrating staff role changes and electronic health record functionality within safety-net clinics to address provision of tobacco cessation care.
        Jt Comm J Qual Patient Saf. 2019; 45: 798-807
        • Hughes JR
        • Cohen B
        • Callas PW
        Treatment seeking for smoking cessation among young adults.
        J Subst Abuse Treat. 2009; 37: 211-213
        • Messer K
        • Trinidad DR
        • Al-Delaimy WK
        • Pierce JP
        Smoking cessation rates in the United States: a comparison of young adult and older smokers.
        Am J Public Health. 2008; 98: 317-322
        • Curry SJ
        • Sporer AK
        • Pugach O
        • Campbell RT
        • Emery S
        Use of tobacco cessation treatments among young adult smokers: 2005 National Health Interview Survey.
        Am J Public Health. 2007; 97: 1464-1469
        • Scott-Sheldon LA
        • Lantini R
        • Jennings EG
        • et al.
        Text messaging-based interventions for smoking cessation: a systematic review and meta-analysis.
        JMIR MHealth UHealth. 2016; 4: e49
        • Spohr SA
        • Nandy R
        • Gandhiraj D
        • Vemulapalli A
        • Anne S
        • Walters ST
        Efficacy of SMS text message interventions for smoking cessation: a meta-analysis.
        J Subst Abuse Treat. 2015; 56: 1-10
        • Fingrut W
        • Stewart L
        • Cheung KW
        Choice of smoking cessation counselling via phone, text, or email in emergency department patients.
        Prev Med Rep. 2016; 4: 597-600
        • Kruse GR
        • Park E
        • Haberer JE
        • et al.
        Proactive text messaging (GetReady2Quit) and nicotine replacement therapy to promote smoking cessation among smokers in primary care: a pilot randomized trial protocol.
        Contemp Clin Trials. 2019; 80: 48-54
        • Grau LE
        • Pham T
        • O'Leary T
        • Weiss J
        • Toll B
        • Bernstein SL
        Smokers’ perspectives on texting for tobacco dependence treatment: a qualitative analysis.
        Nicotine Tob Res. 2017; 19: 307-313
        • Villanti AC
        • West JC
        • Klemperer EM
        • et al.
        Smoking-cessation interventions for U.S. young adults: updated systematic review.
        Am J Prev Med. 2020; 59: 123-136
        • Jamal A
        • Phillips E
        • Gentzke AS
        • et al.
        Current cigarette smoking among adults — United States, 2016.
        MMWR Morb Mortal Wkly Rep. 2018; 67: 53-59
        • Siahpush M
        • McNeill A
        • Borland R
        • Fong GT
        Socioeconomic variations in nicotine dependence, self-efficacy, and intention to quit across four countries: findings from the International Tobacco Control (ITC) Four Country Survey.
        Tob Control. 2006; 15: iii71-iii75
        • Creamer MR
        • Wang TW
        • Babb S
        • et al.
        Tobacco product use and cessation indicators among adults - United States, 2018.
        MMWR Morb Mortal Wkly Rep. 2019; 68: 1013-1019
        • Businelle MS
        • Kendzor DE
        • Reitzel LR
        • et al.
        Mechanisms linking socioeconomic status to smoking cessation: a structural equation modeling approach.
        Health Psychol. 2010; 29: 262-273
        • Haas JS
        • Linder JA
        • Park ER
        • et al.
        Proactive tobacco cessation outreach to smokers of low socioeconomic status: a randomized clinical trial [published correction appears in JAMA Intern Med. 2015;175(5):869].
        JAMA Intern Med. 2015; 175: 218-226
        • Campbell HS
        • Baskerville NB
        • Hayward LM
        • Brown KS
        • Ossip DJ
        The reach ratio–a new indicator for comparing quitline reach into smoking subgroups.
        Nicotine Tob Res. 2014; 16: 491-495
        • Allen AM
        • Yuan NP
        • Wertheim BC
        • Krupski L
        • Bell ML
        • Nair U
        Gender differences in utilization of services and tobacco cessation outcomes at a state quitline.
        Transl Behav Med. 2019; 9: 663-668
        • Babb S
        • Malarcher A
        • Schauer G
        • Asman K
        • Jamal A
        Quitting smoking among adults - United States, 2000-2015.
        MMWR Morb Mortal Wkly Rep. 2017; 65: 1457-1464