300,000 quitters and counting; A systematic approach to tobacco cessation

Abstract

Objective

To describe Kaiser Permanente Northern California's (KPNC) systematic implementation of universal tobacco screening, evidence-based interventions, and performance measures to achieve long-term smoking cessation success.

Methods

We outline seven key components of KPNC's tobacco screening and intervention program that contributed to a significant decline in smoking prevalence. We also report changes in the prevalence of current smokers within KPNC from 2014 to 2023 using linear regression analyses.

Results

Key factors driving the success of the tobacco cessation program included risk-based screening algorithms, alert prompts for at-risk patients, system-wide medical champions, performance tracking, virtual coaching, widespread messaging, and comprehensive medication management. Implementing this multifaceted approach across all facilities was associated with a significant reduction in smoking prevalence, from 8.6% in 2014 to 5.8% in 2023 (p < 0.0001).

Conclusion

Our comprehensive, system-wide approach resulted in substantial public health gains and highlights the potential of similar preventive strategies as healthcare systems transition toward value-based care.

1. Introduction

Cigarette smoking is a major cause of cardiovascular disease (CVD) and causes one of every four deaths from CVD [1]. In 2021, an estimated 11.5% (28.3 million) of U.S. adults currently smoked cigarettes [2]. In a large, real-world study, young adults who were current smokers had more than twice the risk of premature CVD compared with never-smokers [3].

Kaiser Permanente Northern California (KPNC) is an integrated healthcare system with more than 4.5 million members. In 2014, universal screening for tobacco use among adult members was updated, partnered with evidence-based interventions and performance measures to achieve long-term quit success, redefining what smoking cessation outcome is attainable within an integrated delivery system [4].

2. Methods

Outpatient efforts included all adult Northern California members aged ≥18 who received care within one of our 15 service areas, which includes 207 outpatient facilities. During the rooming process, the medical assistant (MA) initially screens for tobacco use based on a risk-based algorithm. Tobacco screening prompts are activated (∼250,000 per month) across 50 departments, including ∼800 surgical cases per month. Smoking status is highlighted by an identifier noting positive tobacco status, to flag clinicians making them aware of active tobacco use. Our electronic medical record (EMR) also has alerts built into the daily schedule which reflect active tobacco use. Our approach integrates multiple evidence-based strategies tailored to the clinical environment within a large, integrated healthcare system, helping to ensure that patients receive both behavioral and medical support, which increases the likelihood of long-term quit success. For performance evaluation, we conducted exploratory analyses to examine the prevalence of tobacco use and cessation among adult KPNC members aged 18 and older from 2014 to 2023 and tested each outcome for linear trends to assess significant increases or decreases in the outcome over time since adopting the systematic approach. The Research Determination Committee for the Kaiser Permanente Northern California region determined that the project did not meet the regulatory definition of research involving human subjects per 45 CFR 46.102(d).

3. Results

Adopting this multifaceted approach across all facilities was associated with a drop in tobacco prevalence (from 8.6% in 2014to 5.8% in 2023) (Fig. 1). Linear regression analyses showed that the average prevalence of smoking decreased by approximately 0.34% each year (p-value <0.0001). For the quit percentage, on average, the quit rate has increased by approximately 0.41% each year (p-value = 0.02). A critical feature in reducing morbidly and mortality of cigarette use, the reduction in current smoking in KPNC contributing to an estimated 3 million life-years saved from all causes.

Fig. 1.

Smoking Cessation Implementation Program in a Large Integrated Healthcare System.

Legend. Tobacco use prevalence decreased on average by 0.34% each year (p<0.0001). The percentage of current tobacco cessation increased on average by 0.41% each year (p=0.02).

4. Discussion

The successful adoption of this program relied on seven key features (Fig. 1):

4.1. Risk-Based Screening Algorithms

Successful smoking cessation programs incorporate coordinated in-reach and outreach strategies. This includes screening patients and delivering timely, personalized interventions based on their smoking status. A critical feature in tobacco-based screening is adopting a risk-based algorithm to avoid the unnecessary screening of every patient, every time, especially in low-risk cases (never smokers). This optimizes efficiency and reduces patient and clinician fatigue from repetitive questioning. Our EMR has a built-in screening algorithm based on clinical risk and associated risk for relapse to ensure that clinicians are consistently aware of patients’ smoking status, leading to more timely interventions. Patients aged 13 to <18 are screened at every visit regardless of smoking history. Patients aged ≥18 are screened at every visit if they are current smokers or quit in the last year, and every 2 years if they are never smokers. Adding follow-up outreach by phone or email to those who smoke or recently quit provides an additional layer of support. Patients’ smoking status is entered into the EMR by medical assistants and other staff. A successful quit status is based on two entries of “former smoker” at least three weeks apart. If a patient returns to smoking at any time their smoking status changes back to current smoker.

4.2. Alert Prompts on Tobacco Status for At-Risk Patients

We emphasize smoking cessation efforts at critical touch points, including hospital admissions, surgical consultations, and prenatal care, maximizing opportunities for intervention.

4.2.1. Hospital Admission

With every hospital admission, smokers are required to be smoke-free for the duration of their admission. Upon admission, smoking status is visible to Emergency Room physicians and admitting physicians, and clinical teams are prompted to provide tobacco cessation counseling. Prepopulated nicotine replacement therapy (NRT) prescriptions are included in admission order sets, so early on, smokers can be placed on medical therapy to address new onset withdrawal symptoms. Discharge physicians also notify their local health education department so they can place post-discharge calls to the home, supporting patients to maintain their quit status and use of medications as needed. This approach has been associated with an increase in the utilization of NRT in the inpatients and post discharge setting leading to an improvement in post-hospitalization quit rates [5].

4.2.2. Surgical Consultation

Perioperative smoking cessation is critical to optimize surgical outcomes intraoperatively and during the recovery period. We have integrated surgical cessation workflows that enhance screening and timely intervention. Any surgical referral from primary care is prompted to check smoking status and encourage quitting tobacco prior to any surgical consultation. Surgeons submitting a surgical case request are also prompted to order carbon monoxide (CO) testing on the day of surgery as a means of assessing tobacco use in the prior 24 hours. This program is associated with increased rates of biochemically verified smoking cessation rates on the day of surgery [6].

4.2.3. Pregnancy

Upon pregnancy intake, smoking history is determined as part of the prenatal initial evaluation. Women who continue to smoke during their pregnancy or smoke daily prior to their pregnancy are offered counseling with a licensed mental health clinician who specializes in prenatal substance use to assess their usage, help them abstain from tobacco and other drugs, and reduce the risk for relapse during pregnancy and postpartum. Supplemental counseling sessions can occur throughout the pregnancy based on risk and the clinician's perception of need.

4.3. System-wide Medical Champions

One critical feature in launching a broad-scale smoking cessation campaign is to create visibility at the medical centers and a vehicle through which education, communication, and sharing of best practices can be imparted to physicians and staff regularly. To do this, each medical center has appointed dedicated tobacco consultants or champions with allocated administrative time. This role is defined by a job description, and an expectation that annual quit target goals are drafted by the tobacco teams at each medical center. This group of champions meets twice a year as a peer group, where they learn from one another and share Northern California performance measures regularly with their medical center peers.

4.4. Tracking Performance Metrics

Each year, our regional tobacco team sets a Northern California quit target, with specific measures for each medical center. We track each site's performance monthly and provide results to KPNC consultants and quality leads regularly. This report is then shared at the medical center to reinforce the importance of this work and drive performance measures. This measure is also one of clinical data points on the KPNC quality report, shared with KPNC leadership and insurance purchasers who are interested to see performance on these critical clinical drivers of health outcomes.

4.5. Virtual Coaching

The gold standard in supporting tobacco cessation is to provide timely and personalized counseling and medical therapy. To ensure this, we have a free telephonic wellness service to support these quit attempts. This service relies on experts in behavior change and is overseen by a physician to allow for tailored medical therapy. Physicians can refer patients, review these appointments, and see the medications used to support a quit attempt. Patients can also self-refer. These coaches are also well-versed in weight and stress management, so additional factors influencing a quit attempt can also be addressed during these sessions.

4.6. Socializing Message at Broad Scale

Upon initiation of this work, we designed a KPNC competition that ran throughout all our medical centers. The goal was to create an ideal tagline for our campaign; We received close to 100 submissions from multiple sites to come up with the #50,000 Quitters Campaign and an associated logo. This event created increased visibility, and additional buy in from physicians and staff who participated in the competition. To this day, we have kept the Quitters Campaign as our tagline, but with over #300,000 quitters to date since its inception in 2014, our target has grown incrementally over this 10-year period.

4.7. Medication Management

We created smart order sets, so busy clinicians can easily order the right medication in the right dose each time. For NRT, we have built order sets based on tobacco usage to ensure patients get adequate NRT as part of their drug therapy, potentially reducing the risk of relapse due to withdrawal symptoms. Importantly, there are no associated copays for prescribed NRT when filled at a KPNC pharmacy.

We recognize the limitations of this quality-improvement analysis for a Short Communication, since prevalence rates were calculated using aggregated, shifting data across a 10-year period, we are unable to provide detailed characteristics for a single population nor conduct stratified analyses by age, sex, ethnicity and risk factors.

5. Conclusion

Our global and holistic systems approach has generated promising outcomes with enormous reach and public health impact. Comparable interventions could be applied across most healthcare systems, even in settings with fewer resources or without an integrated electronic health record system. Any system can inquire about smoking status, encourage patients to quit, prescribe cessation medications, and connect patients to smoking cessation counseling services (either within the healthcare system or through external resources like state quit lines). Implementation of similar, comprehensive preventive approaches will be key as healthcare systems shift towards value-based care [7].

CRediT authorship contribution statement

Renee Fogelberg: Writing – review & editing, Writing – original draft, Methodology, Data curation, Conceptualization. Kelly C. Young-Wolff: Writing – review & editing, Writing – original draft, Conceptualization. Jaya Nadella: Formal analysis, Data curation. Mehreen Khan: Writing – review & editing. Yi-Fen Irene Chen: Writing – review & editing. Jamal S. Rana: Writing – review & editing, Writing – original draft, Methodology, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. No funding was received for this study.