Proactive Tobacco Treatment More Successful than Usual Care among Veterans Attempting to Quit Smoking

BACKGROUND:
Tobacco use remains the number one cause of premature death and morbidity in the United States. Most cigarette smokers want to quit smoking, and about 50% make a quit attempt each year, but only 6% achieve long-term cessation. This randomized controlled trial – the Veterans Victory over Tobacco Study – compared the effects of a proactive tobacco cessation care model versus a traditional cessation care model on the use of tobacco treatment and subsequent population-level smoking cessation rates. Veterans from four VAMCs were recruited from 10/09 to 9/10 and were randomized to either usual care (i.e., reactive care) or the proactive care intervention. Veterans in the usual care group (n=2,604) received access to tobacco treatment services from their VAMC. Veterans in the proactive care intervention group (n=2,519) received proactive outreach (mailed invitation materials followed by telephone outreach); and were offered a choice of smoking cessation services (telephone care or in-person care). The primary outcome was six-month prolonged smoking abstinence one year after randomization. Investigators also analyzed baseline demographics, clinical characteristics (i.e., distance to VAMC, comorbid psychiatric conditions), and smoking history.

FINDINGS:

• Proactive tobacco cessation care that connected smokers to evidence-based telephone or in-person smoking cessation services is effective for increasing long-term, population-level cessation rates. The six-month prolonged smoking abstinence rate at one year was 14% for Veterans in the proactive care group, a significant increase compared to 11% for Veterans in the usual care group, and much higher than the 6% population-level cessation rate of the total US population.
• The proactive care group reported significantly higher rates of behavioral counseling combined with medication treatment compared to usual care (13% versus 5%). There was also a significant increase in receipt of a smoking cessation medication from VA providers among proactive care compared to usual care (35% versus 30%).
• There were no significant differences in the baseline characteristics for demographics, distance to their VAMC, and comorbid smoking-related conditions between the two groups. Also, about 85% of the usual care group and 83% of the proactive care group were daily smokers.

LIMITATIONS:

• The follow-up survey response rate was 66%, and there is the potential for non-response bias.
• It is not possible to determine which specific components of the multi-component intervention were responsible for the effectiveness of the intervention; however, all components are ready to implement in actual clinical practice.

IMPLICATIONS:

• A 3% increase in the population-level cessation rate is highly significant from a public health perspective because all smokers were included regardless of motivational level to quit smoking.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IAB 05-303). Dr. Fu is Director of HSR&D's Center for Chronic Disease Outcomes Research in Minneapolis, MN.

Fu SS, van Ryn M, Sherman S, et al. Proactive Tobacco Treatment and Population-Level Cessation: A Pragmatic Randomized Controlled Trial. JAMA Internal Medicine March 10, 2014;e-pub ahead of print.