title: Proactive tobacco cessation outreach to smokers of low socioeconomic status: a randomized clinical trial.
abstract: OBJECTIVE
  Widening socioeconomic disparities in mortality in the United States are largely explained by slower declines in tobacco use among smokers of low socioeconomic status (SES) than among those of higher SES, which points to the need for targeted tobacco cessation interventions. Documentation of smoking status in electronic health records (EHRs) provides the tools for health systems to proactively offer tobacco treatment to socioeconomically disadvantaged smokers.
  
  
  OBJECTIVE
  To evaluate a proactive tobacco cessation strategy that addresses sociocontextual mediators of tobacco use for low-SES smokers.
  
  
  METHODS
  This prospective, randomized clinical trial included low-SES adult smokers who described their race and/or ethnicity as black, Hispanic, or white and received primary care at 1 of 13 practices in the greater Boston area (intervention group, n = 399; control group, n = 308).
  
  
  METHODS
  We analyzed EHRs to identify potentially eligible participants and then used interactive voice response (IVR) techniques to reach out to them. Consenting patients were randomized to either receive usual care from their own health care team or enter an intervention program that included (1) telephone-based motivational counseling, (2) free nicotine replacement therapy (NRT) for 6 weeks, (3) access to community-based referrals to address sociocontextual mediators of tobacco use, and (4) integration of all these components into their normal health care through the EHR system.
  
  
  METHODS
  Self-reported past-7-day tobacco abstinence 9 months after randomization ("quitting"), assessed by automated caller or blinded study staff.
  
  
  RESULTS
  The intervention group had a higher quit rate than the usual care group (17.8% vs 8.1%; odds ratio, 2.5; 95% CI, 1.5-4.0; number needed to treat, 10). We examined whether use of intervention components was associated with quitting among individuals in the intervention group: individuals who participated in the telephone counseling were more likely to quit than those who did not (21.2% vs 10.4%; P < .001). There was no difference in quitting by use of NRT. Quitting did not differ by a request for a community referral, but individuals who used their referral were more likely to quit than those who did not (43.6% vs 15.3%; P < .001).
  
  
  CONCLUSIONS
  Proactive, IVR-facilitated outreach enables engagement with low-SES smokers. Providing counseling, NRT, and access to community-based resources to address sociocontextual mediators among smokers reached in this setting is effective.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT01156610.
authors.affiliation: Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts2Department of Social and Behavior Sciences, Harvard School of Public Health, Boston, Massachusetts3Harvard Medical School, Boston, Massachusetts.
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: Haas
authors.affiliation: Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts3Harvard Medical School, Boston, Massachusetts.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Linder
authors.affiliation: Harvard Medical School, Boston, Massachusetts4Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston5Division of General Internal Medicine, Massachusetts General Hospital, Boston.
authors.forename: Elyse R
authors.initials: ER
authors.lastname: Park
authors.affiliation: Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Irina
authors.initials: I
authors.lastname: Gonzalez
authors.affiliation: Harvard Medical School, Boston, Massachusetts4Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston5Division of General Internal Medicine, Massachusetts General Hospital, Boston.
authors.forename: Nancy A
authors.initials: NA
authors.lastname: Rigotti
authors.affiliation: Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Elissa V
authors.initials: EV
authors.lastname: Klinger
authors.affiliation: Department of Social and Behavior Sciences, Harvard School of Public Health, Boston, Massachusetts.
authors.forename: Emily Z
authors.initials: EZ
authors.lastname: Kontos
authors.affiliation: Harvard Medical School, Boston, Massachusetts.
authors.forename: Alan M
authors.initials: AM
authors.lastname: Zaslavsky
authors.affiliation: Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Phyllis
authors.initials: P
authors.lastname: Brawarsky
authors.affiliation: Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Lucas X
authors.initials: LX
authors.lastname: Marinacci
authors.affiliation: Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Stella
authors.initials: S
authors.lastname: St Hubert
authors.affiliation: Harvard Medical School, Boston, Massachusetts6Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.
authors.forename: Eric W
authors.initials: EW
authors.lastname: Fleegler
authors.affiliation: Department of Social and Behavior Sciences, Harvard School of Public Health, Boston, Massachusetts.
authors.forename: David R
authors.initials: DR
authors.lastname: Williams
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003159:Community-Institutional Relations; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011203:Poverty; D011320:Primary Health Care; D011446:Prospective Studies; D016540:Smoking Cessation / Q000379:methods / Q000706:statistics & numerical data*; D055815:Young Adult