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Rates of Enrollment in Smoking Cessation Services Following Fax Referrals From a Children's Hospital
Rates of Enrollment in Smoking Cessation Services Following Fax Referrals From a Children’s Hospital Laura L. Sisterhen, MD, MPH; Christine E. Sheffer, PhD; Zoran Bursac, PhD, MPH; Ellen P. Fischer, PhD (29%) enrolled. Women were more likely to enroll than men (odds ratio [OR] 1.81; 95% confidence interval [95% CI], 1.09– 3.01). Whites were twice as likely to enroll than African Americans (OR 2.35; 95% CI, 1.28–4.33). Older age (OR 1.04; 95% CI, 1.01–1.06) and higher self-efficacy scores (OR 1.13; 95% CI, 1.02–1.26) increased the likelihood of enrollment.
Objective.—The aim of this study was to describe the rates of enrollment in tobacco dependence treatment among smoking adults who accepted a fax referral from health care providers at a children’s hospital, and to examine smoker characteristics associated with enrollment. Methods.—Secondary analysis of the state-sponsored fax referral and treatment program data on all referrals from Arkansas Children’s Hospital in 2005 to 2007 was conducted. Enrollment was defined as attendance at 1 or more counseling sessions within 1 year of referral. Logistic regression analyses were used to identify demographic and tobacco-related characteristics associated with enrollment versus nonenrollment in a treatment program among those contacted by the program. Results.—Of the 749 faxed referrals to the program, 157 (21.0%) enrolled in a treatment program and received 1 or more treatment sessions; 505 were contacted by the program, and of these, 147
Conclusions.—Approximately 1 in 5 smokers who accepted a fax referral enrolled in and received intensive treatment services for tobacco dependence. Thus, innovative approaches are needed to increase enrollment among younger, African American, and male smokers. KEY WORDS: enrollment; fax referral; tobacco use cessation; telephone counseling; pediatric Academic Pediatrics 2010;10:200–4
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numerous barriers to referring caregivers to smoking cessation programs, including perceptions that caregivers are not interested and will ignore pediatricians’ advice.7 Telephone counseling services (quit lines) are now widely available in North America, and nearly all quit lines provide a special fax referral form for health care providers to conveniently refer patients to treatment.8 Upon receipt of a faxed referral, the program initiates contact with the smoker and assists him/her with enrollment. Although this process makes practical sense, there is little in the published literature on the outcome of referrals, especially those faxed from a pediatric setting. In this study, we provide a descriptive report on the enrollment status in a 2-year period of faxed referrals from a large, tertiary children’s hospital to state-sponsored referral and treatment services for tobacco dependence. We also describe smoker characteristics associated with enrollment in treatment for tobacco dependence. Based on the transtheoretical model of behavior change,9,10 we hypothesized that persons with higher levels of selfefficacy (confidence to quit smoking and stay quit when tempted) and persons in the ‘‘preparation’’ and ‘‘action’’ stages of readiness (intend to quit in the next 30 days or have already made a quit attempt, respectively) would be more likely to enroll in treatment.
xposure to secondhand smoke is a major cause of childhood morbidity and mortality, causing childhood pneumonia, bronchiolitis, asthma, otitis media with effusion, as well as extended hospital stays and recovery times.1–3 Approximately one third of children in the United States are exposed to secondhand tobacco smoke in the home.4 Brief interventions for smoking cessation are recommended by the US Public Health Service clinical practice guideline for the treatment of tobacco use and dependence and endorsed by the American Academy of Pediatrics.5,6 All health care providers should ask patients and caregivers (ie, foster parents, grandparents, and other relatives who care for children) about tobacco use at every visit and offer advice and assistance to those who use tobacco; however, in practice, pediatricians seldom refer caregivers to cessation programs.7 Pediatricians cite From the Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark (Dr Sisterhen); Departments of Health Behavior and Health Education (Dr Sheffer), and Biostatistics (Dr Bursac), College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Ark; Departments of Psychiatry and Epidemiology, Colleges of Medicine and Public Health, University of Arkansas for Medical Sciences, Little Rock, Ark (Dr Fischer); and Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Ark (Dr Fischer). Address correspondence to Laura L. Sisterhen, MD, MPH, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, 1 Children’s Way, Slot 900, Little Rock, Arkansas 72202-3591 (e-mail: [email protected]). Received for publication May 13, 2009; accepted March 2, 2010. ACADEMIC PEDIATRICS Copyright Ó 2010 by Academic Pediatric Association
METHODS Study Design, Setting, and Data Sources We conducted a secondary analysis of data collected on all smokers who accepted a referral to the Arkansas fax
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referral program (SOSWorks) from personnel at Arkansas Children’s Hospital (ACH) over the 2-year period from May 6, 2005 to July 25, 2007 (n ¼ 749). During the study period, statewide tobacco referral and treatment services in Arkansas were directed by the second author (Christine E. Sheffer) at the University of Arkansas for Medical Sciences. The University of Arkansas for Medical Sciences Institutional Review Board approved this study. ACH is a large tertiary pediatric hospital and teaching affiliate of University of Arkansas for Medical Sciences. ACH employs a tobacco interventionist to assist ACH health care providers in addressing smoking cessation. The tobacco interventionist provides one 5-minute counseling session to smokers, written materials, and an offer to fax a referral. All ACH providers can order a tobacco intervention consultation for inpatients, outpatients, relatives, and caregivers. Most consultations are requested by the General Pediatric Clinic. Although the General Pediatric Clinic has a systematic method (clinic note prompts) of identifying and documenting caregiver tobacco use, there is no hospital-wide policy or procedure at ACH. Providers also have the option of faxing a referral directly without the assistance of the tobacco interventionist. Following receipt of the faxed referral, tobacco treatment specialists at the referral program, SOSWorks, made up to 6 attempts to contact the smoker by telephone. Once a smoker was contacted, the tobacco treatment specialists collected demographic and tobacco-related information on the referred smoker. Following data collection, the tobacco treatment specialists offered to schedule an appointment for the smoker to receive either telephone counseling through the quit line or in-person counseling at a treatment clinic near his/her home, in accordance with the smoker’s preferences. Outcome Measure The primary outcome measure was the proportion of referred smokers who enrolled in treatment within 1 year of referral. Enrollment in treatment was defined as attending 1 or more structured, evidence-based treatment sessions. Attendance was determined by treatment program record review. Predictor Measures Variables included in our analyses were gender, race/ ethnicity (white, African American, Hispanic/Latino, Pacific Islander, American Indian/Alaskan Native, multiethnic, or other), usual number of cigarettes smoked per day, readiness to quit, motivation to quit, self-efficacy for quitting, and, for women, pregnancy status. To determine usual number of cigarettes smoked per day, smokers were asked, ‘‘How many cigarettes do you smoke on a usual day?’’ Readiness to quit was assessed with the transtheoretical model by asking the smoker, ‘‘Tell me about your plans to quit using tobacco.’’ Options included standard responses used with the transtheoretical model to assess readiness: ‘‘have already stopped’’ (action), ‘‘plan on stopping, or stopping again, in next 30 days’’
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(preparation), ‘‘plan on stopping in next 6 months’’ (contemplation), ‘‘plan on stopping but not in next 6 months’’ (precontemplation), and ‘‘no plans to stop smoking’’ (precontemplation).9,10 Readiness to quit status was dichotomized as action/preparation or contemplation/ precontemplation. We included persons in the action stage because they were seeking assistance, still in the process of quitting, and at high risk of relapse. These smokers were likely to have made a quit attempt in response to the health care provider advice between the time of the referral and contact by SOSWorks. Motivation and self-efficacy were measured by asking the questions, ‘‘On a scale from 0 to 10, where 0 is none at all and 10 is the most ever, how much do you want to quit smoking?’’ and ‘‘ . . . how confident are you that you can quit and stay quit for good?’’ respectively.11,12 Statistical Analyses SAS version 9.2 (SAS Institute Inc, Cary, NC) was used for all analyses, with 2-sided alpha at the .05 level for statistical significance. Summary statistics were calculated to describe the characteristics of referred smokers. Univariate analyses were performed using c2 for categorical variables and 2-sample t test for normally distributed continuous variables. Because motivation and selfefficacy scores were not normally distributed, the Wilcoxon signed rank test was used to test distributional equality between smokers who did and did not enroll. We used multivariate logistic regression to predict enrollment among those contacted. Predictor variables included age, gender, race/ethnicity, cigarettes smoked per day, readiness to quit, motivation to quit, and selfefficacy. Race/ethnic categories were collapsed into white, African American, and unknown/other for analysis. We conducted separate sensitivity analyses to assess the effect of including those of unknown race/ethnicity first in the African American category and second, in the white category. RESULTS During the 2-year period, 749 smokers accepted a referral to SOSWorks from ACH. The majority of referrals were white (53.7%), 21% were African American, 0.9% other (5 Hispanic, 2 Asian, 1 other), whereas race/ ethnicity was unknown for 24.4%. Two thirds of referrals were female (69.4%). The mean age was 31.4 years 9.3 (range, 14–64, with 10 aged less than 18 years of age). Nearly all were Arkansas residents (99.3%) and reported English as their preferred language (99.2%). Of the 749 smokers referred, 21.0% enrolled in a treatment program. Most enrolled within 30 days of the faxed referral (137/ 157), 11 enrolled between 30 and 60 days, and 9 enrolled between 60 and 310 days of the referral. SOSWorks was able to contact 67.4% (N ¼ 505) of referred smokers. Those contacted did not differ from those not contacted in terms of race, gender, or language preference; however those not contacted were significantly younger than those contacted (mean age, 30.2 vs 31.9 years, P ¼ .02).
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Nearly all those contacted (89.7%) desired treatment and were planning to or had made a recent quit attempt (86%). Those contacted reported high motivational levels (mean 9.3) and moderate levels of self-efficacy (mean 7.9). Of those that desired treatment (n ¼ 453), most (88.3%) requested treatment from the quit line; 11.3% requested inperson treatment; and 2 selected self-help software only. Of the 505 smokers contacted by SOSWorks, 29.1% enrolled in treatment. Those who enrolled were older, more likely to be white, and reported higher levels of motivation to quit and self-efficacy for quitting (Table 1). Among the subset of smokers contacted by SOSWorks, increasing age, increasing self-efficacy scores, being female, and being white were independent and statistically significant predictors of enrollment. As seen in Table 2, the odds of enrollment increased 13 percentage points for each 1-unit increase in self-efficacy score. Associations between enrollment and cigarettes smoked per day, readiness, and motivation were not statistically significant. White smokers were more than twice as likely as African American smokers to enroll in treatment. When the unknown group was included in the African American category, the odds ratios in the model did not change substantially or significantly. However, when the unknown group was included in the white category, the odds ratio for the association between being white and enrollment decreased (odds ratio 1.61; 95% confidence interval, 0.97–2.65) and became nonsignificant. Although sensitivity analyses explored the impact of combining the unknown race/ethnicity group with other race/ethnicity groups, we present the results with the unknowns as a separate category because the group was so large (Table 2).
DISCUSSION Our findings demonstrate that about two thirds of faxed referrals from ACH were contacted by the referral program and nearly one third (29.1%) of those contacted enrolled in treatment within 1 year of the referral. Factors associated with increased probability of enrollment were female gender, white race, increasing age, and higher levels of self-efficacy. Although this enrollment rate may seem low, it is similar to the 23.6% enrollment rate reported by the Ohio faxed referral program and falls within the range of enrollment rates reported in the literature (14.7%– 53%).13–17 We hypothesized that smokers with higher self-efficacy and those in the preparation/action stage of readiness to quit would have higher rates of enrollment. The transtheoretical model posits that a person making a behavior change, such as quitting smoking, will progress through a series of stages over time. Prior to making a quit attempt, termed ‘‘action,’’ a smoker will progress from precontemplation (resistance to change) to contemplation (weighing the benefits of quitting smoking against the costs of quitting) to preparation (having a plan for action). Because nicotine is so highly addictive, many smokers make multiple quit attempts and cycle through some or all of the stages several times before achieving long-term abstinence.9 Our results
ACADEMIC PEDIATRICS Table 1. Characteristics of Smokers Contacted by the Faxed Referral Program Enrolled at 1 Year
Characteristic
Total N ¼ 505
Yes n ¼ 147 No. (%)
No n ¼ 358 No. (%)
Gender Female 348 110 (74.8) 238 (66.5) Male 157 37 (25.2) 120 (33.5) Race White 267 92 (62.6) 175 (48.9) African American 98 23 (15.6) 75 (20.9) Other 5 2 (1.3) 3 (0.8) Unknown 135 30 (20.4) 105 (29.3) Pregnant Yes 17 5 (4.5) 12 (5.0) No 315 103 (93.6) 212 (89.1) Unknown 16 2 (1.8) 14 (5.9) Readiness to quit† Action 6 0 6 (1.7) Preparation 426 136 (92.5) 290 (81.0) Contemplation 29 6 (4.1) 23 (6.4) Precontemplation 1 0 1 (0.2) Unknown 43 5 (3.4) 38 (10.6) Age, y§ 31.9 9.4 34.0 9.9 31.0 9.1 Motivationk 9.3 1.2 9.5 1.0 9.2 1.2 Self-efficacyk 7.9 2.3 8.3 1.9 7.7 2.4 Cigarettes per day§ 19.5 12.1 21.1 12.6 18.8 11.8
P Value .07
.02*
.78
.19‡
.003 .03 .02 .053
*Comparison between white, African American, and unknown/other. †Action: having already quit; preparation: planning to quit in next 30 days; contemplation: planning to quit in next 6 months; precontemplation: planning to quit, but not in next 6 months, or no plans to quit. ‡Comparison between action/preparation and contemplation/precontemplation. §Mean SD. kMean SD, measured on a scale of 0–10.
supported the hypothesis regarding self-efficacy, but not the hypothesis regarding readiness. Readiness to quit was not associated with enrollment. The lack of a significant association with readiness to quit and motivation may be due to the limited variability in the scores among respondents. The process of accepting a referral is likely to selfselect for those who are more motivated and more ready to quit. Those who are not ready simply do not agree to a referral. The significance of age and race as predictors of enrollment is consistent with the literature on participation rates in cessation programs among young adult smokers.18 The reasons for the disparity in race is unclear; however, African Americans may be less likely to enroll because of a general lack of trust in health care institutions.19 Lower socioeconomic status, more common in African Americans, may also contribute to a lack of resources that might enable enrollment. An awareness of these factors may help providers personalize their approach and the effectiveness of their referrals. These results may generalize to other pediatric settings. We were not able to evaluate the impact of the tobacco interventionist’s consultation on enrollment rates. Her presence could have increased enrollment given the additional counseling and her expertise, or could have decreased enrollment if smokers felt she had already
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Table 2. Logistic Regression Results for Enrollment Within 1 Year of Referral Among Those Contacted by the Faxed Referral Program (N ¼ 505)* Characteristic
Odds Ratio
95% CI
P Value
Age Gender Male Female Race African American White Other/unknown Cigarettes per day Readiness to quit (stage of change) Precontemplation/ contemplation Action/preparation Motivation Self-efficacy
1.04
1.01–1.06
.005
Reference 1.81
1.09–3.01
.02
Reference 2.35 1.31 1.01
1.28–4.33 0.67–2.57 0.99–1.03
.006 .44 .39
0.56–4.00 0.97–1.49 1.02–1.26
.42 .10 .02
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cannot know how many smokers would have enrolled in treatment without a faxed referral. However, unassisted referral enrollment rates are generally quite low,21 and proactive telephone calls have been shown to increase enrollment.22 The lack of data on treatment outcomes may be perceived as a limitation of this study. However, assessing abstinence was outside the scope of this study. Treatment for tobacco dependence has been shown to be effective with a wide variety of populations;5 there is no reason to expect treatment outcomes following referrals from ACH to differ significantly from those achieved by other patients in this and similar evidence-based treatment programs.
Reference 1.51 1.20 1.13
CI ¼ confidence interval. *Model included all independent variables shown in table. Model goodness of fit was measured by the Hosmer-Lemeshow test: chi square ¼ 5.1; df ¼ 8; P ¼ .75.
Conclusion In summary, approximately 1 in 5 smokers who accepted a fax referral in the context of a child’s health care visit enrolled in and received intensive treatment services. Thus, innovative approaches are needed to increase enrollment among younger, African American, and male smokers. ACKNOWLEDGMENTS
counseled them. Comparable studies that did not utilize a counselor achieved similar results. A number of other cost-effective strategies can be implemented to facilitate faxed referrals, such as converting fax forms into an electronic format automatically populated with the necessary information and electronically faxed through the electronic medical record system. Adding 5 minutes of physician counseling (accomplished by the interventionist in this context) to every encounter with a smoker may or may not be feasible, or even necessary. The responsibilities for asking about tobacco use, advising the smoker to quit, and referring for treatment can be shared among various staff members.5 Quit lines are now widely available in North America, and nearly all quit lines provide a special faxed referral form for physicians to conveniently refer patients to treatment free of charge.8 Although the cost for staff time to offer and fax a referral has been estimated to be $1.75 per referred patient,20 this is truly a minimal investment to achieve an often dramatic reduction in disease by eliminating exposure to secondhand tobacco smoke. In addition, diagnostic and treatment codes exist for pediatrician counseling on parental tobacco use, which could offset these minimal costs—provided there is reimbursement. Limitations The limitations of this study include missing data or data that would be informative but was not collected by the referral program. Among those contacted, 15% were missing motivation and self-efficacy level data, and 27% were missing race/ethnicity data. Data that would be of interest and were not collected include whether referred smokers were patients or caregivers and the context of the visit (child’s hospitalization or outpatient visit). Furthermore, in the absence of a comparison group, we
The faxed referral and treatment programs in this study were supported by grants and contracts awarded to Dr. Christine Sheffer from the Arkansas Department of Health with Master Settlement Funds. We thank Debbie Rushing, CTTS, and Suzanne Speaker, MS, for assistance with the preparation of the manuscript.
REFERENCES 1. Best D; Committee on Environmental Health; Committee on Native American Child Health; Committee on Adolescence. From the American Academy of Pediatrics: Technical report–Secondhand and prenatal tobacco smoke exposure. Pediatrics. 2009;124:e1017–e1044. 2. DiFranza JR, Lew RA. Morbidity and mortality in children associated with the use of tobacco products by other people. Pediatrics. 1996;97: 560–568. 3. DiFranza JR, Aligne CA, Weitzman M. Prenatal and postnatal environmental tobacco smoke exposure and children’s health. Pediatrics. 2004;113(4 suppl):1007–1015. 4. US Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Secondhand Smoke: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006. 5. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, Md: US Department of Health and Human Services, Public Health Service; 2008. 6. American Academy of Pediatrics (Committee on Environmental Health, Committee on Substance Abuse, Committee on Adolescence, and Committee on Native American Child Health). Policy statement tobacco use: a pediatric disease. Pediatrics. 2009;124:1474–1487. 7. Perez-Stable EJ, Juarez-Reyes M, Kaplan C, et al. Counseling smoking parents of young children: comparison of pediatricians and family physicians. Arch Pediatr Adolesc Med. 2001;155:25–31. 8. Cummins SE, Bailey L, Campbell S, et al. Tobacco cessation quitlines in North America: a descriptive study. Tob Control. 2007;16(suppl 1): i9–i15. 9. Velicer WF, Prochaska JO, Fava JL, et al. Smoking cessation and stress management: applications of the Transtheoretical Model of behavior change. Homeostasis. 1998;38:216–233.
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10. DiClemente CC, Prochaska JO, Fairhurst SK, et al. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol. 1991;59: 295–304. 11. McKee SA, O’Malley SS, Salovey P, et al. Perceived risks and benefits of smoking cessation: gender-specific predictors of motivation and treatment outcome. Addict Behav. 2005;30:423–435. 12. Moolchan ET, Berlin I, Robinson ML, Cadet JL. Characteristics of African American teenage smokers who request cessation treatment: implications for addressing health disparities. Arch Pediatr Adolesc Med. 2003;157:533–538. 13. Bentz CJ, Bayley KB, Bonin KE, et al. The feasibility of connecting physician offices to a state-level tobacco quit line. Am J Prev Med. 2006;30:31–37. 14. Willett JG, Hood NE, Burns EK, et al. Clinical faxed referrals to a tobacco quitline: reach, enrollment, and participant characteristics. Am J Prev Med. 2009;36:337–340. 15. Wadland WC, Holtrop JS, Weismantel D, et al. Practice-based referrals to a tobacco cessation quit line: assessing the impact of comparative feedback vs general reminders. Ann Fam Med. 2007;5: 135–142.
ACADEMIC PEDIATRICS 16. Ebbert JO, Carr AB, Patten CA, et al. Tobacco use quitline enrollment through dental practices: a pilot study. J Am Dent Assoc. 2007;138: 595–601. 17. Mahabee-Gittens EM, Gordon JS, Krugh ME, et al. A smoking cessation intervention plus proactive quitline referral in the pediatric emergency department: a pilot study. Nicotine Tob Res. 2008;10: 1745–1751. 18. Audrain-McGovern J, Halbert CH, Rodriguez D, et al. Predictors of participation in a smoking cessation program among young adult smokers. Cancer Epidemiol Biomarkers Prev. 2007;16:617–619. 19. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: The National Academies Press; 2003. 20. Wolfenden L, Wiggers J, Campbell E, et al. Feasibility, acceptability, and cost of referring surgical patients for postdischarge cessation support from a quitline. Nicotine Tob Res. 2008;10:1105–1108. 21. Perry RJ, Keller PA, Fraser D, Fiore MC. Fax to quit: a model for delivery of tobacco cessation services to Wisconsin residents. WMJ. 2005;104:37–40, 44. 22. Winickoff JP, Buckley VJ, Palfrey JS, et al. Intervention with parental smokers in an outpatient pediatric clinic using counseling and nicotine replacement. Pediatrics. 2003;112:1127–1133.
Objective.—The aim of this study was to describe the rates of enrollment in tobacco dependence treatment among smoking adults who accepted a fax referral from health care providers at a children’s hospital, and to examine smoker characteristics associated with enrollment. Methods.—Secondary analysis of the state-sponsored fax referral and treatment program data on all referrals from Arkansas Children’s Hospital in 2005 to 2007 was conducted. Enrollment was defined as attendance at 1 or more counseling sessions within 1 year of referral. Logistic regression analyses were used to identify demographic and tobacco-related characteristics associated with enrollment versus nonenrollment in a treatment program among those contacted by the program. Results.—Of the 749 faxed referrals to the program, 157 (21.0%) enrolled in a treatment program and received 1 or more treatment sessions; 505 were contacted by the program, and of these, 147
Conclusions.—Approximately 1 in 5 smokers who accepted a fax referral enrolled in and received intensive treatment services for tobacco dependence. Thus, innovative approaches are needed to increase enrollment among younger, African American, and male smokers. KEY WORDS: enrollment; fax referral; tobacco use cessation; telephone counseling; pediatric Academic Pediatrics 2010;10:200–4
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numerous barriers to referring caregivers to smoking cessation programs, including perceptions that caregivers are not interested and will ignore pediatricians’ advice.7 Telephone counseling services (quit lines) are now widely available in North America, and nearly all quit lines provide a special fax referral form for health care providers to conveniently refer patients to treatment.8 Upon receipt of a faxed referral, the program initiates contact with the smoker and assists him/her with enrollment. Although this process makes practical sense, there is little in the published literature on the outcome of referrals, especially those faxed from a pediatric setting. In this study, we provide a descriptive report on the enrollment status in a 2-year period of faxed referrals from a large, tertiary children’s hospital to state-sponsored referral and treatment services for tobacco dependence. We also describe smoker characteristics associated with enrollment in treatment for tobacco dependence. Based on the transtheoretical model of behavior change,9,10 we hypothesized that persons with higher levels of selfefficacy (confidence to quit smoking and stay quit when tempted) and persons in the ‘‘preparation’’ and ‘‘action’’ stages of readiness (intend to quit in the next 30 days or have already made a quit attempt, respectively) would be more likely to enroll in treatment.
xposure to secondhand smoke is a major cause of childhood morbidity and mortality, causing childhood pneumonia, bronchiolitis, asthma, otitis media with effusion, as well as extended hospital stays and recovery times.1–3 Approximately one third of children in the United States are exposed to secondhand tobacco smoke in the home.4 Brief interventions for smoking cessation are recommended by the US Public Health Service clinical practice guideline for the treatment of tobacco use and dependence and endorsed by the American Academy of Pediatrics.5,6 All health care providers should ask patients and caregivers (ie, foster parents, grandparents, and other relatives who care for children) about tobacco use at every visit and offer advice and assistance to those who use tobacco; however, in practice, pediatricians seldom refer caregivers to cessation programs.7 Pediatricians cite From the Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark (Dr Sisterhen); Departments of Health Behavior and Health Education (Dr Sheffer), and Biostatistics (Dr Bursac), College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Ark; Departments of Psychiatry and Epidemiology, Colleges of Medicine and Public Health, University of Arkansas for Medical Sciences, Little Rock, Ark (Dr Fischer); and Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Ark (Dr Fischer). Address correspondence to Laura L. Sisterhen, MD, MPH, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, 1 Children’s Way, Slot 900, Little Rock, Arkansas 72202-3591 (e-mail: [email protected]). Received for publication May 13, 2009; accepted March 2, 2010. ACADEMIC PEDIATRICS Copyright Ó 2010 by Academic Pediatric Association
METHODS Study Design, Setting, and Data Sources We conducted a secondary analysis of data collected on all smokers who accepted a referral to the Arkansas fax
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referral program (SOSWorks) from personnel at Arkansas Children’s Hospital (ACH) over the 2-year period from May 6, 2005 to July 25, 2007 (n ¼ 749). During the study period, statewide tobacco referral and treatment services in Arkansas were directed by the second author (Christine E. Sheffer) at the University of Arkansas for Medical Sciences. The University of Arkansas for Medical Sciences Institutional Review Board approved this study. ACH is a large tertiary pediatric hospital and teaching affiliate of University of Arkansas for Medical Sciences. ACH employs a tobacco interventionist to assist ACH health care providers in addressing smoking cessation. The tobacco interventionist provides one 5-minute counseling session to smokers, written materials, and an offer to fax a referral. All ACH providers can order a tobacco intervention consultation for inpatients, outpatients, relatives, and caregivers. Most consultations are requested by the General Pediatric Clinic. Although the General Pediatric Clinic has a systematic method (clinic note prompts) of identifying and documenting caregiver tobacco use, there is no hospital-wide policy or procedure at ACH. Providers also have the option of faxing a referral directly without the assistance of the tobacco interventionist. Following receipt of the faxed referral, tobacco treatment specialists at the referral program, SOSWorks, made up to 6 attempts to contact the smoker by telephone. Once a smoker was contacted, the tobacco treatment specialists collected demographic and tobacco-related information on the referred smoker. Following data collection, the tobacco treatment specialists offered to schedule an appointment for the smoker to receive either telephone counseling through the quit line or in-person counseling at a treatment clinic near his/her home, in accordance with the smoker’s preferences. Outcome Measure The primary outcome measure was the proportion of referred smokers who enrolled in treatment within 1 year of referral. Enrollment in treatment was defined as attending 1 or more structured, evidence-based treatment sessions. Attendance was determined by treatment program record review. Predictor Measures Variables included in our analyses were gender, race/ ethnicity (white, African American, Hispanic/Latino, Pacific Islander, American Indian/Alaskan Native, multiethnic, or other), usual number of cigarettes smoked per day, readiness to quit, motivation to quit, self-efficacy for quitting, and, for women, pregnancy status. To determine usual number of cigarettes smoked per day, smokers were asked, ‘‘How many cigarettes do you smoke on a usual day?’’ Readiness to quit was assessed with the transtheoretical model by asking the smoker, ‘‘Tell me about your plans to quit using tobacco.’’ Options included standard responses used with the transtheoretical model to assess readiness: ‘‘have already stopped’’ (action), ‘‘plan on stopping, or stopping again, in next 30 days’’
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(preparation), ‘‘plan on stopping in next 6 months’’ (contemplation), ‘‘plan on stopping but not in next 6 months’’ (precontemplation), and ‘‘no plans to stop smoking’’ (precontemplation).9,10 Readiness to quit status was dichotomized as action/preparation or contemplation/ precontemplation. We included persons in the action stage because they were seeking assistance, still in the process of quitting, and at high risk of relapse. These smokers were likely to have made a quit attempt in response to the health care provider advice between the time of the referral and contact by SOSWorks. Motivation and self-efficacy were measured by asking the questions, ‘‘On a scale from 0 to 10, where 0 is none at all and 10 is the most ever, how much do you want to quit smoking?’’ and ‘‘ . . . how confident are you that you can quit and stay quit for good?’’ respectively.11,12 Statistical Analyses SAS version 9.2 (SAS Institute Inc, Cary, NC) was used for all analyses, with 2-sided alpha at the .05 level for statistical significance. Summary statistics were calculated to describe the characteristics of referred smokers. Univariate analyses were performed using c2 for categorical variables and 2-sample t test for normally distributed continuous variables. Because motivation and selfefficacy scores were not normally distributed, the Wilcoxon signed rank test was used to test distributional equality between smokers who did and did not enroll. We used multivariate logistic regression to predict enrollment among those contacted. Predictor variables included age, gender, race/ethnicity, cigarettes smoked per day, readiness to quit, motivation to quit, and selfefficacy. Race/ethnic categories were collapsed into white, African American, and unknown/other for analysis. We conducted separate sensitivity analyses to assess the effect of including those of unknown race/ethnicity first in the African American category and second, in the white category. RESULTS During the 2-year period, 749 smokers accepted a referral to SOSWorks from ACH. The majority of referrals were white (53.7%), 21% were African American, 0.9% other (5 Hispanic, 2 Asian, 1 other), whereas race/ ethnicity was unknown for 24.4%. Two thirds of referrals were female (69.4%). The mean age was 31.4 years 9.3 (range, 14–64, with 10 aged less than 18 years of age). Nearly all were Arkansas residents (99.3%) and reported English as their preferred language (99.2%). Of the 749 smokers referred, 21.0% enrolled in a treatment program. Most enrolled within 30 days of the faxed referral (137/ 157), 11 enrolled between 30 and 60 days, and 9 enrolled between 60 and 310 days of the referral. SOSWorks was able to contact 67.4% (N ¼ 505) of referred smokers. Those contacted did not differ from those not contacted in terms of race, gender, or language preference; however those not contacted were significantly younger than those contacted (mean age, 30.2 vs 31.9 years, P ¼ .02).
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Nearly all those contacted (89.7%) desired treatment and were planning to or had made a recent quit attempt (86%). Those contacted reported high motivational levels (mean 9.3) and moderate levels of self-efficacy (mean 7.9). Of those that desired treatment (n ¼ 453), most (88.3%) requested treatment from the quit line; 11.3% requested inperson treatment; and 2 selected self-help software only. Of the 505 smokers contacted by SOSWorks, 29.1% enrolled in treatment. Those who enrolled were older, more likely to be white, and reported higher levels of motivation to quit and self-efficacy for quitting (Table 1). Among the subset of smokers contacted by SOSWorks, increasing age, increasing self-efficacy scores, being female, and being white were independent and statistically significant predictors of enrollment. As seen in Table 2, the odds of enrollment increased 13 percentage points for each 1-unit increase in self-efficacy score. Associations between enrollment and cigarettes smoked per day, readiness, and motivation were not statistically significant. White smokers were more than twice as likely as African American smokers to enroll in treatment. When the unknown group was included in the African American category, the odds ratios in the model did not change substantially or significantly. However, when the unknown group was included in the white category, the odds ratio for the association between being white and enrollment decreased (odds ratio 1.61; 95% confidence interval, 0.97–2.65) and became nonsignificant. Although sensitivity analyses explored the impact of combining the unknown race/ethnicity group with other race/ethnicity groups, we present the results with the unknowns as a separate category because the group was so large (Table 2).
DISCUSSION Our findings demonstrate that about two thirds of faxed referrals from ACH were contacted by the referral program and nearly one third (29.1%) of those contacted enrolled in treatment within 1 year of the referral. Factors associated with increased probability of enrollment were female gender, white race, increasing age, and higher levels of self-efficacy. Although this enrollment rate may seem low, it is similar to the 23.6% enrollment rate reported by the Ohio faxed referral program and falls within the range of enrollment rates reported in the literature (14.7%– 53%).13–17 We hypothesized that smokers with higher self-efficacy and those in the preparation/action stage of readiness to quit would have higher rates of enrollment. The transtheoretical model posits that a person making a behavior change, such as quitting smoking, will progress through a series of stages over time. Prior to making a quit attempt, termed ‘‘action,’’ a smoker will progress from precontemplation (resistance to change) to contemplation (weighing the benefits of quitting smoking against the costs of quitting) to preparation (having a plan for action). Because nicotine is so highly addictive, many smokers make multiple quit attempts and cycle through some or all of the stages several times before achieving long-term abstinence.9 Our results
ACADEMIC PEDIATRICS Table 1. Characteristics of Smokers Contacted by the Faxed Referral Program Enrolled at 1 Year
Characteristic
Total N ¼ 505
Yes n ¼ 147 No. (%)
No n ¼ 358 No. (%)
Gender Female 348 110 (74.8) 238 (66.5) Male 157 37 (25.2) 120 (33.5) Race White 267 92 (62.6) 175 (48.9) African American 98 23 (15.6) 75 (20.9) Other 5 2 (1.3) 3 (0.8) Unknown 135 30 (20.4) 105 (29.3) Pregnant Yes 17 5 (4.5) 12 (5.0) No 315 103 (93.6) 212 (89.1) Unknown 16 2 (1.8) 14 (5.9) Readiness to quit† Action 6 0 6 (1.7) Preparation 426 136 (92.5) 290 (81.0) Contemplation 29 6 (4.1) 23 (6.4) Precontemplation 1 0 1 (0.2) Unknown 43 5 (3.4) 38 (10.6) Age, y§ 31.9 9.4 34.0 9.9 31.0 9.1 Motivationk 9.3 1.2 9.5 1.0 9.2 1.2 Self-efficacyk 7.9 2.3 8.3 1.9 7.7 2.4 Cigarettes per day§ 19.5 12.1 21.1 12.6 18.8 11.8
P Value .07
.02*
.78
.19‡
.003 .03 .02 .053
*Comparison between white, African American, and unknown/other. †Action: having already quit; preparation: planning to quit in next 30 days; contemplation: planning to quit in next 6 months; precontemplation: planning to quit, but not in next 6 months, or no plans to quit. ‡Comparison between action/preparation and contemplation/precontemplation. §Mean SD. kMean SD, measured on a scale of 0–10.
supported the hypothesis regarding self-efficacy, but not the hypothesis regarding readiness. Readiness to quit was not associated with enrollment. The lack of a significant association with readiness to quit and motivation may be due to the limited variability in the scores among respondents. The process of accepting a referral is likely to selfselect for those who are more motivated and more ready to quit. Those who are not ready simply do not agree to a referral. The significance of age and race as predictors of enrollment is consistent with the literature on participation rates in cessation programs among young adult smokers.18 The reasons for the disparity in race is unclear; however, African Americans may be less likely to enroll because of a general lack of trust in health care institutions.19 Lower socioeconomic status, more common in African Americans, may also contribute to a lack of resources that might enable enrollment. An awareness of these factors may help providers personalize their approach and the effectiveness of their referrals. These results may generalize to other pediatric settings. We were not able to evaluate the impact of the tobacco interventionist’s consultation on enrollment rates. Her presence could have increased enrollment given the additional counseling and her expertise, or could have decreased enrollment if smokers felt she had already
ACADEMIC PEDIATRICS
Enrollment Following Faxed Referrals to a Tobacco Program
Table 2. Logistic Regression Results for Enrollment Within 1 Year of Referral Among Those Contacted by the Faxed Referral Program (N ¼ 505)* Characteristic
Odds Ratio
95% CI
P Value
Age Gender Male Female Race African American White Other/unknown Cigarettes per day Readiness to quit (stage of change) Precontemplation/ contemplation Action/preparation Motivation Self-efficacy
1.04
1.01–1.06
.005
Reference 1.81
1.09–3.01
.02
Reference 2.35 1.31 1.01
1.28–4.33 0.67–2.57 0.99–1.03
.006 .44 .39
0.56–4.00 0.97–1.49 1.02–1.26
.42 .10 .02
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cannot know how many smokers would have enrolled in treatment without a faxed referral. However, unassisted referral enrollment rates are generally quite low,21 and proactive telephone calls have been shown to increase enrollment.22 The lack of data on treatment outcomes may be perceived as a limitation of this study. However, assessing abstinence was outside the scope of this study. Treatment for tobacco dependence has been shown to be effective with a wide variety of populations;5 there is no reason to expect treatment outcomes following referrals from ACH to differ significantly from those achieved by other patients in this and similar evidence-based treatment programs.
Reference 1.51 1.20 1.13
CI ¼ confidence interval. *Model included all independent variables shown in table. Model goodness of fit was measured by the Hosmer-Lemeshow test: chi square ¼ 5.1; df ¼ 8; P ¼ .75.
Conclusion In summary, approximately 1 in 5 smokers who accepted a fax referral in the context of a child’s health care visit enrolled in and received intensive treatment services. Thus, innovative approaches are needed to increase enrollment among younger, African American, and male smokers. ACKNOWLEDGMENTS
counseled them. Comparable studies that did not utilize a counselor achieved similar results. A number of other cost-effective strategies can be implemented to facilitate faxed referrals, such as converting fax forms into an electronic format automatically populated with the necessary information and electronically faxed through the electronic medical record system. Adding 5 minutes of physician counseling (accomplished by the interventionist in this context) to every encounter with a smoker may or may not be feasible, or even necessary. The responsibilities for asking about tobacco use, advising the smoker to quit, and referring for treatment can be shared among various staff members.5 Quit lines are now widely available in North America, and nearly all quit lines provide a special faxed referral form for physicians to conveniently refer patients to treatment free of charge.8 Although the cost for staff time to offer and fax a referral has been estimated to be $1.75 per referred patient,20 this is truly a minimal investment to achieve an often dramatic reduction in disease by eliminating exposure to secondhand tobacco smoke. In addition, diagnostic and treatment codes exist for pediatrician counseling on parental tobacco use, which could offset these minimal costs—provided there is reimbursement. Limitations The limitations of this study include missing data or data that would be informative but was not collected by the referral program. Among those contacted, 15% were missing motivation and self-efficacy level data, and 27% were missing race/ethnicity data. Data that would be of interest and were not collected include whether referred smokers were patients or caregivers and the context of the visit (child’s hospitalization or outpatient visit). Furthermore, in the absence of a comparison group, we
The faxed referral and treatment programs in this study were supported by grants and contracts awarded to Dr. Christine Sheffer from the Arkansas Department of Health with Master Settlement Funds. We thank Debbie Rushing, CTTS, and Suzanne Speaker, MS, for assistance with the preparation of the manuscript.
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