Overview

This program at an urban safety net primary care clinic utilized motivational interviewing and a visual, easy-to-understand decision-making aid to promote smoking cessation.

Organization Name

University of Virginia - Affiliated Medical Center

Organization Type

• Academic Medical Center
• Safety net hospital

National/Policy Context

• There are approximately 42 million Americans who smoke in the U.S.
• Of smokers in the U.S., there is a large disparity in tobacco use based on populations’ ethnicity, socioeconomic status, and education level.  
• Decision aids are visual or written tools to aid patients in better understanding risky health behaviors and empowering them to make healthier lifestyle decisions.

Patient Population Served and Payor Information

• The target population in this intervention consisted of mostly underserved patients in an urban safety net clinic. 75% of the patients were covered by Medicaid or received free care. 

Tools or Products Developed

• Decision aid: Easy-to-understand visual aid to motivate patients to quit smoking. The tool is a web-based application where patients are able to enter their age, the average number of packs they smoke per day, and the number of years that they have been smoking. The tool integrates these personalized responses from each patient to generate a response with the additional number of years of life they could gain from smoking cessation. A visual representation of the tool is shown below:
  

  Figure: Graphic representation of the decision-aid.

Training

• Two medical students were trained to perform motivational interviews with patients in the intervention.   

Tech Involved

• Electronic medical record
• Statistical software
• Website

Team Members Involved

• Clinical Trainee or Student

Workflow Steps

• The study personnel review the daily clinic schedule and check EHR records to recruit patients with a confirmed status of “current smoker” to be part of the program. 
• The participants meet with a research assistant, after a scheduled office visit, to provide verbal consent to be involved in the intervention. 
• Each participant completes a one-page questionnaire about their baseline tobacco use including packs of cigarettes they smoke per day, and the age at which they began smoking. 
• These patients also rate their willingness-to-quit smoking by responding to a ladder questionnaire, which contains response choices on a sliding scale of 1-10 (1- being no interest in cessation to 10 indicating that they have already taken steps to stop).
• A cohort of patients received one session of motivational interviewing with the decision aid and then retook the willingness-to-quit survey. 
• Another cohort of patients, the control group, undergo motivational interviews without the decision aid. 
• 1 and 3 months later, patients were asked about their readiness-to-quit and if they made an attempt, regardless of the duration of the attempt, to stop smoking.

Where We Are

• Date (Month/Year) Project Described Started: October 1, 2016 – March 31, 2017
• Date (Month/Year) Paper Published: October 2018

Outcomes

• Readiness to quit smoking: The participants’ readiness to quit smoking was measured through the readiness-to-quit ladder before and after exposure to either the motivational interview and decision (intervention group) or just the motivational interview (control group).
  • After the interview: 21.1% of the patients showed an improved willingness-to-quit and there was no significant difference between the control and intervention group (P=0.79).
  • 1 month later: 40% in the intervention group showed increased interest to quit smoking and the control group had an increase of 41.2% (P =0.92). 
  • 3 months later: 48.8% in the intervention group showed increased interest to quit smoking and the control group had an increase of 48.3% (P=0.30).   
• Attempts to quit smoking: 
  • 15.4% in the intervention made a quit attempt and 25% in the control group made an attempt to quit  (P=0.30).

Future Outcomes

• The decision aid will be trialed without the use of motivational interviews in order to better understand its impact.
• The decision aid will be trialed with pharmaceutical therapy to augment patients’ efforts to stop smoking.

Benefits

• The patients were very receptive to having a visual-aid that positively showed the benefit of smoking cessation compared to just learning as normal about the negative effects of smoking.
• The project highlights the importance of having diverse health education materials, especially targeted at underserved populations.

Unique Challenges

• The intervention was a pilot program with a small sample size that might limit its generalizability to larger populations. 
• The use of self-reporting could have created significant bias in the measured outcomes. 
• The intervention was limited to only one motivational interview session; patients might have benefited from multiple sessions. 
• The decision aid was used concurrently with another interventional tool, motivational interview, so it was hard to discern its effect.

Sources

• Agarwal SD, Kerwin M, Meindertsma J, Wolf AMD. A Novel Decision Aid to Encourage Smoking Cessation Among Patients at an Urban Safety Net Clinic. Prev Chronic Dis. 2018 Oct 11;15:E124. doi: 10.5888/pcd15.180215. PubMed PMID: 30316305; PubMed Central PMCID: PMC6198679.
• Jamal A, Homa DM, O’Connor E, Babb SD, Caraballo RS, Singh T, Hu SS, King BA. Current cigarette smoking among adults – United States, 2005-2014. MMWR Morb Mortal Wkly Rep. 2015 Nov 13;64(44):1233-40. doi: 10.15585/mmwr.mm6444a2. PubMed PMID: 26562061.
• Weymiller AJ, Montori VM, Jones LA, Gafni A, Guyatt GH, Bryant SC, Christianson TJ, Mullan RJ, Smith SA. Helping patients with type 2 diabetes mellitus make treatment decisions: statin choice randomized trial. Arch Intern Med. 2007 May 28;167(10):1076-82. PubMed PMID: 17533211.