Buster Halcomb was just 5, a scruffy shoeshine boy in a billiard hall in Cumberland, Ky., when three men approached with packs of “tailor-made” cigarettes.
“Bring them home to your mom and dad,” they told him. He did, and kept a few for himself, too. By age 7, smoking had become a habit, one that the now 66-year-old is ready to quit on account of his own health and for the sake of his new granddaughter.
“I loved that baby even before she was born,” he gushed. “I know that if I smell like smoke, I am not going to be holding her.”
Halcomb, along with his wife, Julia, are quitting smoking together with the help of UC Quits, a University of California program run by the UC Tobacco Cessation Network that links every UC patient who smokes to the California Smoker’s Helpline 1-800-NOBUTTS, through use of the patient’s electronic health record (EHR).
“It’s going well,” says Halcomb. “I mean, you’ve got your ups and downs, but we’re doing it.”
Patients more apt to quit with provider push
The program aims to simplify and streamline what should be routine preventive health care, but too often is neglected by providers. What began as a pilot project at UC Davis through a grant from the UC’s Center for Health Quality and Innovation is now a UC-wide program led by UC Davis internal medicine physician and tobacco control researcher Elisa Tong. Patients seen at UC San Diego, UCLA, UC Irvine and UCSF also have access to the program.
The idea is to reach people at risk of tobacco-related diseases when they are more open to quitting — in the hospital or during doctor visits. Project leaders estimate that at least 100,000 people who get their care at a UC medical center can directly benefit; already, more than 3,600 patients who smoke have been referred to the California Smokers Helpline, operated by UC San Diego.
The UC Tobacco Cessation Network also is designed to meet federal and other health care targets for improving patient outcomes and lowering the costs of care.
“The goal is to try to address tobacco use at every clinical encounter, and ultimately align with tobacco quality measures set forth by the Centers for Medicaid and Medicare Services, which will probably offer incentives to health systems based on how they are performing on tobacco,” says Tong.
Tobacco’s toll on health
The health impacts of smoking are indisputable: tobacco use is a leading cause of preventable illness in the United States, including cardiovascular disease and several types of cancer. By the same token, quitting can have immediate and long-term health benefits. But nicotine is an addictive drug, and most smokers attempt to quit several times before they’re successful.
Health care provider involvement increases the chances that someone will quit, explains Linda Sarna, interim dean of the UCLA School of Nursing and a UC Quits nurse champion.
“When a provider has an interaction with a patient who smokes it’s an opportunity to connect the dots and help the patient understand how their condition is influenced by tobacco use,” she says.
After several unsuccessful quit attempts, Halcomb acknowledged that his doctor’s recommendation in mid-December came at a good time — just hours before his daughter gave birth and brought her new baby to her parents’ home to live.
“Everybody who smokes knows that if the doctor says something, deep down they feel ashamed,” he says.
Cancer care providers can play an especially important role in helping patients quit smoking, says Tong.
“When smokers are diagnosed with cancer, it is a ‘teachable moment,’” she explains. “It’s an opportunity to educate patients about the importance of quitting to improve treatment outcomes, as well as to prevent secondary cancers from developing.”
The Surgeon General reports that smoking is associated with poorer response to cancer treatment and wound-healing, and that it increases treatment-related toxicity. Continued tobacco use also decreases cancer survival rates.
But too few providers address tobacco cessation with patients. Even many NCI-designated cancer centers don’t offer tobacco treatment or education materials.
Training health care providers key
To address the gap in oncology settings outside of the university system, Tong is working with directors of the UC Davis Cancer Care Network of community cancer centers to share UC Quits’ evidence-based tobacco cessation practices, lung cancer screening and prevention programs.
“We hope collaborations with our affiliate cancer centers will lead to new programs to improve cancer treatment and survival outcomes,” she says.
Training all UC providers is a critical component of the program. Sarna worked with UC nurses to understand their role in supporting quit efforts, including strategies to help smokers suffering nicotine withdrawal.
At UC Davis, nurse and tobacco specialist Cari Shulkin is a UC Quits consultant who also teaches nurses how to help patients quit smoking.
“We set up a framework to make it easy for them to counsel patients, provide resources, including the helpline, and to do a proper follow-up,” explains Shulkin.
In addition, the Smoking Cessation Leadership Center, run by UCSF Distinguished Professor of Health and Healthcare Steve Schroeder, coordinated educational materials to help providers flag smokers in the hospital or clinic, inform patients about the benefits of quitting and how to do it. At UC Davis, for example, Halcomb was given a prescription for nicotine patches and tobacco lozenges.
Health care providers now can “e-refer” patients to the helpline, which triggers a call to the patient from a trained counselor, said Helpline Project Director Chris Anderson, whose team worked across the UC health centers to connect the helpline to electronic health record (EHR) systems and integrate the referral capability into clinical workflows.
“Practicing modern medicine is complicated; we’re asked to do a lot with the patient in a short amount of time,” says Scott MacDonald, a UC Davis primary care physician and EHR medical director. He works with information technology analysts to develop EHR alerts to remind physicians to talk to patients about smoking during the office visit.
“By putting tools into the EHR, we can make these tasks easier for the doctors,” he says.
Mark Avdalovic, UC Davis pulmonologist and associate EHR medical director, lends his expertise to ensure that the clinician alerts appear in the EHR at a time when the clinician has the best opportunity to discuss smoking cessation and refer the patient to the helpline.
“The more our physicians are adept at using the EHR, the better the patient will do,” he says.
Offered in six languages, counseling can involve up to six sessions spread over the course of a quit attempt, from a routine intake survey to a quitting preparation conversation and relapse prevention sessions. Anderson says UC Quits’ long-term goal is to screen patients at every clinical visit, “so the patient who doesn’t quit this time gets encouraged to do so next time.”
Halcomb says this time he’s determined to quit for good.
“They call me from the quitline every week and explain the addiction, give me tools to work with and the motivation to maintain stability,” he says, adding that learning how smoking affects his body and hearing success stories have helped him stay on course.
“They inspire me every time they call,” he adds. “Smoking is not the way to go. Life is too short to mangle it up. And we want to see our grandchildren grow up.”