Tobacco Cessation among Low-Income Women Promoted More Successfully with Tested Dissemination Strategies


Low-income women smokers received more information and support about quitting after their health care providers received training, materials and access to a telephone counseling service, found University of Illinois at Chicago researchers in a dissemination study.

In 12 public health clinics serving women with children in northern Illinois, the percentage of smokers who reported receiving a self-help booklet about quitting doubled to 32 percent after new strategies to promote smoking cessation were implemented. Additional gains, such as an increase in providers counseling patients to quit and smokers receiving proactive counseling by phone, were seen in clinics given more resources. Clinics that experienced staff or organizational changes or other disruptions over the two-year study saw less success in implementing national standards for the promotion of smoking cessation.

Implementation studies like this are critical in reducing the national smoking rate, especially among vulnerable groups, said Clara Manfredi, research professor of community health sciences and lead investigator of the study.

“We focused on improving smoking cessation interventions in maternal and child public health clinics because they serve many low-income women, who still have a high smoking prevalence—at about 30 percent in this study—and because of the additional health risks to their children, who are exposed to secondhand smoke," she said.

About 20.8 percent of Americans smoke, less than half the rate seen in the 1960s (44 percent). The U.S. Department of Health and Human Services has called for a reduction of the smoking rate to 12 percent by 2020 and an increase in tobacco cessation counseling in health care settings to achieve this goal.

The researchers tested three strategies to implement standards in the guideline published by the U.S. Public Health Service (PHS), which, they wrote, are not widely applied.

None of the clinics used a specific smoking cessation program before the study, but all were implementing some of the recommendations in the PHS guideline, last updated in 2008, which Manfredi called "encouraging."

"All the clinics had in place a system to identify smokers, and about two thirds of smokers surveyed in the pre-dissemination phase reported receiving provider advice to quit during their recent clinic visit," she said. "However, implementation of other guideline recommendations, such as giving providers better counseling tools and assisting smokers with motivational and self-help materials and additional counseling, was very poor."

Manfredi and her colleagues randomized the 12 clinics into three groups and tested a different strategy in each group to support implementation of the standards.

In the group receiving the simplest support, clinic providers received copies of the PHS guideline and a smoking cessation program proven to reduce smoking among low-income women, including training and one year’s supply of self-help booklets for smokers and other program materials.

One staff member at each clinic in this group attended a train-the-trainer workshop on administering the smoking cessation program, called “It’s Time.” Manfredi and her colleagues designed and tested this program in maternal and child health clinics in the 1990s.

In addition to the materials and training received by the first group, clinics in the second group had access to a telephone service to which they could refer their patients for free counseling on quitting cigarettes. Clinics in the first group were given cards referring smokers to the state’s smoking quit line.

The third group of clinics had all the resources available to the second group, plus on-site training for all their providers in the smoking cessation program and more personalized assistance in setting up the program. The researchers visited this group of clinics several times during the study and phoned them regularly to discuss concerns about implementing the guidelines.

Fewer than one in 10 smokers (6.5 percent) reported receiving self-help booklets from clinics in the first group in the year before the study’s dissemination activities. In the year afterward, almost two in five (37.1 percent) in that group reported receiving a booklet.

In the second group of clinics, 8.5 percent of smokers received a booklet before the study’s dissemination and 28.5 did afterward.

In the third group of clinics, there was little change in the rate of booklet receipt; 33.8 percent of smokers reported receiving them at the beginning of the study and 32.4 percent did at the end.

Manfredi said that an important recommendation from the PHS guideline is to complement health care providers’ advice to quit during regular visits—which at best can be only brief and of limited effectiveness—with additional interventions, such as a referral to smoking cessation classes, support groups or counseling sessions. The percent of smokers reporting such "extras" also rose over the study among patients in the second group of clinics (from 1.1 to 9.5 percent) and the third group (from 2.0 to 17.0). Almost all these smokers used the proactive telephone counseling service, Manfredi said. 

The clinical setting also influenced the success of implementation. The most successful clinics were county-run clinics in small or mid-size towns, serving mostly white women and providing only prenatal care, family planning, immunization and similar services not requiring a physician. Among the least successful were three clinics in larger urban health care centers with multiple medical departments besides the maternal and child health clinics, which included care by physicians and served mostly African Americans.

"The dissemination strategies worked well for one type of clinic, the small county clinics which are pretty much self-contained and traditionally focused on prevention, case management and health education services, and where the administrators involved in the study participation decisions participated directly in the day-to-day implementation," Manfredi said. "The strategies did not work at all in the three clinics in the large urban settings, whose bureaucratic organizations provided little support for this department-specific initiative. The officers involved in the study participation decisions were not directly involved in the day-to-day implementation of the study," she said.

Understanding the contextual factors that lead to successful implementation is critical to ensure the value of a public health intervention, said Manfredi. Her co-investigator and co-author, Young Ik Cho, agreed.

"This is one of the few experimental studies aimed at improving how public health practitioners are implementing the PHS guideline in the real world," said Cho, a research associate professor at the UIC Survey Research Laboratory and clinical associate professor in health policy and administration. Because so few studies of this type are done, the standards for conducting them are still being defined, he said.

Manfredi said they addressed concerns about real-world issues by "controlling for a number of contextual factors and monitoring whether secular events during the two years in the clinic altered conditions in any individual clinic or study group."

"Implementation takes a long time to measure," she said. "But despite the difficulties of experimental research under real-world conditions, it’s important to study how to improve dissemination and implementation.”

In smoking cessation, “we know a lot about what works and what doesn’t work for health care-based interventions. This knowledge is already in the PHS guideline,” Manfredi said, “but if we don’t take this knowledge and these guidelines and find a way to achieve their large-scale implementation across a variety of health care systems, then the public health benefit will never be achieved."

Manfredi, Cho and their UIC colleagues worked with the Illinois Department of Human Services to complete the study, which was reported in the April issue of the journal Health Education Research.

This news release was written by Veronica Johnston, IHRP communications director.