BACKGROUND: Although office-based and telephone support services enhance the rate of smoking cessation in managed care systems, it is not clear whether such services are effective for very low-income smokers. We evaluated the comparative effectiveness of usual care (physician-delivered advice and follow-up) and usual care enhanced by 6 computer-assisted telephonic-counseling sessions by office nurses and telephone counselors for smoking cessation in very low-income smokers in Medicaid managed care.
METHODS: A randomized clinical trial comparing the 2 approaches was conducted in 3 Michigan community health centers. All clinicians and center staff received standard training in usual care. Selected nurses and telephone counselors received special training in a computer-assisted counseling program focusing on relapse prevention.
RESULTS: The majority of the study population (233 adult smokers with telephones) were white (64%) women (70%) with annual incomes of less than $10,000 (79%) and with prescriptions of nicotine replacement therapy (>90%). At 3 months, quit rates (smoke-free status verified by carbon monoxide monitors) were 8.1% in the usual-care group and 21% in the telephonic-counseling group (P=.009) by intention-to-treat analysis. Special tracking methods were successful in maintaining participants in treatment.
CONCLUSIONS: Smoking cessation rates are enhanced in a population of very low-income smokers if individualized telephonic-counseling is provided. State and Medicaid managed care plans should consider investing in both office-based nurse and centralized telephonic-counseling services for low-income smokers.
Clinical practice guidelines on smoking cessation1 advocate that clinicians identify all smokers, advise them to quit, and arrange follow-up care. Arranging systematic follow-up care is often the most difficult of those steps in a primary medical practice because counseling for smoking cessation is often not reimbursed.2 Telephone support counseling services offering proactive follow-up with scheduled sessions have achieved long-term success rates from 25% to 30%.3-8 We were able to achieve a long-term quit rate of 36% in a community-based trial of computer-assisted telephone support counseling by nurses and telephone counselors trained in computer skills and relapse prevention.9 In this study more than 57% of the practice-based participants were covered by Medicaid insurance. There were no statistically significant differences in quit rates for Medicaid (33%) and non-Medicaid (36%) smokers at 6 months using a community denominator analysis approach.9
Managed care provides an advantageous system for the delivery of preventive services.10 Most indemnity insurance plans cover few preventive services, mostly limited to screening and immunizations, despite “findings…that the counseling and education services are among the most effective interventions available to clinicians to achieve the goals of health promotion and disease prevention.”10 Group Health Cooperative (GHC) of Puget Sound has demonstrated with a comprehensive systematic population-based health care approach that the prevalence of smoking can be reduced from 25% to 15.5% over 10 years among more than 550,000 adult enrollees.11 This tremendous change within a population was achieved by multiple approaches, including identification, tracking, community outreach, comprehensive clinician and staff education, free coverage of services to participants, accessible telephone counseling, and self-help materials.11 This is an outstanding example of an effective comprehensive program on smoking cessation within a private managed care system resulting in the overall reduction of smoking for a large population. It serves as a model for other preventive services concerning such common topics as alcohol consumption abuse, cancer screening, or coronary artery disease.
The prevalence of smoking among Medicaid health maintenance organizations (HMOs) versus commercial HMO participants is reported to be much higher. In recent Michigan surveys of health plans, 19.4% of the participants in commercial HMOs reported being current smokers compared with 44.1% of Medicaid HMO participants.12 Medicaid participants are clearly a high-risk population for tobacco use and the medical consequences of smoking. Many states are moving from a fee-for-service approach to Medicaid coverage as a prospective capitated payment approach within managed care. Before the course of our study all Medicaid participants were moved into managed care plans by the State of Michigan. This context provided the ideal setting for examination of the impact of a systematic approach to smoking cessation by office-based and telephone counseling follow-up care for smokers covered by Medicaid managed care.
Brief advice on smoking cessation from a physician alone results in long-term quit rates of less than 10%.13 With the supplementation of brief physician advice with higher-dose nicotine gum or transdermal nicotine in randomized-controlled settings, long-term quit rates are increased to 15% to 25%.14-16 In the context of community practice relying on general volunteers, long-term quit rates are lower than strictly controlled trials.17 It seems that pharmacotherapy clearly enhances brief advice by physicians for smoking cessation.16 In a primary care medical practice-based study, Daughton and colleagues18 state that “data clearly indicate that counseling seems to maximize smoking cessation rates with the nicotine patch.” Most studies (including that by Daughton and coworkers) have examined the relative effectiveness of pharmacotherapy against placebo. Our study proposes to answer the following questions: What is the comparative efficacy in quit rates by adding nurse and telephone counseling support for follow-up care to physician advice alone when all smokers receive the same pharmacotherapy? Does added behavioral support actually improve quit rates when all smokers use pharmacotherapy, or is there no difference? Can significant quit rates be achieved in low-income populations? Are there special measures required to maintain follow-up and protocol compliance in Medicaid smokers? What are the barriers to decreasing the high prevalence of smoking among participants in Medicaid managed care plans?