Enhancing Smoking Cessation of Low-Income Smokers in Managed Care

Our study examined the effectiveness of a comprehensive program for smoking cessation provided by nurse and telephone counselors who were assisted by a computer-guided program focusing on relapse prevention in very low-income smokers covered by Medicaid managed care. The intention-to-treat results of a 21% quit rate at 3 months were consistent with our previously reported study,⁹ which included a sizable subpopulation of Medicaid patients. If adjustments are made in the denominator based on community trials¹⁷ as our previous study⁹ for reasonable loss-to-follow, then the CO-verified quit rates at 3 months would be 13% (usual care) and 31% (telephonic care) (P=.011). Our report is unique because we directly compared the effectiveness of telephone counseling support with usual care (brief physician advice and follow-up) in a true experimental trial in community practice. Though most participants received prescriptions for transdermal nicotine, the variation in usage was similar in both study groups because randomization allows a true comparison of the behavioral intervention effects. The recruitment data showing that approximately 50% of referred smokers in primary care are willing to enroll in a program is consistent with our previous study⁹ and other reports.²⁴ This demonstrates that Medicaid smokers are generally as willing to participate in smoking cessation services as other smokers.

Although all providers received formal training on the smoking cessation guidelines,¹ were aware of the study, and had “green card” reminders on study charts, they offered appropriate follow-up care only 26% of the time at return visits (based on post-study chart audit documentation). These findings are consistent with national surveys of physicians in primary care practices² that show follow-up care as the greatest shortcoming. It seems that physicians need to have comprehensive office systems in place to ensure even brief follow-up care²⁶ for smoking cessation. Telephone counseling support with a guided computer system definitely enhances follow-up care. By closely tracking participants for changes in addresses and telephone services, reasonable follow-up can be maintained even in low-income smokers. In our study, 60% of the participants in the telephonic-counseling group received at least 4 treatment sessions. Opinions of providers and staff during post-study focus groups were very positive. All 3 practices decided to continue a nurse-based approach for relapse prevention counseling after the study and expressed a need for the telephone support services to continue.

Limitations

One of the possible weaknesses of this study is the lack of long-term follow-up at 6 to 12 months for quit rates to ensure continued differences in effectiveness. Because of lack of funding, we were only able to obtain follow-up at 3 months. However, our findings are similar to the data in our previously reported community demonstration trial,⁹ which did not have a usual care comparison. Though the 2 reports refer to different populations, in our previous report⁹ using an intention-to-treat denominator the CO-verified quit rates were approximately 20% at 6 months in the Medicaid population. When using a community-based denominator that accounted for loss to follow-up, the 6-month quit rate was 33%. These results are consistent with strictly controlled trials where the majority of participants used nicotine replacement therapies.¹⁶

It is of interest to note that in this very low-income population, providing $50 to verify self-reported smoking cessation by CO monitor not only yielded considerable follow-up at 3 months but may have biased self-reporting in the usual care group where only 56% of the reports were verified. This finding shows the importance of using biochemical verification of smoking cessation even in community-based clinical trials.

Continued Research

Our study poses several questions for further research. Are the quit rates obtained by the described telephonic-counseling program sustainable over time at 1 to 2 years post-treatment in low-income populations? Can these approaches for relapse prevention be adapted to meet the needs of special groups, such as pregnant smokers, difficult to reach smokers at home, and high-risk smokers with diseases such as diabetes, heart disease, asthma, and severe disabilities when offered in conjunction with disease management services within managed care plans? This is of particular importance when the majority of low-income smokers report personal, smoking-related, and family health problems as reasons for quitting smoking. Though such behavioral support services are reported to be cost-effective in commercial managed care populations,²⁵ what is the cost-effectiveness of these services when adapted to meet the needs of special populations?

Conclusions

Telephonic-counseling for smoking cessation supported by a computer-guided program on relapse prevention is both practical and effective even for low-income smokers covered by Medicaid managed care. Special tracking approaches are required to maintain low-income smokers in treatment and to ensure provider follow-up. State Medicaid programs and insurance plans should consider investing in both office-based and centralized telephonic smoking cessation services to enhance smoking cessation for low-income smokers.