Proactive Population Health Strategy to Offer Tobacco Dependence Treatment to Smokers in a Primary Care Practice Network

  • Sara KalkhoranEmail author
  • Elizabeth M. Inman
  • Jennifer H. K. Kelley
  • Jeffrey M. Ashburner
  • Nancy A. Rigotti
Original Research



Population-based strategies can expand the reach of tobacco cessation treatment beyond clinical encounters.


To determine the effect of two population-based tobacco cessation strategies, compared with usual care, on providing tobacco treatment outside of clinical encounters.


3-arm pragmatic randomized controlled trial.


Current smokers ≥ 18 years old with a primary care provider at one of five community health centers in Massachusetts were identified via the electronic health record (n = 5225) and recruited using automated phone calls.


One intervention group involved engagement with a health system–based tobacco coach (internal care coordination), and the other connected patients to a national quitline (external community referral).


Proportion of smokers with documentation of any evidence-based cessation treatment in the 6 months after enrollment.

Key Results

Of 639 individuals who responded to the proactive treatment offer, 233 consented and were randomized 1:1:1 to study arm. At 6-month follow-up, the pooled intervention group, compared with usual care, had higher documentation of any smoking cessation treatment (63% vs. 34%, p < 0.001), cessation medication prescription (52% vs. 30%, p = 0.002), and counseling (47% vs. 9%, p < 0.001). Internal care coordination was more effective than external community referral at connecting smokers to any cessation treatment (76% vs. 50%, p = 0.001) and at providing cessation medication (66% vs. 39%, p < 0.001), but comparable at linking smokers to cessation counseling resources.


Smokers responding to a population-based, proactive outreach strategy had better provision of tobacco cessation treatment when referred to either a health system–based or community-based program compared with usual care. The health system–based strategy outperformed the quitline-based one in several measures. Future work should aim to improve population reach and test the effect on smoking cessation rates.

Trial Registration NCT03612895


smoking cessation primary care population health clinical trials 


Funding Information

This study was financially supported by the Pfizer Independent Grants for Learning and Change (IGLC). IGLC grant recipients were selected independent of Pfizer, by the Smoking Cessation Leadership Center at the University of California, San Francisco. Dr. Kalkhoran is financially supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (K23HL136854).

Compliance with Ethical Standards

Conflict of Interest

Drs. Rigotti and Kalkhoran receive royalties from UpToDate, Inc. Dr. Rigotti has been an unpaid consultant to Pfizer, Inc. and a paid consultant to Achieve Life Sciences. No other authors have any conflicts of interest to disclose.


The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Supplementary material

11606_2019_5079_MOESM1_ESM.docx (13 kb)
Supplemental Table 1 (DOCX 12 kb)


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Sara Kalkhoran
    • 1
    • 2
    • 3
    Email author
  • Elizabeth M. Inman
    • 1
    • 4
  • Jennifer H. K. Kelley
    • 1
    • 4
  • Jeffrey M. Ashburner
    • 2
    • 3
  • Nancy A. Rigotti
    • 1
    • 2
    • 3
    • 4
  1. 1.Tobacco Research and Treatment CenterMassachusetts General HospitalBostonUSA
  2. 2.Division of General Internal Medicine, Department of Medicine Massachusetts General HospitalBostonUSA
  3. 3.Harvard Medical SchoolBostonUSA
  4. 4.Mongan Institute Health Policy CenterMassachusetts General HospitalBostonUSA

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