Tobacco dependence program: a multifaceted systems approach to reducing tobacco use among kaiser permanente members in northern california.

By Ali Goldstein, MPH Scott Gee, MD Rachelle Mirkin, MPH Introduction Tobacco use is the single greatest preventable cause of morbidity and premature mortality in the United States today and is responsible for more than 440,000 deaths—about one in five—each year. Because of the chronic and relapsing nature of tobacco dependence, addressing this problem at a health system level remains difficult. Tobacco use is so entrenched in the lifestyles of many Americans—including approximately 390,000 Northern California Kaiser Permanente (KP) members— that nothing short of a multifaceted program can even begin to address the problem. To combat the enormous burden on the health of our members caused by tobacco dependence, the Kaiser Permanente Northern California Region (KPNC) undertook a systems approach that relies on the incremental impact of multiple interventions. The KPNC Tobacco Dependence Program has contributed to a more than 10% reduction in smoking prevalence as well as to a 30% increase in HEDIS scores on the “Advising smokers to quit” measure for the period spanning from reporting year 1998 through reporting year 2003, substantially increased both attendance at tobacco-cessation programs and use of antismoking medication, and has become a model for health care systems nationwide. Initiated in 1998 and fully implemented by 2004, the Tobacco Dependence Program (Figure 1) hypothesized that a multifaceted, evidence-based program can reduce tobacco use among members of KPNC by using four main strategies: • For patients: routine assessment of tobacco use, counseling, and referral. For clinicians: training, audit, and feedback linked to incentives • Enhanced health plan benefits • Menu of tobacco cessation programs for members • Worksite and community tobacco control efforts. Key relationships studied in this program can be identified by answering three questions: • How effectively does the combination of clinician training, audit, and feedback improve rates at which clinicians advise patients to quit smoking? • Will enhanced benefits for smoking-cessation medications and programs increase the number of smoking-cessation medication prescriptions and the number of members attending tobacco-cessation programs? • How effectively is the prevalence of tobacco use decreased by clinical training, audit, feedback, enhancement of health plan benefits, and policies for worksite control of tobacco use? The Tobacco Dependence Program is aligned with KP’s mission to provide affordable, high-quality