Recent cessation attempts and receipt of cessation services among a diverse primary care population – A mixed methods study

Smoking rates are high among low-income populations who seek care in safety-net clinics. While most safety-net clinics screen for cigarette smoking, there are substantial disparities in the delivery of smoking cessation counseling in these systems. We conducted a mixed method study between July 2016 and April 2017 to examine receipt of smoking cessation counseling and estimate recent cessation attempts among primary care patients in four safety-net clinics in San Francisco. We used the electronic health record (EHR) to examine receipt of cessation services and estimate cessation attempts, defined as transition from current to former smoking status during the 9-month study period. We conducted interviews with 10 staff and 16 patients to assess barriers to and facilitators of providing cessation services. Of the 3301 smokers identified via EHR, the majority (95.6%) received some type of cessation counseling during at least one clinical encounter, and 17.6% made a recent cessation attempt. Recent smoking cessation attempts and receipt of smoking cessation services differed significantly by clinic after adjusting for demographic factors. We identified patient and staff-level pre-disposing, reinforcing and enabling factors to increase delivery of cessation care, including increasing access to cessation medications and higher intensity counseling using a team-based approach. The EHR presents a useful tool to monitor patients' recent cessation attempts and access to cessation care. Combining EHR data with qualitative methods can help guide and streamline interventions to improve quality of cessation care and promote quit attempts among patients in safety-net settings.