Although the health benefits of smoking cessation are well documented, only about 6% of smokers successfully quit each year. Quitlines deliver highly effective telephone-based smoking cessation services, but this intervention reaches only 1% to 2% of smokers each year. “Most households in the United States have phones, making quitlines one of the few modalities with the potential to have broad enough reach to make a significant impact,” says Jennifer Irvin Vidrine, PhD. “Quitlines could serve a much larger smoking population, but they generally have not been well integrated or institutionalized within healthcare systems.”

The formalization of partnerships with healthcare providers has been identified as a key strategy for increasing the impact of quitlines. Several national initiatives have been developed to facilitate the delivery of smoking cessation treatment in medical settings, most notably “Ask-Advise-Refer,” or AAR. “The AAR program was designed to help clinicians routinely assess smoking status among all patients,” explains Dr. Vidrine. “It’s also intended to help clinicians deliver brief advice to quit smoking and refer smokers to guideline-recommended cessation treatments. Unfortunately, referrals to quitlines are low, and most smokers passively referred to quitlines fail to call for assistance.”


Testing a Quitline New Method with EHR

Dr. Vidrine and colleagues conducted a group randomized trial designed to evaluate a new approach to disseminating quitline-delivered cessation treatment through a healthcare system partnership. The study, published in JAMA Internal Medicine, evaluated Ask-Advise-Connect (AAC), an approach designed to address clinic- and patient-level barriers to linking smokers to treatment through the help of an automated connection system within electronic health records (EHRs).

Click here for a video presentation released by JAMA Internal Medicine on Dr. Vidrine’s article.

“AAC is similar in some ways to fax and email referral programs that have been tested in previous studies,” says Dr. Vidrine. “What makes AAC unique is that connections to the quitline are made through an automated link contained within the EHR, which is intended to greatly streamline the process of linking smokers with treatment. In addition, AAC is implemented by licensed vocational nurses (LVNs) and medical assistants, which shifts the burden of counseling and referrals away from busy clinicians.”

In the study, Dr. Vidrine and colleagues randomized five clinics to AAC and another five to AAR, their control condition. In both AAC and AAR, LVNs and medical assistants were trained to assess and record the smoking status of all patients visiting primary care clinics at all visits in the EHR and provide all smokers with brief advice to quit. In AAC, the names and phone numbers of smokers who agreed to be connected were sent electronically to the quitline each day. Patients were called proactively by the quitline within 48 hours of receipt of their information. In AAR, smokers were offered a quitline referral card and encouraged to call on their own for assistance with quitting.

Increasing Treatment Enrollment

In the AAC clinics, 7.8% of all identified smokers enrolled in treatment, compared with a 0.6% rate that was observed in the AAR clinics, representing a 13-fold increase in treatment enrollment. “AAC outperformed AAR in terms of reach and impact,” Dr. Vidrine says (Figure). “Although many smokers declined to be connected or were unreachable by the quitline, the streamlined, automated, and brief nature of AAC has the potential for extraordinarily broad reach, which ultimately enhances its potential public health impact.”

Dr. Vidrine notes that AAC resulted in one of the highest rates of enrollment in smoking cessation treatment to date. “Given that 70% of all smokers in the U.S. visit a primary care physician each year, AAC has tremendous potential to increase the uptake of smoking cessation treatment. The key is to proactively recruit patients using the AAC approach.” The potential public health impact of AAC is also highlighted by the results of a recent meta-analysis, which found that active versus passive recruitment approaches to quitline treatment enrollment resulted in equivalent cessation outcomes.

Reducing Barriers to Smoking Cessation Treatment

A critically important component of healthcare reform is that information on smoking assessment and treatment be systematically tracked and recorded. Meaningful use criteria for tobacco cessation require clinicians to screen the smoking status of more than half of all patients aged 13 or older and track the percentage of patients aged 18 and older who are current tobacco users who receive advice, cessation treatments, or recommendations to use medications and other strategies. “The AAC approach addresses each of these areas,” says Dr. Vidrine. “AAC can greatly reduce barriers to smoking cessation treatment and can be implemented in various settings. The benefits of quitline-delivered counseling are numerous, and innovative approaches like AAC may have important implications for reducing tobacco-related morbidity and mortality.”


Vidrine JI, Shete S, Cao Y, et al. Ask-advise-connect: a new approach to smoking treatment delivery in health care settings. JAMA Intern Med. 2013;173:458-464. Available at:

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