ALE Spotlight: Improving the Tobacco Treatment Program at Whittier Street Health Center

By Siyu “Sylvia” Chen, MS/MPH Candidate ’19

At the Applied Learning Experience (ALE) Fair in spring 2019, I met my future preceptors at the booth for the Community Benefits Office of the Dana-Farber Cancer Institute (DFCI). Information about a tobacco cessation program quickly caught my attention, and after a brief introduction, I knew this was the ALE that I was looking for. My grandfather had been a heavy smoker for almost thirty years of his life and although he quit in his late-50’s, the damaged caused by long-term heavy smoking still compromised his health and lung functions. I saw this ALE project as a great opportunity for me to learn about smoking cessation from a public health perspective and to hone my knowledge and skills in a real-world setting.

Tobacco smoking is the leading cause of preventable deaths in the United States.1 The past couple decades have seen a decrease in the prevalence of smoking among adults from 23.3% in 2000 to 14% in 2017.2 However, national surveys reveal that smoking rates remain high among vulnerable populations, such as people with low income, serious psychological distress, or a disability/limitation.3 

For my ALE, I conducted a quality improvement project for the Tobacco Treatment Program at the Whittier Street Health Center (WSHC), located in Roxbury, MA. The patient population of WSHC is very diverse and medically complex, often suffering from multiple chronic health conditions4 and with a relatively high prevalence of smoking. The Tobacco Treatment Program offers free cessation counseling for patients and assists them with obtaining quitting aids, such as nicotine replacement therapy. The goal of the Tobacco Treatment Program is to reduce smoking and tobacco-related cancers.

As part of the program, an intake questionnaire is filled out by a cessation counselor for each participant, which includes demographics, smoking history, social environment, substance use, quitting history, and other information. The objective of my ALE project was to analyze the questionnaire data and, based on the results and a literature review, recommend ways to improve the program’s tobacco cessation success rates. My ALE was the first time that anyone had organized and analyzed the questionnaire data that have been accumulating over the past 4 years.

During my implementation semester, I encoded and analyzed the data using the statistical software R. The analysis revealed several insights about the program participants. Since 2015, the Tobacco Treatment Program provided 439 counseling sessions to 169 patients, of those 144 reported reducing their tobacco consumption and 57 successfully quit smoking. Participants were at the mean age of 50 years old and the majority of them smoked more than 6 cigarettes per day and had an average smoking history of 29 years. Many suffered from psychological distress, for example depression and anxiety, and multiple chronic health conditions, such as high blood pressure and diabetes. To identify which modifiable factors were associated with success in quitting smoking among this population, my preceptor and I used multivariable logistic regression models. We found that participants whose spouses were also smokers or were allowed to smoke at home, or who attended fewer counseling sessions, had significantly lower chances of quitting smoking, compared to their counterparts.

The findings of my project highlight the impact of environmental influences on smoking cessation and show that future emphasis should be placed on encouraging dual-smoker couples to participate in counseling sessions together and on supporting participants to establish rules against smoking indoors. The results also confirm the effectiveness of the tobacco cessation counseling offered by the Tobacco Treatment Program – attending more counseling sessions was associated with a higher chance of quitting. Thus, implementing measures to encourage either attendance at in-person sessions or participation in phone calls, such as incentives and regular follow-up calls, could improve the program’s outcomes.

While the Tobacco Treatment Program has achieved some success in tobacco cessation among participants, we also recognize that the participants are only a small subset of the target population. The Tobacco Treatment Program has received an increasing number of referrals from WSHC physicians over the years, but only a handful of patients actually enroll in the program. To extend and amplify the influence of the Tobacco Treatment Program, it would be beneficial to conduct a future investigation to understand the barriers to attending counseling sessions and improve recruitment targeting.

Over the course of six months, I planned and implemented a quality improvement project for a community-focused program with the help from my preceptors and ALE instructor. We encountered and resolved various obstacles along the way, and I learned to be flexible, optimistic, and proactive. I am grateful for the support and guidance from my ALE instructor, Professor Virginia R. Chomitz, and my preceptors at the Community Benefits Office of Dana-Farber Cancer Institute, Rachel Levine and Sarah Peterson.

References

1. Centers for Disease Control and Prevention. Health Effects of Cigarette Smoking [Internet]. Centers for Disease Control and Prevention [updated 2018 Jan 17; accessed 2019 Mar 6]. Available from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm
2. American Lung Association. Overall Tobacco Trends [Internet]. American Lung Association [updated 2019 June 13; accessed 2019 Aug 16]. Available from https://www.lung.org/our-initiatives/research/monitoring-trends-in-lung-disease/tobacco-trend-brief/overall-tobacco-trends.html
3. Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults in the United States [Internet]. [Place unknown]: Centers for Disease Control and Prevention [updated 2019 Feb 4; accessed 2019 Mar 6]. Available from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
4. Dana-Farber Cancer Institute. FY’18 Community Benefits Report. Boston: Dana-Farber Cancer Institute; 2019.