Short CommunicationThe need for tobacco cessation in a free clinic population
Highlights
► We assess a sample of uninsured patients at six free clinics. ► We report on prevalence and correlates of tobacco use and provider cessation advice. ► The prevalence of tobacco use was more than twice the national and state average. ► Rates of tobacco screening and cessation advice fell well below USPHS guidelines. ► Free clinics present an opportunity to reduce tobacco harm in a high risk group.
Introduction
Despite overall declines in the prevalence of tobacco use, tobacco-related health disparities persist (CDC, 2011). Socioeconomic status (SES) is a powerful determinant of tobacco-related health disparities (Pleis & Lethbridge-Çejku, 2007). Smoking among the unemployed is 45%, compared to 28% among full-time workers (CDC, 2011). Smoking prevalence among those without health insurance is 34%, compared to 18% among those with private insurance (Pleis & Lethbridge-Çejku, 2007). Although low SES smokers are as likely to make a quit attempt as their high SES counterparts, they are only half as likely to succeed (Kotz & West, 2009). Those with the lowest SES, many of whom are uninsured, are at the highest risk for tobacco-related morbidity and mortality (Vidrine et al., 2009, Ward et al., 2004).
The US Public Health Service guidelines (PHS Guidelines) recommend that health providers use the evidence-based 5-As approach — ask, advise, assess, assist, and arrange — to identify and counsel tobacco users (Fiore et al., 2008). Three-minute tobacco cessation interventions by primary care providers can increase the odds of quitting by 30% (Fiore, 2000, Kreuter et al., 2000). However, the uninsured are three times less likely than those with insurance to receive smoking advice from a healthcare provider (Parnes, Main, Holcomb, & Pace, 2002). The lack of access to smoking cessation interventions among the uninsured contributes to tobacco-related health disparities in this population (Parnes, Main, Holcomb, & Pace, 2002).
Free clinics, of which there are over 1200 across the U.S., are one of the few health care resources exclusively for the uninsured (Darnell, 2010, Darnell, 2011). Free clinics are private, non-profit organizations which provide medical care free of charge. They rely primarily on volunteer medical staff and do not accept reimbursement from third-party payors (Fleming & Mills, 2005). Because they do not receive governmental funding, they have limited resources and are also exempt from most public oversight, including the Joint Commission on Accreditation of Healthcare Organizations guideline that requires hospitals to be smoke-free to gain accreditation. With a predominately volunteer workforce and lack of policy infrastructure that mandates tobacco cessation counseling, we hypothesized that free clinic patients would have higher than average tobacco use rates and receive lower than average cessation advice and counseling from their healthcare providers.
Because free clinics fill such an important gap in access to healthcare and may represent an opportunity to reach low SES tobacco users, their implementation of the PHS guidelines is essential. This report, part of a larger study to increase free clinics' adoption of the PHS guidelines, describes the need for tobacco cessation in a free clinic population.
Section snippets
Sample
The 74 free clinics that were members of the North Carolina Association of Free Clinics at the start of the study were assessed for eligibility. Of the 46 clinics that responded, 1 was excluded because they did not provide medical and/or dental services, 5 were excluded due to being located further than a 3-hour drive from the research team, 7 were excluded due to being open fewer than 2 days per week, and 20 were excluded because they reported that they already provide comprehensive tobacco
Patient characteristics
Of 160 free clinic patients who were invited to participate, 158 patients completed the exit interview and two (1%) patients declined. As seen in Table 1, the majority were females (77%), African American (46%) or white (41%), non-Hispanic (92%), and high school graduates (70%). The mean age of participants was 45 years. Most patients reported living with a smoker (64%) and having a chronic disease (78%) such as hypertension, diabetes, or asthma. The vast majority of patients reported a visit at
Discussion and conclusions
This study describes the prevalence and correlates of tobacco use and provider cessation advice among a novel population of uninsured free clinic patients. We found that 53% of free clinic patients currently used tobacco, twice the national and North Carolina average (both 21%) and higher than previous literature describing the uninsured (up to 34%) (Centers for Disease Control and Prevention, 2010a, Centers for Disease Control and Prevention, 2010b, North Carolina Tobacco Prevention and
Role of funding sources
Funding for this work was provided by the National Institute on Drug Abuse (R21DA024631). The National Institute on Drug Abuse had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or decision to submit the manuscript for publication.
Contributors
All authors contributed to designing the study and writing the protocol. Jessica Richardson Pockey and Kristie Foley conducted literature searches and provided summaries of previous research studies. Eun-Young Song conducted the statistical analysis. Jessica Richardson Pockey wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript.
Conflict of interest statement
All authors declare that they have no conflicts of interest.
Acknowledgements
Preliminary data for this study were presented at the 17th annual meeting for the Society for Research on Nicotine and Tobacco (SRNT) in February, 2011, in Toronto, Canada.
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