According to the 2008 Public Health Service (PHS) guideline Treating Tobacco Use and Dependence there is strong evidence that screening, brief intervention and pharmacotherapy can produce significant and sustained reductions in tobacco use [1]. However, clinicians find it challenging to deliver all of the recommended 5As (ask, advise, assess, assist, arrange) in the context of a busy practice [2]. Strategies to assist providers in streamlining treatment, such as including smoking as a vital sign, increases screening rates but does not increase cessation assistance as a standalone intervention [3–6]. Reorganizing the practice environment to help clinicians delegate the time consuming steps of counseling and arranging follow-up may improve rates of treatment delivery and enhance the level of support smokers receive. One way this can be accomplished is by linking health care settings with statewide telephone counseling programs.

Telephone quitlines have proven effective in increasing smoking cessation and are now available in all 50 states in the US through a national network of tobacco quitlines [1]. All but one state quitline allows providers to refer patients through fax referral programs [7]. The "Fax-to-Quit" program, as it is referred to in New York State, aims to simplify the referral process by offering clinical practices a method to link patients to a free proactive telephone counseling service using a fax referral form. In a proactive approach the counselor initiates the call, in contrast to reactive telephone counseling in which the patient initiates contact. A recent meta analysis found that smokers who receive proactive counseling are 56% more likely to quit compared with self help [8].

Recent studies suggest that connecting clinicians to telephone tobacco quitline counselors through fax referral systems is feasible and may induce providers to intervene more consistently with their patients who smoke [9–17]. However this service has not been well studied in community health centers (CHCs) that serve low income minority populations. The primary purpose of this pilot study was to examine the effect of implementing the fax-to-quit system plus an expanded vital sign chart stamp that prompted providers to offer the first 4As compared to the vital sign chart stamp alone on the level of cessation support smokers received.

Tobacco quitlines are an effective yet largely untapped referral resource for health care providers who may not have the time or resources to offer onsite smoking cessation counseling. In this study, a fax referral system combined with an expanded vital sign chart prompt was associated with higher rates of provider initiated assistance and referral to the Quitline compared with the chart prompts alone. These results suggest that Fax-to-Quit programs can be implemented in busy CHC practices, and similar to previous research, can facilitate cessation assistance through referrals to state-level telephone counseling services [9–17].

The high rates of baseline screening and advice to quit offered by clinicians in all study sites was likely related to the expanded vital sign chart stamp which was implemented three months prior to the start of this study. The Ambulatory Care Network QI committee's decision to use the enhanced chart stamp was informed by research demonstrating that smoking status vital sign chart stamps that only prompt providers to screen for tobacco use do not consistently increase provider delivered advice to quit or cessation assistance [3–6]. However, our results suggest that even a more elaborate chart stamp, which prompts providers to refer and prescribe, may not be adequate to trigger clinician action without an accompanying referral system in place that is fully operationalized (i.e. staff training, technical assistance, staff roles defined in relation to the referral system, faxing process in place). Comparison sites were aware of the Quitline and the fax referral system, but they only received preprinted referral pads with the Quitline telephone number which they were advised to give to smokers who were ready to quit. In contrast, intervention sites received additional training and ongoing technical assistance that was specifically related to implementing and using the fax referral system.

Several evaluations of state level quitline referral systems have noted the need for supportive infrastructure including a site champion, training, technical assistance and feedback to facilitate the interaction between clinicians and the centralized quitline, increase adoption and ensure successful implementation [10, 16–19]. Intervention clinics received several of these components, while comparison sites were familiar with the Fax-to-Quit program but did not receive the support that may be needed to fully utilize the service. Simply knowing about the program may not be enough to promote consistent and sustainable referrals. Post intervention qualitative interviews with physicians and staff, the results of which are reported in another publication, support this premise [20]. Health care providers and staff in intervention sites described numerous benefits of the chart stamp and Fax-to-Quit systems but pointed out that those new systems, even ones that will ultimately simplify care processes, can initially interrupt workflow and must overcome organizational barriers to ensure full integration and sustainability [20].

Of note, this study coincided with implementation of a well funded aggressive statewide tobacco control program that included funding of 19 cessation centers across the state. Initiated in 2004, the centers were established to implement and disseminate the PHS tobacco use treatment guidelines in a wide range of health care settings (inpatient and outpatient). Specific emphasis was made on increasing clinician referrals to the New York State Quitline via the Fax-to-Quit program. Statewide cessation center activities have been associated with a 132% increase in fax referrals from providers over the past 5 years. Referrals increased from 4,215 in 2005 to a projected 9,796 for 2009. Moreover, health care settings that have received the most attention in terms of technical assistance and implementation support have the highest rates of referrals [[10], NYSDOH Quitline, 2009 unpublished data].

The Fax-to-Quit program offers several advantages to patients and providers, including easy access to a free, evidence-based counseling program regardless of insurance status, the ability to serve diverse multilingual populations, links to local cessation programs that providers may not be aware of, and in many states, free pharmacotherapy [6, 9, 16, 21]. Enhancing fax referrals may also increase overall engagement of providers in cessation activities. Although changing practice patterns related to prescribing was not a specific target of the intervention, we found that intervention sites were almost twice as likely to offer assistance with smoking cessation medications. A recent survey of Swedish General Practitioners (GPs) also found that GPs who referred to a quitline were more likely to be active in other smoking cessation activities. Provider knowledge and use of the quitline may have an additional positive effect on overall engagement in treating tobacco use [22].

One of the drawbacks of the proactive program is low contact rates. Studies of fax referral programs in health care settings report quitline contact rates ranging from approximately 40-70% [10–16, 23, 24]. During the intervention period only 41% of patients were reached, which is lower than the average NYSDOH contact rate of 53% (NYS DOH unpublished, 2009). The low contact rates in this study may be related to the demographic characteristics of this population. Mahabee-Gittens reported similar contact rates (46%) in a study of low income, minority parents referred for proactive quitline counseling in a pediatric emergency room [14].

Improving connection rates may require additional staff and provider training to ensure that patients are assessed properly. In addition, patient education prior to referral may help normalize the service, clarify expectations and overcome resistance that patients may not be willing to express to their doctor [20]. One of the providers interviewed for this study reported connecting patients to the Quitline while they were still in the office. Assisting patients through care coordinators or other staff during or soon after the visit may improve connection rates and increase referrals [24]. An additional reason to address this issue is the potentially negative impact of low patient contact rates on provider referrals. Providers may be discouraged from continuing to refer patients to a program that cannot consistently reach their patients. Collaboration with providers and quitlines is needed to develop new strategies for improving patient connections with proactive quitline counseling [16].

Ask-advise-refer and ask and act models that integrate the 5As into an abbreviated intervention supported by quitline fax referral or web-based programs have been promoted as a method to simplify adoption of guideline recommended tobacco use treatment in primary care [25–29]. The Fax-to-Quit program provides a simple method for implementing this more streamlined approach. However, there are several questions regarding how to best integrate quitline-practice linkages and the impact of these programs on provider practice patterns and patient outcomes. For example, are providers less likely to engage patients and provide follow-up if they assume the quitline will take over this responsibility, and does this reduce the impact on cessation outcomes compared to the 5As approach [21, 23, 30, 31]? Borland et al. found that the option for referring did not result in GPs providing less effective smoking cessation counseling within the consultation, but this requires further study [30]. Second, what are the barriers to adopting and maintaining fax or email referral systems in busy clinical settings? Further studies are needed to identify the specific implementation strategies and systems level approaches that work to facilitate routine delivery of tobacco cessation services and specifically, routine referral to state-level quitlines.

A number of limitations require consideration. The study sample was small and the CHCs were not randomized. The CHCs practice, however, under the same administrative umbrella at one academic institution and serve the same patient population. Moreover, an analysis of patient and provider characteristics demonstrated no baseline differences between sites. There were also no differential changes in patient characteristics at the baseline and follow-up time periods. However, our findings require replication. Another potential limitation was the dependence on patient self reports. We collected faxed forms at the intervention sites only, which confirmed patient reports of fax referrals, but we did not have the same data from the comparison sites.

State quitlines provide an important resource for health care providers and patients. Smokers in every state in the U.S. have free access to telephone quitlines through 1-800-QUIT-NOW and the fax referrals system is available in 49 of 50 states [7]. These programs have the potential to be replicated across a multitude of health care settings and may be a key strategy for facilitating routine cessation assistance and referrals into routine primary care.