Tobacco assessments decline in primary care

Key takeaways:

• Tobacco cessation counseling also decreased during the COVID-19 pandemic.
• Tobacco assessments may have been disrupted by the shift to telehealth and never reestablished upon the return to in-person care.

The monthly rates of tobacco assessments in primary care decreased by half during the early months of the COVID-19 pandemic and remained low despite transitions back to in-person care, according to a recent study.

“Since the start of the pandemic, several studies have shown a decline in receipt of preventive care and chronic disease management,” Susan A. Flocke, PhD, a professor in the department of family medicine at Oregon Health & Science University, and colleagues wrote in Annals of Family Medicine. “Little is known about the impact of the pandemic on addressing tobacco use. Given the relevance of tobacco use for severe symptoms of COVID-19, it is important to understand the pandemic’s impact on tobacco assessment and cessation assistance.”

Furthermore, diminishing the harms of smoking is “particularly important in the context of community health centers (CHCs) which provide primary care services for a large proportion of socioeconomically disadvantaged patients,” the researchers wrote.

To evaluate changes in tobacco assessments and cessation assistance, Flocke and colleagues analyzed electronic health record data from 217 CHCs across 13 states. The analysis included 759,138 in-person and telehealth visits that occurred from Jan. 1, 2019, to July 31, 2021.

Tobacco assessment rates declined from 155.7 per 1,000 patients in January 2019 to February 2020 to 77.7 per 1,000 patients in March 2020 to May 2020, equaling a 50% decrease. Although rates rose from June 2020 to May 2021, they remained 33.5% below pre-pandemic levels, according to Flocke and colleagues.

Provisions of tobacco cessation counseling also decreased, although to a lesser extent, from 109.5 per 1,000 tobacco users in January 2019 to February 2020 to 87.1 per 1,000 tobacco users in March 2020 to May 2020. Like tobacco assessments, provisions increased to 107.9 per 1,000 tobacco users from June 2020 to May 2021, though were still 2.5% lower than pre-pandemic levels.

“Provision of tobacco cessation medications was low, 43.9 per 1,000 tobacco users from January 2019 to February 2020, and declined slightly across the time periods,” the researchers wrote.

Flocke and colleagues noted it is possible that tobacco assessments were interrupted during the transition to telehealth and never reestablished when care returned to the physical clinical setting.

“Tobacco assessment before the pandemic was likely conducted by medical assistants during the rooming process involving vital signs and tobacco use history,” they wrote. “It is likely that telehealth visits changed this workflow such that gathering vital signs — typically done by the person who ‘roomed the patient’ — was omitted as a step before initiating the interaction between the patient and clinician.”

Additionally, though telehealth services could be effective in assessing patients’ tobacco history and potential treatments, “lack of standard workflow on when and who should assess tobacco history during telehealth visits in CHCs could have impeded tobacco assessment performance,” the researchers wrote.

They concluded that due to the health consequence of tobacco use, “all primary care settings should have a process in place to routinely assess tobacco status and to provide assistance for quitting.”

“Careful examination of procedural changes that promote or impede assessment of tobacco, including adaptation to support tobacco assessment via telehealth, is needed to guide resilient procedures that can weather operational changes,” they wrote.