Vol.3, No.1, 75-83 (2013) Open Journal of Preventive Medicine
http://dx.doi.org/10.4236/ojpm.2013.31010
Use of systems change and health information
technology to integrate comprehensive tobacco
cessation services in a statewide system for delivery
of healthcare
Sarah Moody-Thomas1*, Michael D. Celestin Jr.1, Ronald Horswell2
1School of Public Health, Louisiana State University Health Sciences Center, New Orleans, USA;
*Corresponding Author:
2Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, USA
Received 27 October 2012; revised 28 November 2012; accepted 7 December 2012
ABSTRACT
Despite the availability of effective treatments
and recommendations for systems change, full
application of the US Public Health Service
clinical practice guideline for the treatment of
tobacco use is seldom achieved. The present
report describes a comprehensive, structured
approach used to implement the guideline and
to integrate evidence-based cessation services
into a system for delivery of health care. The
PRECEDE-PROCEDE model and systems stra-
tegies were employed to design and implement
the Tobacco Control Initiative (TCI), which pro-
vides evidence-based cessation services for the
patients of a statewide public hospital system.
For the TCI, multi-level assessments, pilot pro-
grams, electronic data collection, and perform-
ance feedback were needed to produce sys-
tem-wide changes in workflow and in the qualit y
of care for tobacco users. Although there are
advances in hea lth information t echnology (HIT),
systems approaches are required for respond-
ing effectively to the Health Information Tech-
nology for Economic and Clinical Health (HI-
TECH) Act and to standards governing use of
electronic data related to treatment of tobacco
use and depende nce.
Keywords: Tobacco Cessation; Health Care
Delivery System; Systems Change
1. INTRODUCTION
Tobacco use remains a public health challenge. As the
most preventable cause of death and illness, it is the pri-
mary risk factor for cardiovascular disease [1] and the
leading cause of death in the U.S. [2]. It also undermines
management of chronic conditions such as diabetes,
asthma and HIV/AIDS [3]. Over the past 60 years, ef-
fecttive treatments and policies have decreased tobacco
use in the US; there are now fewer current smokers and
more never smokers. However, the proportion of former
smokers has remained steady for several decades [4].
Those who continue to smoke are more likely to have
limited wealth, low educational attainment, and to repre-
sent racial/ethnic minorities (e.g., African Americans,
Hispanics, and Native Americans) [5]. The burden of
tobacco use is evident in the poor health outcomes in
these groups, making it imperative to find ways to in-
crease the use of effective treatments.
Health care delivery systems reach large populations
of tobacco users. Of the 45 million adult smokers in the
US, 70% visit a health care provider each year [6]; such
contacts provide opportunities for cessation. Even brief
advice to quit given by a health care provider increases
cessation rates [7], and the effect of provider advice is
stronger for smokers on Medicaid and uninsured groups
of smokers than for those with private insurance [8].
The US Public Health Service (USPHS) clinical prac-
tice guideline (CPG) for treating tobacco use and de-
pendence, initially produced in 1996, primarily recom-
mends medication and counseling. An updated guideline,
issued in 2000, encourages health care delivery systems
to promote tobacco cessation and to ensure that smokers
are identified and engaged during clinical encounters.
The 5A’s clinical protocol (Ask, Advise, Assess, Assist,
and Arrange) is complemented by six system-level
strategies to facilitate integration of evidence-based
treatments of tobacco use into routine health care prac-
tices. The strategies include: 1) identification of tobacco
users; 2) provision of education, resources, and perfor-
mance feedback to health care clinicians; 3) use of dedi-
cated staff to coordinate and promote delivery of treat-

S. Moody-Thomas et al. / Open Journal of Preventiv e Medicine 3 (2013) 75-83
76
ment; 4) adoption of policies to create supportive ser-
vices; 5) reduction of patients’ out-of-pocket costs for
behavioral and pharmacologic treatments; and 6) reim-
bursement of clinicians delivering cessation treatments
[9]. Initiatives sponsored by the Robert Wood Johnson
Foundation heightened awareness of the issue and pro-
duced evidence supporting the feasibility and effective-
ness of changing aspects of health care practice to sup-
port treatment of tobacco dependence (e.g., methods to
identify smokers in primary care office settings and fax
referrals to treatment) [10-12].
Despite evidence of the effectiveness of a “systems ap-
proach” [11], widespread implementation of the USPHS
CPG continues to lag [13]. Health care systems often
lack the resources, infrastructure, and organizational cul-
ture needed to overcome barriers to change [14]. Few
studies have examined implementation of the CPG for
treatment of tobacco use in health care systems serving
the most medically vulnerable [15-17].
In view of the fact that Louisiana’s smoking rate in
2001 (24.6%) exceeded that of the nation (22.9%) [18],
the Louisiana state legislature enacted an excise tax on
cigarettes in 2002. A portion of the proceeds were dedi-
cated to the provision of cessation services to patients of
the state’s public hospital system, which is among the
largest “safety-net” organizations for health care delivery
in the country. Comprised of ten sites, this integrated
state-run provider group is operated by the Louisiana
State University (LSU) System (see Figure 1).
In the LSU System, every resident of the state is enti-
tled to receive care in any site without regard for enroll-
ment or eligibility criteria. Louisiana’s most medically
vulnerable are cared for each year, with more than
70,000 admissions, and nearly 1.4 million outpatient and
emergency department visits for 400,000 state residents.
Patients are 52% female, 49 years of age on average,
77% African American, and 49% uninsured. Facilities

LSUHealth
NewOrleans
Figure 1. LSU health New Orleans system sites.
also serve as training sites for medical and allied health
professionals.
The disease management program of the LSU Health
New Orleans (LSUH-NO) system, representing 7 of the
10 public hospitals, was initiated to monitor modifiable
risk factors and coordinate services to improve health
outcomes of patients with chronic conditions. With its
existing organizational structure, delivery of proto-col-
driven clinical care to defined populations, information
technology capacity for patient tracking, and the possi-
bility of performance feedback and program evaluation,
this program was identified as an access point for the
integration of cessation services into routine health care
delivery. Details of this program are described elsewhere
[19]. Electronic health records and health information
technology (HIT) hold promise for facilitating imple-
mentation of the CPG [20]. At the time the disease man-
agement program was initiated neither the electronic
identification of tobacco users nor documentation of pro-
vider intervention was included in the existing infra-
structure.
The present report describes the development, imple-
mentation, and evaluation of the Tobacco Control Initia-
tive (TCI), a multifaceted program employing system
strategies recommended in the USPHS CPG and HIT to
integrate evidence-based cessation services into a public
health care network.
2. METHODS
2.1. Conceptual Framework
Systems’ thinking [21] was utilized to comprehend the
complexity of the healthcare delivery system, interpret
multiple layers of assessments conducted among stake-
holders, and apply findings toward development of ob-
jectives, strategies, and activities, all organized within
the structure of the PRECEDE-PROCEED model. This
model allows analysis of a situation and design of a
health program. It also provides a structure for assessing
health and quality of life needs and for designing, im-
plementing, and evaluating health promotion and other
public health programs to meet those needs. The model,
which directs attention to outcomes rather than to inputs,
guides planners through a process that starts with desired
outcomes and identifies strategies for achieving objec-
tives. A fundamental characteristic of the model is the
participation of its intended audience [22].
2.2. Program Development
Formative research was conducted to 1) delineate the
organizational structure, processes of care, and IT ca-
pacities within the system; 2) determine provider aware-
ness and application of the USPHS CPG and the feasibil-
ity of using recommended systems strategies; 3) identify

S. Moody-Thomas et al. / Open Journal of Preventiv e Medicine 3 (2013) 75-83 77
barriers to CPG implementation; 4) characterize preva-
lence and patterns of tobacco use and treatment prefer-
ences among patients; and 5) perform a pilot implemen-
tation of evidence-based cessation services in a clinical
setting. In 2003, a baseline site survey was conducted.
The survey was adapted from a series of assessments
conducted by the American Association of Health Plans
(AAHP) a comprehensive and widely used appraisal of
tobacco-related interventions in health care systems [23].
At each site, the survey was administered to representa-
tives from relevant departments [24]. This study received
exempt research status from the LSU Health Sciences
Center Internal Review Board (IRB).
In 2004, a baseline patient survey characterized pre-
valence and patterns of tobacco use among patients. A
scheme involving stratified two-stage cluster sampling
was used to recruit 770 patients to complete face-to-face
surveys during visits to targeted primary care clinics
[unpublished data]. The target population for this study
was defined as adults who use LSU primary care clinics
as their principal source of health care. This study was
approved by the LSU Health Sciences Center IRB.
Also in 2004, a pilot evaluation of the cessation pro-
gram was conducted in the dental clinic of one of the
network sites. The pilot study was designed to identify
and address system barriers to implementation of the
clinical protocol based on the 5A’s. The pilot program
integrated tobacco cessation services into existing proc-
esses and included: 1) provider and staff training; 2)
identification and assessment of tobacco users; 3) referral
to cessation services; 4) delivery of pharmacotherapy and
behavioral counseling; and, 5) provision of telephone
follow-ups. After data from the assessments and the pilot
were compiled, meetings were held at each site to intro-
duce the TCI as a standardized, system-wide intervention
for tobacco cessation designed to integrate cessation ser-
vices into routine health care delivery, present roles and
responsibilities of TCI and site staff, and identify a to-
bacco team leader and potential multi-disciplinary team
members.
2.3. Program Implementation
In conjunction with the systems strategies delineated
in the CPG, a pragmatic approach to implementing a
tobacco cessation program in a network setting guided
implementation of the TCI [25]. A centralized manage-
ment team was established to conduct site visits, develop
program content, hire cessation coordinators, train site
clinicians and staff, and create processes for data collec-
tion and reporting.
2.4. Program Evaluation
The following measures were used to assess program
development and implementation: 1) number of site vis-
its (e.g., presentations at meetings); 2) number of multi-
disciplinary tobacco control teams formed; 3) develop-
ment of a system-wide, standardized process of care
(paper and electronic, for in-patients, out-patients, and
emergency) for identification, documentation, and treat-
ment; 4) number of dedicated staff hired for each hospi-
tal; 5) development of data sources (e.g., tobacco registry,
referrals, and service delivery databases); 6) number of
treatment options established (self-help, group counsel-
ing, and medication) at each hospital; and 7) number of
clinicians trained in evidence-based practice and process
of care.
Evaluation of the impact of the TCI was guided by the
document, “A National Blueprint for Disseminating and
Implementing Evidence-Based Clinical and Community
Strategies to Promote Tobacco-Use Cessation,” pre-
sented at the National Conference on Tobacco or Health
in 2002 [26]. The blueprint was designed to direct activ-
ties related to tobacco cessation and to ensure that effec-
tive, multi-level efforts support cessation across health
care plans and community organizations. The overall
goal of the TCI is to implement and evaluate multi-level
tobacco cessation services in all hospitals. To do so, ob-
jectives for system, provider, and tobacco users were set.
The TCI adapted objectives recommended for the four
levels of intervention proposed in the blueprint: clinician,
system, tobacco user, and evaluation (see Table 1).
Patient responses to the ASK, ADVISE, ASSESS, and
ASSIST queries were entered by LSUH-NO clinical
personnel into CLIQ (CLinical InQuiry), the LSUH-NO
electronic medical record. Patient data on ARRANGED
cessation services and follow-up were entered by TCI
site personnel into the LSUH-NO Cessation Manage-
ment and Evaluation Database (CMED), a relational da-
tabase used to record and manage tobacco cessation ac-
tivity. Data from CLIQ and CMED were migrated to the
LSUH-NO Disease Management & Evaluation Database
(DMED) and merged to calculate rates of provider per-
formance on a monthly basis. Longitudinal data on pa-
tient smoking status allowed classifying patients as
“smoked in the past 30 days” or “smoked in the past 12
months” and were used to derive quit attempts, sustained
quit rates, and relapse rates. Data were also available to
identify patients diagnosed with chronic diseases (e.g.
asthma, diabetes, HIV-AIDS).
3. RESULTS
3.1. Formative Research
Site assessments indicated respondents were generally
not aware of the CPG and thus had not implemented it.
Barriers to implementation were found to be lack of time,
space, and skills to engage tobacco users, lack of a con-
sistent place to refer patients for treatment, treatment

S. Moody-Thomas et al. / Open Journal of Preventiv e Medicine 3 (2013) 75-83
78
Table 1. TCI objectives, 2003.
Objectives
System
1) Integrate evidence-based treatments into regular healthcare delivery for all patients. Specifically, Implement evidence-based reminder system
to identify and document tobacco use and status at every visit.
a) Conduct baseline assessment of prevalence of tobacco use among LSUH-NO patients.
b) Identify where in processes of care tobacco use status may be documented.
c) Create a system-wide “tobacco registry”.
2) Increase to 75% the proportion of clinics that provide evidence-based treatments for patients who use tobacco products.
3) Decrease out-of-pocket costs for evidence-based treatments (e.g. counseling, medications).
Clinician
1) Increase the use of the 5As approach to identify, asses, and treat tobacco users. Specifically.
a) Increase to 100% the proportion of patients who are asked about tobacco use status and documented at every visit.
b) Increase to 90% the proportion of patients who are advised to quit and assessed for readiness to quit at every clinic visit.
c) Increase to 75% the proportion of patients using tobacco and willing to make a quit attempt who are assisted (counseling and medication).
d) Increase to 50% the proportion of patients using tobacco who attempt to quit, for whom follow up contact is arranged.
2) In conjunction with system changes, provide and promote continuing education (training) to ensure clinicians (health care providers) have
the skills needed to deliver and promote evidence-based treatment.
Tobacco User
1) Increase to 10% annually the number of smokers who are trying to quit, who stay abstinent for a full year or longer.
Evaluation
1) Continuously evaluate the effectiveness of strategies and use findings to inform changes in strategies.
costs, and patients’ motivation to quit. All sites ex-
pressed a need for personnel dedicated to the delivery
and coordination of care for tobacco users. However,
there was no system-wide policy delineating a protocol
for the treatment of tobacco use.
An estimated 26% of patients were identified as cur-
rent smokers, two thirds of which smoked their first
cigarette within 30 minutes of awakening; nearly all re-
ported wanting to quit. Preferred treatments, if cost was
not an issue, included cessation classes and pharmaco-
therapy (e.g., nicotine replacement therapy, Zyban). Al-
though more than one third indicated they would call a
quit line for assistance, nearly the same number would
use non-evidence based treatments (e.g., acupuncture,
herbs, and hypnosis); nearly one quarter would get in-
formation from the internet.
Results of the pilot at the dental clinic indicated: 1)
evidence-based cessation services could be integrated
into routine processes of care; 2) in lieu of an electronic
health record, the use of standardized forms facilitated
process implementation and helped to identify problems
therein; 3) provider and staff training were an essential
component of service implementation; 4) dedicated staff
were needed to ensure patient referral and participation
and delivery of cessation services; 5) barriers to patient
participation in behavioral counseling had to be addressed;
and, 6) issues related to dispensing medication and capac-
ity of on-site pharmacies warranted attention.
3.2. Program Evaluation
TCI formed seven site-specific tobacco teams to dis-
cuss program status and generate process improvement
strategies. These teams created synergy among multi-
disciplinary team members, coordinated program im-
plementation, and participated in interviewing and hiring
TCI staff. A standardized process for identifying and
treating tobacco users was developed in conjunction with
the tobacco teams from all LSUH-NO sites (see Figure
2).
In regions across the state, the TCI (staff, services, and
referral systems) was implemented in four phases, based
upon site readiness and personnel recruitment efforts.
The use of HIT evolved as the system’s capabilities
developed. Prior to 2004, all documentation was made in
clinical charts and required manual verification. Further,
the charts did not prompt adherence to the clinical pro-
tocol. In 2004, the TCI introduced a paper referral form
to document assessment of tobacco use, cessation medi-
cation consults, and referral to on-site group behavioral
counseling. Forms were collected and entered by TCI
staff into CMED for treatment follow-up and provider
feedback.
In 2005, an electronic Tobacco Registry was created
by asking all patients “Have you used tobacco in the past
30 days?” during the financial certification that is required
every 180 days. The registr provided a denominator y

S. Moody-Thomas et al. / Open Journal of Preventiv e Medicine 3 (2013) 75-83 79
Figure 2. Flowchart for outpatient documentation and treatment of tobacco use.
of all smokers, essential for analytic and program evalu-
ation purposes. Data were stored in the administrative
database and paired with CMED and the DMED. DMED
captured administrative data, such as patient encounters,
for each chronic illness and provided data to assess qual-
ity of care, access to care, and health outcomes for all
LSUH-NO disease management programs.
Although the Tobacco Registry data were useful, the
status of patients’ tobacco use was not available to clini-
cians at the point of care. In 2007, the same question was
included in CLIQ. This provided an opportunity to ac-
cess information in the clinical setting regarding smoking
status, as well as to prompt the reassessment and treat-
ment of smokers, every 90 days. In 2008, the Plan, Do,
Check, Act (PDCA) model was used to pilot a standard-
ized process for documenting use of the 5 A’s protocol.
In 2009, LSUH-NO deployed a revised CLIQ screening
system that included all 5 A’s as well as electronic refer-
ral to evidence-based cessation services. This HIT up-
grade made it possible to achieve programmatic goals. In
2010, LSUH-NO again revised the CLIQ screening to
identify smokers interested in quitting, in addition to
those ready to quit in 30 days, and required that self-help
information be given to all smokers instead of including
as a choice for treatment. See Figure 3 for a timeline of
events.
TCI field staff based at each site was hired to accom-
plish the program goals. Essential functions included
facilitating behavioral counseling, telephone follow-up
calls, patient recruitment, internal marketing to patients
and providers, convening tobacco teams, and data collec-
tion and reporting. The staff members were required to
participate in weekly conference calls that highlighted
best practices, protocol adherence, and opportunities for
process improvement. Comprehensive training and de-
velopment activities were provided to enhance the skill
levels of TCI field staff. Training included program ori-
entation, computer-based tobacco control education, be-
havioral counseling curriculum, motivational enhance-
ment therapy, social marketing, team building, and data

S. Moody-Thomas et al. / Open Journal of Preventiv e Medicine 3 (2013) 75-83
80
Figure 3. TCI timeline of events.
base management.
Provider engagement regarding tobacco use was
documented on elements of the 5 A’s protocol (see Fig-
ure 4).
Arrange, defined as provider referral to cessation spe-
cialists for receipt of selected services, reached 100%
because it was an electronic referral system via CliQ.
TCI staff provided face-to-face in-service training on
identification and treatment of tobacco users, referral
procedures, and available evidence-based cessation re-
sources for 210 doctors in 2006. In 2007, the TCI linked
the University of Wisconsin’s web-based training on
Treatment of Tobacco Use and Dependence (TTUD) to
the existing LSUH-NO provider e-learning system. With
face-to-face in-service training and the web-based course,
the number of clinicians trained increased to 934 in 2007,
1445 in 2008, and 1472 in 2009. In 2008, the LSUH-NO
adopted a policy requiring completion of the online
course by all nurses and other staff. Documentation of
completion was entered into their personnel files.
Quit rates (defined as quit after 90 days and sustained
quit after another 90 days and calculated electronically
using CliQ) increased from 5.0% in 2008 to 9.6% in
2009. Also in 2009, chronically ill patients (except those
with HIV) reported lower 30-day (26%) prevalence rates
than the general patient population (29%). Asthma pa-
tients were least likely to report smoking (18%) and had
a higher quit rate (15%) compared to other groups (p >
0.05). In contrast, HIV patients were more likely to re-
port smoking (43%) and had the lowest quit rate (6%) (p
< 0.05).
4. DISCUSSION
This report describes how the PRECEED/PROCEED
planning and delivery model [22] was used in conjunc-
tion with systems thinking [21] to design and implement
comprehensive, evidence-based tobacco cessation ser-
vices in a healthcare system serving the medically vul-
nerable. Multilevel assessments, pilot projects, and rapid
learning studies provide information about patient treat-
ment preferences and organizational structures affecting
CPG implementation. Electronic identification of all to-
bacco users prompts routine screening, assessment, and
treatment and creates a data source for determining
population-based smoking prevalence, program evalua-
tion, and performance feedback. This approach ensures
stakeholder involvement in the development of workflow
and treatment protocols and fidelity of protocol imple-
mentation, delivers performance feedback for adminis-
trators and providers, and maximizes the likelihood of
sustainable integration of cessation services in the health-
care setting [27].
CPGs are designed using existing evidence and, when
implemented, are expected to improve patterns of care
and health outcomes [28]. CPG implementation, how-
ever, is difficult to achieve due to the complex intervene-
tions prescribed and to the complex environments in
which it is to be implemented [29,30]. With a systems
approach, the TCI created synergy of implementation
strategies and built the infrastructure for CPG imple-
mentation. This process is referred to as “organizational
innovation” [11]. Although there are examples of evi-
dence-based cessation services within health care set-
tings [31-34], none describe development and imple-
mentation of a comprehensive, standardized, system-
wide program for tobacco treatment [6,13].
Rigotti emphasizes the need for a comprehensive to-
bacco care management system by stating, “if tobacco
treatment is to be integrated into the rapidly evolving US
health care system, we must create a comprehensive care
management system similar to that used for other chronic
diseases” [6,33,35-36]. The TCI accessed the LSUH-NO

S. Moody-Thomas et al. / Open Journal of Preventiv e Medicine 3 (2013) 75-83 81
Figure 4. 5 A’s intervention (2007-2010).
system through its existing Disease Management Pro-
gram. The CPG offered the advantage of evidence-based
tactics to guide the implementation process. The TCI, a
comprehensive tobacco management system, was created
to implement the CPG. The process included identifica-
tion of all eligible patients, direct outreach to the specific
population, central coordination of treatment sites, and
system-wide, standardized interventions. Although these
components are recommended [36], other disease man-
agement programs in the LSUH-NO system do not offer
them.
5. CONCLUSIONS
The TCI program is an inclusive tobacco cessation in-
tervention. Its structure and support allow the program to
identify sub-groups of patients (e.g., diabetic smokers)
and specific patient behaviors (relapse among recent
quitters) to be targeted with more focused interventions.
This coupling of program structure with the capabilities
of modern electronic medical records should lead to ad-
ditional tobacco control innovations.
The Health Information Technology for Economic and
Clinical Health (HITECH) Act, which was part of the
American Recovery and Reinvestment Act of 2009, is
designed to promote the adoption and meaningful use of
HIT. It incentivizes the adoption of electronic health re-
cords and sets criteria for minimum data requirements
for comparability and multi-site sharing [37]. While elec-
tronic health records can produce large quantities of data,
solutions to real-world impediments to change and inno-
vation come through systems thinking [38]. Identifica-
tion of the interrelated parts of the system is an initial
process. The interventionist must also determine the
order in which to initiate change strategies within and
among components and the policies needed to reinforce
and sustain change. Innovation does not translate to im-
proved population health without widespread and sus-
tained uptake of effective changes. Although real-world
constraints persist, the LSU Health System has experi-
enced organizational innovation, and the infrastructure is
in place for more formal investigations in regard to ideal
time, places, approaches, and methods for dissemination
and implementation [27].
The TCI highlights the promise of technology and ap-
propriate policies to improve care in a delivery system
serving the medically vulnerable. The program illustrates
a partnership between medicine and public health, in
which basic, clinical, behavioral, and systems sciences
converge to make treatment of tobacco use standard care.
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