Public health impact of a novel smoking cessation outreach program in Ontario, Canada

Despite the availability of smoking cessation treatments that increase long-term quit success [1, 2], a majority of quit attempts are made unassisted [3]. Low rates of treatment utilization have prompted various strategies to increase demand and reduce disparities in access to pharmacotherapy and behavioural support. For example, nicotine replacement therapy (NRT) products have been made available over-the-counter, coverage for NRT and other cessation medications has expanded [4, 5] and many quitlines provide free NRT with counselling support [6]. This has led to increased NRT use [5, 7‐10] and rates of cessation [8, 11]. However, barriers to access still exist for some populations with negative social determinants of health, leading to intervention-generated inequalities [12, 13].

In 2005, the Smoking Treatment for Ontario Patients (STOP) program was established to distribute free NRT to smokers wanting to quit across the province, including rural and remote areas. For more than a decade, the STOP program has made use of and evaluated various methods for distribution of free NRT including large-scale mail-outs [14] as well as providing free NRT with brief counselling through community pharmacies [15], addiction treatment agencies [16] and primary care settings [17]. Since its inception, the program’s approach has been to use both existing healthcare infrastructure as well as new and innovative means to reach smokers from all parts of the province, especially those experiencing socioeconomic and health-related disparities such as lower income or concurrent mental illness.

In 2006, the STOP program partnered with Ontario’s Public Health Units (PHUs) to pilot a program offering individual or group counselling and NRT. PHUs are official health agencies that administer public health programs and services to the community. Every urban and rural municipality (and its surrounding area) in Ontario is served by a PHU, so they have wide reach across the province. The program provided eligible smokers in the local catchment area with up to 10 weeks of NRT and multiple counseling sessions with a PHU staff member trained in smoking cessation counselling. Though all 36 PHUs in Ontario were invited, only 12 implemented the program, as many did not have the resources or capacity to participate. At the end of the pilot program, feedback from the PHUs that participated highlighted benefits of the program including increased access to cessation treatment and increased demand for existing cessation services. However, many PHUs did not have the time or resources available to handle the additional workload on an ongoing basis. The funder was willing to provide some but not all the resources necessary for such a program. This required innovation and adaptation of the intervention to fit the setting without losing the active ingredients which were access to NRT, brief behavioural support and self-help material.

Mobile and pop-up clinics have been utilized as an innovative method to bring healthcare services to local communities to reduce or eliminate financial and other access barriers to health care among underserved communities and disadvantaged populations such as the homeless, uninsured and those living in rural or remote communities [18‐21]. They have been used to deliver a wide range of health services such as vision, dental, and general medical care [19, 21]; screening for various diseases [22‐27]; as well as psychiatric crisis services [28] and treatment for alcohol and drug abuse [29]. However, to our knowledge, no mobile or pop-up clinic has been designed to provide free pharmacotherapy and brief behavioural support to assist with smoking cessation. In order to provide treatment in partnership with PHUs while minimizing demands on their time and resources, in 2007 we developed a new outreach program (STOP on the Road) whereby, similar to a mobile or pop-up clinic, we travelled to communities across Ontario and partnered with the local PHU to deliver a brief group smoking cessation intervention.

The decision was supported by the absence of evidence that group cessation support is less effective than individual support and evidence that is more effective than self-help alone [30, 31]. The intervention consisted of a 1-h psychoeducational presentation to the group, covering topics such as behavioural strategies for quitting, followed by a 5- to 15-min consultation with each individual to review completed assessment forms and dispense NRT with self-help materials. Over time we assisted PHUs in building the capacity to offer the intervention without our on-site presence, but with ongoing operational and financial support.

The objective of this paper is two-fold: (1) describe the use of a theory-guided approach to the implementation of a smoking cessation outreach program and (2) evaluate its public health impact over 10 years (2007–2016) using the RE-AIM framework [32]. Recognizing that demonstrating treatment efficacy in highly controlled research settings does not necessarily translate into effectiveness in real-world settings, the RE-AIM model was developed to evaluate public health interventions based on five factors conceptualized as determinants of overall impact: reach, effectiveness, adoption, implementation and maintenance [32]. Accordingly, the model predicts public health interventions will have greater impact if they reach the target population, produce the intended outcomes in the long-term, and are easily implemented consistently and sustainably over time [32].

The use of implementation science with a focus on defining the innovation and addressing stages and drivers of implementation have led to a unique scaled-up smoking cessation program in Ontario, Canada with demonstrated public health impact. The RE-AIM evaluation indicated the program had a high level of adoption that was largely maintained over time, it reached smokers across the province including some groups that may be more likely to experience barriers to accessing treatment, and it successfully helped smokers achieve and maintain abstinence from smoking. A high rate of adoption was largely maintained over time, demonstrating the continued demand for this service in the province. This was evident despite the fact that during this time the STOP program had also expanded its reach through partnerships with other health care organizations across the province, which by 2016 had included 237 primary care organizations and 54 addictions agencies. A greater proportion of PHUs adopted STOP on the Road compared to the pilot program, suggesting the workshops were easier for PHUs to implement than brief individual counselling. Furthermore, a high level of adoption by PHUs was recovered after a temporary cessation of workshops due to lack of funding; therefore, this model may be well suited to other settings where funding may not be stable. Each PHU is autonomous, governed by its own board of health, with its own unique mandate and strategic priorities that may vary over time. Thus, one organizational barrier to adoption was that workshops may not have been aligned with an individual PHU’s current priorities. For example, one PHU no longer provides direct services to individuals and therefore does not offer workshops.

The proportion of eligible smokers reached was somewhat higher compared to Ontario’s quitline [44, 45]. Reach was similar to reports for other free NRT giveaway programs that provided up to 2 weeks of free NRT, though it was lower than the reach of one program that provided 6 weeks [46]. Similar to these previous giveaway programs, reach was limited by the amount of NRT available for distribution. Additional funding may have enabled a greater number of smokers to be reached. Every PHU in Ontario at some point offered a workshop during the 10-year period, thus the program was able to reach communities across all of Ontario, including rural communities which are more likely to be underserved. According to the Canadian census, during the evaluation timeframe approximately 14–15% of the population in Ontario resided in a rural area (according to their definition) [47, 48]. To the extent that the definitions of rural area are comparable, this suggests there was equitable reach for rural residents in most years. However, the proportion of rural residents unexpectedly decreased in 2015–2016 and needs additional monitoring and investigation to ensure there is continued reach in rural communities. The program was also more likely to reach particular subgroups of smokers that may face increased difficulty with quitting and greater barriers to treatment, such as those with lower income [49] or with a mood disorder diagnosis [50, 51]. Approximately one-third of our sample reported an annual household income before tax of less than $20,000, which for most households is below the threshold the Government of Canada sets to classify households as having a low income [52]. This figure is considerably higher than the prevalence of low-income in Ontario around this time (11% in 2005 and 10% in 2015) [53]. However, as we did not have data available on barriers to accessing treatment, we can only speculate on how this program may have improved access to treatment for particular groups, such as those with low income (i.e., annual household income <$20,000) or those living in rural communities.

The 7-day point prevalence abstinence rates we report are similar to those of various free NRT giveaway programs [46]. While year-to-year comparisons are problematic due to varying response rates, effectiveness did not appear to decrease once PHUs began delivering the workshops independently, as expected given the primary active component of the intervention was the NRT and the material delivered was standardized.

This program evaluation demonstrates that an outreach program using workshops to deliver smoking cessation treatment is effective and easily adoptable by existing public health organizations. There were only opportunity costs for the implementer, which was the time devoted to implementation and training. However, this was an appropriate use of their resources and allowed PHUs to meet their standard of addressing smoking cessation in their community. However, the program as we implemented it does require some pre-existing infrastructure that may not be present in some jurisdictions. Initially a small, centralized team was responsible for coordinating and travelling to deliver the intervention in various communities, with the public health staff role primarily being recruitment from the local community. This particular model may be more easily extended to other jurisdictions without this level of pre-existing infrastructure, as alternative partners or methods may be used to engage with the local community for the purpose of recruitment. Capacity building so that each site can deliver the intervention independently is not required in order to implement this program, but we have demonstrated how it can permit workshops to be offered more regularly without incurring increased travel expenses.

This program can be implemented to improve access to treatment in settings where there are insufficient resources for establishing a quitline or smoking cessation clinic. Quitlines that provide free medication have higher reach but require greater infrastructure and resources to set up and operate. Since Ontario’s quitline does not provide free pharmacotherapy, we were unable to compare the treatment and cost-effectiveness of providing NRT in workshops versus through a quitline. Workshops initially were offered on a more infrequent basis and individuals waiting for treatment may have dropped out due to waning motivation. In this manner, quitlines are more effective in reaching people when they are ready and motivated to quit. However, offering workshops more frequently mitigates this problem. The workshops’ group format allows more people to be served with limited resources. In addition, the social modeling of quitting behaviour may be advantageous in smaller communities where groups of people quit together. This has been demonstrated in the community dynamics of smoking behaviour in the town of Framingham [54]. While it is encouraging to see that the program is able to reach smokers that may have greater barriers to accessing treatment (i.e., low income, rural residence) or to achieving long-term abstinence (e.g., psychiatric comorbidity), they may require additional or more intensive treatment in order to achieve long-term success. Though we provided participants with a list of resources for seeking additional cessation support, additional free NRT was not available through these programs. There was also no opportunity for prescription medication such as varenicline or bupropion, since no prescriber was involved in the process.

A few limitations of the evaluation are noted. We were not able to evaluate the intervention fully on all dimensions of the RE-AIM framework. We did not have a measure of Implementation at the organizational level; assessment of time and costs was challenging since they were shared and not formally tracked. We also did not monitor or measure fidelity to the protocol, though we took measures to prevent or discourage modification of the intervention components. However, it is possible some adaptation to the local setting would have in fact been beneficial and could be explored in a future study. Response to the follow-up survey was not high and was especially low once we switched to the more cost-effective method of conducting follow-ups exclusively via online survey. With insufficient resources to supplement with telephone surveys, those without Internet access or sufficient digital literacy may have been unable to respond to follow-up and are not represented in the outcome data from more recent years. Thus, our evaluation of effectiveness may have been biased due to nonresponse and proportion quit may have been over (or under) estimated. Finally, our evaluation employed only quantitative methods and a mixed methods approach could have enriched our understanding and appraisal of the intervention on each dimension [55].

To our knowledge, this is the first report to describe the use of implementation science models and evaluation for public health impact of an outreach program to provide evidence-based smoking cessation treatment to smokers wanting to quit. This model can be adopted in other jurisdictions where there is a gap in smoking cessation services. Additional research is needed to identify and address the limitations of this program and assess the cost-effectiveness and compare it with other programs.