Results Summary

What was the research about?

Tobacco use is the leading cause of preventable death in the United States. Primary care teams, such as doctors, nurses, and medical assistants, can help patients quit using tobacco. But clinic staff don’t always have the support they need to talk with patients about tobacco or refer patients to quitlines. Quitlines are services people can call to get telephone counseling for tobacco addiction.

In this study, the research team compared two ways to help primary care clinic staff identify patients who use tobacco and offer them help:

  • Ask-Advise-Connect, or AAC. AAC changes the role of medical assistants to ask patients about tobacco use. They also give brief advice and use the electronic health record, or EHR, to refer patients who want help to a quitline.
  • AAC plus the Teachable Moments Communication Process, or TMCP. TMCP trains clinicians, like doctors and nurses, on how to talk with patients based on their concerns about tobacco use.

What were the results?

One year after AAC changes happened at the clinics, medical assistants were more likely to

  • Ask patients if they used tobacco
  • Advise patients to quit tobacco
  • See how ready patients were to quit

Also, patients at these clinics were more likely to accept a referral to a quitline.

After adding TMCP, patients at the clinics were more likely to receive advice to quit tobacco.

Clinicians only used TMCP with 8 percent of patients. When they used TMCP, clinicians were more likely to prescribe medicine to help quit tobacco. Other outcomes did not improve.

Who was in the study?

The study used EHR data from 224,079 visits by 176,061 adult patients. Patients were from eight clinics in one health system in the Cleveland area. Of these patients, 50 percent were white, 46 percent were African American, and 4 percent were other races; 12 percent were Hispanic or Latino. Also, 57 percent were ages 35–65, 70 percent were women, and 26 percent were tobacco users.

What did the research team do?

The research team first worked with the health system to make changes to their EHR system, including

  • Adding an electronic referral between clinics and a quitline in Ohio
  • Adding AAC guidance to EHR systems
  • Using a team-based approach to tobacco screening and training staff to use the new EHR system

Next, the research team trained clinicians in TMCP.

The research team looked at patient care at the clinics at three time periods: before making any changes, after putting AAC in place in clinics, and after adding TMCP.

Clinicians, clinic staff, Ohio’s health department staff, quitline staff, and patients who use tobacco helped design the study and review results.

What were the limits of the study?

Only eight percent of clinicians used TMCP to talk with patients. Results might differ if more clinicians used this approach.

Future research could look at ways to increase how often clinicians use TMCP.

How can people use the results?

Clinics and health systems can use the results when deciding how to help patients quit tobacco.

Final Research Report

View this project's final research report.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments. 

Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:

  • The reviewers asked why the study design chosen, a cluster randomized trial with a stepped-wedge design, was well suited to address the study’s aims. They suggested that it was a flaw in the study that the Teachable Moments Communication Process (TMCP) was used at clinicians’ discretion and that intervention uptake was inconsistent across sites. The researchers explained that the participating health system wanted all clinics to eventually receive the intervention rather than some just serving as control clinics. The stepped-wedge design allowed the researchers to start each clinic with the control condition and then implement the TMCP intervention in each clinic at randomly assigned time points. The researchers said they did not view the variability in clinicians’ communication styles or the site uptake of the intervention as faults of the study. They noted that this was a pragmatic trial, and the site variability in uptake and use of the TMCP intervention demonstrated the need for future research to provide performance feedback to clinicians. The researchers did acknowledge that they could have improved the study by proactively and systematically collecting site-level data to help explain the observed variability.
  • The reviewers asked for clarity about whether the researchers performed intent-to-treat analyses on the data. The researchers explained that they analyzed the data in three ways: (1) intent-to-treat analyses based on when the clinic site should have received the TMCP training, regardless of whether the clinicians attended the training; (2) per-protocol analyses using only the sample of clinicians who attended the training; and (3) analyses comparing when trained clinicians used and did not use the intervention.
  • The reviewers noted that very small numbers of patients who were referred to the two smoking cessation programs that the study used as interventions, completed those programs. The reviewers asked how these rates compared with what was seen in past studies and to what extent participation in such programs is associated with successfully quitting smoking. The researchers said their study focused on success in improving the referral process to such programs, not engagement with the programs after referral. They chose to include the data on intervention engagement because few studies presented these data, but they could be useful for future studies. However, this was not the focus of the study.

Conflict of Interest Disclosures

Project Information

Susan (Sue) Flocke, PhD
Oregon Health & Science University^
$528,736 *
Using a Teachable Moment Communication Process to Improve Outcomes of Quitline Referrals

Key Dates

September 2015
September 2020

Study Registration Information

^This project was originally affiliated with Case Western Reserve University.

Final Research Report

View this project's final research report.

Journal Articles


Has Results
Award Type
Health Conditions Health Conditions These are the broad terms we use to categorize our funded research studies; specific diseases or conditions are included within the appropriate larger category. Note: not all of our funded projects focus on a single disease or condition; some touch on multiple diseases or conditions, research methods, or broader health system interventions. Such projects won’t be listed by a primary disease/condition and so won’t appear if you use this filter tool to find them. View Glossary
Populations Populations PCORI is interested in research that seeks to better understand how different clinical and health system options work for different people. These populations are frequently studied in our portfolio or identified as being of interest by our stakeholders. View Glossary
Intervention Strategy Intervention Strategies PCORI funds comparative clinical effectiveness research (CER) studies that compare two or more options or approaches to health care, or that compare different ways of delivering or receiving care. View Glossary
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Last updated: October 18, 2023