The COVID-19 pandemic impacted primary health care in a multitude of ways, but little is known about how the pandemic impacted assessments of whether patients use tobacco.
A new Oregon Health & Science University study published in the Annals of Family Medicine finds that routine tobacco use assessments plummeted by 50% during the first wave of the COVID-19 pandemic and did not return to pre-pandemic levels. Researchers warn this could mean people have less information about and access to resources to help quit tobacco products and reduce associated health risks, including more severe illness from COVID-19.
“We know the urgency of the pandemic created numerous operational issues for primary care health centers,” says Sue Flocke, Ph.D., a professor of family medicine in the OHSU School of Medicine and a co-leader of the OHSU Knight Cancer Institute’s Cancer Prevention and Control program. “Many primary care physicians were re-deployed to urgent COVID areas, there was a rapid increase in telehealth visits, and many practices had pandemic-related staffing shortages. All of these things had the potential to affect routine patient care and the delivery of cancer preventive services and tobacco use assessments.”
To better understand the extent of this impact, Flocke teamed up with fellow researchers from the BRIDGE-C2 Center and OCHIN, Inc., a national network of community health centers that deliver care to more than a million underserved patients. The BRIDGE-C2 Center — or Building Research in Implementation and Dissemination to close Gaps and achieve Equity in Cancer Control Center — was first announced in 2019. It is funded by a $7.5 million grant from the National Cancer Institute, part of the National Institutes of Health, to improve strategies for implementing proven cancer screening and prevention practices.
Together, Flocke and these groups analyzed health record data from 217 primary care clinics from January 2019 through July 2021. That data included telehealth and in-person visits for 759,138 adult patients 18 and older to determine how monthly rates of tobacco assessment had been affected by the COVID-19 pandemic.
The team found that between March and May 2020, tobacco assessment monthly rates went from 155.7 per 1,000 patients down to 77.7 per 1,000 patients — a 50% decline. There was a subsequent increase in tobacco assessment between June 2020 and May 2021; however, assessments remained 33.5% lower than pre-pandemic levels.
Impact on primary care practices with major consequences
Flocke says these findings are significant given tobacco use can increase the severity of COVID-19 symptoms. She says smoking is also associated with many types of cancer — and nearly 30% of all preventable cancers — along with a host of chronic diseases, including diabetes, heart disease and lung disease.
“We know that a large portion of people who use tobacco do want to quit, but the vast majority of them do not have access to or do not use available resources,” she says. “Health care providers can provide access to a wide variety of resources, including referral for tobacco cessation counseling and prescriptions for FDA-approved tobacco cessation medications. A successful quit attempt typically requires many tries — that’s why these discussions are so important.”
The onset of the COVID-19 pandemic brought a substantial shift to telehealth visits. In this study of community health centers, telehealth visits went from less than 1% of visits to 70% of visits in a span of two months. This massive change in how primary care visits were conducted could have altered routine patient check-in processes, when tobacco use would typically be assessed as a clinical vital sign.
Flocke says the team was not able to evaluate the effect of the modality of visit — meaning in-person office versus telehealth — on the assessment of tobacco use with the data for this study; however, they are testing this and potential differential effects on subgroups of patients in a subsequent study.
Research reported in this announcement was supported by the National Cancer Institute of the National Institutes of Health under award number P50CA244289. This program is supported by funding provided through the Cancer MoonshotSM. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
his work was conducted with the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) Clinical Research Network (CRN). ADVANCE is led by OCHIN in partnership with Health Choice Network, Fenway Health, and Oregon Health & Science University. ADVANCE is funded through the Patient-Centered Outcomes Research Institute (PCORI), contract number RI-OCHIN-01-MC.
This work was a part of the Implementation Science Centers in Cancer Control (ISCS) Program, which supports the rapid development, testing, and refinement of innovative approaches to implement a range of evidence-based cancer control interventions. Centers all feature "implementation laboratories" involving clinical and community sites that will engage in implementation research across the cancer control continuum to advance methods in studying implementation and develop and validate reliable measures of key implementation science constructs. These Centers collectively provide leadership for an Implementation Science consortium across this and other Cancer MoonshotSM initiatives.