Proactive Tobacco Treatment and Population-Level Cessation: A Pragmatic Randomized Clinical Trial

Study Questions:

Do proactive tobacco cessation care strategies improve smoking cessation rates?


This randomized clinical trial, The Veterans Victory Over Tobacco Study, included smokers ages 18-80 years. Using a registry of current smokers, patients were randomized to usual care or proactive care. Proactive care combined: 1) proactive outreach, and 2) offer of choice of smoking cessation services (telephone or in-person). Proactive outreach included mailed invitations, followed by telephone outreach, to motivate smokers to seek treatment with choice of services. The primary outcome was 6-month prolonged smoking abstinence at 1 year, and was assessed by a follow-up survey among all current smokers regardless of interest in quitting or treatment utilization.


A total of 5,123 participants were included in the primary analysis. The follow-up survey response rate was 66%. There were no significant differences between the baseline characteristics for age, sex, race/ethnicity, distance to their Veterans Administration hospital, and comorbid smoking-related conditions between the two groups. Overall, the mean age of participants was 56.1 years. The sample was diverse: 22.7% black, 4.5% Hispanic, 64.7% white, and 8.1% classified as other or unknown. The mean (standard error) number of cigarettes smoked per day was 17.7 (0.3) and 18.0 (0.3) for the usual care and proactive care groups, respectively. Approximately 85% of the usual care group and 83% of the proactive care group were daily smokers. The population-level, 6-month prolonged smoking abstinence rate at 1 year was 13.5% for proactive care compared with 10.9% for usual care (p = 0.02). Logistic regression mixed-model analysis showed a significant effect of the proactive care intervention on 6-month prolonged abstinence (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.03-1.57). In analyses accounting for nonresponse using likelihood-based not missing at random models, the effect of proactive care on 6-month prolonged abstinence persisted (OR, 1.33; 95% CI, 1.17-1.51).


The investigators concluded that proactive, population-based tobacco cessation care using proactive outreach to connect smokers to evidence-based telephone or in-person smoking cessation services is effective for increasing long-term population-level cessation rates.


This study suggests that efforts beyond the doctor’s office to reach out to smokers may translate into small, but statistically significant increases in smoking cessation.

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