In the efforts to curtail tobacco use in the United States, a clinical practice guidelines goal is that every tobacco user should receive an intervention and be offered treatment at every health care visit (1). Evidence-based tobacco cessation services by telephone, called quitlines, are available throughout North America and are a component of efforts to achieve this goal (2). In the United States, all quitlines are linked through 1 electronic portal —1-800-QUIT NOW — that automatically connects callers to their state’s quitline.

Quitline services are generally funded by state-level tobacco control programs or a mix of state, federal, and private partners. Typically, a quitline counselor will conduct a screening interview and offer 1 or more counseling sessions before, during, and after a quit attempt. Some quitlines also offer free nicotine patches or other medications, self-help materials, and access to Internet resources. Most quitlines conduct evaluation calls after 6 months to assess clients’ quit status (3).

In April 2002, the Massachusetts Tobacco Control Program (now called the Tobacco Cessation and Prevention Program), an initiative of the Massachusetts Department of Public Health (MDPH), launched QuitWorks, a tobacco cessation program through faxed referrals that links health care organizations, providers, and patients to the state’s quitline. The goal was to fill a gap for providers who lacked a consistent resource to which to refer patients who use tobacco. The MDPH and 8 commercial and Medicaid health plans forged a partnership to make QuitWorks universally available and free to any provider in the state and to all residents, regardless of insurance status.

Following Massachusetts’ lead, other states adopted the fax-referral option. By 2009, all 50 US states, the District of Columbia, Puerto Rico, Guam, and all 10 Canadian provinces reported offering these services, although the range of program practices varied widely across locations (State quitline programs, unpublished survey of state quitline referral practices, 2010).

The heart of the QuitWorks program is a simple Health Insurance Portability and Accountability Act–compliant enrollment form completed by the provider, the patient, or both. The patient signs the form and the provider sends it to the quitline by fax or other electronic means. By signing the form, the patient gives consent for the quitline to call and authorizes the quitline to send reports on the patient’s progress to the provider. All referring providers receive 2 reports on each patient referred — 1 within 5 weeks on quitline attempts to reach the patient and the services accepted, and a second 7 months later on the patient’s quit status.

Throughout its history, QuitWorks has primarily received referrals from 4 classes of facilities — hospitals (56.0%), outpatient clinics (14.0%), community health centers (10.1%), and provider practices (8.7%). The remaining 11.3% consists of providers with no organization or groups that do not easily fall into the categories above, such as nursing homes, public housing programs, visiting nurses, or other human service providers.

QuitWorks has steadily grown during its 10 years of operations. Following its launch, the 8 commercial and Medicaid health plan partners conducted a promotion effort in 2002 and 2003, including delivery of QuitWorks kits door-to-door to 4,800 providers. This effort resulted in a substantial increase in referrals. Referrals increased again in 2005 as a result of hospital activity to meet 2004 Joint Commission tobacco measures (4) and expanded promotions to hospitals and community health centers. By 2006, QuitWorks had developed on-site technical assistance and clinical training services needed to integrate QuitWorks into the clinical workflow, medical record systems, and performance reporting. Beginning in 2009, the availability of free starter kits of nicotine patches for QuitWorks patients statewide contributed substantially to a new spike in referrals, as did the implementation of a fully electronic health records system in Atrius Health, a major QuitWorks user. Periodic free e-mail, newsletter, and fax promotions, conducted each year by MDPH and health plan partners, also increased in 2009 and 2010.

QuitWorks now includes many features not available when it was launched in 2002, among them a web site (www.quitworks.org), customized and flexible manual and electronic referral options, enrollment forms, and reports for participating organizations. The availability in 2011 of Centers for Medicare and Medicaid Services (CMS) incentives for meaningful use of health information technology (5-7) has accelerated the trend among providers to use QuitWorks electronic referral options. Privacy, consent, and security issues for all QuitWorks innovations have been addressed with the assistance of expert consultants and cleared by provider, health plan, public health, and legal departments.

QuitWorks has tracked the number of referrals and referring providers since the program’s inception. In addition, all facilities are classified in the QuitWorks database into 6 categories (health care, health plans, human service organizations, worksites/unions, professional or health care associations, and other), which are further classified by health care type (medical, dental, behavioral health, nursing home, wellness programs, and visiting nurse association), facility type (hospitals, community health centers, outpatient clinics or systems, and provider practices), and specialty (eg, obstetrics-gynecology, pediatrics). This allows the QuitWorks team to plan operations, establish goals, and analyze performance across similar types of institutions.

To better understand trends in referral rates to QuitWorks and influencing factors, we conducted a joinpoint analysis of the referral dates. Published by the National Cancer Institute, joinpoint software (National Cancer Institute, Bethesda, Maryland) is used to detect underlying trends in time-based data (8). The “joinpoints” are those points in time where a previous trend ends and a new one begins. In this analysis, we used the number of monthly referrals as the basic input data to the joinpoint software, while the basic output was the annual percentage rate change in referrals during each segment or time phase. The analysis used a log linear model to predict monthly observations. The minimum number of joinpoints was set to 0 and the maximum was set to 5. The minimum number of observations on either side of a joinpoint was set to 6. Models were selected by repetitive permutation tests, and significance levels were adjusted with a Bonferroni correction. Significance tests are based on a Monte Carlo simulation to determine the frequency with which events occur.

Between April 1, 2002, and March 31, 2011, 32,967 tobacco users received referrals from thousands of providers statewide. Our analysis suggests that QuitWorks has had 3 phases of referrals (Figure 1).

During the first phase, from April 2002 through November 2005, monthly referrals increased from approximately 100 to approximately 325, an annual percentage change (APC) of 38.3% (P < .001). During the second phase, from December 2005 through January 2009, the number of referrals to QuitWorks did not change significantly (APC = −7.6%, P = .30). However, in February 2009, referrals to QuitWorks began to substantially increase (APC = 69.2%, P < .001) during the next 2.25 years. QuitWorks received 3,909 referrals in 2009, 7,067 referrals in 2010, and approximately 9,000 in 2011. The program is on pace to receive approximately 10,000 referrals in 2012. With limited funding to promote the quitline directly to consumers through a media campaign, QuitWorks provider referrals have become the primary source of quitline clients. Since November 2009, provider referrals have accounted for approximately 80% of total client volume of the Massachusetts quitline.

Our examination of referral patterns also suggests that QuitWorks has become an integral component of health care delivery over time, in part because major users have begun to incorporate referrals into their electronic health records. In addition, reflecting the evolution of the program, the sources of referrals have varied over time.

Quitlines have been widely adopted in North America and worldwide, and an indicator of their success is the 269% rise in the median number of referrals, including fax referrals, in the United States and Canada, from health care providers from fiscal year (FY) 2005 through FY 2009 (3). However, the overall reach of quitlines remains low, at approximately 1%, even though some states with media promotion or nicotine patch giveaways have boosted reach to nearly 10% (9). Awareness of quitlines and their use by physicians, compared with potential use, also remain low (10). The dilemma facing many quitlines and their state funders is how to increase reach to justify funding levels and, conversely, how to obtain sufficient levels of both public and private funding to both create and meet demand. The integration of quitlines into the health care system may provide a partial solution to this dilemma especially if referral programs evolve, as they have in Massachusetts, into fully electronic referrals that conform to health information technology referral protocols.

The availability of fax and electronic referral quitline programs can effectively advance systematic and sustainable tobacco use interventions in health care. Quitlines are a strategy poised to reach many tobacco users, including subpopulations in which disparities exist in tobacco use or tobacco cessation. Emerging (11-13) and anecdotal evidence (unpublished survey of Massachusetts health care providers, May 2011) suggests that the availability of referral programs can aid identification of tobacco users and brief interventions that precede referral. During the next several years, as health care reform takes effect and more people become eligible for services, the value of incorporating low-cost quitlines as an adjunct to provider counseling and intervention will likely increase.

Best practice examples in the field must continue to be identified, documented, and disseminated through the Centers for Disease Control and Prevention (CDC). The timing is right to make progress now. CMS meaningful use core measures (14,15) and new Joint Commission tobacco use measure sets (16) are likely to influence health care providers to seek linkages to community resources to address tobacco use effectively.

The Massachusetts experience suggests a new strategic direction for state tobacco control programs and their quitlines. As a result of QuitWorks, tens of thousands of tobacco users have received interventions, both in health care settings and through the quitline. By integrating electronic referral to quitlines into routine care, tobacco control programs can extend their impact to reduce tobacco use, reduce risks for chronic disease, improve health, and potentially reduce health care costs. Lessons learned from the QuitWorks experience, as described in the themes discussed below and listed in the Box, may help other state-based quitlines meet the goal that every tobacco user should receive an intervention and be offered treatment at every health care visit.