Using a Teachable Moment Communication Process to Improve Outcomes of Quitline Referrals
Phase: NA
Conditions: Smoking, Tobacco Dependence
Sponsor: Case Western Reserve University

Using a teachable moment communication process to improve outcomes of quitline referrals 
1 
2 
Principal Investigator: Flocke, Susan, PhD, 
3 
Department of Family Medicine 
4 
Oregon Health & Science University 
5 
3800 SW Sam Jackson Park Rd. 
6 
Portland, OR 97239  USA 
7 
flocke@ohsu.edu 
8 
9 
Site Principal Investigator: Seeholzer, Eileen, MD, MS, MetroHealth Health System 
10 
2500 MetroHealth Drive 
11 
Cleveland OH 44109 USA 
12 
13 
Co-Investigators: 
14 
Love, Thomas, PhD, MetroHealth 
15 
Kaelber, David, MD, MetroHealth 
16 
Albert (Antognoli), Elizabeth, PhD, MPH, Case Western Reserve University 
17 
Study Staff: 
18 
Lewis, Steve, MS, MBA, MetroHealth 
19 
Rose, Jeanmarie, MPA, Case Western Reserve University 
20 
Gill, India, MPH, Case Western Reserve University 
21 
22 
Institution receiving the PCORI award: Oregon Health & Science University, Portland Oregon, USA 
23 
24 
PCORI award number: IHS-1503-29879-IC 
25 
ClinicalTrials.gov registration: NCT02764385  
Last updated December 11, 2020
26 
27 

Project summary 
28 
Background: Guidelines urge primary care practices to provide routine tobacco cessation care. 
29 
Implementation of effective and sustainable strategies is lacking, especially for socially and economically 
30 
disadvantaged populations.  We test a systems-based approach that engages the medical assistant that 
31 
assesses the patient’s vital signs at the beginning of a routine visit and the added effect of a clinician-
32 
based approach that draws on a relationship-centered communication strategy. 
33 
Objectives: This project aimed to: 1) Improve delivery and documentation of smoking cessation care to 
34 
disadvantaged patients using an Ask-Advise-Connect (AAC) systems-based approach, 2) Test the effect 
35 
of combining the clinician-based Teachable Moments Communication Process (TMCP) intervention with 
36 
AAC on advice to quit, referrals to cessation counseling and provision of tobacco cessation medications  
37 
and 3) Examine the narratives of patient subgroups to understand and improve the referral experience. 
38 
Methods: This study engaged a healthcare system and eight primary care clinical sites with two 
39 
interventions. The 3-month period before the AAC intervention represented a pre-AAC control period 
40 
(baseline). All sites received the AAC strategy throughout the study and its use was evaluated for a 
41 
minimum of 6 months (AAC-only). Next, using a group-randomized stepped-wedge design, sites received 
42 
the TMCP intervention (AAC+TMCP). The patient population is 40% Medicaid, 23.9% Medicare, 6.1% 
43 
uninsured and 30% commercially insured. The AAC strategy involved changes to the electronic health 
44 
record (EHR), a new role for medical assistants and a new capacity to send electronic referrals to the 
45 
Quitline (QL) to enroll patients in tobacco cessation counseling. Next, in accord with their practice’s 
46 
place in the stepped wedge design, 44 of the 60 eligible clinicians attended training in the TMCP, an 
47 
approach to counseling patients to quit tobacco aligned with patient readiness. Generalized linear 
48 
models tested the effect of interventions on immediate outcome measures of process, including 
49 
delivery of advice, offer of assistance and referrals accepted, and QL contact and enrollment rates. 
50 
Receipt of tobacco cessation medications and quit attempts were also assessed. The primary outcome 
51 
was QL contact. In-depth interviews were conducted with 55 patients referred to the QL to explore their 
52 
experiences and identify opportunities to improve the referral process. 
53 
54 
55 
56 
57 
58 
59 

60 
61 
62 
63 
64 
65 
66 
67 
68 
69 
70 
71 
72 
73 
74 
75 
76 
77 
78 
79 
80 
81 
82 
83 
84 
85 
86 

1 
Rationale & background information 
87 
Smoking is the leading cause of preventable mortality. Smoking rates in the United States have 
88 
declined, but remain particularly high among socially and economically disadvantaged populations, who 
89 
are also less likely to use supports for quitting smoking.1-5 Therefore, implementing and evaluating 
90 
strategies that work for socially and economically disadvantaged populations is a high priority. Among 
91 
U.S. smokers, 59% report seeing a primary care clinician at least yearly,6 making primary care a major 
92 
avenue for providing tobacco cessation assistance tailored to each patient’s medical history. However, 
93 
evidence-based interventions addressing tobacco cessation are generally underused.7 New healthcare 
94 
policy initiatives, requiring assessments of tobacco use and assistance to quit, call for integration of 
95 
tobacco cessation interventions into primary care.8  
96 
Referral to quitlines (QLs) that provide evidence-based, effective and cost-efficient assistance with 
97 
smoking cessation,5,9-12 is recommended as an effective strategy for tobacco cessation assistance.13-17 
98 
However, a clinician’s recommendation to call a QL typically results in poor calling rates (range 1.6% - 
99 
19%).18 Yet, success rates increase when QLs proactively call patients after receiving a direct clinician 
100 
referral (by fax or electronically).19-23 Still, clinicians underutilize direct referrals,24 potentially due to low 
101 
integration of the referral system into the office workflow.24 Research demonstrates the feasibility of 
102 
closed loop electronic referrals using the electronic health record (EHR)25 for connecting with QLs. The 
103 
advantage of eReferral is that patient information is securely transmitted between the referring clinician 
104 
and the QL, and QL enrollment and counseling completion records become part of the patient medical 
105 
record.  
106 
Two intervention approaches for providing patients with assistance for smoking cessation have 
107 
shown promise in the primary care setting. Ask-Advise-Connect (AAC) is a systems-based approach that 
108 
uses the EHR to remind clinicians to ask about tobacco use and give advice to quit, and then 
109 
electronically connects interested smokers to tobacco cessation counseling services such as the QL. The 
110 
Teachable Moment Communication Process (TMCP) is a relationship and communication-focused 
111 
strategy designed to counsel patients about behavior change by responding in a way both appropriate 
112 
to and aligned with patient’s readiness for a change.26-29 These approaches are feasible, complementary 
113 
and have the potential to be integrated into a health system to improve sustainability. 
114 
Ask-Advise-Connect (AAC): This proactive, direct messaging EHR-to-QL referral approach has been 
115 
shown to increase the number of tobacco users receiving QL treatment by 13- to 30-fold.30,31 However, a 
116 
major drawback of AAC is a low rate of contacting referred patients. Prior studies found that the QL was 
117 
able to contact less than 42% of referred patients. This poor contact rate diminishes the sustainability of 
118 
the approach, and is likely due to referring patients inappropriately, ignoring cessation readiness.25,32,33 
119 

2 
In this study, we assess the patient’s readiness to quit and willingness to be connected to the QL prior to 
120 
making an eReferral, thereby assuring appropriate referrals. A drawback of some studies of AAC 
121 
implementation strategies is that they rely on study research staff to carry out a key step30,31 rather than 
122 
a design that is fully integrated and sustainable in a clinical practice. In this study, we train MAs/nurses 
123 
to implement the AAC, and modify EHR functionality to facilitate an eReferral, thereby providing a more 
124 
sustainable approach.  
125 
Teachable Moments Communication Process (TMCP): With the TMCP, smoking talk is initiated in an 
126 
opportunistic way so that it fits into the flow of addressing problems during a primary care visit.  In 
127 
providing cessation advice, TMCP calls for clinicians to convey concern, express optimism and 
128 
partnership, and recommend quitting tobacco. Finally, central to this approach is eliciting an honest 
129 
assessment of the patient’s level of cessation readiness and responding in alignment with this readiness. 
130 
Research shows that the TMCP approach increases patient motivation to make a quit attempt. Evidence 
131 
is accumulating that the TMCP intervention is feasible in primary care and acceptable to patients and 
132 
clinicians, leading to significant increases in clinicians’ use of recommended counseling behaviors and 
133 
activating patients during primary care visits.27,29,34,35  
134 
We propose that the AAC and the TMCP interventions have mutually complementing strengths, and 
135 
their combined implementation might synergistically boost positive outcomes.36  The AAC intervention is 
136 
designed to be deployed at every visit so that all patients are assessed for smoking status, advised to 
137 
quit, assessed about readiness to quit, and given the opportunity to receive assistance. Since it is a part 
138 
of every office visit, the AAC can reach a large percentage of patients. The TM intervention, in contrast, 
139 
is situation-specific and driven by identification of and clinician action on a salient concern that arises 
140 
during the visit. By leveraging concerns that are salient to the patient, the TMCP can activate patients to 
141 
move forward along the readiness to quit continuum. It also reinforces the value of quitting by 
142 
incorporating clinician advise to quit, which has been shown to increase quit rates.22 If implemented 
143 
together, these intervention could have a synergistic effect (see Figure 1) whereby the interventions 
144 
operate at different levels of influence to mutually reinforce each other. Their combined effect has great 
145 
potential to increase the proportion of appropriate referrals (i.e., eligible and ready patients) to the QL, 
146 
increase the likelihood of successful patient contact and enrollment, positively affect patients’ ratings of 
147 
the experience, and support positive movement towards cessation. 
148 

3 
149 
150 
Study goals and objectives 
151 
1. Improve delivery and documentation of smoking cessation advice and assistance to socially and
152 
economically disadvantaged patients using an Ask-Advise-Connect approach integrated into the EHR.
153 
2. Test the effect of combining the TMCP with AAC on process outcomes, QL referral outcomes and
154 
smoking outcomes.
155 
3. Examine the narratives of subgroups of individuals to better understand the referral experience and
156 
identify ways to improve it.
157 
158 
Study Design and Timing.  This study involves two interventions. This report is focused on the TMCP 
159 
intervention and the AAC information is provided for context. The full report will be publically available 
160 
on the PCORI website after the 12-month embargo period passes.  
161 
The AAC was conducted first at the clinic-level and the TMCP was conducted second at the clinician-
162 
level. It also includes qualitative data collection to complement the quantitative evaluations. Figure 2 
163 
illustrates the three main data collection sources (EHR, patient surveys, and in-depth interviews) and the 
164 
three time periods of data collection (pre-AAC, AAC-only, and AAC+TMCP). The 3-month period before 
165 
the AAC intervention represented a pre-AAC control period (baseline).  Both interventions were 
166 
implemented using a stepped wedge design, as indicated in Figure 2. The start date represents the date 
167 
Figure 1. AAC and TMCP conceptual model 

4 
of the first clinic’s exposure to the interventions. The step graphic between each condition represents 
168 
the starting points for each of the clinics’ exposure to the interventions. This design allowed us to test 
169 
the additional impact of TMCP beyond the gains realized via AAC across all of the clinics by the end of 
170 
the step-wedge implementation. On a rolling basis, data collection indicated the intervention exposure 
171 
statuses for each clinic and assessed visit level process outcomes.  
172 
Figure 3 provides more detail about the timing of the AAC and the TMCP intervention 
173 
implementation at each of the 8 sites. AAC was the first intervention implemented, and the AAC training 
174 
at the first clinic was conducted on February 15, 2017. This training was then conducted at the other 
175 
seven clinics at approximately 2-week intervals, but the timing of the training was not randomized. 
176 
Trainings were scheduled during regularly scheduled monthly staff meetings for each clinic. The training 
177 
date was noted such that a period of pre- and a period of post-training could be defined for each clinic. 
178 
Approximately 6 months after the implementation of the AAC in the last site, the TMCP intervention was 
179 
implemented, again in a stepped pattern.  
180 
For the TMCP, the eight clinics were randomized to an implementation time point using the 
181 
following approach. A single digit number was assigned to each site. A list of 100 random single digit 
182 
numbers was generated and using this list, as a site number came up in the random list it was assigned 
183 
the next sequential time point. We encountered two anomalies with randomization of the sites. First, 
184 
after implementing the AAC intervention, the site that was randomized to receive the TMCP training 
185 
first lost their practice manager. MetroHealth requested that we delay the implementation of the TMCP 
186 
in that site due to challenges with daily operations until a new practice manager was effectively in place. 
187 
This site was moved to be last. Second, also after the implementation of the AAC intervention, one of 
188 
the sites closed. A replacement site was identified to receive the AAC intervention and was included as 
189 
the last site for training for the TMCP. The TMCP implementation time points were scheduled as close to 
190 
1-month intervals as possible. The first clinic received the TMCP training on October 25, 2017.  The 
191 
amount of time a clinic was in any one of the three defined study conditions varied but is accounted for 
192 
in the analyses.  
193 

5 
Figure 2. Schema of data collection time points (for EHR, surveys, and in-depth interviews) across all 
194 
sites. 
195 
196 

1 
197 
Figure 3. AAC and TMCP intervention implementation dates and periods of time before, between and after interventions for each site. 
198 
199 
200 
201 
Year
Month
Aug Sept Oct
Nov Dec Jan
Feb Mar April May June July Aug Sept Oct
Nov Dec Jan
Feb Mar April May June July Aug Sept Oct
Nov Dec Jan
Feb Mar April
Site 1
4/20
10/25*
Site 2
3/17
11/8
Site 3
2/22
1/9
Site 4
4/17
2/16
Site 5
2/15
3/14
Site 6
4/12
4/12
Site 7
2/17
5/15
Site 8**
9/15
6/22
* Due to technical problems for some clinicians, a second TMCP implementation date was conducted on 11/2
** This site was added to replace a site that had been randomized and received the AAC training, but closed shortly after AAC training.
Pre AAC
AAC-only
AAC+TMCP
2016
2017
2018
2019

2 
Research methods 
Participating sites and randomization 
Eight community-based primary care practices in a large safety-net healthcare system in 
Cleveland Ohio participated in this stepped wedge comparative effectiveness study. Using a random 
number list generated by the study analyst, the sites were randomized to separate intervention time 
points (1-month intervals) in which all clinicians (MD, DO, NPs) who spend 40% or more of the work 
week providing patient care were scheduled to attend the TMCP training. The health system requested 
that the intervention be implemented first in one site. The remaining 7 sites followed the randomization 
procedure. The principal investigator informed each clinical director of the site’s assigned time point and 
scheduled a training date. 
Prior to the baseline period for this study, all eight clinics engaged in an AAC system change 
initiative to improve the provision of tobacco cessation support.16 The systems change engaged 
MAs/RNs to use an EHR supported AAC strategy. The MA/RN role, which normally included Asking about 
tobacco status, expanded to: 1) Using a brief scripted phrase, to Advise those who use tobacco to quit; 
2) Assessing interest in quitting tobacco in the next 30 days; 3) for patients interested in quitting now,
asking if they would like assistance to quit from a coach or counselor; and 4) for those choosing 
assistance, Connecting the patient by an electronic referral (e-referral) sent to either the Ohio Quitline 
(QL) or to the in-house Freedom from Smoking (FFS) program. Eligibility for free QL services included 
being aged 18 or older with Medicaid or no insurance, or being pregnant. The QL included up to 5 
telephonic counseling sessions and access to web and online chat support. The QL offers nicotine 
replacement therapy (NRT), if indicated, and with approval from the referring clinician, the NRT is 
mailed to the patient. Individuals not eligible for the QL were referred to the in-system FFS program – an 
in-person 8-session group tobacco cessation class offered by the healthcare system. The EHR 
automatically assessed patient eligibility with payer data and generated the correct referral order in a 

3 
process that was seamless for both the MA/RN and the patient. The AAC serves as the comparator for 
the TMCP. 
TMCP Training Implementation 
The TMCP intervention included a 50-minute web-based module that clinicians completed on 
office computers, followed by 90 minutes of skills practices with Standardized Patients (SPs) in the 
practices’ exam rooms. Trainings were conducted at the practice sites during a clinical work day with 
cancellation of 2.5 hours of clinical activity to accommodate the training. 
Web Module 
 The web module, based on our previous work,14 consists of: 1) didactic content describing the 
TMCP rationale and process; 2) actor-portrayed examples of provider-patient interactions in each step 
of the TMCP; and 3) learning self-assessments. During the web module, clinicians were asked to interact 
with the content by repeating certain phrases aloud and thinking about and then saying aloud how they 
might respond to a patient with a specific level of readiness. Self-assessments (i.e. quizzes) were 
integrated after each major learning topic. After each question was answered, the clinician was provided 
with the reason why the response was either correct or incorrect. 
The training included skills practices for clinicians to learn each TMCP skill through enactment. 
Skills practices took place in the clinic exam rooms, providing a realistic setting.  The clinician 
participants rotated through 6-8 different scenarios played by SPs. The SPs were actors with prior SP 
experience and received five hours of training specific to this study. Each SP was trained to act out two 
unique ‘case scenarios’ that they would routinely play in the skills practices. For each skills practice, the 
clinician was provided basic SP information, such as age, sex, and smoking history. Skills practices were 
observed by study team members that served as coaches to provide feedback and additional training in 
technique. Coaches used a checklist of TMCP skills to insure complete assessment and to guide 

4 
feedback. Each SP case was also created as a test patient in the EHR so that clinicians could practice 
using the TMCP document flowsheet with each SP, as described below. 
Development of document flowsheet 
Document flowsheets are EHR tools used to document information in a structured manner.  The 
TMCP flowsheet outlines the steps and phrases for the TMCP for clinicians to use as a guide with 
patients, eliminating the need to memorize each sequential TMCP step. The flowsheet is also a simple 
standardized tool to record patient responses with minimal clinician effort. With this tool, both the 
delivery of TMCP and the recording of patient information are done simply and result in retrievable 
records for future care. 
During the skills training each clinician was shown how to use the TMCP flowsheet and had it 
added to his/her EHR tool shortcuts. Clinicians were asked to use the flowsheet during the skills practice 
scenarios to gain experience and comfort with its features. As needed, coaches could address any 
difficulty clinicians had using the flowsheet during the feedback period after a skills practice. An EHR 
tobacco cessation order set could be used by providers to order tobacco cessation medication and to 
order QL or FFS classes and was also reviewed during skills practice. 
Debriefing about the training and follow-up 
Following the completion of the web-module and the skills practices, the providers re-grouped 
with the research team to debrief about their experiences. Feedback on format, length of training, 
processes, content etc. were discussed as well as the perceived value overall. Approximately one month 
after the TMCP training participating clinicians were sent follow-up messages through the EHR that 1) 
offered reminders about the TMCP, 2) encouraged clinicians to use the TMCP, and 3) provided 
instruction for using the tobacco cessation flowsheet. Clinicians were invited to respond to messages 
with questions and or feedback. 
Study sample 

5 
The study sample consists of eight sites, 60 clinicians from those sites and all adult patient visits 
during the study period. Figure 3 shows the timing of the training and implementation of the TMCP 
interventions at each of the eight study sites. Study data collection began August 2016 and concluded 
April 2019. One of the original eight clinics that received the AAC training closed shortly afterwards. A 
replacement site (#8) was identified from a similar neighborhood, and the original clinic was excluded 
from all analyses. The replacement site received the AAC training and was assigned to receive the TMCP 
intervention training 1 month after the TMCP training implementation was conducted at the last clinic 
that had been randomized. This approach allowed sufficient time for data collection and assessment 
between the implementation of the AAC and the implementation of the TMCP intervention. 
Measures 
Clinician characteristics gathered from the health system included: sex, degree (MD, DO, NP), 
specialty and years since last clinical training. Patient characteristics including sex, race, ethnicity, 
insurance type and smoking status, were drawn from the EHR. 
TMCP-specific variables include training participation, online learning module completion and 
quiz score. Use of the TMCP flowsheet by clinicians during visits was measured for 6-months after 
training to indicate use of the TMCP. Clinician’s documentation of any portion of the TMCP flowsheet 
was counted as ‘use’. 
Outcome measures include contact by the QL or FFS among those patients that accepted a 
referral and provision of brief advice. Secondary outcomes include medication orders (i.e. varenicline, 
bupropion or nicotine replacement therapy) enrollment among those referred to cessation support (QL 
or FFS), and quit attempts. For this study, a quit attempt is defined as a change in smoking status from 
current smoker to former smoker and documentation of a quit date in the EHR. Quit attempts are 
evaluated for all smokers. 

6 
We report the rates of Ask, Advise, Assessment of readiness to quit and acceptance of a referral 
(Connect) to tobacco cessation assistance for the AAC intervention (AAC only) period and the time 
period after the TMCP intervention (AAC+TMCP). Each of these indicators is measured from discrete 
fields in the EHR. As shown in Figure 1, the timing of the AAC and the TMCP intervention 
implementation and the time periods between the two interventions varied. 
We assessed patients’ experiences with the clinic’s processes. The survey samples included at 
least 17 smokers from each of the eight sites for the AAC only and the AAC+TMCP study periods. 
Patients who attended a primary care visit during a specified period were invited to complete the survey 
by web or phone, depending on the participant’s preferred contact method. The survey included 11 
items about being treated with respect, feeling listened to, and whether the advice was helpful. 
Responses were measured using a 5- point Likert scale rating from excellent to poor. 
Statistical analyses 
We describe clinician characteristics and patient visits during the study period, and participation 
in the training and uptake of the TMCP as documented by flowsheet usage. Analyses compared adjusted 
rates for the AAC+TMCP intervention to AAC only period using a generalized estimating equation (GEE) 
approach, with robust estimation of variances. Specifically, we modeled the log odds of a particular 
outcome of interest for a particular patient as a function of intervention status (AAC only vs. TMCP + 
AAC) at each time point, incorporating random practice site and clinician effects. Three analyses were 
conducted: 1) intent to treat, 2) per protocol (i.e. clinicians that participated in the TM training), and 3) 
per documented use of the TMCP approach in a visit. We report rates of performance, odds ratios (OR) 
and 95% confidence intervals (95% CI). We used 10% as a minimally important difference. Data analyses 
were performed April 2019 - August 2020. Because this was an educational intervention for clinicians, all 
of whom ultimately received the training, neither the clinicians nor the study team could be blinded to 
the group assignment; this design also made it impossible to blind the analyst to group assignment. 

7 
Safety considerations 
This is a minimal risk study and involved clinicians participating in an educational intervention to 
improve communication skills to address tobacco cessation. Maintaining confidentiality of identifiable 
data for study participants was the primary study consideration. 
Follow-up 
Follow up for adverse effects of the intervention are not applicable. Performance feedback reports were 
provided at 1, 2, and 3 months post training and provided an outlet for participating clinicians to contact 
the study staff with questions or comments. 
Quality assurance 
Fidelity of the delivery of the Teachable Moment intervention was maximized by using a web-based 
learning module, extensive training of the standardized patients and the coaches and routine debriefing 
after each training session. Close monitoring of data allowed us to quickly identify and resolve problems 
(e.g. systematic data entry omissions). A check for data inconsistencies during the analysis phase 
included checking the range and distribution of all variables and identifying and resolving potential 
errors. We expected minimal missing data (less than 2%) on the variables collected from the EHR. 
Missing data on patient surveys in our preliminary studies was negligible (less than 1%). We followed 
similar principles to maximize participation and survey completion. Those principles include keeping the 
survey short, topic-focused, a reading level of 6th grade or less, clear and acceptable wording of items 
and response categories per cognitive interviewing and pilot testing, and a clear introduction of the 
relevance of the measure to the potential participant. The anticipated small rates of missing data will be 
handled through imputation strategies that take missingness patterns into account.  Given that this is an 
educational intervention for clinicians, a data safety monitoring board was not necessary for this clinical 
trial. 
 Expected outcomes of the study 

8 
This study will contribute to understanding the effectiveness of a health system-wide change in the way 
discussion about tobacco cessation during a medical encounter is documented, and potential gains from 
a patient-centered method of delivering tobacco cessation assessment and advice. The potential 
benefits of improved documentation and patient-centered approaches could improve patient outcomes 
such as chronic disease maintenance and lower incidences of some cancers and heart disease. Widely 
implemented, these changes are likely to improve medical practice through more efficient patient 
counseling and better systematic documentation of tobacco cessation service delivery. 
Dissemination of results and publication policy 
We will use traditional channels of dissemination including scientific journal publications, presentations 
at national professional association meetings, and data briefs. These findings will be of particular 
interest to health services researchers, primary care audiences and tobacco researchers. We also 
anticipate disseminating other products from this work. Examples of other products that will be 
prepared for dissemination include training modules, trainer’s guide, and workbooks for the TM 
intervention. The team will use a dissemination tool to facilitate identification of product, audience, 
priority and modality of dissemination. Authorship will follow OHSU and MetroHealth / Case Western 
Reserve University guidelines for lead author, co authors and acknowledgements for contribution to the 
work. 
Duration of the project 
The duration of the intervention phase of the project is detailed in Figure 3. Prior to the start of the first 
intervention the study team focused on developing and pilot testing EHR tools and trainings. During the 
active intervention period activities included data acquisition, analyses and generating findings for each 
of the study aims. Data analysis and manuscript writing followed the conclusion of data collection and 
continuing beyond the funded study period. 

9 
Problems anticipated 
We anticipate encountering technical challenges over the duration of the study as the EHR routine 
upgrades which are now conducted on a 6-month timeframe have the potential to break links and 
disrupt new features that are established to support this intervention. Routine checking of functionality 
and monitoring data will help identify problems so they can be resolved quickly. 
Project management 
Primary Investigator, Dr. Flocke, (Health Services Research, Implementation and Dissemination 
Research, Preventive Medicine), will lead all aspects of this initiative, and, in collaboration with the co-
investigators and stakeholder team, will facilitate the generation of manuscripts and other materials for 
dissemination from the project. Eileen Seeholzer, MD, MS, Co-Investigator and MetroHealth Site PI, is 
currently an Associate Professor of Medicine at the Center for Healthcare Research and Policy, and has 
training and expertise with system change and quality improvement. She will serve as the key liaison 
with partners at MetroHealth and will work closely with the Information Systems team and primary care 
clinics. She will contribute to all aspects of the study and dissemination of findings. Thomas Love, PhD, 
Co-Investigator is a Professor in the Department of Medicine, Epidemiology and Biostatistics at CWRU 
and will lead the quantitative analysis. Steven Lewis, MS, MBA will work closely with Dr. Love and is 
responsible for data management and analyses. Dr Love and Mr. Lewis will contribute to the generation 
and interpretation findings and dissemination of study products. David Kaelber, MD, MPH, Co-
Investigator is an Associate Professor of Internal Medicine, Pediatrics, Epidemiology and Biostatistics. He 
is the Chief Medical Informatics Officer (CMIO) at MetroHealth, and Director or the Center for Clinical 
Informatics Research and Education. Dr. Kaelber will contribute to the study design, intervention 
features specific to the EHR and will contribute to the interpretation and dissemination of findings. 
Elizabeth Albert, PhD is a medical anthropologist and qualitative expert. She is the lead qualitative 
analyst, leads the adaptation of the TMCP intervention to a web-based platform, leads the training and 

10 
management of the standardized patients and the coaches and will contribute to the interpretation of 
findings, writing of manuscripts, and dissemination of findings.  Jeanmarie Rose, MBA serves as a 
research assistant who is responsible for contributing to the qualitative and survey data collection and 
analyses, study regulatory reporting, and will contribute to the interpretation of findings, writing of 
manuscripts and the dissemination of findings. India Gill, MPH serves as a project manager, organizing 
team meetings, monitoring grant management and reporting, contributes to the qualitative and survey 
data collection and analyses, study regulatory reporting, and will contribute to the interpretation of 
findings, writing of manuscripts and the dissemination of findings. 
Ethics 
All of the study procedures followed the approved guidelines for the conduct of this intervention and 
data collection. The study was deemed a minimal risk study by the ethics review board and informed 
consent was waived. 
Informed consent forms 
Informed consent was waived for the clinician participants in the Teachable Moment intervention 
described in this study. For the subset of patients that were surveyed about their visit experience, 
electronic or verbal consent was obtained prior to completion of the brief survey. 

11 
References 
1.
Cokkinides VE, Halpern MT, Barbeau EM, Ward E, Thun MJ. Racial and ethnic disparities
in smoking-cessation interventions: analysis of the 2005 National Health Interview
Survey. Am J Prev Med. 2008;34(5):404-412.
2.
Fix BV, Hyland A, Rivard C, et al. Usage patterns of stop smoking medications in
Australia, Canada, the United Kingdom, and the United States: findings from the 2006-
2008 International Tobacco Control (ITC) Four Country Survey. International journal of
environmental research and public health. 2011;8(1):222-233.
3.
Fu SS, Sherman SE, Yano EM, van Ryn M, Lanto AB, Joseph AM. Ethnic disparities in the
use of nicotine replacement therapy for smoking cessation in an equal access health
care system. Am J Health Promot. 2005;20(2):108-116.
4.
Trinidad DR, Perez-Stable EJ, White MM, Emery SL, Messer K. A nationwide analysis of
US racial/ethnic disparities in smoking behaviors, smoking cessation, and cessation-
related factors. Am J Public Health. 2011;101(4):699-706.
5.
U.S. Department of Health and Human Services. Quitting Smoking Among Adults ---
United States, 2001--2010. Morb Mortal Wkly Rep. 2011;60(44):1513-1519.
6.
Centers for Disease Control and Prevention. National Health Interview Survey, 2011
Data Release. In:2012.
7.
Thorndike AN, Regan S, Rigotti NA. The treatment of smoking by US physicians during
ambulatory visits: 1994 2003. Am J Public Health. 2007;97(10):1878-1883.
8.
National Prevention Coucil. National Prevention Strategy. In. Washington, DC2011.
9.
Fiore M, Jaen C, Baker T. Treating Tobacco Use and Dependence: 2008 Update. In:
Services UDoHaH, ed2008.
10.
NAQC. NAQC Issue Paper: Quality Improvement Initiative Issue Paper- Quitline Referral
Systems. 2013.
11.
Ossip-Klein DJ, McIntosh S. Quitlines in North America: evidence base and applications.
Am J Med Sci. 2003;326(4):201-205.
12.
Stead L, Perera R, Lancaster T. Telephone counselling for smoking cessation (Review).
Cochrane Database Syst Rev. 2009;3:1-85.
13.
Fiore MC. Treating tobacco use and dependence: an introduction to the US Public
Health Service Clinical Practice Guideline. Respir Care. 2000;45(10):1196-1199.
14.
Riley WT, Glasgow RE, Etheredge L, Abernethy AP. Rapid, responsive, relevant (R3)
research: a call for a rapid learning health research enterprise. Clin Transl Med.
2013;2(1):10.
15.
Simons VA, Flynn SP, Flocke SA. Practical behavior change counseling in primary care.
Primary care. 2007;34(3):611-622, vii.
16.
U.S. Department of Health and Human Services Agency for Healthcare Research and
Quality. The Guide to Clinical Preventive Services 2010-2011: Recommendations of the
U.S. Preventive Services Task Force. In:2010.
17.
Wasserman MP. Guide to community preventive services: state and local opportunities
for tobacco use reduction. Am J Prev Med. 2001;20(2 Suppl):8-9.
18.
North American Quitline Consortium. The use of quitlines among priority populations in
the U.S.: Lessons from the scientific evidence. 2011.

12 
19.
Bentz CJ, Bayley KB, Bonin KE, et al. Provider feedback to improve 5A's tobacco
cessation in primary care: a cluster randomized clinical trial. Nicotine Tob Res.
2007;9(3):341-349.
20.
Redmond LA, Adsit R, Kobinsky KH, Theobald W, Fiore MC. A decade of experience
promoting the clinical treatment of tobacco dependence in Wisconsin. WMJ.
2010;109(2):71-78.
21.
Rothemich SF, Woolf SH, Johnson RE, et al. Promoting primary care smoking-cessation
support with quitlines: the QuitLink Randomized Controlled Trial. Am J Prev Med.
2010;38(4):367-374.
22.
Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician
advice for smoking cessation. Cochrane Database Syst Rev. 2013(5):CD000165.
23.
Warner DD, Land TG, Rodgers AB, Keithly L. Integrating tobacco cessation quitlines into
health care: Massachusetts, 2002-2011. Prev Chronic Dis. 2012;9:E133.
24.
Mathew M, Goldstein AO, Kramer KD, Ripley-Moffitt C, Mage C. Evaluation of a direct
mailing campaign to increase physician awareness and utilization of a quitline fax
referral service. J Health Commun. 2010;15(8):840-845.
25.
Adsit RT, Fox BM, Tsiolis T, et al. Using the electronic health record to connect primary
care patients to evidence-based telephonic tobacco quitline services: a closed-loop
demonstration project. Transl Behav Med. 2014;4(3):324-332.
26.
Cohen DJ, Clark EC, Lawson PJ, Casucci BA, Flocke SA. Identifying teachable moments for
health behavior counseling in primary care. Patient education and counseling.
2011;85(2):e8-15.
27.
Flocke SA, Clark E, Antognoli E, et al. Teachable moments for health behavior change
and intermediate patient outcomes. Patient education and counseling. 2014;96(1):43-
49.
28.
Flocke SA, Stange KC. Direct observation and patient recall of health behavior advice.
Prev Med. 2004;38(3):343-349.
29.
Lawson PJ, Flocke SA. Teachable moments for health behavior change: a concept
analysis. Patient education and counseling. 2009;76(1):25-30.
30.
Vidrine JI, Shete S, Cao Y, et al. Ask-Advise-Connect: a new approach to smoking
treatment delivery in health care settings. JAMA Intern Med. 2013;173(6):458-464.
31.
Vidrine JI, Shete S, Li Y, et al. The Ask-Advise-Connect approach for smokers in a safety
net healthcare system: a group-randomized trial. Am J Prev Med. 2013;45(6):737-741.
32.
Sadasivam RS, Hogan TP, Volkman JE, et al. Implementing point of care "e-referrals" in
137 clinics to increase access to a quit smoking internet system: the Quit-Primo and
National Dental PBRN HI-QUIT Studies. Transl Behav Med. 2013;3(4):370-378.
33.
Willett JG, Hood NE, Burns EK, et al. Clinical faxed referrals to a tobacco quitline: reach,
enrollment, and participant characteristics. Am J Prev Med. 2009;36(4):337-340.
34.
Flocke SA, Antognoli E, Step MM, Marsh S, Parran T, Mason MJ. A Teachable Moment
Communication Process for smoking cessation talk: description of a group randomized
clinician-focused intervention. BMC health services research. 2012;12:109.
35.
Flocke SA, Step MM, Antognoli E, et al. A randomized trial to evaluate primary care
clinician training to use the Teachable Moment Communication Process for smoking
cessation counseling. Prev Med. 2014;69:267-273.

13 
36.
Weiner BJ, Lewis MA, Clauser SB, Stitzenberg KB. In search of synergy: strategies for
combining interventions at multiple levels. J Natl Cancer Inst Monogr.
2012;2012(44):34-41.