Association of Tobacco Assessment and Cessation Assistance with Social Determinants of Health Risk in Primary Care

Context: Several studies have documented that individuals with greater social determinants of health risks (SDOH) are more likely to use tobacco. What is not known is if provision of tobacco cessation assistance is equally likely for individuals with different levels of SDOH risk.

Objective: To examine the association of level of risk of 11 SDOH indicators and provision of assistance for tobacco cessation.

Design and Analysis: Observational study.

Setting or Dataset: Electronic health record data from 11 community-based clinics within a safety-net system in the Midwest from 07/01/2021-3/31/2024.

Population Studied: 119,926 adult patients with one or more primary care visits during the 30-month study period.

Outcome Measures: Assessment of tobacco use; Among patients with current tobacco use, provision of advice to quit, referral to tobacco cessation counseling and tobacco cessation medication orders.

Results: Among 119,926 patients, 40% did not have SDOH assessed; 31% had 3 or more social needs identified during screening, 11% had 2, 7% had 1, and 11% had no social needs. Tobacco use assessment was highest for those with no SDOH risk (80% vs. 75%, 75% and 77% for 1, 2 and 3+, respectively). Current tobacco use overall was 24% and the association with SDOH was non-linear; 24%, 17%, 14% and 24% for no SDOH risk, 1, 2 and 3+ respectively. Among patients that currently use tobacco, those with no SDOH risk were significantly more likely to receive advice to quit than each of the other SDOH risk groups. The difference was the largest for no SDOH risk (61%) vs. SDOH risk 3+ (51%), OR, 95% CI (1.5, 1.4-1.6). Referral to counseling (7.5% overall) and provision of tobacco cessation medications (3.5% overall) were very low and did not significantly differ by level of SDOH risk.

Conclusions: In this safety-net system, among those assessed, 80% had at least 1 SDOH risk and use of tobacco was 24%. Level of SDOH risk was not associated with likelihood of tobacco assessment and assistance, except for a significantly higher likelihood of advice to quit for those with no SDOH risk. These findings indicate no disparity in delivery of evidence-based tobacco cessation treatment by SDOH risk. However, given the low rates of referral for counseling and provision of FDA-approved tobacco cessation medications, systematic efforts to increase tobacco cessation treatment are needed but implementation strategies should concurrently assess and address social needs.