Recognizing the Need
For more than 30 years, The Free Medical Clinic in Columbia, South Carolina has provided quality medical care to uninsured members of the community, at no cost. The clinic offers primary care, medications and referrals to specialists. Now, they offer one more service: tobacco cessation counseling and resources.
The need for cessation resources was great. 42 percent of patients who visit The Free Medical Clinic use tobacco, twice the average among South Carolina adults.1,2
Dr. Todd Krump, medical director of The Free Medical Clinic, has seen how tobacco use negatively impacts the health of his patients. A third of the clinic's patients have diabetes and ten percent have heart disease, two chronic conditions related to tobacco use.1
Melissa Goforth, Area Manager of the American Lung Association in South Carolina, also notes the financial drain tobacco puts on the clinic's patients.
"Tobacco most impacts those who can afford it the least. It is a huge economic burden for the patients. To be a patient at this clinic, an individual can only make $16,100, a family of four can make no more than $33,000 a year. Tobacco is robbing these patients of income they need," she said.
To encourage patients to quit tobacco, The Free Medical Clinic made its own grounds smokefree. Goforth says this makes the clinic a supportive place for those interested in quitting and reinforces the idea that healthy environments are smokefree environments.
"One of the first things I had to show was that this was systems change. We were working towards long-term, sustainable change in the way patients, staff and volunteers address tobacco," she said.
The Free Medical Clinic needed to identify and track the tobacco status of its patients in order to connect patients with cessation resources. However, existing systems to track tobacco use depended on electronic medical records and the clinic still uses paper records. Creating a separate paper form for tobacco use would add paperwork and increase waiting times. This had stopped similar clinics from tracking tobacco use in the past but the staff at The Free Medical Clinic employed creative problem-solving.
Brief, Consistent Interventions
Another piece of the systems change effort at The Free Medical Clinic was designing tobacco interventions with the patients. These interventions had to be brief since there's a high demand for the clinic's services. Lengthy interventions would reduce the number of patients the clinic could serve in a given day. Intervention methods also had to be easy for staff to learn. Like most similar clinics, The Free Medical Clinic has few permanent staff and relies heavily on volunteers and medical students. New staff must be trained quickly in order to keep everything running efficiently.
When a patient is first identified as a tobacco user, a physician's assistant conducts a brief assessment. While that takes staff time, one-on-one counseling increases the likelihood of quitting smoking. Of course, most patients are not ready to quit after a single assessment so multiple interventions are planned.
"For most patients who quit tobacco, it is a process, not a single decision. Just asking them to quit once isn't as effective as it could be. By asking at every visit, clinic staff help patients move towards a quit attempt. When they are ready, they help patients set a quit date and get them free patches or lozenges. Afterwards, they check in to see how they are doing," said Goforth.
Interventions need to take place at appointments since the patients often change addresses and phone numbers and it can be very difficult to reach them between appointments.
While all of the intervention methods selected by Goforth and The Free Medical Clinic were evidence-based, Volunteer Coordinator Sandy Earles wanted to test them out as she was a smoker herself.
"I tried to quit a few times in the past but it never worked. I tried out the methods we were going to use with patients, tracking how much I was smoking and working up to a quit date. Now, I haven't smoked in over a year," said Earles.
Earles is now responsible for training volunteers and students on the tobacco intervention strategies and uses her own example as a success story. Earles has become a champion for The Free Medical Clinic in changing the system of how tobacco users are identified and provided with resources to successfully quit.
Sustainability and Growth
Dr. Krump and the rest of the staff at The Free Medical Clinic are pleased with the changes they made. Their tobacco intervention is sustainable and they believe it will reduce chronic disease rates among their patients.
Goforth hopes other free clinics follow the example set by The Free Medical Clinic. She knows the systems they set up – smokefree grounds, tracking tobacco use and brief interventions – are low-cost and manageable for any free clinic. She is also willing to share her experience with any free clinic that wishes to make a similar change.
Goforth is hopeful that the medical students who spend a rotation at The Free Medical Clinic will pass on the work as they move forward in their careers.
"The medical students who trained with us will go on to work all over the region. That's a lot of new doctors who understand the importance of brief tobacco interventions and know how to conduct them," she says.
King BA, Dube SR, Tynan MA. Current Tobacco Use Among Adults in the United States: Findings From the National Adult Tobacco Survey. AJPH, Nov 2012; 102(11):e93-e11.
Page last updated: April 9, 2020