CA Quits: Redesigning the Health Care System to Combat California’s Smoking Disparities

Abstract

Over the last fifty years, the adult smoking rate in the United States (US) declined dramatically, from 42 to 15.5 percent. Despite this success, smoking remains the single leading cause of preventable death and disease in the nation. In addition, smoking has emerged as a disparity among population subgroups—with higher smoking rates among groups that are disproportionately low-income, burdened with adverse health and social conditions, and represent racial/ethnic and other minorities. For example, the smoking prevalence among American Indian/Alaskan Native populations is nearly 40 percent or 2.6 times higher than the national average. Likewise, among those who have achieved the education attainment of a GED, the smoking prevalence is 40 percent. And among individuals diagnosed with serious psychological distress smoking rates are approximately 36 percent, or more than twice the national average. Consequently, new strategies are needed to reach smokers and further tobacco control goals. The state of California is leading this effort with the longest standing, publicly funded tobacco control program in the nation: the California Tobacco Control Program (CTCP). The CTCP has used cutting-edge strategies to reduce smoking rates and has recently adopted a new paradigm, the “End Game”. The End Game aspires to achieve 0% smoking by 2035. This goal is ambitious given the state’s number of smokers, currently: 3.2 million. To reach these smokers, the CTCP proposes a novel strategy: engage safety net health care systems to help cessation efforts. This concept, a decade in development, is realized in the CA Quits project. This DELTA project is a formative evaluation of CA Quits, a CTCP-funded health care redesign initiative that proposes to steward collaborations between three stakeholder sectors: public health departments, Medicaid insurance plans, and safety net health care systems. Together, these sectors will support the integration of evidence-based smoking cessation treatments into safety net clinical settings. The project theory of change is Collective Impact (CI) which posits that large-scale societal problems are best resolved using cross-sector stakeholder collaborations focused on a singular goal. CI is the latest framework identified in “coalition” and “participatory action research” literature. Two questions are addressed by this DELTA project: 1) Are stakeholder incentives sufficiently aligned to motivate participation in the CA Quits project? and 2) Is Collective Impact theory applicable to the CA Quits concept and targeted stakeholders? Qualitative methods are used to assess the alignment of CA Quits’ goals with sectors’ goals. The results demonstrate that multisector stakeholder incentives sufficiently align, but, require tailoring for each sector. The results also demonstrate that CI is an appropriate change theory. Key lessons learned are that there are significant barriers and drivers for addressing smoking among populations burdened with smoking disparities. The primary drivers are: Government, funder and leadership mandates which provide a structural impetus to address smoking. The primary barriers are: local politics, emerging recreational marijuana use, and social determinants, each of which confounds effective intervening.