# Comparing an opt-out to an opt-in approach for smoking cessation in VA primary care clinics

> **NIH VA I01** · VA  MEDICAL CENTER · 2020 · —

## Abstract

ABSTRACT
 Smoking is the leading preventable cause of death in the US, and health care systems are able to
reach a large number of smokers and effectively engage them into evidence based tobacco treatment.
Effective cessation approaches include medications and behavioral treatment (including face-to-face
counseling, telephone counseling and text messaging). While delivery of smoking cessation medications has
increased, it has proven more difficult to increase the delivery of behavioral treatments. Within primary care,
health care providers are effective at counseling smokers to quit, yet few providers actually deliver longitudinal
counseling due to time pressures and competing priorities. The two main evidence-based approaches
available in the U.S. for behavioral tobacco dependence treatment include Quitlines (to deliver telephone
counseling) and text messaging programs. Tobacco Quitlines are effective and our prior studies have explored
different approaches to increasing use of Quitlines, yet many questions remain about how best to do this within
health care systems. Similarly, text messaging is effective at helping smokers to quit, but is rarely used in
health care. While 11% of smokers reported having used a quit smoking program that involves text messaging,
no studies to date have examined health care-based approaches to increase engagement in text messaging
programs, such as VA’s SmokefreeVET. Our prior research shows that nearly all smokers are capable of
receiving text messages and most feel that it would help them to quit. National mandates call for health care
systems to refer all smokers to treatment, yet there is little guidance on how to achieve this objective. Studies
from behavioral economics and other fields suggest that how the referral is framed is extremely important.
Systems typically use an opt-in approach where the default is “no treatment”, unlike conditions such as
diabetes or hypertension where we treat people unless they opt-out of treatment. An opt-out approach has
proven much more effective in other settings, such as organ donation, screening for sexually transmitted
diseases and recruitment for research studies. Aside from an uncontrolled UK study among pregnant women,
no studies have tested an opt-out approach for smokers in ambulatory care.
 We propose a Type I hybrid effectiveness/implementation study to evaluate two population-based
approaches for increasing use of Quitlines and text messaging at two VA sites. Specifically, we will test the
default bias, examining whether an opt-out approach to referral is more effective than an opt-in approach. We
will randomly assign teams to either an opt-out or opt-in approach to referring smokers to treatment. In the opt-
out approach, the default is that everyone is referred to treatment unless they actively choose not to be. In the
opt-in approach, people are offered treatment but must actively choose to enroll in it.
 Our specific aims are: (1) To compare the effectiveness ...

## Key facts

- **NIH application ID:** 9761306
- **Project number:** 5I01HX002455-02
- **Recipient organization:** VA  MEDICAL CENTER
- **Principal Investigator:** STEVEN FU
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2020
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2018-08-01 → 2022-07-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9761306

## Citation

> US National Institutes of Health, RePORTER application 9761306, Comparing an opt-out to an opt-in approach for smoking cessation in VA primary care clinics (5I01HX002455-02). Retrieved via AI Analytics 2026-05-22 from https://api.ai-analytics.org/grant/nih/9761306. Licensed CC0.

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