Comparing two approaches to remote biochemical verification of self-reported cessation in very low-income smokers

A Scoping Review and Meta-analysis of the Use of Remote Biochemical Verification Methods of Smoking Status in Tobacco Research

INTRODUCTION

Increasing digital delivery of smoking cessation interventions has resulted in the need to employ novel strategies for remote biochemical verification.

AIMS AND METHODS

This scoping review and meta-analysis aimed to investigate best practices for remote biochemical verification of smoking status. The scientific literature was searched for studies that reported remotely obtained (not in-person) biochemical confirmation of smoking status (ie, combustible tobacco). A meta-analysis of proportions was conducted to investigate key outcomes, which included rates of returned biological samples and the ratio of biochemically verified to self-reported abstinence rates.

RESULTS

A total of 82 studies were included. The most common samples were expired air (46%) and saliva (40% of studies), the most common biomarkers were carbon monoxide (48%) and cotinine (44%), and the most common verification methods were video confirmation (37%) and mail-in samples for lab analysis (26%). Mean sample return rates determined by random-effects meta-analysis were 70% for smoking cessation intervention studies without contingency management (CM), 77% for CM studies, and 65% for other studies (eg, feasibility and secondary analyses). Among smoking cessation intervention studies without CM, self-reported abstinence rates were 21%, biochemically verified abstinence rates were 10%, and 47% of individuals who self-reported abstinence were also biochemically confirmed as abstinent.

CONCLUSIONS

This scoping review suggests that improvements in sample return rates in remote biochemical verification studies of smoking status are needed. Recommendations for reporting standards are provided that may enhance confidence in the validity of reported abstinence rates in remote studies.

IMPLICATIONS

This scoping review and meta-analysis included studies using remote biochemical verification to determine smoking status. Challenges exist regarding implementation and ensuring high sample return rates. Higher self-reported compared to biochemically verified abstinence rates suggest the possibility that participants in remote studies may be misreporting abstinence or not returning samples for other reasons (eg, participant burden, inconvenience). Remote biochemical confirmation of self-reported smoking abstinence should be included in smoking cessation studies whenever feasible. However, findings should be considered in the context of challenges to sample return rates. Better reporting guidelines for future studies in this area are needed.

Helping low-income smokers quit: findings from a randomized controlled trial comparing specialized quitline services with and without social needs navigation

Background

Quitting smoking is especially challenging for low-income smokers due to high stress, high smoking prevalence around them, and limited support for quitting. This study aimed to determine whether any of three interventions designed specifically for low-income smokers would be more effective than standard tobacco quitline services: a specialized quitline, the specialized quitline with social needs navigation, or the standard quitline with social needs navigation.

Methods

Using a randomized 2 × 2 factorial design, low-income daily cigarette smokers (n = 1944) in Missouri, USA who called a helpline seeking assistance with food, rent or other social needs were assigned to receive Standard Quitline alone (n = 485), Standard Quitline + Social Needs Navigation (n = 484), Specialized Quitline alone (n = 485), or Specialized Quitline + Social Needs Navigation (n = 490). The target sample size was 2000, 500 per group. The main outcome was 7-day self-reported point prevalence abstinence at 6-month follow-up. Multiple imputation was used to impute outcomes for those missing data at 6-month follow-up. Binary logistic regression analyses were used to assess differences between study groups.

Findings

Participants were recruited from June 2017 to November 2020; most were African American (1111 [58%]) or White (666 [35%]), female (1396 [72%]), and reported <$10,000 (957 [51%]) or <$20,000 (1529 [82%]) annual pre-tax household income. At 6-month follow-up (58% retention), 101 participants in the Standard Quitline group reported 7-day point prevalence abstinence (20.8% of those assigned at baseline, 38.1% after imputation). Quit rates in the Specialized Quitline (90 quitters, 18.6%, 38.1%) and Specialized Quitline + Social Needs Navigation (103 quitters, 21.0%, 39.8%) were not different from the Standard Quitline. Quit rates for Standard Quitline + Social Needs Navigation (74 quitters, 15.3%, 30.1%) were significantly lower than Standard Quitline (OR = 0.70, 95% CI = 0.50-0.98).

Interpretation

A specialized version of a state tobacco quitline was no more effective than standard quitline services in helping low-income smokers quit. Adding social needs navigation to a standard quitline decreased its effectiveness.

Trial registration

ClinicalTrials.gov Identifier: NCT03194958.

Funding

National Cancer Institute: R01CA201429.

Stress, depression, sleep problems and unmet social needs: Baseline characteristics of low-income smokers in a randomized cessation trial

BACKGROUND

Low-income Americans smoke cigarettes at higher rates and quit less than other groups.

METHODS

To increase their engagement in and success using evidence-based cessation methods, we tested two interventions using a 2x2 randomized factorial design: (1) telephone navigation to reduce financial strain and address social needs such as food, rent and utility payment; and (2) a specialized tobacco quitline designed for low-income smokers. From June 2017 to November 2020, we enrolled 1,944 low-income smokers in Missouri, USA, recruited through the Missouri 2-1-1 helpline, into the trial. This paper describes recruitment, key characteristics and life circumstances of this high-risk population.

RESULTS

After eligibility screening, 1,944 participants completed baseline and were randomized. Participants were racially diverse (58% African American), poor (51% < $10,000 annual pre-tax household income) and many reported less than high school education (30%). They reported a mean of 2.5 unmet social needs, especially childcare and paying bills, had high rates of stress, depressive symptoms and sleep problems, and most were in fair or poor health. There were few differences between these variables, and no differences between tobacco use and cessation variables, across the four study groups and between participants recruited pre and during the COVID-19 pandemic.

CONCLUSIONS

Trial recruitment through the 2-1-1 helpline is feasible for reaching a population of low-income smokers. Low-income smokers face myriad daily challenges beyond quitting smoking. Cessation interventions need to account for and address these life circumstances.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03194958.