The Equity Impact of Proactive Outreach to Smokers: Analysis of a Randomized Trial

Differences in the effectiveness of individual-level smoking cessation interventions by socioeconomic status

BACKGROUND

People from lower socioeconomic groups are more likely to smoke and less likely to succeed in achieving abstinence, making tobacco smoking a leading driver of health inequalities. Contextual factors affecting subpopulations may moderate the efficacy of individual-level smoking cessation interventions. It is not known whether any intervention performs differently across socioeconomically-diverse populations and contexts.

OBJECTIVES

To assess whether the effects of individual-level smoking cessation interventions on combustible tobacco cigarette use differ by socioeconomic groups, and their potential impact on health equalities.

SEARCH METHODS

We searched the Cochrane Database of Systematic Reviews from inception to 1 May 2023 for Cochrane reviews investigating individual-level smoking cessation interventions. We selected studies included in these reviews that met our criteria. We contacted study authors to identify further eligible studies.

SELECTION CRITERIA

We included parallel, cluster or factorial randomised controlled trials (RCTs) investigating any individual-level smoking cessation intervention which encouraged complete cessation of combustible tobacco cigarette use compared to no intervention, placebo, or another intervention in adults. Studies must have assessed or reported smoking quit rates, split by any measure of socioeconomic status (SES) at longest follow-up (≥ six months), and been published in 2000 or later.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening, data extraction, and risk of bias assessment. We assessed the availability of smoking abstinence data by SES in lieu of selective reporting. The primary outcome was smoking cessation quit rates, split by lower and higher SES, at the longest follow-up (≥ six months). Where possible, we calculated ratios of odds ratios (ROR) with 95% confidence intervals (CIs) for each study, comparing lower to higher SES. We pooled RORs by intervention type in random-effects meta-analyses, using the generic inverse-variance method. We subgrouped by type of SES indicator and economic classification of the study country. We summarised all evidence in effect direction plots and categorised the intervention impact on health equality as: positive (evidence that the relative effect of the intervention on quit rates was greater in lower rather than higher SES groups), possibly positive, neutral, possibly neutral, possibly negative, negative, no reported statistically significant difference, or unclear. We evaluated certainty using GRADE.

MAIN RESULTS

We included 77 studies (73 from high-income countries), representing 127,791 participants. We deemed 12 studies at low overall risk of bias, 13 at unclear risk, and the remaining 52 at high risk. Included studies investigated a range of pharmacological interventions, behavioural support, or combinations of these. Pharmacological interventions We found very low-certainty evidence for all the main pharmacological interventions compared to control. Evidence on cytisine (ROR 1.13, 95% CI 0.73 to 1.74; 1 study, 2472 participants) and nicotine electronic cigarettes (ROR 4.57, 95% CI 0.88 to 23.72; 1 study, 989 participants) compared to control indicated a greater relative effect of these interventions on quit rates in lower compared to higher SES groups, suggesting a possibly positive impact on health equality. CIs for both estimates included the possibility of no clinically important difference and of favouring higher SES groups. There was a lower relative effect of bupropion versus placebo on quit rates in lower compared to higher SES groups, indicating a possibly negative impact on health equality (ROR 0.05, 95% CI 0.00 to 1.00; from 1 of 2 studies, 354 participants; 1 study reported no difference); however, the CI included the possibility of no clinically important difference. We could not determine the intervention impact of combination or single-form nicotine replacement therapy on relative quit rates by SES. No studies on varenicline versus control were included. Behavioural interventions We found low-certainty evidence of lower quit rates in lower compared to higher SES groups for print-based self-help (ROR 0.85, 95% CI 0.52 to 1.38; 3 studies, 4440 participants) and text-messaging (ROR 0.76, 95% CI 0.47 to 1.23; from 3 of 4 studies, 5339 participants; 1 study reported no difference) versus control, indicating a possibly negative impact on health equality. CIs for both estimates included the possibility of no clinically important difference and of favouring lower SES groups. There was very low-certainty evidence of quit rates favouring higher SES groups for financial incentives compared to balanced intervention components. However, the CI included the possibility of no clinically important difference and of favouring lower SES groups (ROR 0.91, 95% CI 0.45 to 1.85; from 5 of 6 studies, 3018 participants; 1 study reported no difference). This indicates a possibly negative impact on health equality. There was very low-certainty evidence of no difference in quit rates by SES for face-to-face counselling compared to less intensive counselling, balanced components, or usual care. However, the CI included the possibility of favouring lower and higher SES groups (ROR 1.26, 95% CI 0.18 to 8.93; from 1 of 6 studies, 294 participants; 5 studies reported no difference), indicating a possibly neutral impact. We found very low-certainty evidence of a greater relative effect of telephone counselling (ROR 4.31, 95% CI 1.28 to 14.51; from 1 of 7 studies, 903 participants; 5 studies reported no difference, 1 unclear) and internet interventions (ROR 1.49, 95% CI 0.99 to 2.25; from 1 of 5 studies, 4613 participants; 4 studies reported no difference) versus control on quit rates in lower versus higher SES groups, suggesting a possibly positive impact on health equality. The CI for the internet intervention estimate included the possibility of no difference. Although the CI for the telephone counselling estimate only favoured lower SES groups, most studies narratively reported no clear evidence of interaction effects.

AUTHORS' CONCLUSIONS

Currently, there is no clear evidence to support the use of differential individual-level smoking cessation interventions for people from lower or higher SES groups, or that any one intervention would have an effect on health inequalities. This conclusion may change as further data become available. Many studies did not report sufficient data to be included in a meta-analysis, despite having tested the association of interest. Further RCTs should collect, analyse, and report quit rates by measures of SES, to inform intervention development and ensure recommended interventions do not exacerbate but help reduce health inequalities caused by smoking.

Effectiveness of non-pharmacological community-based nursing interventions for smoking cessation in adults: A systematic review

OBJECTIVE

The purpose of this systematic review was to determine the effectiveness of non-pharmacological community-based nursing interventions for smoking cessation in adults.

METHOD

Studies published between January 1, 2008 and December 31, 2017 were comprehensively searched to 14 databases. Quality Assessment Tool for Quantitative Studies was used to examine the methodological quality of the included studies. The obtained studies were listed on a code table by title, summary, and author/s' name. A narrative synthesis was used interpreting the data. This study was registered to PROSPERO (ID: CRD42018088007).

RESULTS

Strong-quality rated three randomized controlled studies were included. Nurses were found to perform intensive behavioral support, brief-advice and mTobacco cessation interventions. These were effective on changing knowledge, belief and attitudes. No sufficient evidence on the cessation rate and the non-relapse rate was found.

DISCUSSION

This review puts forward that non-pharmacological community-based smoking cessation interventions by nurses has an impact on changing knowledge, belief and attitudes in adult smokers. Findings can encourage public health nurses to use their counsellor role more actively. Improving the health literacy of the adult smokers via these findings can facilitate their intention to behavior change. Findings can be a useful resource for policy makers and governments in controlling the smoking epidemic.

A Proactive Outreach Strategy Using a Local Area Code to Refer Unassisted Smokers in a Safety Net Health System to a Quitline: A Pragmatic Randomized Trial

INTRODUCTION

Proactive outreach offering tobacco treatment is a promising strategy outside of clinical settings, but little is known about factors for engagement. The study objective is to examine the impact of caller area code in a proactive, phone-based outreach strategy on consenting low-income smokers to a quitline e-referral.

AIMS AND METHODS

This pragmatic randomized trial included unassisted adult smokers (n = 685), whose preferred language was English or Spanish, in a Los Angeles safety-net health system. Patients were randomized to receive a call from a local or generic toll-free area code. Log-binomial regression was used to examine the association between area code and consent to a quitline e-referral, adjusted for age, gender, language, and year.

RESULTS

Overall, 52.1% of the patients were contacted and, among those contacted, 30% consented to a referral. The contact rate was higher for the local versus generic area code, although not statistically significant (55.6% vs. 48.7%, p = .07). The consent rate was higher in the local versus generic area code group (adjusted prevalence ratio 1.29, 95% CI 1.01-1.65) and also higher for patients under 61 years old than over (adjusted prevalence ratio 1.47, 95% CI 1.07-2.01), and Spanish-speaking than English-speaking patients (adjusted prevalence ratio 1.40, 95% CI 1.05-1.86).

CONCLUSIONS

Proactive phone-based outreach to unassisted smokers in a safety net health system increased consent to a quitline referral when local (vs. generic) area codes were used to contact patients. While contact rate did not differ by area code, proactive phone-based outreach was effective for engaging younger and Spanish-speaking smokers.

IMPLICATIONS

Population-based proactive phone-based outreach from a caller with a local area code to unassisted smokers in a safety net health system increases consent to an e-referral for quitline services. Findings suggest that a proactive phone-based outreach, a population-based strategy, is an effective strategy to build on the visit-based model and offer services to tobacco users, regardless of the motivational levels to quit.

Pain and smoking study (PASS): A comparative effectiveness trial of smoking cessation counseling for veterans with chronic pain

Introduction

Smoking is associated with greater pain intensity and pain-related functional interference in people with chronic pain. Interventions that teach smokers with chronic pain how to apply adaptive coping strategies to promote both smoking cessation and pain self-management may be effective.

Methods

The Pain and Smoking Study (PASS) is a randomized clinical trial of a telephone-delivered, cognitive behavioral intervention among Veterans with chronic pain who smoke cigarettes. PASS participants are randomized to a standard telephone counseling intervention that includes five sessions focusing on motivational interviewing, craving and relapse management, rewards, and nicotine replacement therapy versus the same components with the addition of a cognitive behavioral intervention for pain management. Participants are assessed at baseline, 6, and 12 months. The primary outcome is smoking cessation.

Results

The 371 participants are 88% male, a median age of 60 years old (range 24–82), and smoke a median of 15 cigarettes per day. Participants are mainly white (61%), unemployed (70%), 33% had a high school degree or less, and report their overall health as “Fair” (40%) to “Poor” (11%). Overall, pain was moderately high (mean pain intensity in past week = 5.2 (Standard Deviation (SD) = 1.6) and mean pain interference = 5.5 (SD = 2.2)). Pain-related anxiety was high (mean = 47.0 (SD = 22.2)) and self-efficacy was low (mean = 3.8 (SD = 1.6)).

Conclusions

PASS utilizes an innovative smoking and pain intervention to promote smoking cessation among Veterans with chronic pain. Baseline characteristics reflect a socioeconomically vulnerable population with a high burden of mental health comorbidities.

Concordance Between Electronic Health Record and Tumor Registry Documentation of Smoking Status Among Patients With Cancer

PURPOSE

Patients with cancer who use tobacco experience reduced treatment effectiveness, increased risk of recurrence and mortality, and diminished quality of life. Accurate tobacco use documentation for patients with cancer is necessary for appropriate clinical decision making and cancer outcomes research. Our aim was to assess agreement between electronic health record (EHR) smoking status data and cancer registry data.

MATERIALS AND METHODS

We identified all patients with cancer seen at University of Florida Health from 2015 to 2018. Structured EHR smoking status was compared with the tumor registry smoking status for each patient. Sensitivity, specificity, positive predictive values, negative predictive values, and Kappa statistics were calculated. We used logistic regression to determine if patient characteristics were associated with odds of agreement in smoking status between EHR and registry data.

RESULTS

We analyzed 11,110 patient records. EHR smoking status was documented for nearly all (98%) patients. Overall kappa (0.78; 95% CI, 0.77 to 0.79) indicated moderate agreement between the registry and EHR. The sensitivity was 0.82 (95% CI, 0.81 to 0.84), and the specificity was 0.97 (95% CI, 0.96 to 0.97). The logistic regression results indicated that agreement was more likely among patients who were older and female and if the EHR documentation occurred closer to the date of cancer diagnosis.

CONCLUSION

Although documentation of smoking status for patients with cancer is standard practice, we only found moderate agreement between EHR and tumor registry data. Interventions and research using EHR data should prioritize ensuring the validity of smoking status data. Multilevel strategies are needed to achieve consistent and accurate documentation of smoking status in cancer care.

Achieving Equity in the Reach of Smoking Cessation Services Within the NCI Cancer Moonshot-Funded Cancer Center Cessation Initiative

Background: Ensuring equitable access to smoking cessation services for cancer patients is necessary to avoid increasing disparities in tobacco use and cancer outcomes. In 2017, the Cancer Center Cessation Initiative (C3I) funded National Cancer Institute (NCI)-designated Cancer Centers to integrate evidence-based smoking cessation programs into cancer care. We describe the progress of C3I Cancer Centers in expanding the reach of cessation services across cancer populations.

Methods: Cancer centers (n=17) reported on program characteristics and reach (the proportion of smokers receiving evidence-based cessation treatment) for two 6-month periods. Reach was calculated overall and by patient gender, race, ethnicity, and age.

Results: Average reach increased from 18.5% to 25.6% over 1 year. Reach increased for all racial/ethnic groups, and in particular for American Indian/Alaska Native (6.6–24.7%), Asian/Native Hawaiian/Pacific Islander (7.3–19.4%), and black (18.8–25.9%) smokers. Smaller gains in reach were observed among Hispanic smokers (19.0–22.8%), but these were similar to gains among non-Hispanic smokers (18.9–23.9%). By age group, smokers aged 18–24 years (6.6–14.5%) and >65 years (16.1–24.5%) saw the greatest increases in reach.

Conclusion: C3I Cancer Centers achieved gains in providing smoking cessation services to cancer patients who smoke, thereby reducing disparities that had existed across important subgroups. Taking a population-based approach to integrating tobacco treatment into cancer care has potential to increase reach equity. Implementation strategies including targeted and proactive outreach to patients and interventions to increase providers' adoption of evidence-based smoking cessation treatment may advance reach even further.

Smoking Cessation in Lower Socioeconomic Groups: Adaptation and Pilot Test of a Rolling Group Intervention

Background

Socioeconomic inequalities in smoking rates persist and tend to increase, as evidence-based smoking cessation programs are insufficiently accessible and appropriate for lower socioeconomic status (SES) smokers to achieve long-term abstinence. Our study is aimed at systematically adapting and pilot testing a smoking cessation intervention for this specific target group.

Methods

First, we conducted a needs assessment, including a literature review and interviews with lower SES smokers and professional stakeholders. Next, we selected candidate interventions for adaptation and decided which components needed to be adopted, adapted, or newly developed. We used Intervention Mapping to select effective methods and practical strategies and to build a coherent smoking cessation program. Finally, we pilot tested the adapted intervention to assess its potential effectiveness and its acceptability for lower SES smokers.

Results

The core of the adapted rolling group intervention was the evidence-based combination of behavioral support and pharmacotherapy. The intervention offered both group and individual support. It was open to smokers, smokers who had quit, and quitters who had relapsed. The professional-led group meetings had a fixed structure. Themes addressed included quitting-related coping skills and health-related and poverty-related issues. Methods applied were role modeling, practical learning, reinforcement, and positive feedback. In the pilot test, half of the 22 lower SES smokers successfully quit smoking. The intervention allowed them to “quit at their own pace” and to continue despite a possible relapse. Participants appraised the opportunities for social comparison and role modeling and the encouraging atmosphere. The trainers were appreciated for their competencies and personal feedback.

Conclusions

Our adapted rolling group intervention for lower SES smokers was potentially effective as well as feasible, suitable, and acceptable for the target group. Further research should determine the intervention's effectiveness. Our detailed report about the adaptation process and resulting intervention may help reveal the mechanisms through which such interventions might operate effectively.

Health benefits and economic advantages associated with increased utilization of a smoking cessation program

Rationale, aim & objective: The goal of this study was to examine the health and economic impacts related to increased utilization of the Duke Smoking Cessation Program resulting from the addition of two relatively new referral methods - Best Practice Advisory and Population Outreach. Materials & methods: In a companion paper 'Comparison of Referral Methods into a Smoking Cessation Program', we report results from a retrospective, observational, comparative effectiveness study comparing the impact of three referral methods - Traditional Referral, Best Practice Advisory and Population Outreach on utilization of the Duke Smoking Cessation Program. In this paper we take the next step in this comparative assessment by developing a Markov model to estimate the improvement in health and economic outcomes when two referral methods - Best Practice Advisory and Population Outreach - are added to Traditional Referral. Data used in this analysis were collected from Duke Primary Care and Disadvantaged Care clinics over a 1-year period (1 October 2017-30 September 2018). Results: The addition of two new referral methods - Best Practice Advisory and Population Outreach - to Traditional Referral increased the utilization of the Duke Smoking Cessation Program in Primary Care clinics from 129 to 329 smokers and in Disadvantaged Care clinics from 206 to 401 smokers. The addition of these referral methods was estimated to result in 967 life-years gained, 408 discounted quality-adjusted life-years saved and total discounted lifetime direct healthcare cost savings of US$46,376,285. Conclusion: Health systems may achieve increased patient health and decreased healthcare costs by adding Best Practice Advisory and Population Outreach strategies to refer patients to smoking cessation services.

Proactive tobacco treatment for veterans with posttraumatic stress disorder

OBJECTIVE

Individuals with posttraumatic stress disorder (PTSD) smoke at higher rates compared to the general population and experience significant barriers to initiating cessation treatment. Proactive outreach addresses these barriers by directly engaging with smokers and facilitating access to treatment. The objective of the present study was to evaluate a proactive outreach intervention for increasing rates of treatment utilization and abstinence among veteran smokers with and without PTSD.

METHOD

This is a secondary analysis of a randomized controlled trial conducted from 2013 to 2017 that demonstrated the effectiveness of proactive outreach among veterans using Veterans Affairs mental health care services. Electronic medical record data were used to identify participants with (n = 355) and without (n = 1,583) a diagnosis of PTSD. Logistic regressions modeled cessation treatment utilization (counseling, nicotine replacement therapy [NRT], and combination treatment) and abstinence (7-day point prevalence and 6-month prolonged at 6- and 12-month follow-ups) among participants randomized to proactive outreach versus usual care in the PTSD and non-PTSD subgroups, respectively.

RESULTS

Compared to usual care, proactive outreach increased combined counseling and NRT utilization among participants with PTSD (odds ratio [OR] = 26.25, 95% confidence interval [3.43, 201.17]) and without PTSD (OR = 10.20, [5.21, 19.98]). Proactive outreach also increased 7-day point prevalence abstinence at 12 months among participants with PTSD (OR = 2.62, [1.16, 5.91]) and without PTSD (OR = 1.61, [1.11, 2.34]).

CONCLUSIONS

Proactive outreach increased treatment utilization and abstinence among smokers with and without PTSD. Smokers with PTSD may need additional facilitation to initiate cessation treatment but are receptive when it is offered proactively. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Proactive outreach tobacco treatment for socioeconomically disadvantaged smokers with serious mental illness

Smokers with serious mental illness (SMI) face individual, interpersonal, and healthcare provider barriers to cessation treatment utilization and smoking abstinence. Proactive outreach strategies are designed to address these barriers by promoting heightened contact with smokers and facilitating access to evidence-based treatments. The present study examined the effect of proactive outreach among smokers with SMI (n = 939) who were enrolled in the publicly subsidized Minnesota Health Care Programs (MHCP) and compared this effect to that observed among MHCP smokers without SMI (n = 1382). Relative to usual care, the intervention increased treatment utilization among those with SMI (52.1% vs 40.0%, p = 0.002) and without SMI (39.3% vs 25.4%, p < 0.001). The intervention also increased prolonged smoking abstinence among those with SMI (14.9% vs 9.4%, p = 0.010) and without SMI (17.7% vs 13.6%, p = 0.09). Findings suggest that implementation of proactive outreach within publicly subsidized healthcare systems may alleviate the burden of smoking in this vulnerable population. Trial Registration ClinicalTrials.gov identifier: NCT01123967.

Individual-level behavioural smoking cessation interventions tailored for disadvantaged socioeconomic position: a systematic review and meta-regression

BACKGROUND

Socioeconomic inequalities in smoking cessation have led to development of interventions that are specifically tailored for smokers from disadvantaged groups. We aimed to assess whether the effectiveness of interventions for disadvantaged groups is moderated by tailoring for socioeconomic position.

METHODS

For this systematic review and meta-regression, we searched MEDLINE, PsycINFO, Embase, Cochrane Central Register, and Tobacco Addiction Register of Clinical Trials and the IC-SMOKE database from their inception until Aug 18, 2019, for randomised controlled trials of socioeconomic-position-tailored or non-socioeconomic-position-tailored individual-level behavioural interventions for smoking cessation at 6 months or longer of follow-up in disadvantaged groups. Studies measured socioeconomic position via income, eligibility for government financial assistance, occupation, and housing. Studies were excluded if they were delivered at the community or population level, did not report differential effects by socioeconomic position, did not report smoking cessation outcomes from 6 months or longer after the start of the intervention, were delivered at a group level, or provided pharmacotherapy with standard behavioural support compared with behavioural support alone. Individual patient-level data were extracted from published reports and from contacting study authors. Random-effects meta-analyses and mixed-effects meta-regression analyses were done to assess associations between tailoring of the intervention and effectiveness. Meta-analysis outcomes were summarised as risk ratios (RR). Certainty of evidence was assessed within each study using the Cochrane risk-of-bias tool version 2 and the grading of recommendations assessment, development, and evaluation approach. The study is registered with PROSPERO, CRD42018103008.

FINDINGS

Of 2376 studies identified by our literature search, 348 full-text articles were retrieved and screened for eligibility. Of these, 42 studies (26 168 participants) were included in the systematic review. 30 (71%) of 42 studies were done in the USA, three (7%) were done in the UK, two (5%) each in the Netherlands and Australia, and one (2%) each in Switzerland, Sweden, Turkey, India, and China. 26 (62%) of 42 studies were trials of socioeconomic-position-tailored interventions and 16 (38%) were non-socioeconomic-position-tailored interventions. 17 (65%) of 26 socioeconomic-position-tailored interventions were in-person or telephone-delivered behavioural interventions, four (15%) were digital interventions, three (12%) involved financial incentives, and two (8%) were brief interventions. Individuals who participated in an intervention, irrespective of tailoring, were significantly more likely to quit smoking than were control participants (RR 1·56, 95% CI 1·39-1·75; I2=54·5%). Socioeconomic-position-tailored interventions did not yield better outcomes compared with non-socioeconomic-position-tailored interventions for disadvantaged groups (adjusted RR 1·01, 95% CI 0·81-1·27; β=0·011, SE=0·11; p=0·93). We observed similar effect sizes in separate meta-analyses of non-socioeconomic-position-tailored interventions using trial data from participants with high socioeconomic position (RR 2·00, 95% CI 1·36-2·93; I2=82·7%) and participants with low socioeconomic position (1·94, 1·31-2·86; I2=76·6%), although certainty of evidence from these studies was graded as low.

INTERPRETATION

We found evidence that individual-level interventions can assist disadvantaged smokers with quitting, but there were no large moderating effects of tailoring for disadvantaged smokers. Improvements in tailored intervention development might be necessary to achieve equity-positive smoking cessation outcomes.

FUNDING

Cancer Research UK.

Uneven Access to Smoke-Free Laws and Policies and Its Effect on Health Equity in the United States: 2000-2019

Tobacco control measures have played an important role in the reduction of the cigarette smoking prevalence among US adults.However, although overall smoking prevalence has declined, it remains high among many subpopulations that are disproportionately burdened by tobacco use, resulting in tobacco-related health disparities. Slow diffusion of smoke-free laws to rural regions, particularly in the South and Southeast, and uneven adoption of voluntary policies in single-family homes and multiunit housing are key policy variables associated with the disproportionate burden of tobacco-related health disparities in these subpopulations.Developing policies that expand the reach of comprehensive smoke-free laws not only will facilitate the decline in smoking prevalence among subpopulations disproportionately burdened by tobacco use but will also decrease exposure to secondhand smoke and further reduce tobacco-caused health disparities in the United States.