Re-examining phone counseling for smoking cessation: Does the evidence apply to low-SES smokers?

Contextual factors in systematic reviews: understanding public health interventions in low socioeconomic status and disadvantaged populations

BACKGROUND

Evaluations of public health interventions require an understanding of the contextual factors that shape their effectiveness. Context (including socioeconomic, cultural, and environmental factors) plays a critical role in establishing how interventions achieve impact, why outcomes can vary and whether the interventions of interest can be translated from one context to another. This overview explores the extent to which systematic reviews of public health interventions for low-income or low socioeconomic status (SES) populations report contextual factors influencing outcomes.

METHODS

Systematic reviews were identified through a scoping review and updated searches in March 2023. Reviews focused on interventions targeting smoking, unhealthy diet, physical inactivity, and harmful alcohol use in disadvantaged groups. Reviews were screened for eligibility, and data were extracted on contextual factors related to intervention implementation and effectiveness. Data were synthesised using a framework approach, categorising findings by behaviour and level of intervention.

RESULTS

Applying a very broad definition of context, 29 of 86 identified reviews provided some degree of contextual data which varied across interventions but was largely restricted to intervention implementation and delivery factors. For example, environmental characteristics, such as crime and perceived personal safety, affected the use of physical activity infrastructure in disadvantaged areas. Food voucher schemes had mixed results, with social and economic factors affecting their use and effectiveness. However, most reviews lacked sufficient reporting on contextual data, limiting conclusions on the role of context in intervention outcomes.

CONCLUSIONS

Contextual factors are often underreported in systematic reviews of public health interventions targeting disadvantaged populations. Such underreporting is likely to be similar in other areas of public health. This limits policymakers' ability to adapt interventions to specific settings. Improved reporting and consideration of context in systematic reviews are needed to ensure that interventions are appropriately tailored to the needs of low-income and low SES groups.

Increasing a Quitline's Reach to Low-Income Tobacco Users Through 211 Agencies

INTRODUCTION

Low-income individuals bear a disproportionate share of the burden of tobacco use. This study tested the feasibility of increasing a quitline's reach to low-income tobacco users by collaborating with 211 information and referral agencies, which primarily serve people experiencing economic hardship.

AIMS AND METHODS

Study participants (N = 114 888) were adult tobacco users referred to the California quitline by 211 agencies, referred by healthcare clinics, or self-referred from April 17, 2021 to December 31, 2023. All were offered telephone counseling. Those referred by 211 received $20 for completing one counseling session. A subset (n = 2021) was followed up at 7 months. Referral outcomes, baseline characteristics, counseling and quitting aid utilization, and quitting outcomes were analyzed by referral source in 2024.

RESULTS

Over a 2.7-year period, 211 agencies referred 55 151 clients to the quitline. Participants referred by 211 were more than twice as likely as healthcare-referred participants to enroll in quitline services (34.0% vs. 15.9%, p < .0001). They were more likely than healthcare- and self-referred participants to be female, lesbian, gay, bisexual, transgender, or queer/questioning, Black or multiracial, younger, less educated, and Medicaid-insured; more likely to complete a first counseling session (64.2% vs. 59.7% and 55.7%; both ps < .0001); and completed a similar number of sessions, 2.4. They were less likely to use quitting aids. Quit rates (ie, 30-day point prevalence abstinence) at 7-month follow-up were similar for all three groups.

CONCLUSIONS

A collaboration between a quitline and 211 agencies connected large numbers of underserved, low-income tobacco users to evidence-based cessation treatment.

IMPLICATIONS

The study shows that quitlines and 211 agencies can collaborate effectively to help low-income tobacco users quit. It shows that when offered a modest incentive, 211-referred participants engage in counseling as much as healthcare- and self-referred participants and are as likely to quit. If 211 agencies across the US referred at the same rate as agencies in this study, an estimated 65 000 additional tobacco users annually would receive treatment. Total reach at full implementation would likely be much higher. Quitline and 211 funders and other supporters should find ways to sustain these gains and expand their reach.

Risk Factors for Adults with Chronic Obstructive Pulmonary Disease in the United States, Utilizing State-Based Surveillance

Chronic Obstructive Pulmonary Disease (COPD) is a complex and heterogeneous condition. Exposure to tobacco smoke and air pollutants are key risk factors for COPD development; however, other risk factors include race/ethnicity, sex of adults, a history of asthma, occupational exposures, and chronic respiratory infections. Data for the current study were from the 2022 Behavioral Risk Factor Surveillance Survey. Chi-squares and multinomial logistic regression analyses, adjusted with the survey's sampling weight, were used to examine how critical health indicators impacted a COPD diagnosis. Participants (N = 311,175) were adults aged 45 years and older. Adjusted multinomial regression analyses showed adults who reported asthma, current and former smoking, poor physical health, depression, less physical activity, and fatigue were more likely to report COPD. Those with COPD were more likely to be male than female. Moreover, those with COPD reported higher rates of health insurance coverage, and yet had lower income and more financial difficulty affording a doctor for health services. In a follow up regression analysis, examining racial differences in COPD for participants, American Indian adults had a higher odds of reporting COPD than the "other" race groups. Because COPD remains a leading cause of death and disability in the U.S., and racial disparities persist in respiratory outcomes, continuing to identify risk factors for vulnerable groups could assist health program planners with development of successful health messaging.

Health and Demographic Factors for Chronic Obstructive Pulmonary Disease Among Hispanic Adults in the United States: Analysis of Behavioral Risk Factor Surveillance System Survey Data

Introduction: Appropriate diagnosis and regular primary care appointments are markers of quality chronic obstructive pulmonary disease (COPD) care. Underdiagnosis of COPD has been associated with an absence of health insurance, lower socioeconomic status, and race and ethnicity. Methods: This study examined predictors of COPD using data from the Behavioral Risk Factor Surveillance System (BRFSS, 2021) to provide information for prevention messaging and interventions. Participants included Hispanic adults (n = 17,782) aged 45 years and older. Chi-square tests and a multinomial logistic regression analysis (adjusted with the BRFSS weighting variable) were used to understand how sex, income, health status, smoking behaviors, asthma morbidity, and health insurance coverage were related to having COPD. Results: Patients with poor health, lower income level, current smokers, former smokers, or asthma were more likely to report COPD. Females were more likely to report COPD than males. Patients with COPD were more likely to be without health insurance when compared to those who did not have COPD, indicating unmet medical needs. Conclusion: Studies such as this one, aiming to evaluate the relationship between COPD prevalence and predictors of health and outcomes among Hispanic patients in the United States will remain important for developing health messaging to attenuate disease progression.

A Safety Net Tobacco Use Cessation Resource: Quitline Service Usage, 2019

INTRODUCTION

Quitlines are free, accessible evidence-based services that may provide an important resource for people facing barriers to clinical treatment for cessation of tobacco use.

METHODS

Using 2019 intake data from the National Quitline Data Warehouse, we examined quitline service usage, stratified by sociodemographic characteristics. Only US quitlines reporting service type data were included (n = 40 [of 51]). Callers (aged ≥12 years) who registered with a quitline, reported current use of a tobacco product, and received at least 1 service comprised the analytic data. Chi-square tests examined differences in quitline services received by participant characteristics.

RESULTS

In 2019, 182,544 people reporting current use of a tobacco product received at least 1 service from a quitline in 39 states and the District of Columbia. Among them, 80.4% had attained less than a college or university degree and 70.4% were uninsured or enrolled in Medicaid or in Medicare (aged <65 years). By educational attainment (aged ≥25 years), receipt of cessation medications ranged from 59.4% of callers with a college or university degree to 65.0% of callers with a high school diploma (P < .001). The range by insurance coverage was 59.3% of callers with private insurance to 74.7% of callers with Medicare (aged <65 years) (P < .001).

CONCLUSION

Quitlines served as a resource for low-SES populations in 2019, providing cessation services to many people who may face barriers to clinical cessation treatment. Strengthening and expanding quitlines may help to increase cessation among populations with a disproportionately high prevalence of tobacco product use and improve the health and well-being of people in the US.

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.

Neighborhood Characteristics and the Burden of E-Cigarette, or Vaping, Product Use-Associated Lung Injury: An Ecological Comparison Study

Purpose: E-cigarette, or vaping, product use-associated lung injury (EVALI) is a severe consequence of vaping first described in 2019. Investigating associations between neighborhood-level characteristics and EVALI cases is an important step in identifying at-risk communities to implement future targeted prevention programs. Methods: We retrospectively identified 41 adolescents <19 years hospitalized for treatment for EVALI at Children's Medical Center Dallas from December 2018 to June 2021. Patient ZIP codes were extracted from the electronic medical record and were compared with Dallas area ZIP codes containing no EVALI cases. Socioeconomic status (SES) characteristics were obtained from the 2019 American Community Survey, and they were mapped for ZIP codes using ESRI ArcMap geospatial processing software. A parallel analysis was conducted utilizing data of adolescents hospitalized with appendicitis. Results: Ninety-five percent of our cohort used tetrahydrocannabinol-containing products, and 66% obtained their vaping products from informal sources. EVALI cases were less likely to reside in higher SES ZIP codes as measured by the proportion of the population with at least a high school education (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.92-0.99), access to broadband access (OR: 0.95, 95% CI: 0.91-0.99), and private health insurance (OR: 0.97, 95% CI: 0.95-0.99). Alternatively, they were more likely to reside in lower SES ZIP codes as measured by proportion of the population without any health insurance (OR: 1.07, 95% CI: 1.01-1.12). No neighborhood level low SES characteristics were associated with appendicitis hospitalizations. Conclusions: Although small in magnitude, EVALI cases were associated with lower SES ZIP codes but not with vape shop density.