Culturally specific interventions for African American smokers: an efficacy experiment

Effectiveness of culturally tailoring smoking cessation interventions for reducing or quitting combustible tobacco: A systematic review and meta-analyses

BACKGROUND AND AIMS

Standard approaches to smoking cessation may not be as effective for certain populations, and tailoring on cultural factors could improve their effectiveness. This systematic review measured the effectiveness of culturally tailoring smoking cessation interventions on quitting or reducing smoking combustible tobacco.

METHOD

We searched MEDLINE, PsychInfo, Embase and Cochrane Central Register from inception to 21 June 2023 for randomized controlled trials (RCTs) of community-based, primary care or web-based interventions for smoking cessation in adults who smoked tobacco, with measurement of smoking abstinence or reduction at least 3 months following baseline. We examined comparisons between either an intensity-matched culturally tailored intervention and a non-tailored intervention or a standard non-tailored intervention and the same intervention plus a culturally tailored adjunct. We sub-grouped studies according to the level of tailoring and performed subgroup analyses where appropriate. We assessed risk of bias and certainty of evidence.

RESULTS

We identified 43 studies, 33 of which were meta-analyzed (n = 12 346 participants). We found moderate certainty evidence, limited by heterogeneity, that intensity-matched culturally tailored cessation interventions increased quit success when compared with non-tailored interventions at 3-month follow-up or longer (n = 5602, risk ratio [RR] = 1.29 95% confidence interval [CI] 1.10, 1.51, I2  = 47%, 14 studies). We found a positive effect of adding a culturally tailored component to a standard intervention compared with the standard intervention alone (n = 6674, RR = 1.47, 95% CI 1.10, 1.95, I2  = 74%, 18 studies), but our certainty in this effect was low due to imprecision and substantial statistical heterogeneity.

CONCLUSION

Culturally tailored smoking cessation interventions may help more people to quit smoking than a non-tailored intervention. Adapting or adding cultural components to smoking cessation interventions originally developed for majority populations could improve cessation rates in populations who do not fully identify with majority cultural norms.

Differences in cessation attempts and cessation methods by race/ethnicity among US adult smokers, 2016-2018

BACKGROUND

Advice to quit smoking and cessation patterns vary by race/ethnicity in the United States. This study aims to provide the up-to-date prevalence of quit advice, quit attempts and use of smoking cessation methods (particularly e-cigarettes) by race/ethnicity among US adult smokers.

METHODS

We used data from Wave 4 (2016-2018) of the Population Assessment of Tobacco and Health (PATH) Study. Using past-12-month and current adult cigarette smokers (n = 9,272), we conducted multivariable models to examine the association between race/ethnicity and advice to quit and quit attempts. Further, using a subset of those who made quit attempts (n = 5,046), we examined the use of smoking cessation methods, including e-cigarettes, by race/ethnicity, controlling for associated factors.

RESULTS

Compared to Non-Hispanic [NH] White smokers, Hispanic smokers were less likely to receive quit advice (aPR [95 % CI] = 0.88 [0.78, 1.00]), but more likely to make quit attempts (1.14 [1.06, 1.23]). NH Black smokers (vs. NH Whites) were more likely to receive quit advice (1.06 [1.00, 1.12]) and more likely to make quit attempts (1.22 [1.15, 1.29]). NH Black smokers (vs. NH Whites) were more likely to use behavioral treatment (e.g., counseling) (1.84 [1.22, 2.77]). Hispanic smokers were less likely to use e-cigarettes to quit smoking than Whites (0.48 [0.33, 0.71]) and use pharmacotherapy (0.62 [0.44, 0.88]).

CONCLUSIONS

We found different patterns in cessation attempts and cessation methods by race/ethnicity among US adult smokers. Efforts to eliminate disparities must increase access and use of proven cessation therapies for these groups.

Longitudinal Associations Between Changes in Cigarette Smoking and Alcohol Use, Eating Behavior, Perceived Stress, and Self-Rated Health in a Cohort of Low-Income Black Adults

BACKGROUND

Black adults in the U.S. experience significant health disparities related to tobacco use and obesity. Conducting observational studies of the associations between smoking and other health behaviors and indicators among Black adults may contribute to the development of tailored interventions.

PURPOSE

We examined associations between change in cigarette smoking and alcohol use, body mass index, eating behavior, perceived stress, and self-rated health in a cohort of Black adults who resided in low-income urban neighborhoods and participated in an ongoing longitudinal study.

METHODS

Interviews were conducted in 2011, 2014, and 2018; participants (N = 904) provided at least two waves of data. We fit linear and logistic mixed-effects models to evaluate how changes in smoking status from the previous wave to the subsequent wave were related to each outcome at that subsequent wave.

RESULTS

Compared to repeated smoking (smoking at previous and subsequent wave), repeated nonsmoking (nonsmoking at previous and subsequent wave) was associated with greater likelihood of recent dieting (OR = 1.59, 95% CI [1.13, 2.23], p = .007) and future intention (OR = 2.19, 95% CI [1.61, 2.98], p < .001) and self-efficacy (OR = 1.64, 95% CI [1.21, 2.23], p = .002) to eat low calorie foods, and greater odds of excellent or very good self-rated health (OR = 2.47, 95% CI [1.53, 3.99], p < .001). Transitioning from smoking to nonsmoking was associated with greater self-efficacy to eat low calorie foods (OR = 1.89, 95% CI [1.1, 3.26], p = .021), and lower perceived stress (β = -0.69, 95% CI [-1.34, -0.05], p = .036).

CONCLUSIONS

We found significant longitudinal associations between smoking behavior and eating behavior, perceived stress, and self-rated health. These findings have implications for the development of multiple behavior change programs and community-level interventions and policies.

Targeted Truth: An Experiment Testing the Efficacy of Counterindustry Tobacco Advertisements Targeted to Black Individuals and Sexual and Gender Minority Individuals

INTRODUCTION

Some groups disproportionately suffer from tobacco-related illnesses-in part, because the tobacco industry has strategically targeted these groups. To combat industry targeting, antitobacco media campaigns (eg, the truth campaign) have used analogous messaging strategies, describing the industry's targeted marketing practices to reach these vulnerable groups. We tested the efficacy of counterindustry tobacco advertisements targeted to vulnerable groups (Black individuals and sexual and gender minority [SGM] individuals).

AIMS AND METHODS

From March to July 2020, we recruited N = 1161 young adults in the United States, including n = 430 Black young adults and n = 452 SGM young adults (with n = 108 identifying as Black and SGM). In a web-based, between-subjects experiment, participants were randomized to watch one of four types of advertisement ("ad"): (1) ads from the truth antismoking campaign not targeted toward a specific vulnerable group, (2) Black-targeted truth ads, (3) SGM-targeted truth ads, or (4) unrelated control ads. We examined effects on support for tobacco control policies, counterindustry motivation, counterindustry beliefs, perceived effectiveness, and anger toward the industry.

RESULTS

Relative to control, non-targeted ads increased policy support, and Black-targeted ads increased motivation and beliefs. Targeted ads elicited anger regardless of the audience targeted. However, in general, neither Black identity nor SGM identity moderated the effects of the targeted ads.

CONCLUSIONS

We offer little evidence that targeted counterindustry ads are especially influential for their intended group. However, targeted counterindustry appeals may be successful at evoking industry anger regardless of the audience targeted.

IMPLICATIONS

Counterindustry advertisements from the truth campaign targeting Black individuals and SGM individuals had limited effect on tobacco control policies, counterindustry motivation, and counterindustry beliefs. However, counterindustry ads evoked anger toward the industry regardless of ingroup status, which in turn was positively associated with anti-industry outcomes. These results, considered alongside the extant literature, suggest little benefit to developing targeted counterindustry tobacco campaigns for specific groups and instead point to the utility of developing campaigns that appeal to broader audiences.

Print-based self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials that provide a structured programme for smokers to follow may increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine the effectiveness of different forms of print-based self-help materials that provide a structured programme for smokers to follow, compared with no treatment and with other minimal contact strategies, and to determine the comparative effectiveness of different components and characteristics of print-based self-help, such as computer-generated feedback, additional materials, tailoring of materials to individuals, and targeting of materials at specific groups.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Trials Register, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The date of the most recent search was March 2018.

SELECTION CRITERIA

We included randomised trials of smoking cessation with follow-up of at least six months, where at least one arm tested print-based materials providing self-help compared with minimal print-based self-help (such as a short leaflet) or a lower-intensity control. We defined 'self-help' as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in accordance with standard methodological procedures set out by Cochrane. The main outcome measure was abstinence from smoking after at least six months' follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each study and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a random-effects model.

MAIN RESULTS

We identified 75 studies that met our inclusion criteria. Many study reports did not include sufficient detail to allow judgement of risk of bias for some domains. We judged 30 studies (40%) to be at high risk of bias for one or more domains.Thirty-five studies evaluated the effects of standard, non-tailored self-help materials. Eleven studies compared self-help materials alone with no intervention and found a small effect in favour of the intervention (n = 13,241; risk ratio (RR) 1.19, 95% confidence interval (CI) 1.03 to 1.37; I² = 0%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for indirect relevance to populations in low- and middle-income countries because evidence for this comparison came from studies conducted solely in high-income countries and there is reason to believe the intervention might work differently in low- and middle-income countries. This analysis excluded two studies by the same author team with strongly positive outcomes that were clear outliers and introduced significant heterogeneity. Six further studies of structured self-help compared with brief leaflets did not show evidence of an effect of self-help materials on smoking cessation (n = 7023; RR 0.87, 95% CI 0.71 to 1.07; I² = 21%). We found evidence of benefit from standard self-help materials when there was brief contact that did not include smoking cessation advice (4 studies; n = 2822; RR 1.39, 95% CI 1.03 to 1.88; I² = 0%), but not when self-help was provided as an adjunct to face-to-face smoking cessation advice for all participants (11 studies; n = 5365; RR 0.99, 95% CI 0.76 to 1.28; I² = 32%).Thirty-two studies tested materials tailored for the characteristics of individual smokers, with controls receiving no materials, or stage-matched or non-tailored materials. Most of these studies used more than one mailing. Pooling studies that compared tailored self-help with no self-help, either on its own or compared with advice, or as an adjunct to advice, showed a benefit of providing tailored self-help interventions (12 studies; n = 19,190; RR 1.34, 95% CI 1.20 to 1.49; I² = 0%) with little evidence of difference between subgroups (10 studies compared tailored with no materials, n = 14,359; RR 1.34, 95% CI 1.19 to 1.51; I² = 0%; two studies compared tailored materials with brief advice, n = 2992; RR 1.13, 95% CI 0.86 to 1.49; I² = 0%; and two studies evaluated tailored materials as an adjunct to brief advice, n = 1839; RR 1.72, 95% CI 1.17 to 2.53; I² = 10%). When studies compared tailored self-help with non-tailored self-help, results favoured tailored interventions when the tailored interventions involved more mailings than the non-tailored interventions (9 studies; n = 14,166; RR 1.42, 95% CI 1.20 to 1.68; I² = 0%), but not when the two conditions were contact-matched (10 studies; n = 11,024; RR 1.07, 95% CI 0.89 to 1.30; I² = 50%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for risk of bias.Five studies evaluated self-help materials as an adjunct to nicotine replacement therapy; pooling three of these provided no evidence of additional benefit (n = 1769; RR 1.05, 95% CI 0.86 to 1.30; I² = 0%). Four studies evaluating additional written materials favoured the intervention, but the lower confidence interval crossed the line of no effect (RR 1.20, 95% CI 0.91 to 1.58; I² = 73%). A small number of other studies did not detect benefit from using targeted materials, or find differences between different self-help programmes.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that when no other support is available, written self-help materials help more people to stop smoking than no intervention. When people receive advice from a health professional or are using nicotine replacement therapy, there is no evidence that self-help materials add to their effect. However, small benefits cannot be excluded. Moderate-certainty evidence shows that self-help materials that use data from participants to tailor the nature of the advice or support given are more effective than no intervention. However, when tailored self-help materials, which typically involve repeated assessment and mailing, were compared with untailored materials delivered similarly, there was no evidence of benefit.Available evidence tested self-help interventions in high-income countries, where more intensive support is often available. Further research is needed to investigate effects of these interventions in low- and middle-income countries, where more intensive support may not be available.

A scoping review and meta-analysis of psychosocial and pharmacological treatments for cannabis and tobacco use among African Americans

The rates of co-occurring cannabis and tobacco use are higher among African Americans relative to other racial/ethnic groups. One plausible approach to treating co-use among African Americans is to examine the effectiveness of treatments for the sole use of cannabis and tobacco to identify effective approaches that might be combined to treat the dual use of these substances. The current meta-analysis sought to include studies that reported cannabis and/or tobacco use outcomes from randomized clinical trials (RCTs) with 100% African American samples. A total of 843 articles were considered for inclusion, 29 were reviewed by independent qualitative coders, and 22 were included in the review. There were no articles on cannabis use treatment with a 100% African American sample, resulting in a need to lower the threshold (60%) and conduct a scoping review of cannabis studies. Preliminary evidence from a small number of studies (k = 7) supports the use of Motivational Interviewing and Cognitive-Behavioral Therapy to treat cannabis use among African Americans, but not Contingency Management. Results from a meta-analysis of 15 tobacco studies found higher rates of smoking abstinence in the treatment condition relative to control conditions overall and across short and long-term follow-up periods. Significant differences in smoking abstinence were also found when examining the effects of pharmacological treatments relative to their control conditions. The clinical and research implications of these findings for future psychosocial and pharmacological trials for cannabis and tobacco use and co-use among African Americans are described. (PsycINFO Database Record

Effects of a culturally specific tobacco cessation intervention among African American Quitline enrollees: a randomized controlled trial

BACKGROUND

African Americans suffer disproportionately from tobacco-related illness and have more difficulty quitting smoking than other racial/ethnic groups. Previous research indicates that African American treatment-seekers are high utilizers of tobacco quitlines, yet cessation rates via quitlines are lower relative to whites. The goal of the present study is to test the effectiveness of adding a culturally specific, video-based, adjunct to standard quitline care. It is hypothesized that the integration of an evidence-based intervention (Pathways to Freedom: Leading the Way to a Smoke-Free Community©; PTF) into quitline services will increase cessation and treatment engagement compared to control conditions, and that effects will be moderated by sociocultural factors (e.g., culturally specific intervention expectancies, acculturation, and ethnic identity).

METHODS

This study is a 3-arm semi-pragmatic randomized controlled trial (RCT). Participants will be 1050 enrollees in the North Carolina State quitline (QuitlineNC) who self-identify as African American. Usual quitline care includes up to 4 proactive quit coaching calls, website access, and two-weeks of nicotine patch therapy. Eligible study participants will be randomized to receive (1) standard quitline services plus PTF (PTF); (2) quitline services plus a standard tobacco cessation DVD (attention control); or (3) quitline services alone (usual care). Assessments will be conducted at baseline, 3 and 6-months post-enrollment. The primary outcome will be biochemically verified 7 day ppa at 6-months. Generalized linear mixed models (GLMMs) and hierarchical logistic regression will be used to assess the effects of treatment group on cessation outcomes and to test potential moderators.

DISCUSSION

This study will answer questions regarding the implementation and effectiveness of integrating a culturally specific video intervention into a real-world, population-level tobacco intervention. It will also aid our understanding of individual-difference variables that are associated with success. If an incremental benefit is found, this trial will have implications for increasing the responsiveness of tobacco quitlines for African Americans, reducing tobacco cessation disparities, and best practices for improving minority health. In addition, the PTF intervention has the potential for widespread disseminated through quitlines, which are available across the United States.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03064971 . Registered on February 22, 2017.

Mass media interventions for smoking cessation in adults

BACKGROUND

Mass media tobacco control campaigns can reach large numbers of people. Much of the literature is focused on the effects of tobacco control advertising on young people, but there are also a number of evaluations of campaigns targeting adult smokers, which show mixed results. Campaigns may be local, regional or national, and may be combined with other components of a comprehensive tobacco control policy.

OBJECTIVES

To assess the effectiveness of mass media interventions in reducing smoking among adults.

SEARCH METHODS

The Cochrane Tobacco Addiction Group search strategy was combined with additional searches for any studies that referred to tobacco/smoking cessation, mass media and adults. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) and a number of electronic databases. The last search was carried out in November 2016.

SELECTION CRITERIA

Controlled trials allocating communities, regions or states to intervention or control conditions; interrupted time series.Adults, 25 years or older, who regularly smoke cigarettes. Studies which cover all adults as defined in studies were included.Mass media are defined here as channels of communication such as television, radio, newspapers, billboards, posters, leaflets or booklets intended to reach large numbers of people, and which are not dependent on person-to-person contact. The purpose of the mass media campaign must be primarily to encourage smokers to quit. They could be carried out alone or in conjunction with tobacco control programmes.The primary outcome was change in smoking behaviour. This could be reported as changes in prevalence, changes in cigarette consumption, quit rates, or odds of being a smoker.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed all studies for inclusion criteria and for study quality (MB, LS, RTM). One author (MB) extracted data, and a second author (LS) checked them.Results were not pooled due to heterogeneity of the included studies and are presented narratively and in table form.

MAIN RESULTS

Eleven campaigns met the inclusion criteria for this review. Studies differed in design, settings, duration, content and intensity of intervention, length of follow-up, methods of evaluation and also in definitions and measures of smoking behaviour used. Among seven campaigns reporting smoking prevalence, significant decreases were observed in the California and Massachusetts statewide tobacco control campaigns compared with the rest of the USA. Some positive effects on prevalence in the whole population or in the subgroups were observed in three of the remaining seven studies. Three large-scale campaigns of the seven presenting results for tobacco consumption found statistically significant decreases. Among the eight studies presenting abstinence or quit rates, four showed some positive effect, although in one of them the effect was measured for quitting and cutting down combined. Among the three that did not show significant decreases, one demonstrated a significant intervention effect on smokers and ex-smokers combined.

AUTHORS' CONCLUSIONS

There is evidence that comprehensive tobacco control programmes which include mass media campaigns can be effective in changing smoking behaviour in adults, but the evidence comes from a heterogeneous group of studies of variable methodological quality. One state-wide tobacco control programme (Massachusetts) showed positive results up to eight years after the campaign. Another (California) showed positive results during the period of adequate funding and implementation and in final evaluation since the beginning of the programme. Six of nine studies carried out in communities or regions showed some positive effects on smoking behaviour and at least one significant change in smoking prevalence (Sydney). The intensity and duration of mass media campaigns may influence effectiveness, but length of follow-up and concurrent secular trends and events can make this difficult to quantify. No consistent relationship was observed between campaign effectiveness and age, education, ethnicity or gender.

Randomized Controlled Trial of Group-Based Culturally Specific Cognitive Behavioral Therapy Among African American Smokers

Introduction

This study tested the efficacy of group-based culturally specific cognitive behavioral therapy (CBT) for smoking cessation among low-income African Americans.

Methods

Participants (N = 342; 63.8% male; M = 49.5 years old; M cigarettes per day = 18) were randomly assigned to eight sessions of group-based culturally specific or standard CBT, plus 8 weeks of transdermal nicotine patches. Biochemically verified 7-day point prevalence abstinence (ppa) was assessed at the end-of-therapy (ie, CBT) (EOT), and 3-, 6-, and 12-month follow-ups. Primary outcomes were the longitudinal intervention effect over the 12-month follow-up period, and 7-day ppa at the 6-month follow-up. Secondary outcomes included 7-day ppa at the EOT and 12-month follow-up, and intervention ratings. Generalized linear mixed modeling tested the longitudinal effect and logistic regression tested effects at specific timepoints.

Results

Generalized linear mixed modeling demonstrated a longitudinal effect of intervention condition. Specifically, 7-day ppa was two times (P = .02) greater following culturally specific CBT versus standard CBT when tested across all timepoints. Analyses by timepoint found no significant difference at 6 or 12 months, yet culturally specific CBT was efficacious at the EOT (62.5% vs. 51.5% abstinence, P = .05) and the 3-month follow-up (36.4% vs. 22.9% abstinence, P = .007). Finally, intervention ratings in both conditions were high, with no significant differences.

Conclusions

Culturally specific CBT had a positive longitudinal effect on smoking cessation compared to a standard approach; however, the effects were driven by short-term successes. We recommend the use of group-based culturally specific CBT in this population when possible, and future research on methods to prevent long-term relapse.

Implications

Culturally specific interventions are one approach to address smoking-related health disparities; however, evidence for their efficacy in African Americans is equivocal. Moreover, the methodological limitations of the existing literature preclude an answer to this fundamental question. We found a positive longitudinal effect of culturally specific CBT versus standard CBT for smoking cessation across the follow-up period. Analyses by assessment point revealed that the overall effect was driven by early successes. Best practices for treating tobacco use in this population should attend to ethnocultural factors, but when this is not possible, standard CBT is an alternative approach for facilitating long-term abstinence.

Targeted mass media interventions promoting healthy behaviours to reduce risk of non-communicable diseases in adult, ethnic minorities

BACKGROUND

Physical activity, a balanced diet, avoidance of tobacco exposure, and limited alcohol consumption may reduce morbidity and mortality from non-communicable diseases (NCDs). Mass media interventions are commonly used to encourage healthier behaviours in population groups. It is unclear whether targeted mass media interventions for ethnic minority groups are more or less effective in changing behaviours than those developed for the general population.

OBJECTIVES

To determine the effects of mass media interventions targeting adult ethnic minorities with messages about physical activity, dietary patterns, tobacco use or alcohol consumption to reduce the risk of NCDs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, ERIC, SweMed+, and ISI Web of Science until August 2016. We also searched for grey literature in OpenGrey, Grey Literature Report, Eldis, and two relevant websites until October 2016. The searches were not restricted by language.

SELECTION CRITERIA

We searched for individual and cluster-randomised controlled trials, controlled before-and-after studies (CBA) and interrupted time series studies (ITS). Relevant interventions promoted healthier behaviours related to physical activity, dietary patterns, tobacco use or alcohol consumption; were disseminated via mass media channels; and targeted ethnic minority groups. The population of interest comprised adults (≥ 18 years) from ethnic minority groups in the focal countries. Primary outcomes included indicators of behavioural change, self-reported behavioural change and knowledge and attitudes towards change. Secondary outcomes were the use of health promotion services and costs related to the project.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the references to identify studies for inclusion. We extracted data and assessed the risk of bias in all included studies. We did not pool the results due to heterogeneity in comparisons made, outcomes, and study designs. We describe the results narratively and present them in 'Summary of findings' tables. We judged the quality of the evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology.

MAIN RESULTS

Six studies met the inclusion criteria, including three RCTs, two cluster-RCTs and one ITS. All were conducted in the USA and comprised targeted mass media interventions for people of African descent (four studies), Spanish-language dominant Latino immigrants (one study), and Chinese immigrants (one study). The two latter studies offered the intervention in the participants' first language (Spanish, Cantonese, or Mandarin). Three interventions targeted towards women only, one pregnant women specifically. We judged all studies as being at unclear risk of bias in at least one domain and three studies as being at high risk of bias in at least one domain.We categorised the findings into three comparisons. The first comparison examined mass media interventions targeted at ethnic minorities versus an equivalent mass media intervention intended for the general population. The one study in this category (255 participants of African decent) found little or no difference in effect on self-reported behavioural change for smoking and only small differences in attitudes to change between participants who were given a culturally specific smoking cessation booklet versus a booklet intended for the general population. We are uncertain about the effect estimates, as assessed by the GRADE methodology (very low quality evidence of effect). No study provided data for indicators of behavioural change or adverse effects.The second comparison assessed targeted mass media interventions versus no intervention. One study (154 participants of African decent) reported effects for our primary outcomes. Participants in the intervention group had access to 12 one-hour live programmes on cable TV and received print material over three months regarding nutrition and physical activity to improve health and weight control. Change in body mass index (BMI) was comparable between groups 12 months after the baseline (low quality evidence). Scores on a food habits (fat behaviours) and total leisure activity scores changed favourably for the intervention group (very low quality evidence). Two other studies exposed entire populations in geographical areas to radio advertisements targeted towards African American communities. Authors presented effects on two of our secondary outcomes, use of health promotion services and project costs. The campaign message was to call smoking quit lines. The outcome was the number of calls received. After one year, one study reported 18 calls per estimated 10,000 targeted smokers from the intervention communities (estimated target population 310,500 persons), compared to 0.2 calls per estimated 10,000 targeted smokers from the control communities (estimated target population 331,400 persons) (moderate quality evidence). The ITS study also reported an increase in the number of calls from the target population during campaigns (low quality evidence). The proportion of African American callers increased in both studies (low to very low quality evidence). No study provided data on knowledge and attitudes for change and adverse effects. Information on costs were sparse.The third comparison assessed targeted mass media interventions versus a mass media intervention plus personalised content. Findings are based on three studies (1361 participants). Participants in these comparison groups received personal feedback. Two of the studies recorded weight changes over time. Neither found significant differences between the groups (low quality evidence). Evidence on behavioural changes, and knowledge and attitudes typically found some effects in favour of receiving personalised content or no significant differences between groups (very low quality evidence). No study provided data on adverse effects. Information on costs were sparse.

AUTHORS' CONCLUSIONS

The available evidence is inadequate for understanding whether mass media interventions targeted toward ethnic minority populations are more effective in changing health behaviours than mass media interventions intended for the population at large. When compared to no intervention, a targeted mass media intervention may increase the number of calls to smoking quit line, but the effect on health behaviours is unclear. These studies could not distinguish the impact of different components, for instance the effect of hearing a message regarding behavioural change, the cultural adaptation to the ethnic minority group, or increase reach to the target group through more appropriate mass media channels. New studies should explore targeted interventions for ethnic minorities with a first language other than the dominant language in their resident country, as well as directly compare targeted versus general population mass media interventions.

Cultural adaptations to augment health and mental health services: a systematic review

BACKGROUND

Membership in diverse racial, ethnic, and cultural groups is often associated with inequitable health and mental health outcomes for diverse populations. Yet, little is known about how cultural adaptations of standard services affect health and mental health outcomes for service recipients. This systematic review identified extant themes in the research regarding cultural adaptations across a broad range of health and mental health services and synthesized the most rigorous experimental research available to isolate and evaluate potential efficacy gains of cultural adaptations to service delivery.

METHODS

MEDLINE, PsycINFO, CINAHL, EMBASE, and grey literature sources were searched for English-language studies published between January 1955 and January 2015. Cultural adaptations to any aspect of a service delivery were considered. Outcomes of interest included changes in service provider behavior or changes in the behavioral, medical, or self-reported experience of recipients.

RESULTS

Thirty-one studies met the inclusion criteria. The most frequently tested adaptation occurred in preventive services and consisted of modifying the content of materials or services delivered. None of the included studies focused on making changes in the provider's behavior. Many different populations were studied but most research was concerned with the experiences and outcomes of African Americans. Seventeen of the 31 retained studies observed at least one significant effect in favor of a culturally adapted service. However there were also findings that favored the control group or showed no difference. Researchers did not find consistent evidence supporting implementation of any specific type of adaptation nor increased efficacy with any particular cultural group.

CONCLUSIONS

Conceptual frameworks to classify cultural adaptations and their resultant health/mental health outcomes were developed and applied in a variety of ways. This review synthesizes the most rigorous research in the field and identifies implications for policy, practice, and research, including individualization, cost considerations, and patient or client satisfaction, among others.

Tobacco-Related Health Disparities Across the Cancer Care Continuum

BACKGROUND

Use of tobacco is the leading preventable cause of death in the United States. Racial/ethnic minorities and individuals of low socioeconomic status disproportionately experience tobacco-related disease and illness. Unique challenges and circumstances exist at each point in the cancer care continuum that may contribute to the greater cancer burden experienced by these groups.

METHODS

We reviewed tobacco-related disparities from cancer prevention to cancer survivorship. We also describe research that seeks to reduce tobacco-related disparities.

RESULTS

Racial/ethnic minorities and low-income individuals experience unique social and environmental contextual challenges such as greater environmental cues to smoke and greater levels of perceived stress and social discrimination. Clinical practice guidelines support the effectiveness of pharmacotherapy and behavioral counseling for racial and ethnic minorities, yet smoking cessation rates are lower in this group when compared with non-Hispanic whites. Superior efficacy for culturally adapted interventions has not yet been established.

CONCLUSIONS

To reduce health disparities in this population, a comprehensive strategy is needed with efforts directed at each point along the cancer care continuum. Strategies are needed to reduce the impact of contextual factors such as targeted tobacco marketing and social discrimination on smoking initiation and maintenance. Future efforts should focus on increasing the use of evidence-based cessation treatment methods and studying its effectiveness in these populations. Attention must also be focused on improving treatment outcomes by reducing smoking in diverse racial and ethnic patient populations.

Barriers and motivators to reducing secondhand smoke exposure in African American families of head start children: a qualitative study

OBJECTIVE

To identify barriers and motivators for reducing secondhand smoke exposure (SHSe) for families of African-American, low-income, urban children.

METHOD

Audiotaped intervention sessions of 52 African-American caregivers of Head Start children who reported being a smoker and/or had at least one smoker in the home were randomly sampled from a larger trial examining the effectiveness of a motivational-interviewing intervention in reducing child's SHSe. Counseling sessions were qualitatively coded to identify barriers and motivators to implementing a home smoking ban or quitting smoking.

RESULTS

African-American families identified several themes that were either or both barriers and motivators for SHSe reduction, including: asking others not to smoke, other family living in the home, neighborhood safety, absence of childcare, cost/availability of cessation tools, physician support and prevention of health problems.

DISCUSSION

Urban, low-income African-American families face numerous barriers to reducing SHSe. Families were able to identify many motivators for reducing SHSe, suggesting an awareness of the importance for SHSe reduction but uncertainty in their confidence to change behaviors. Counseling should include tailoring to be most effective in supporting health behavior change. Greater emphasis on motivators is needed, such as low-cost/free cessation tools, engagement from physicians and greater involvement of extended family members.

The Process of Adapting the Evidence-Based Treatment for Tobacco Dependence for Smokers of Lower Socioeconomic Status

INTRODUCTION

Tobacco use is the leading cause of preventable death and disease and contributes significantly to socioeconomic health disparities. The prevalence of smoking among individuals of lower socioeconomic status (SES) in the US, many of whom are African American (AA), is three to four times greater than the prevalence of smoking among individuals of higher SES. The disparity in tobacco dependence treatment outcomes between lower and higher SES smokers contributes to tobacco-related health disparities and calls for adapting evidence-based treatment to more fully meet the needs of lower SES smokers.

AIMS

We sought to adapt the evidence-based treatment for tobacco dependence using recommended frameworks for adapting evidence-based treatments.

METHODS

We systematically applied the recommended steps for adapting evidence-based treatments described by Barrera and Castro and Lau. The steps included information gathering, preliminary adaptation design, preliminary adaptation tests, and adaptation refinement. We also applied the PEN-3 Model for incorporating AA values and experiences into treatment approaches and a community-engaged approach.

RESULTS/FINDINGS

Findings from each step in the process contributed to the results. The final results were incorporated into a revised treatment called the RITCh Study Tobacco Dependence Treatment Manual and Toolkit.

CONCLUSIONS

To our knowledge, this is the first adaptation of evidence-based treatment for tobacco dependence that has systematically applied these recommended frameworks. The efficacy of the treatment to reduce treatment outcome disparities is now being examined in a randomized controlled trial in which the revised treatment is being compared with a standard, individualized cognitive-behavioral approach.

Targeting cancer information to African Americans: the trouble with talking about disparities

Cancer messages that are designed for African Americans often include information on Black-White cancer disparities to raise Black adults' perceived cancer risk and increase cancer screening. Whether disparities messages achieve this, and how Blacks feel about hearing that they are worse off than are Whites, largely remain unknown. This study examined Blacks' responses to two mock newspaper articles on colorectal cancer: a disparities article and a nondisparities article. A random sample of 400 Black adults read the articles and answered questions on their reactions to both. Results revealed that readers of the disparities article felt significantly more insulted, discouraged, and angry about it than did readers of the nondisparities article. Article type played no role in desires or intentions to have colon cancer screening among participants of screening age, and no role in perceived cancer risk or intentions to suggest colon cancer screening to family among participants of any age. These findings suggest that disparities messages might not increase perceived cancer risk or increase interest in cancer screening as widely theorized and intended; instead, they simply may elicit anger and discouragement among African Americans.

Sociocultural correlates of cigarette smoking among African-American men versus women: Implications for culturally specific cessation interventions

Low socioeconomic status, racial discrimination, and low acculturation are the major sociocultural correlates of smoking among African-American adults. This study is the first to examine all three variables simultaneously and to analyze gender differences in their association with smoking. Results for the sample revealed that low education and low acculturation predicted smoking but racial discrimination did not. For women, low acculturation was the sole predictor of smoking, whereas for men, socioeconomic status variables were the sole predictors. This suggests that low acculturation may be associated with smoking among African-American women only. Hence, culturally specific smoking cessation programs designed for low-acculturated African-Americans might be effective for African-American women alone.

Print-based self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials giving advice and information may help them and increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine: the effectiveness of different forms of print-based self-help materials, compared with no treatment and with other minimal contact strategies; the effectiveness of adjuncts to print-based self help, such as computer-generated feedback, telephone hotlines and pharmacotherapy; and the effectiveness of approaches tailored to the individual compared with non-tailored materials.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register. Date of the most recent search April 2014.

SELECTION CRITERIA

We included randomized trials of smoking cessation with follow-up of at least six months, where at least one arm tested a print-based self-help intervention. We defined self help as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the participants, the nature of the self-help materials, the amount of face-to-face contact given to intervention and to control conditions, outcome measures, method of randomization, and completeness of follow-up.The main outcome measure was abstinence from smoking after at least six months follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a fixed-effect model.

MAIN RESULTS

We identified 74 trials which met the inclusion criteria. Many study reports did not include sufficient detail to judge risk of bias for some domains. Twenty-eight studies (38%) were judged at high risk of bias for one or more domains but the overall risk of bias across all included studies was judged to be moderate, and unlikely to alter the conclusions.Thirty-four trials evaluated the effect of standard, non-tailored self-help materials. Pooling 11 of these trials in which there was no face-to-face contact and provision of structured self-help materials was compared to no intervention gave an estimate of benefit that just reached statistical significance (n = 13,241, risk ratio [RR] 1.19, 95% confidence interval [CI] 1.04 to 1.37). This analysis excluded two trials with strongly positive outcomes that introduced significant heterogeneity. Six further trials without face-to-face contact in which the control group received alternative written materials did not show evidence for an effect of the smoking self-help materials (n = 7023, RR 0.88, 95% CI 0.74 to 1.04). When these two subgroups were pooled, there was no longer evidence for a benefit of standard structured materials (n = 20,264, RR 1.06, 95% CI 0.95 to 1.18). We failed to find evidence of benefit from providing standard self-help materials when there was brief contact with all participants (5 trials, n = 3866, RR 1.17, 95% CI 0.96 to 1.42), or face-to-face advice for all participants (11 trials, n = 5365, RR 0.97, 95% CI 0.80 to 1.18).Thirty-one trials offered materials tailored for the characteristics of individual smokers, with controls receiving either no materials, or stage matched or non-tailored materials. Most of the trials used more than one mailing. Pooling these showed a benefit of tailored materials (n = 40,890, RR 1.28, 95% CI 1.18 to 1.37) with moderate heterogeneity (I² = 32%). The evidence is strongest for the subgroup of nine trials in which tailored materials were compared to no intervention (n = 13,437, RR 1.35, 95% CI 1.19 to 1.53), but also supports tailored materials as more helpful than standard materials. Part of this effect could be due to the additional contact or assessment required to obtain individual data, since the subgroup of 10 trials where the number of contacts was matched did not detect an effect (n = 11,024, RR 1.06, 95% CI 0.94 to 1.20). In two trials including a direct comparison between tailored materials and brief advice from a health care provider, there was no evidence of a difference, but confidence intervals were wide (n = 2992, RR 1.13, 95% CI 0.86 to 1.49).Only four studies evaluated self-help materials as an adjunct to nicotine replacement therapy, with no evidence of additional benefit (n = 2291, RR 1.05, 95% CI 0.88 to 1.25). A small number of other trials failed to detect benefits from using additional materials or targeted materials, or to find differences between different self-help programmes.

AUTHORS' CONCLUSIONS

Standard, print-based self-help materials increase quit rates compared to no intervention, but the effect is likely to be small. We did not find evidence that they have an additional benefit when used alongside other interventions such as advice from a healthcare professional, or nicotine replacement therapy. There is evidence that materials that are tailored for individual smokers are more effective than non-tailored materials, although the absolute size of effect is still small. Available evidence tested self-help interventions in high income countries; further research is needed to investigate their effect in contexts where more intensive support is not available.

Efficacy of a DVD-based smoking cessation intervention for African Americans

INTRODUCTION

Previous research suggests that African American smokers may have improved outcomes if interventions are culturally specific. However, few interventions sufficiently address the unique needs of this population in a format with large reach potential. The purpose of this study was to test the efficacy of a newly developed digital video disc (DVD)-based cessation intervention targeting African Americans.

METHODS

In a 2-arm randomized trial, smokers (N = 140) were randomly assigned to view either the new Pathways to Freedom (PTF) DVD or a standard control DVD. Participants were assessed at baseline, immediately postviewing the DVD, and at a 1-month follow-up. The primary outcomes were feasibility and process variables, including intervention evaluations, readiness to quit, and risk perceptions, and smoking-related behavior changes were examined as secondary outcomes.

RESULTS

Findings demonstrated the hypothesized positive effects of the PTF DVD compared with the control DVD on content evaluations, risk perceptions, and readiness to quit at follow-up.

CONCLUSIONS

We found initial evidence for the efficacy of the PTF DVD as a stand-alone intervention. Future research will test the efficacy of the DVD for smoking cessation in a larger randomized trial. The ultimate goal of this research is to validate a new intervention for an underserved community of smokers that can be used in multiple settings, such as community health clinics, primary care, quitlines, cessation clinics, and seminars/workshops.

Smoking cessation interventions for ethnic minority groups--a systematic review of adapted interventions

OBJECTIVE

Existing smoking cessation interventions tend to be under utilized by ethnic minority groups. We sought to identify smoking cessation interventions that have been adapted to meet the needs of African-, Chinese- and South Asian-origin populations, to increase understanding of the approaches used to promote behavior change, to assess their acceptability to the target populations, and to evaluate their effectiveness.

METHODS

Two reviewers independently searched for, identified, critically appraised and extracted data from studies identified from 11 databases (January 1950-April 2013). Study quality was assessed using validated instruments (EPHPP and STROBE). Adaptations were independently coded using an established typology, and findings descriptively summarized and thematically synthesized.

RESULTS

23 studies described interventions adapted for African-Americans, and five for Chinese-origin populations. No intervention adapted for South-Asian populations was identified. Six studies directly compared a culturally adapted versus a non-adapted intervention. Adapted interventions were more acceptable to ethnic minority groups, but this did not translate into improvements in smoking cessation outcomes.

CONCLUSIONS

Given the evidence of greater acceptability of adapted interventions, it may be ethically preferable to use these. There is, however, no clear evidence of the effectiveness of adapted interventions in promoting smoking cessation in ethnic minority groups.

Culturally specific versus standard group cognitive behavioral therapy for smoking cessation among African Americans: an RCT protocol

BACKGROUND

African American smokers experience disproportionately higher rates of tobacco-related illnesses compared to Caucasians. It has been suggested that interventions targeted to specific racial/ethnic groups (i.e., culturally specific) are needed; however, the literature examining the efficacy of culturally specific interventions is equivocal. Moreover, there are few descriptions of methods used to create these interventions. The main aim of this study is to test the efficacy of a culturally specific smoking cessation intervention among African Americans.

METHODS/DESIGN

A 2-arm randomized controlled trial (RCT) will be conducted to assess the efficacy of a culturally specific group cognitive behavioral therapy (CBT), compared to standard group CBT among treatment-seeking smokers from the community. Participants in both conditions receive the transdermal nicotine patch (TNP) for 8-weeks. We intend to randomize at least 247 adult smokers who self-identify as African American into the trial. Enrolled participants are block randomized into one of two groups: Standard group CBT (control) or a culturally specific group CBT (CS-CBT). Groups are matched for time and attention, and consist of eight sessions. The primary outcome variable is 7-day point prevalence abstinence (7-day ppa). Smoking status is assessed at the end-of-counseling (EOC), and 3, 6, and 12-month follow-ups, with self-reported abstinence verified by saliva cotinine. We hypothesize that the CS-CBT condition will produce significantly greater smoking cessation rates compared to the control condition. We also expect that this effect will be moderated by acculturation and ethnic identity, such that the CS-CBT will show the greatest effect on cessation among participants who are less acculturated and have greater ethnic identity.

DISCUSSION

Answering the fundamental question of whether culturally specific interventions lead to incremental efficacy over established, evidence-based approaches is of utmost importance. This study will have implications for the development and implementation of smoking cessation interventions among African Americans and other racial/ethnic minority groups.

TRIAL REGISTRATION

NCT01811758.

Mass media interventions for smoking cessation in adults

BACKGROUND

Mass media tobacco control campaigns can reach large numbers of people. Much of the literature is focused on the effects of tobacco control advertising on young people, but there are also a number of evaluations of campaigns targeting adult smokers, which show mixed results. Campaigns may be local, regional or national, and may be combined with other components of a comprehensive tobacco control policy.

OBJECTIVES

To assess the effectiveness of mass media interventions in reducing smoking among adults.

SEARCH METHODS

The Cochrane Tobacco Addiction Group search strategy was combined with additional searches for any studies that referred to tobacco/smoking cessation, mass media and adults. We also searched the Cochrane Register of Controlled Trials (CENTRAL) and a number of electronic databases. The last search was carried out in February 2013.

SELECTION CRITERIA

Controlled trials allocating communities, regions or states to intervention or control conditions; interrupted time series. Adults, 25 years or older, who regularly smoke cigarettes. Studies which cover all adults as defined in studies were included. Mass media are defined here as channels of communication such as television, radio, newspapers, billboards, posters, leaflets or booklets intended to reach large numbers of people, and which are not dependent on person-to-person contact. The purpose of the mass media campaign must be primarily to encourage smokers to quit. They could be carried out alone or in conjunction with tobacco control programmes. The primary outcome was change in smoking behaviour. This could be reported as changes in prevalence, changes in cigarette consumption, quit rates, odds of being a smoker.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed all studies for inclusion criteria and for study quality. One author (MB) extracted data, and a second author (LS) checked them.Results were not pooled due to heterogeneity of the included studies and are presented narratively and in table form.

MAIN RESULTS

Eleven campaigns met the inclusion criteria for this review. Studies differed in design, settings, duration, content and intensity of intervention, length of follow-up, methods of evaluation and also in definitions and measures of smoking behaviour used. Among nine campaigns reporting smoking prevalence, significant decreases were observed in the California and Massachusetts statewide tobacco control campaigns compared with the rest of the USA. Some positive effects on prevalence in the whole population or in the subgroups were observed in three of the remaining seven studies. Three large-scale campaigns of the seven presenting results for tobacco consumption found statistically significant decreases. Among the seven studies presenting abstinence or quit rates, four showed some positive effect, although in one of them the effect was measured for quitting and cutting down combined. Among the three that did not show significant decreases, one demonstrated a significant intervention effect on smokers and ex-smokers combined.

AUTHORS' CONCLUSIONS

There is evidence that comprehensive tobacco control programmes which include mass media campaigns can be effective in changing smoking behaviour in adults, but the evidence comes from a heterogeneous group of studies of variable methodological quality. One state-wide tobacco control programme (Massachusetts) showed positive results up to eight years after the campaign. Another (California) showed positive results during the period of adequate funding and implementation and in final evaluation since the beginning of the programme. Six of nine studies carried out in communities or regions showed some positive effects on smoking behaviour and at least one significant change in smoking prevalence (Sydney). The intensity and duration of mass media campaigns may influence effectiveness, but length of follow-up and concurrent secular trends and events can make this difficult to quantify. No consistent relationship was observed between campaign effectiveness and age, education, ethnicity or gender.

Two decades of smoking cessation treatment research on smokers with depression: 1990-2010

INTRODUCTION

Adults with depression smoke at higher rates than other adults leaving a large segment of this population, who already incur increased health-related risks, vulnerable to the enormous harmful consequences of smoking. Yet, the impact that depression has on smoking cessation is not clear due to the mixed results of past research. The primary aims of this review were to synthesize the research examining the relationship of depression to smoking cessation outcomes over a 20-year period, to examine the gender and racial composition of these studies, and to identify directions for future research.

METHODS

Potential articles published between January 1, 1990 and December 31, 2010 were identified through a MEDLINE search of the terms "clinical trial," "depression," and "smoking cessation." 68 studies used all three terms and met the inclusion criteria.

RESULTS

The majority of studies examined either a past diagnosis of major depression or current depression symptoms. Within the few studies that examined the interaction of gender and depression on smoking cessation, depression had a greater impact on treatment outcomes for women than men. No study reported examining the interactive impact of race and depression on treatment outcomes.

CONCLUSIONS

Although attention to the relationship of depression and smoking cessation outcomes has increased over the past 20 years, little information exists to inform a treatment approach for smokers with Current Major Depressive Disorder, Dysthymia, and Minor Depression and few studies report gender and racial differences in the relationship of depression and smoking cessation outcomes, thus suggesting major areas for targeted research.

Interventions for recruiting smokers into cessation programmes

BACKGROUND

Tobacco control is a top public health priority around the globe due to the high prevalence of cigarette smoking and its associated morbidity and mortality. Much effort has been focused on establishing the effectiveness of different smoking cessation strategies. This review, however, aims to address the initial challenge faced by smoking cessation programmes: recruitment of smokers.

OBJECTIVES

The primary objective of this review was to determine the effectiveness of different strategies for recruiting smokers into cessation programmes. The secondary objective was to determine the impact that these strategies had on smoking cessation rates at least six months after enrolment into a cessation programme.

SEARCH METHODS

We searched the specialised register of the Cochrane Tobacco Addiction Group using a search strategy which included the terms ('recruit$', 'invit$', 'enter', 'entry', 'enrolment') combined with ('smok$', 'cigarette', 'smoking cessation', 'tobacco') in the title, abstract or keyword fields. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and registers of current and ongoing trials. We also searched the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials and cluster randomised controlled trials that compared at least two different methods of recruiting current smokers into a smoking cessation programme. We also included those studies which focused on the effectiveness of a smoking cessation programme as long as the study involved multiple recruitment methods and reported results of the recruitment phase.

DATA COLLECTION AND ANALYSIS

From each included study, we extracted data on the type of participants, type of recruitment strategies (i.e., setting, mode of communication used, intensity and duration) and comparisons, and on randomisation, allocation concealment, and blinding procedures.Our primary outcome was the proportion of smokers successfully recruited to each cessation programme compared to alternative modalities of recruitment. Our secondary outcome was smoking cessation for at least six months. Given the substantial heterogeneity across recruitment interventions and participants, we adopted a narrative synthesis approach for summarising results.

MAIN RESULTS

This review includes 19 studies with a total of 14,890 participants. We categorised the included studies according to the modes used to deliver the recruitment strategy: head to head comparison of individual recruitment strategies; comparison of the same delivery mode but with different content or intensity; and the addition of another mode to an existing recruitment method.We identified three studies that made head-to-head comparisons of different types of recruitment strategies. Of these, only one study detected a significant effect, finding that a personal phone call was more effective than a generic invitation letter (RR 40.73, 95% CI 2.53 to 654.74). Five studies compared interventions using the same delivery modes but different content. Results showed that tailored messages through an interactive voice response system resulted in a higher recruitment rate than assessment of smoking status alone using the same system (RR 8.64, 95% CI 4.41 to 16.93), and that text messages indicating scarcity of places available were more effective than generic text message reminders (RR 1.45, 95% CI 1.07 to 1.96). One study compared interventions using the same delivery mode but different intensity and found that allowing for more phone call attempts to reach potential participants can result in better recruitment (RR 1.87, 95% CI 1.61 to 2.18). Finally, 10 studies investigated the effect of adding a recruitment mode to existing recruitment strategies. Findings showed that: adding a text message reminder or real quotes from participants to a personal phone call improved recruitment of participants (RR 3.38, 95% CI 1.26 to 9.08 and RR 29.07, 95% CI 1.74 to 485.70, respectively); that adding a personal phone call to an existing newsletter can also increase recruitment rates (RR 65.12, 95% CI 4.06 to 1045.4]); that a reactive-proactive recruitment phase is more effective than a proactive phase alone (63.8% versus 47.5%, RR not available); and that active recruitment at schools is more effective than passive recruitment (p < 0.001, denominator not available for calculation of RR). Additionally, a number of studies in this category showed that providing incentives can effectively increase the number of participants recruited into smoking cessation programmes.Out of the 19 included studies, only four reported on the effect of recruitment strategy on smoking cessation at six months or longer. Three of these studies compared strategies that used the same delivery mode with different content. Their results were non-significant. The remaining three studies evaluated adding an additional mode to an existing recruitment intervention. Only one of them showed a significant difference in the levels of smoking cessation that favoured the enhanced recruitment strategy, but this may have reflected the offer of incentives once in the programme rather than the recruitment strategy itself (RR at 15 or 18 months 2.60, 95% CI 1.48 to 4.56).

AUTHORS' CONCLUSIONS

The substantial heterogeneity across the included studies restricts our ability to draw firm conclusions about the effectiveness of different recruitment strategies in relation to recruitment of participants into smoking cessation programmes or levels of smoking cessation. The limited evidence, however, suggests that the following elements may improve the recruitment of smokers into cessation programmes: personal, tailored interventions; recruitment methods that are proactive in nature; and more intensive recruitment strategies (i.e., those strategies that require increased contact with potential participants).