Struggling to make ends meet: exploring pathways to understand why smokers in financial difficulties are less likely to quit successfully

Courage to Quit® rolling group: Implementation in an urban medical center in primarily low-income Black smokers

BACKGROUND

Continuous "rolling" tobacco group treatments may help reduce cessation disparities by increasing access among underserved people who smoke cigarettes. We evaluated the implementation of a rolling enrollment adaptation of an evidence-based tobacco treatment group intervention, Courage to Quit®-Rolling (CTQ®-R).

METHODS

The 4-session CTQ®-R incorporating psychoeducation, motivational enhancement, and cognitive behavioral skills was evaluated by examining feasibility and preliminary program outcomes with a pre-post design using the SQUIRE method in a sample of 289 primarily low-income, Black people who smoke. Feasibility was measured by examining program retention. Paired t-tests evaluated changes in behavioral intentions and knowledge about smoking cessation and differences in average daily cigarettes smoked from first to last session attended.

RESULTS

CTQ-R was feasible to implement in an urban medical center program enrolling primarily low-income Black people who smoke, with 52% attending at least 2 sessions and 24% completing the full program. Participants demonstrated improvements in knowledge of smoking cessation strategies and confidence in quitting (ps < .004). Preliminary effectiveness analyses showed a 30% reduction in average daily cigarette use, with group completers reporting greater reduction than non-completers.

CONCLUSIONS

CTQ®-R is feasible and showed preliminary effectiveness for increasing knowledge about stop smoking skills and reducing cigarette smoking.

IMPLICATIONS

A rolling enrollment smoking group treatment is feasible and may be effective among people who smoke who face historical and systemic barriers to tobacco treatment engagement. Evaluation in other settings and over longer periods of time is needed.

Integrating Financial Coaching and Referrals into a Smoking Cessation Program for Low-income Smokers: a Randomized Waitlist Control Trial

BACKGROUND

Financial distress is a barrier to cessation among low-income smokers.

OBJECTIVE

To evaluate an intervention that integrated financial coaching and benefits referrals into a smoking cessation program for low-income smokers.

DESIGN

Randomized waitlist control trial conducted from 2017 to 2019.

PARTICIPANTS

Adult New York City residents were eligible if they reported past 30-day cigarette smoking, had income below 200% of the federal poverty level, spoke English or Spanish, and managed their own funds. Pregnant or breastfeeding people were excluded. Participants were recruited from two medical centers and from the community.

INTERVENTION

The intervention (n = 208) offered smoking cessation coaching, nicotine replacement therapy, money management coaching, and referral to financial benefits and empowerment services. The waitlist control (n=202) was usual care during a 6-month waiting period.

MAIN MEASURES

Treatment engagement, self-reported 7-day abstinence, and financial stress at 6 months.

KEY RESULTS

At 6 months, intervention participants reported higher abstinence (17% vs. 9%, P=0.03), lower stress about finances (β, -0.8 [SE, 0.4], P=0.02), and reduced frequency of being unable to afford activities (β, -0.8 [SE, 0.4], P=0.04). Outcomes were stronger among participants recruited from the medical centers (versus from the community). Among medical center participants, the intervention was associated with higher abstinence (20% vs. 8%, P=0.01), higher satisfaction with present financial situation (β, 1.0 [SE, 0.4], P=0.01), reduced frequency of being unable to afford activities (β, -1.0 [SE, 0.5], P=0.04), reduced frequency in getting by paycheck-to-paycheck (β, -1.0 [SE, 0.4], P=0.03), and lower stress about finances in general (β, -1.0 [SE, 0.4], P = 0.02). There were no group differences in outcomes among people recruited from the community (P>0.05).

CONCLUSIONS

Among low-income smokers recruited from medical centers, the intervention produced higher abstinence rates and reductions in some markers of financial distress than usual care. The intervention was not efficacious with people recruited from the community.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03187730.

Psychosocial determinants of quit motivation in older smokers from deprived backgrounds: a cross-sectional survey

OBJECTIVES

To identify psychosocial determinants of quit motivation in older deprived smokers. The evidence may be used to optimise smoking cessation interventions for the target population.

DESIGN

Cross-sectional survey using online recruitment methods including Facebook-targeted advertising.

SETTING

UK, 2019.

PARTICIPANTS

Current smokers aged 50 years or older and from a socioeconomically deprived background.

MAIN OUTCOME MEASURES

Measures included motivation to stop smoking, smoking history, perceived social support, self-efficacy for quitting, self-exempting beliefs and lung cancer risk perception. Multivariable regression was used to analyse factors associated with quit motivation.

RESULTS

Of a total 578 individuals who consented to take part, 278 (48.1%) did not meet the inclusion criteria. Of the 300 eligible participants, most were recruited using Facebook (94.0%), were aged 50-64 years (83.7%) and women (85.7%). Most participants were renting from a housing association (72.0%) and had low education (61.0%). Higher motivation to quit was statistically significantly associated with a higher intensity of previous quit attempts (p=0.03), higher quit confidence (p=0.01), higher smoking self-efficacy (p=0.01), a lower risk-minimising beliefs score (p=0.01) and using traditional nicotine replacement therapy (NRT) when trying to stop smoking or cut down (p<0.001).

CONCLUSION

Older smokers from deprived backgrounds face complex barriers to quitting smoking. Interventions are needed to increase self-efficacy for quitting, modify risk-minimising beliefs and target elements of previous quit attempts (ie, the use of NRT) that are associated with motivation to stop smoking.

Roll-your-own smokers' reactions to cessation-efficacy messaging integrated into tobacco packaging design: a sequential mixed-methods study

BACKGROUND

Although loss-framed pictorial warning labels (PWLs) have increased knowledge of the health harms caused by smoking, they may elicit maladaptive responses among some smokers who have tried repeatedly, yet unsuccessfully, to quit smoking. However, research suggests that maladaptive responses may diminish if warnings are complemented with efficacy enhancing messages. Therefore, we explored New Zealand (NZ) adult roll-your-own (RYO) loose tobacco smokers' reactions to self-efficacy and response efficacy messages integrated into the RYO packaging structure and designed to complement PWLs.

DESIGN

We used a sequential mixed-methods design. In-depth interviews gauged participants' (n=22) acceptance of the designs and informed stimuli development for an online survey. The survey (n=785) compared self-efficacy and response efficacy designs to standard Quitline information, and examined agreement with emotions, beliefs and projected behaviours associated with quit attempts.

RESULTS

Our findings suggest placing gain-framed response efficacy messages on the inside flap of RYO tobacco pouches may stimulate specific emotional reactions, beliefs and projected behaviours associated with future quit attempts more effectively than NZ's status quo Quitline information. Those potentially more likely to benefit include smokers who have high baseline response efficacy and who intend to make a quit attempt.

CONCLUSIONS

Integrating cessation-related messaging within tobacco packaging could be a high reach, just-in-time micro-intervention at the point of decision-making. Enhanced efficacy messages could complement and enhance PWLs, and support quitting among groups where smoking prevalence is especially high.

Financial incentives to Medicaid smokers for engaging tobacco quit line treatment: maximising return on investment

BACKGROUND

Low-income smokers experience greater difficulty in quitting smoking than do other smokers. Providing financial incentives for treatment engagement increases smoking cessation success. This study models the cost-effectiveness of varying levels of financial incentives to maximise return on investment (ROI) for engaging low-income Medicaid recipients who smoke to take calls from a tobacco quit line.

METHODS

Participants (N=1900) were recruited from May 2013 to June 2015 through quit line-based (n=980), clinic-based (n=444) or community-based referrals (n=476) into the Wisconsin Medicaid Quit Line Incentive project. Incentive (n=948) and control group participants (n=952) received $30 versus $0 per call, respectively, for taking up to five Wisconsin Tobacco Quit Line (WTQL) calls. Cost-effectiveness analyses estimated the incremental cost-effectiveness ratio for alternative financial incentives for engagement with WTQL calls. Probabilistic sensitivity analysis was employed to determine an optimal strategy for financial incentives to minimise the cost per individual who quit smoking.

RESULTS

Using fixed payments, the incremental cost-effectiveness ratio of $2316 per smoker who quit in the randomised trial decreased to $2150 per smoker who quit when the incentives were modelled at $20 per each of five WTQL calls taken. Using variable payments, the minimal cost per additional smoker who quit was $2125 when incentives for the first four WTQL calls were set at $20, and the financial payment for the fifth WTQL call was set at $70.

CONCLUSIONS

Modelling suggests that financial incentives in the amount of $20 per call for taking the first four quit line calls and $70 for taking a fifth quit line call maximise ROI to engage low-income smokers with evidence-based smoking cessation treatment.

Factors associated with abstinence after a recent smoking cessation attempt across 28 European Union member states

INTRODUCTION

There is a lack of information regarding factors associated with successful smoking cessation on a population and European Union (EU)-wide level. Our study seeks to explore individual and country-level factors associated with abstinence after a recent smoking cessation attempt across the EU.

METHODS

We obtained data from the March 2017 Special Eurobarometer 87.1 (n=27901). Regression analysis was performed on a subset of 1472 individuals who made quit attempts in the past 12 months. Sociodemographic, policy and country-level factors were assessed using logistic regression among smokers and ex-smokers who attempted to quit approximately 12 months before the survey date. We defined and examined the Cessation Ratio (ratio of number of recent quitters to those who did not succeed) across 28 EU Member States.

RESULTS

In all, 14.9% (n=1018) of current smokers and 8.80% (n=454) of ex-smokers attempted to quit in approximately the last 12 months (n=1472). Cessation Ratios ranged from 0.182 (95% CI: 0.045–0.319) in Estonia to 1.060 (95% CI: 0.262–1.860) in Sweden. There is a quadratic, U-shaped relationship between odds of quitting and smoking prevalence. The lowest odds of cessation were observed at a prevalence of 26.3%, with higher odds of cessation observed above and below this point. Respondents who reported financial difficulties were less likely to quit (AOR=0.66; 95% CI: 0.52–0.83). There was no association of likelihood of success with other sociodemographic factors or the Tobacco Control Scale treatment score.

CONCLUSIONS

These findings highlight a need for exploring reasons behind the variation in likelihood of abstinence following a recent quit attempt, in order to design policies targeted at population groups or countries that need greater support.

Financial Hardship, Motivation to Quit and Post-Quit Spending Plans among Low-Income Smokers Enrolled in a Smoking Cessation Trial

Background:

Tobacco spending may exacerbate financial hardship in low-income populations by using funds that could go toward essentials. This study examined post-quit spending plans among low-income smokers and whether financial hardship was positively associated with motivation to quit in the sample.

Methods:

We analyzed data from the baseline survey of a randomized controlled trial testing novel a smoking cessation intervention for low-income smokers in New York City (N = 410). Linear regression was used to examine the relationship between financial distress, food insecurity, smoking-induced deprivation (SID) and motivation to quit (measured on a 0-10 scale). We performed summative content analyses of open-ended survey questions to identify the most common plans among participants with and without SID for how to use their tobacco money after quitting.

Results:

Participants had an average level of motivation to quit of 7.7 (SD = 2.5). Motivation to quit was not significantly related to having high financial distress or food insecurity (P > .05), but participants reporting SID had significantly lower levels of motivation to quit than those without SID (M = 7.4 versus 7.9, P = .04). Overall, participants expressed an interest in three main types of spending for after they quit: Purchases, Activities, and Savings/Investing, which could be further conceptualized as spending on Oneself or Family, and on Needs or Rewards. The top three spending plans among participants with and without SID were travel, clothing and savings. There were three needs-based spending plans unique to a small number of participants with SID: housing, health care and education.

Conclusions:

Financial distress and food insecurity did not enhance overall motivation to quit, while smokers with SID were less motivated to quit. Most low-income smokers, including those with SID, did not plan to use their tobacco money on household essentials after quitting.

Gender differences in the association between modifiable risk factors and financial hardship among middle-aged and older adults

Objective

To identify associations between modifiable risk factors (cigarette smoking, alcohol consumption, and obesity) and financial hardship (difficulty paying bills, food insecurity and medication need) among middle-aged and older Americans in a nationally representative sample.

Methods

This was a cross-sectional study of 8212 persons age 50 years and older who completed the core 2010 Health and Retirement Study survey and the psychosocial questionnaire. We ran separate multinomial logistic regressions to assess the association of three modifiable risk factors and three different financial hardship indicators.

Results

Adjusting for all covariates, compared to men of normal weight, men who were obese had a 1.4 greater odds of difficulty paying their bills (95% CI: 1.08–1.76); former smokers had a 1.8 greater odds of being food insecure (95% CI: 1.05–2.95); current smokers were twice as likely to be food insecure (95% CI: 1.21–3.73); Compared to women who never smoked, current smokers had a 1.5 greater odds of having difficulty paying their bills (95% CI: 1.11–2.02); current smokers had a 1.8 greater odds of being food insecure (95% CI: 1.13–2.91); and women who were obese had a 1.5 greater odds of reducing medication due to cost (95% CI: 1.11, 2.02).

Conclusion

Our findings contribute to the literature on health behaviors and financial hardship by highlighting the cyclical nature between different indicators of socioeconomic status, modifiable risk factors, and poor health outcomes among middle-aged and older adults. Furthermore, findings highlight how modifiable risk factors may culminate in financial hardship in later life.

•

This study contributes to the literature by describing the connection between health and individual and family finances.

•

More than 60% of women in our sample had difficulty paying bills

•

Close to 70% of women were food insecure, and 70% reduced medication use due to cost

•

Modifiable risk behaviors – often socioeconomically patterned, may culminate in financial hardship in later life.

•

This study highlights the importance of ongoing efforts to improve income equity between the genders.

Paying Low-Income Smokers to Quit? The Cost-Effectiveness of Incentivizing Tobacco Quit Line Engagement for Medicaid Recipients Who Smoke

OBJECTIVES

To determine the cost-effectiveness of an incentive-based stop-smoking intervention that paid Medicaid recipients who smoke to take calls from a tobacco quit line.

METHODS

A cost-effectiveness analysis was conducted alongside a randomized controlled trial. The analysis was conducted from a health care systems perspective on the basis of costs and effectiveness over a 6-month follow-up. Participants (n = 1900) were recruited from May 2013 to June 2015 through quit line (n = 980), clinic-based (n = 444), or community-based (n = 476) referrals. Incentive group participants (n = 948) received $30 a call for taking up to five tobacco quit line calls and $40 for biochemically verified tobacco abstinence at 6 months. Control group participants (n = 952) did not receive financial incentives for taking quit line calls. Intervention resource costs included incentive payments to participants, counselor and administrative staff time, and smoking cessation medications. Smoking status at baseline and 6 months was determined for all study participants via carbon monoxide (CO) breath tests (abstinence: CO < 7 ppm). Cost-effectiveness analysis calculated the incremental cost-effectiveness ratio (ICER).

RESULTS

Incentive treatment produced higher 6-month CO-confirmed 7-day point-prevalence abstinence than did the control treatment (21.6 vs. 13.8%; P < 0.001). The ICER of the financial incentives intervention was $2316 (95% confidence interval $1582-$4270) per additional person who quit. The study ICER compares favorably with other smoking treatments, such as varenicline combined with proactive telephone counseling, whose ICER has been estimated at $2600 per additional smoker who quits.

CONCLUSIONS

Use of financial incentives to engage with tobacco quit line treatment is a cost-effective option to enhance smoking cessation rates for low-income smokers.

Individualised tobacco affordability in the UK 2002-2014: findings from the International Tobacco Control Policy Evaluation Project

OBJECTIVE

The existing measures of tobacco affordability (smokers' purchasing power for tobacco) use national estimates of income and average cigarette prices, and exclude roll-your-own (RYO) tobacco. This study developed an individualised measure of tobacco affordability using smokers' own incomes and factory-made (FM) or RYO tobacco purchase prices, and explored how it was impacted by taxation changes, individual characteristics and purchase patterns.

DESIGN

Cross-sectional survey data collated from 10 waves of a longitudinal cohort study.

DATA SOURCES

Adult smokers (n=4062) from the International Tobacco Control Policy Evaluation Project United Kingdom (UK), surveyed between 2002 and 2014, providing 8943 observations over 10 surveys.

ANALYSIS

Affordability was calculated as the percentage of annual income remaining with the individuals after their annual tobacco expenditure. Multilevel linear regression models were used with affordability as the outcome using time, sex, age, geographical region, ethnicity, education, nicotine dependence and tobacco purchase source as the predictor variables.

RESULTS

Affordability of FM cigarettes decreased significantly from 91.5% (±95% CI: 91.0% to 91.9%) in 2002 to 87.8% (87.0% to 88.5%) in 2014; and RYO from 96.3% (95.7% to 96.9%) in 2006 to 93.7% (93.0% to 94.4%) in 2014. Affordability was significantly lower for FM than RYO. Year-on-year decreases were not statistically significant. Tobacco was more affordable for males, those with higher education, less dependent smokers and those purchasing from non-store (potentially illicit) or non-UK sources.

CONCLUSIONS

An individualised measure of tobacco affordability provided useful insights on the impact of tobacco taxes, social inequalities and purchase patterns in the UK. Although tobacco became less affordable, the annual rate of decline was low, suggesting annual tax rises were not large enough.

Subsistence difficulties are associated with more barriers to quitting and worse abstinence outcomes among homeless smokers: evidence from two studies in Boston, Massachusetts

Background

Three-quarters of homeless people smoke cigarettes. Competing priorities for shelter, food, and other subsistence needs may be one explanation for low smoking cessation rates in this population. We analyzed data from two samples of homeless smokers to examine the associations between subsistence difficulties and 1) smoking cessation readiness, confidence, and barriers in a cross-sectional study, and 2) smoking abstinence during follow-up in a longitudinal study.

Methods

We conducted a survey of homeless smokers (N = 306) in 4/2014–7/2014 and a pilot randomized controlled trial (RCT) for homeless smokers (N = 75) in 10/2015–6/2016 at Boston Health Care for the Homeless Program. In both studies, subsistence difficulties were characterized as none, low, or high based on responses to a 5-item scale assessing the frequency of past-month difficulty finding shelter, food, clothing, a place to wash, and a place to go to the bathroom. Among survey participants, we used linear regression to assess the associations between subsistence difficulty level and readiness to quit, confidence to quit, and a composite measure of perceived barriers to quitting. Among RCT participants, we used repeated-measures logistic regression to examine the association between baseline subsistence difficulty level and carbon monoxide-defined brief smoking abstinence assessed 14 times over 8 weeks of follow-up. Analyses adjusted for demographic characteristics, substance use, mental illness, and nicotine dependence.

Results

Subsistence difficulties were common in both study samples. Among survey participants, greater subsistence difficulties were associated with more perceived barriers to quitting (p < 0.001) but not with cessation readiness or confidence. A dose-response relationship was observed for most barriers, particularly psychosocial barriers. Among RCT participants, greater baseline subsistence difficulties predicted less smoking abstinence during follow-up in a dose-response fashion. In adjusted analyses, individuals with the highest level of subsistence difficulty had one-third the odds of being abstinent during follow-up compared to those without subsistence difficulties (OR 0.33, 95% CI 0.11–0.93) despite making a similar number of quit attempts.

Conclusions

Homeless smokers with greater subsistence difficulties perceive more barriers to quitting and are less likely to do so despite similar readiness, confidence, and attempts. Future studies should assess whether addressing subsistence difficulties improves cessation outcomes in this population.

Trial registration

ClinicalTrials.gov: NCT02565381.

Barriers to Quitting Smoking Among Young Adults: The Role of Socioeconomic Status

PURPOSE

The aims of this analysis were to explore how self-reported barriers to quitting vary by socioeconomic status (SES) among young-adult smokers and to assess their relationship to quitting.

DESIGN

This analysis uses 2 waves of telephone-survey data from the Minnesota Adolescent Community Cohort study.

SETTING

Midwestern United States.

PARTICIPANTS

Participants (n = 419) were smokers aged 17 to 24 years.

MEASURES

Socioeconomic status was estimated using the highest level of education completed by the participants' parents. Demographics, smoking behavior, and perceived barriers to quitting were collected via survey questions.

ANALYSIS

Differences in barriers by SES were assessed using prevalence ratios (PRs). Relative risks were calculated to assess the association between barriers and quitting status 1 year later, testing for effect modification by SES.

RESULTS

Compared to the high SES group (n = 314), the low SES group (n = 105) was more likely to report several barriers to quitting; however, only the risk of gaining weight was significantly more common (PR: 1.38 [1.05-1.83]). There were no significant associations between barriers and quitting status 1 year later, but the number of cigarettes per day was consistently related to the likelihood of quitting 1 year later, regardless of SES.

CONCLUSION

Despite the limited generalizability to racially diverse populations and different geographic locations, the results suggest perceived barriers may not differ by SES or predict quitting among young adults; however, nicotine dependence may play an important role.

A Randomized Trial of Incentives for Smoking Treatment in Medicaid Members

INTRODUCTION

Low-income populations are especially likely to smoke and have difficulty quitting. This study evaluated a monetary incentive intended to increase smoking treatment engagement and abstinence among Medicaid recipients who smoke.

STUDY DESIGN

Two-group randomized clinical trial of Incentive (n=948) and Control interventions (n=952) for smoking.

SETTING/PARTICIPANTS

Medicaid recipients recruited from primary care patients (n=920) and callers to the Wisconsin Tobacco Quit Line (n=980).

INTERVENTION

Participants were offered five quitline cessation calls and were encouraged to obtain cessation medication (covered by Medicaid). All participants received payment for completing a baseline assessment and a 6-month smoking test. Only Incentive condition participants received compensation for taking counseling calls ($30 per call) and for biochemically verified abstinence at the 6-month visit ($40).

MAIN OUTCOME MEASURES

Seven-day point-prevalence smoking abstinence 6-months post study entry and cost/quit.

RESULTS

Incentive condition participants had significantly higher biochemically determined 7-day point-prevalence smoking abstinence rates 6 months after study induction than did Controls (21.6% vs 13.8%, respectively, p<0.0001). A positive treatment effect of incentives was present across other abstinence indices, but the size of effects and levels of abstinence varied considerably across indices. Incentive condition participants were also significantly more likely than non-incentivized Control participants to accept Wisconsin Tobacco Quit Line treatment calls and their acceptance of calls mediated their attainment of higher abstinence rates at 6-month follow-up. The cost/quit/participant averaged $4,268.26 for the Control participants and $3,601.37 for the Incentive participants.

CONCLUSIONS

This study shows that fairly moderate levels of incentive payments for treatment engagement and abstinence (a total possible payment of $190) increased very low-income smokers' engagement and success in smoking cessation treatment.

CLINICAL REGISTRATION

This study is registered at www.clinicaltrials.gov: NCT02713594.

Smoking and finances: baseline characteristics of low income daily smokers in the FISCALS cohort

BACKGROUND

Financial stress is a barrier to successful smoking cessation and a key predictor of relapse. Little is known about the financial situation of low-income Australian daily smokers. This study aims to describe and investigate associations between the financial functioning, tobacco use and quitting behaviours of low income daily smokers.

METHODS

Low-income Australian adult smokers in the 'Financial Intervention for Smoking Cessation Among Low-income Smokers (FISCALS) randomised clinical trial completed a structured telephone questionnaire.

RESULTS

The median number of cigarettes typically smoked by the 1047 participants was 23 per day. The median spent on tobacco per week was AU$80. Three quarters (73.0%) reported some financial stress and 43.2% reported smoking-induced deprivation. Financial stress was significantly associated with deprivation (IRR: 1.23, 95% CI 1.21, 1.26, p < 0.001). There were no significant associations either between adjusted financial stress or deprivation and motivation to quit or certainty of quit success.

CONCLUSIONS

Financial stress and smoking induced deprivation were prevalent among low-income daily smokers, but they were not associated with motivation to quit. Smoking cessation interventions need to be responsive to the role financial stress plays in reducing quit attempts and increasing relapse.

TRIAL REGISTRATION

Australian and New Zealand Clinical trials Registry ACTRN12612000725864 6/07/2012.

A longitudinal study of persistent smoking among HIV-positive gay and bisexual men in primary relationships

INTRODUCTION

We examined the stability of smoking behaviors, and factors associated with persistent smoking in a longitudinal study of HIV-positive gay and bisexual men in primary relationships.

METHODS

A sample of 377 HIV-positive men on antiretroviral therapy and their same-sex partners completed five assessments over two years. Participants completed semi-structured interviews which assessed smoking status, sociodemographic factors, relationship dynamics, and HIV-related disease characteristics. Latent transition analysis estimated the amount of transition in smoking over time. Latent class analysis examined factors associated with smoking status across the study period.

RESULTS

At baseline, 28.1% (n=106) of participants reported current smoking. Over 90% of the HIV-positive men remained in the same smoking category over time (68.4% persistent non-smokers; 24.1% persistent smokers). Men whose partners smoked and men with lower income had higher odds of being persistent smokers, whereas older men and men who identified as Latino race/ethnicity had lower odds of being persistent smokers compared to non-smokers.

CONCLUSIONS

Despite efforts to reduce smoking among people living with HIV (PLWH), a substantial subset of men continued to smoke during their two years in the study. Findings suggest that primary partners who also smoke and low income were the strongest predictors of sustained smoking behaviors among HIV-positive men. Additional research is needed to better understand how to increase motivation and support for smoking cessation among PLWH and their primary partners, while attending to how socioeconomic status may inhibit access to and the sustained impact of existing smoking cessation programs.

A qualitative analysis of low income smokers' responses to tobacco excise tax increases

BACKGROUND

While increasing the excise tax applied to tobacco products reduces consumption and smoking prevalence, it may also cause hardship among smokers who do not quit. We explored how smokers living on a low income respond to increasing tobacco excise taxes.

METHODS

Using a social justice perspective, we explored the increasing costs of tobacco with a sample of 27 adult smokers who live below the poverty line (i.e., with an income less than 60% of the median New Zealand income). Face-to-face interviews were conducted in Dunedin, New Zealand, a city with marked income differences, and were undertaken shortly after a further tobacco excise tax increase. The interview guide explored participants' smoking practices, their perceptions of excise tax as a strategy to reduce smoking prevalence, and the strategies they used to manage their tobacco needs.

RESULTS

We identified three key themes: depriving the poor; tobacco as a precious commodity, and desperation. While many participants described smoking as a pleasure or coping mechanism, they also saw it as a burden that they struggled to manage. Despite trying to quit, most had failed to become smokefree and felt victimised by a punitive policy system that coerced change without supporting it. They managed financial pressure by reducing their tobacco consumption but also used increasingly desperate measures, including recycling waste tobacco; participants reported feeling demeaned by measures they saw as their only option.

CONCLUSION

Providing intensive cessation support for lower income smokers could avoid further alienating a group already experiencing considerable disadvantage.

Evaluating Long-term Outcomes of NHS Stop Smoking Services (ELONS): a prospective cohort study

BACKGROUND

NHS Stop Smoking Services (SSSs) provide free at the point of use treatment for smokers who would like to stop. Since their inception in 1999 they have evolved to offer a variety of support options. Given the changes that have happened in the provision of services and the ongoing need for evidence on effectiveness, the Evaluating Long-term Outcomes for NHS Stop Smoking Services (ELONS) study was commissioned.

OBJECTIVES

The main aim of the study was to explore the factors that determine longer-term abstinence from smoking following intervention by SSSs. There were also a number of additional objectives.

DESIGN

The ELONS study was an observational study with two main stages: secondary analysis of routine data collected by SSSs and a prospective cohort study of service clients. The prospective study had additional elements on client satisfaction, well-being and longer-term nicotine replacement therapy (NRT) use.

SETTING

The setting for the study was SSSs in England. For the secondary analysis, routine data from 49 services were obtained. For the prospective study and its added elements, nine services were involved. The target population was clients of these services.

PARTICIPANTS

There were 202,804 cases included in secondary analysis and 3075 in the prospective study.

INTERVENTIONS

A combination of behavioural support and stop smoking medication delivered by SSS practitioners.

MAIN OUTCOME MEASURES

Abstinence from smoking at 4 and 52 weeks after setting a quit date, validated by a carbon monoxide (CO) breath test.

RESULTS

Just over 4 in 10 smokers (41%) recruited to the prospective study were biochemically validated as abstinent from smoking at 4 weeks (which was broadly comparable with findings from the secondary analysis of routine service data, where self-reported 4-week quit rates were 48%, falling to 34% when biochemical validation had occurred). At the 1-year follow-up, 8% of prospective study clients were CO validated as abstinent from smoking. Clients who received specialist one-to-one behavioural support were twice as likely to have remained abstinent than those who were seen by a general practitioner (GP) practice and pharmacy providers [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.2 to 4.6]. Clients who received group behavioural support (either closed or rolling groups) were three times more likely to stop smoking than those who were seen by a GP practice or pharmacy providers (OR 3.4, 95% CI 1.7 to 6.7). Satisfaction with services was high and well-being at baseline was found to be a predictor of abstinence from smoking at longer-term follow-up. Continued use of NRT at 1 year was rare, but no evidence of harm from longer-term use was identified from the data collected.

CONCLUSIONS

Stop Smoking Services in England are effective in helping smokers to move away from tobacco use. Using the 52-week CO-validated quit rate of 8% found in this study, we estimate that in the year 2012-13 the services supported 36,249 clients to become non-smokers for the remainder of their lives. This is a substantial figure and provides one indicator of the ongoing value of the treatment that the services provide. The study raises a number of issues for future research including (1) examining the role of electronic cigarettes (e-cigarettes) in smoking cessation for service clients [this study did not look at e-cigarette use (except briefly in the longer-term NRT study) but this is a priority for future studies]; (2) more detailed comparisons of rolling groups with other forms of behavioural support; (3) further exploration of the role of practitioner knowledge, skills and use of effective behaviour change techniques in supporting service clients to stop smoking; (4) surveillance of the impact of structural and funding changes on the future development and sustainability of SSSs; and (5) more detailed analysis of well-being over time between those who successfully stop smoking and those who relapse. Further research on longer-term use of non-combustible nicotine products that measures a wider array of biomarkers of smoking-related harm such as lung function tests or carcinogen metabolites.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. The UK Centre for Tobacco and Alcohol Studies provided funding for the longer-term NRT study.

Motivating Low Socioeconomic Status Smokers to Accept Evidence-Based Smoking Cessation Treatment: A Brief Intervention for the Community Agency Setting

INTRODUCTION

Individuals of low socioeconomic status (SES), smoke at very high rates but make fewer and less successful quit attempts than do other smokers. Low-SES smokers have specific beliefs about smoking and quitting that may serve as barriers to making quit attempts. The purpose of this study was to test the impact of a brief intervention addressing these beliefs on making calls to a telephone quit line.

METHODS

Of 522 smokers entering the study at 5 Wisconsin Salvation Army (SA) sites, 102 expressed motivation to quit and served as a comparison group. The remaining 420 smokers were not motivated to quit and were randomly assigned to 1 of 3 conditions: an intervention group who received brief counseling focused on cessation goals and beliefs, an attention-control group, and a low contact control group. The primary outcome was the rate at which smokers made a call to the Wisconsin tobacco quit line (WTQL) during their SA visit. Secondary outcome measures included motivational variables, stage of change, changes in beliefs about smoking and quitting, and self-reported abstinence.

RESULTS

Unmotivated participants in the intervention condition called the WTQL at a significantly higher rate (12.2%) than did those in the 2 control conditions (2.2% and 1.4%) (p < .01) and approached the rate of calling by participants who were initially motivated to quit (15.7%). Intervention condition participants also showed improved motivation to quit and stage of change.

CONCLUSIONS

A brief, targeted motivational intervention focusing on cessation goals and beliefs increased the initiation of an evidence-based tobacco cessation treatment by low-SES smokers.

Tobacco use among low-income housing residents: does hardship motivate quit attempts?

PURPOSE

The purpose of this study was to examine material hardship among smokers to determine whether such hardship was positively associated with current attempts to quit tobacco use.

METHODS

We analyzed cross-sectional data from the Health in Common (HIC) study, an observational study to investigate social and physical determinants of cancer risk-related behaviors among residents of low-income housing in three cities in the Boston metropolitan area. In this study, three indicators of hardship were used: food hardship, financial hardship, and material hardship (food and financial hardship combined). Logistic regression models were used to obtain the odds of currently trying to quit among current smokers in the HIC (n = 170) across hardship types experienced, adjusting for sociodemographic and psychosocial factors.

RESULTS

Fully adjusted models revealed no statistically significant association between trying to quit tobacco use and indicators of material hardship: food hardship and financial hardship present (OR 1.33 (0.42-4.2); food hardship and no financial hardship OR 3.83 (0.97-15.13); and financial hardship but no food hardship OR 0.5 (0.1-2.39).

CONCLUSIONS

These findings suggest that even in the presence of material hardship, low-income housing resident tobacco users are not more likely to quit tobacco use; therefore, cessation efforts focused on the financial benefits of quitting may be insufficient to motivate quit attempts among low-income smokers.

Trends and socioeconomic differences in policy triggers for thinking about quitting smoking: Findings from the International Tobacco Control (ITC) Europe Surveys

INTRODUCTION

The aim of the current study is to investigate trends and socioeconomic differences in policy triggers for thinking about quitting in six European countries.

METHODS

Data were derived from all available survey waves of the International Tobacco Control (ITC) Europe Surveys (2003-2013). France conducted three survey waves (n=1420-1735), Germany three waves (n=515-1515), The Netherlands seven waves (n=1420-1668), Ireland three waves (n=582-1071), Scotland two waves (n=461-507), and the rest of the United Kingdom conducted seven survey waves (n=861-1737). Smokers were asked whether four different policies (cigarette price, smoking restrictions in public places, free or lower cost medication, and warning labels on cigarette packs) influenced them to think about quitting. Generalized Estimating Equation (GEE) models were estimated for each country.

RESULTS

Cigarette price was mentioned most often in all countries and across all waves as trigger for thinking about quitting. Mentioning cigarette price and warning labels increased after the implementation of price increases and warning labels in some countries, while mentioning smoking restrictions decreased after their implementation in four countries. All studied policy triggers were mentioned more often by smokers with low and/or moderate education and income than smokers with high education and income. The education and income differences did not change significantly over time for most policies and in most countries.

CONCLUSIONS

Tobacco control policies work as a trigger to increase thoughts about quitting, particularly in smokers with low education and low income and therefore have the potential to reduce health inequalities in smoking.

'Cigarettes are priority': a qualitative study of how Australian socioeconomically disadvantaged smokers respond to rising cigarette prices

Despite substantial modelling research assessing the impact of cigarette taxes on smoking rates across income groups, few studies have examined the broader financial effects and unintended consequences on very low-income smokers. This study explored how socioeconomically disadvantaged smokers in a high-income country manage smoking costs on limited budgets. Semi-structured face-to-face interviews were conducted with 20 smokers recruited from a welfare organization in NSW, Australia. Participants discussed perceived impact of tobacco costs on their essential household expenditure, smoking behaviour and quit cognitions. Interviews were audio-taped, transcribed verbatim and analysed using thematic framework analysis. Instances of smoking-induced deprivation and financial stress, such as going without meals, substituting food choices and paying bills late in order to purchase cigarettes were reported as routine experiences. Price-minimization strategies and sharing tobacco resources within social networks helped to maintain smoking. Participants reported tobacco price increases were good for preventing uptake, and that larger price rises and subsidized cessation aids were needed to help them quit. Socioeconomically disadvantaged smokers engage in behaviours that exacerbate deprivation to maintain smoking, despite the consequences. These data do not suggest a need to avoid tobacco taxation, rather a need to consider how better to assist socioeconomically disadvantaged smokers who struggle to quit.

Community-based navigators for tobacco cessation treatment: a proof-of-concept pilot study among low-income smokers

BACKGROUND

A majority of continuing smokers in the United States are socioeconomically disadvantaged (SED) adults, who are less likely than others to achieve and maintain abstinence despite comparable quit-attempt rates. A national research initiative seeks effective new strategies for increasing successful smoking cessation outcomes among SED populations. There is evidence that chronic and acute stressors may interfere with SED smokers who try to quit on their own. Patient navigators have been effectively used to improve adherence to chronic disease treatment. We designed and have pilot-tested an innovative, non-clinical community-based intervention--smoking cessation treatment navigators--to determine feasibility (acceptance, adherence, and uncontrolled results) for evaluation by randomized controlled trial (RCT).

METHODS

The intervention was developed for smokers among parents and other household members of inner city pre-school for low-income children. Smoking cessation treatment navigators were trained and deployed to help participants choose and adhere to evidence-based cessation treatment (EBCT). Navigators provided empathy, resource-linking, problem-solving, and motivational reinforcement. Measures included rates of study follow-up completion, EBCT utilization, navigation participation, perceived intervention quality, 7-day point abstinence and longest abstinence at three months. Both complete-case and intent-to-treat analyses were performed.

RESULTS

Eighty-five percent of study participants (n = 40) completed final data collection. More than half (53%) enrolled in a telephone quitline and nearly three-fourths (71%) initiated nicotine replacement therapy. Participants completed a mean 3.4 navigation sessions (mean 30 min duration) and gave the intervention very high quality and satisfaction ratings. Self-reported abstinence was comparable to rates for evidence-based cessation strategies (21% among study completers, 18% using intent-to-treat analysis; median 21 days abstinent among relapsers).

CONCLUSIONS

The pilot results suggest that smoking cessation treatment navigators are feasible to study in community settings and are well-accepted for increasing use of EBCT among low-income smokers. Randomized controlled trial for efficacy is warranted.

Individual and interpersonal triggers to quit smoking in China: a cross-sectional analysis

AIMS

To determine the most prominent individual and interpersonal triggers to quit smoking in China and their associations with sociodemographic characteristics.

METHODS

Data come from Waves 1-3 (2006-2009) of the International Tobacco Control (ITC) China Survey, analysed cross-sectionally as person-waves (N=14,358). Measures included sociodemographic and smoking characteristics. Those who quit between waves (4.3%) were asked about triggers that 'very much' led them to stop smoking, and continuing smokers about triggers that 'very much' made them think about quitting. Triggers covered individual (personal health concerns, cigarette price, smoking restrictions, advertisements, warning labels) and interpersonal factors (family/societal disapproval of smoking, setting an example to children, concerns about secondhand smoke).

RESULTS

Over a third of respondents (34.9%) endorsed at least one trigger strongly; quitters were more likely than smokers to mention any trigger. While similar proportions of smokers endorsed individual (24.4%) and interpersonal triggers (24.0%), quitters endorsed more individual (61.1%) than interpersonal (48.3%) triggers. However, the most common triggers (personal health concerns; setting an example to children) were the same, endorsed by two-thirds of quitters and a quarter of smokers, as were the least common triggers (warning labels; cigarette price), endorsed by 1 in 10 quitters and 1 in 20 smokers. Lower dependence among smokers and greater education among all respondents were associated with endorsing any trigger.

CONCLUSIONS

Individual rather than interpersonal triggers appear more important for quitters. Major opportunities to motivate quit attempts are missed in China, particularly with regard to taxation and risk communication. Interventions need to focus on more dependent and less-educated smokers.

A randomized clinical trial of a financial education intervention with nicotine replacement therapy (NRT) for low socio-economic status Australian smokers: a study protocol

BACKGROUND AND AIMS

Reducing smoking prevalence among smokers from low socio-economic status (SES) is a preventative health priority. Financial stress (e.g. shortage of money or inability to pay bills) may be a major barrier to quitting smoking. This study evaluates the efficacy of a financial education and support programme coupled with pharmacotherapy at improving cessation rates at 8-month follow-up among Australian low SES smokers (people receiving a government pension or allowance).

DESIGN

A two-group parallel block randomized (ratio 1 : 1) open-label clinical trial (RCT) with allocation concealment will be conducted. Allocation will be concealed to interviewers at data collection-points.

SETTING

The study will be conducted primarily by telephone with baseline, follow-up interviews and telephone-based support sessions. Nicotine replacement therapy (NRT) delivery will be mail-based.

PARTICIPANTS

Daily smokers who are interested in quitting smoking and are currently in receipt of government benefits (n = 1046) will be recruited through study advertisements placed in newspapers, posters placed in government social assistance agencies and Quitline telephone-based cessation support services. After completion of a baseline computer-assisted telephone interview, participants will be allocated randomly to control or intervention group using a permuted block approach.

INTERVENTION AND COMPARATOR

Participants in both groups will receive 8 weeks of free combination NRT plus Quitline support. Participants in the intervention group will also receive four telephone-delivered financial education and support sessions.

MEASUREMENTS

The primary outcome measure will be prolonged abstinence (at 8-month follow-up) assessed using Russell Standard criteria and biochemically verified (urine cotinine).

COMMENTS

This is the first intervention study to evaluate the potential of co-managing financial stress as a means of enhancing smokers' capacity to quit smoking. Such an intervention may provide a scalable intervention to help low SES smokers to quit.

Correlates of cessation success among Romanian adults

BACKGROUND

Tobacco smoking and its consequences are a serious public health problem in Romania. Evidence-based data on factors associated with successful smoking cessation are crucial to optimize tobacco control. The aim of the study was to determine the sociodemographic and other factors associated with smoking cessation success among adults.

MATERIALS AND METHODS

Data was from a sample of 4,517 individuals derived from the Global Adult Tobacco Survey (GATS). GATS is a cross-sectional, nationally representative household survey implemented in Romania in 2011. Data was analyzed with logistic regression.

RESULTS

Among females, the quit rate was 26.3% compared with 33.1% in males (P < 0.02). We found disparities in cessation success among the analyzed groups of respondents. Being economically active, being aged 40 and above, and having an awareness of smoking health consequences were associated with long-term quitting smoking among men, while initiating smoking at a later age increased the odds of quitting smoking among women. However, cohabitation with nonsmokers was the strongest predictor of successful cessation among both genders.

CONCLUSION

Programs increasing quit rates and encourage cessation among groups less likely to quit, adopting voluntary smoke-free homes, and increasing the awareness of smoking and tobacco pollution risks are needed.

Paying the price: a cross-sectional survey of Australian socioeconomically disadvantaged smokers' responses to hypothetical cigarette price rises

INTRODUCTION AND AIMS

Increases in tobacco taxation can lead to reductions in tobacco consumption and prevalence of use across social groups. However, use of price-minimisation strategies to manage current and future tobacco use and the role of financial stress is less understood. This study aimed to measure the effect of cigarette price increases on price-minimisation strategy endorsement and financial stress among socioeconomically disadvantaged smokers.

DESIGN AND METHODS

Community service organisation welfare recipients in NSW, Australia completed a touchscreen survey. Smoking history, financial stress, highest price to quit and responses to hypothetical cigarette price increases were assessed.

RESULTS

Participants were 354 smokers (response rate = 79%). Most participants received income from a government pension (95%), earned <A$300/week (55%), had not completed secondary schooling (64%), were moderately or heavily nicotine-dependent (60%), reported high financial stress (66%) and spent A$56/week on tobacco. In response to 10% and 20% hypothetical price rises, significantly more participants endorsed trying to quit in response to the larger increase scenario (P < 0.001), and fewer selected no change to their smoking (P < 0.001). Numerous price-minimisation strategies (e.g. switching to cheaper brands/products) were endorsed, but remained constant across hypothetical scenarios; level of financial stress appeared to have little influence. Smokers indicating they would not change their smoking in response to price rises had higher levels of nicotine dependence.

DISCUSSION AND CONCLUSIONS

Socially disadvantaged smokers endorsed numerous price-minimising strategies to maintain smoking at hypothetically increased costs. Larger cigarette price rises motivated more smokers to consider quitting, while price-resistant smokers appeared to have a more entrenched smoker status.

Factors associated with self-assessed increase in tobacco consumption among over-indebted individuals in Germany: a cross-sectional study

Background

Over-indebtedness is an increasing phenomenon in industrialised nations causing individual hardship and societal problems. Nonetheless, few studies have explored smoking among over-indebted individuals.

Methods

A cross-sectional survey (n=949) on retrospectively assessed changes in tobacco consumption was carried out in 2006 and 2007 among clients of 84 officially approved debt and insolvency counselling centres in Germany (response rate 39.7%). Logistic regressions were performed to explore factors associated with reports of increased smoking after onset of over-indebtedness.

Results

63% of all respondents stated daily or occasional tobacco consumption. Almost one fifth reported an increase in smoking after becoming over-indebted. Females were less likely to report increased smoking than men (aOR 0.66, 95% CI 0.44-0.99) whereas respondents who had been over-indebted for more than 10 years were more likely to report increased smoking than those who had been over-indebted for less than five years (aOR 1.66; 95%-CI 1.00-2.76). The odds of increased smoking were also elevated among those who reported that their families and friends had withdrawn from them as a consequence of their over-indebtedness (aOR 1.82; 95%-CI 1.06-3.14).

Conclusions

The study identifies over-indebted individuals and particularly over-indebted men as a high-risk group of smokers. Low levels of social embeddedness/support were associated with a further increase in smoking after becoming over-indebted. Given recent increases of over-indebtedness, the findings highlight the need to develop appropriate public health policies.