Connecting Low-Income Smokers to Tobacco Treatment Services

 

ABSTRACT BODY:

Introduction: The Affordable Care Act calls for using population-level incentive-based interventions to promote smoking cessation within low-income populations, such as the Medicaid population. Cigarette smoking is one of the most significant health behaviors driving costs and adverse health in low-income populations. High smoking rates persist among low-income women, and smoking can account for up to half of mortality disparities associated with socioeconomic status among males. Telehealth offers an opportunity to facilitate delivery of evidence-based smoking cessation services as well as incentive-based interventions to low-income populations. However, research is needed on effective strategies for linking smokers to services, how to couple financial incentives with telehealth, and on how to scale this to population-level practice. The current paper evaluates primary implementation and follow-up results of two strategies for connecting low-income, predominantly female smokers to a telephone tobacco quitline (QL).

Methods: The population-based program consisted of participant-initiated phone contact and two recruitment strategies: (1) direct mail (DM) and (2) opportunistic telephone referrals with connection (ORC). The program offered a $20 incentive to callers from both recruitment groups for being connected to Minnesota’s QL via a three-way call conducted by patient navigators. Participants were 40 years of age or older, 250% below the US federal poverty level, and inadequately insured. Implementation results were participant responsiveness and retention for each recruitment strategy. Summative results were self-report quit status at 7-month follow-up. Analyses consisted of descriptive statistics, cross-tabulations, and mean comparisons with unequal variances in order to examine differences between DM and ORC. Smoking abstinence rates were assessed via ordered logistic regression models using a three-category breakdown of tobacco cessation (0=no quit attempt, 1=quit attempt, 2=continuous abstinence).

Results: The response rate for DM was 8.5%. QL connections occurred for 97% of DM callers (N=870) and 33% of ORC callers (N=4,550). Self-reported continuous smoking abstinence (i.e., 30 smoke-free days at seven-month follow-up) was 20% for the DM group and 16% for ORC. These differences between intervention groups persisted after adjusting for smoking history and demographic characteristics using ordered logistic regression.

Conclusions: Both strategies successfully connected low-income smokers to cessation services and encouraged quit attempts and continuous smoking abstinence. Response rates, connection rates, and quit rates were higher than other interventions with relatively comparable components, but direct program comparisons were not possible. We recommend that future research and population-based programs utilize financial incentives and both recruitment strategies, building on their relative strengths.