Racial and ethnic disparities in smoking-cessation interventions: analysis of the 2005 National Health Interview Survey

BACKGROUND: Recent national surveys document racial and ethnic disparities in receipt of smoking-cessation advice. This study updates and expands prior analyses using survey data for 2005, and evaluates the association between smokers' race and ethnicity and three separate measures of healthcare-encounter-based tobacco interventions: screening, smoking-cessation advice, and use of smoking-cessation aids. METHODS: Analyses are based on 4756 smokers (aged 18 and older) reporting a healthcare encounter within the past year who participated in the 2005 National Health Interview Survey (NHIS). Multivariate-adjusted OR and 95% CI for receipt of tobacco interventions in non-Hispanic black and Hispanic smokers were compared to those of non-Hispanic white smokers, adjusted for smokers' characteristics (sociodemographics, health status, and healthcare-utilization factors, and smoking-related characteristics). Analyses were done in 2006. RESULTS: Results show that compared to white smokers, black and Hispanic smokers had significantly lower odds of (1) being asked about tobacco use (AOR=0.70 and AOR=0.69, respectively); (2) being advised to quit (AOR=0.72 and AOR=0.64, respectively); or (3) having used tobacco-cessation aids during the past year in a quit attempt (AOR=0.60 and AOR=0.59, respectively). Compared to 2000 NHIS published data, the prevalence of receipt of advice to quit from a healthcare provider increased from 52.9% in 2000 to 61.2% in 2005, with increases across racial and ethnic groups. CONCLUSIONS: Despite progress in smokers' being advised to quit during healthcare encounters in the past 5 years, black and Hispanic smokers continue to be less likely than whites to receive and use tobacco-cessation interventions, even after control for socioeconomic and healthcare factors. Further actions are needed to understand and eliminate this disparity.     

Physicians' advice to quit smoking. The glass remains half empty

BACKGROUND: We explored the relationships between advice from a physician to quit smoking and an array of respondents' characteristics, including sociodemographic factors, health status, health insurance status, physician continuity, and intensity of smoking. METHODS: We examined data from the nationally representative 1996-1997 Community Tracking Study Household Survey. We used multivariate logistic regression to model receipt of cessation advice in a sample of 8229 smokers aged 18 years and older who made at least one visit to a physician in the past year. RESULTS: Less than 50% of the subjects reported receiving cessation advice. Advice was less likely for patients who were younger, men, African American, uninsured, healthier, lower health care services users, or lighter smokers, and more likely for those with military health insurance, who attended hospital outpatient clinics, or who belonged to health maintenance organizations. CONCLUSIONS: Physicians continue to miss opportunities to provide smoking cessation advice, a potentially lifesaving intervention. Given the adverse health consequences of tobacco use and the demonstrated benefit of advice to quit, physicians need to improve their cessation counseling efforts.     

Prevalence and Correlates of Smoking among Low-Income Adults Residing in New York City Public Housing Developments—2015

To guide targeted cessation and prevention programming, this study assessed smoking prevalence and described sociodemographic, health, and healthcare use characteristics of adult smokers in public housing. Self-reported data were analyzed from a random sample of 1664 residents aged 35 and older in ten New York City public housing developments in East/Central Harlem. Smoking prevalence was 20.8%. Weighted log-binomial models identified to be having Medicaid, not having a personal doctor, and using health clinics for routine care were positively associated with smoking. Smokers without a personal doctor were less likely to receive provider quit advice. While most smokers in these public housing developments had health insurance, a personal doctor, and received provider cessation advice in the last year (72.4%), persistently high smoking rates suggest that such cessation advice may be insufficient. Efforts to eliminate differences in tobacco use should consider place-based smoking cessation interventions that extend cessation support beyond clinical settings.     

Quitting smoking among adults--United States, 2001-2010

Quitting smoking is beneficial to health at any age, and cigarette smokers who quit before age 35 years have mortality rates similar to those who never smoked. From 1965 to 2010, the prevalence of cigarette smoking among adults in the United States decreased from 42.4% to 19.3%, in part because of an increase in the number who quit smoking. Since 2002, the number of former U.S. smokers has exceeded the number of current smokers. Mass media campaigns, increases in the prices of tobacco products, and smoke-free policies have been shown to increase smoking cessation. In addition, brief cessation advice by health-care providers; individual, group, and telephone counseling; and cessation medications are effective cessation treatments. To determine the prevalence of 1) current interest in quitting smoking, 2) successful recent smoking cessation, 3) recent use of cessation treatments, and 4) trends in quit attempts over a 10-year period, CDC analyzed data from the 2001--2010 National Health Interview Surveys (NHIS). This report summarizes the results of that analysis, which found that, in 2010, 68.8% of adult smokers wanted to stop smoking, 52.4% had made a quit attempt in the past year, 6.2% had recently quit, 48.3% had been advised by a health professional to quit, and 31.7% had used counseling and/or medications when they tried to quit. The prevalence of quit attempts increased during 2001--2010 among smokers aged 25--64 years, but not among other age groups. Health-care providers should identify smokers and offer them brief cessation advice at each visit; counseling and medication should be offered to patients willing to make a quit attempt.     

Latinos report less use of pharmaceutical aids when trying to quit smoking

BACKGROUND: Latino smokers are more likely than white non-Latino smokers to attempt cessation, but less likely to receive cessation advice from physicians or to use nicotine replacement therapy (NRT). Proposed underlying causes have included lighter smoking, lower financial status, and less healthcare access. This study assessed these factors as possible explanations for disparate rates of smoking-cessation support. METHODS: Data were analyzed from a random, population-level telephone survey of Colorado adults that interviewed 10,945 white non-Latino respondents and 1004 Latino respondents. For the current analysis, main outcome measures were receipt of physician advice to quit smoking, use of NRT, and use of bupropion or other anti-depressant for smoking cessation. RESULTS: Latino smokers reported higher prevalence of quit attempts (71.5% v 61.6%, p <0.01) but less physician advice to quit smoking (46.4% v 56.2%, p <0.05) and less use of NRT or an anti-depressant for cessation (10.6% v 24.8%, p <0.0001). Adjusted for potentially confounding factors, the odds ratio (OR) for less Latino use of cessation medications was substantial and significant (full model OR=0.31; 95% confidence interval, 0.17 to 0.57). The adjusted OR for physician cessation advice was not significant. CONCLUSIONS: Population-level differences in health status, smoking level, financial status, or healthcare access do not explain why Latino smokers less often use proven pharmaceutical aids to increase cessation. Further research is needed to understand these disparities, and greater effort is needed to deliver cessation support to Latino smokers seeking to quit.     

Smoking patterns and use of cessation interventions during pregnancy

BACKGROUND: Pregnant smokers should be counseled to quit smoking and offered effective cessation interventions. To improve understanding of how best to increase smoking-cessation rates during pregnancy, this study analyzed population-based surveillance data to describe women's smoking patterns and the use of cessation services during pregnancy. METHODS: Data were analyzed from the 2004 and 2005 New Jersey Pregnancy Risk Assessment Monitoring System, a population-based survey of postpartum women (n=4473). Measures of behaviors included the timing of quit relative to the learning of pregnancy, provider assistance, the use of cessation interventions, and barriers to quitting. Analyses were done in 2007 and 2008. RESULTS: An estimated 16.2% (95% CI=15.1, 17.3) of women smoked before pregnancy. Of these, 49.8% quit before entering prenatal care, and 5.2% quit after entering prenatal care. Almost all women reported that their prenatal care provider asked if they smoked, but only 56.7% reported that a provider counseled them to quit smoking. Only 11.5% of women who smoked in late pregnancy used a cessation method, including self-help materials (6.3%); medications (3.9%); face-to-face counseling (1.7%); telephone-based counseling (1.5%); Internet-based counseling (1.3%); and a class or program (1.0%). The most frequently reported barriers to quitting were cravings for a cigarette, stress, and being around people who smoked. CONCLUSIONS: Nearly half of pregnant New Jersey smokers quit before prenatal care, and very few quit later. Few continuing smokers used a smoking-cessation method when trying to quit or cut back. Efforts should be intensified to increase the knowledge, promotion, and referral to effective interventions to help pregnant smokers quit.     

Patient smoking cessation advice by health care providers: the role of ethnicity, socioeconomic status, and health

OBJECTIVES: We assessed differences by ethnicity in ever receiving advice from providers to quit smoking. We evaluated whether socioeconomic status and health status were moderators of the association. METHODS: We used 2000 Behavioral Risk Factor Surveillance Survey data, a population-based cross-sectional survey. RESULTS: After adjusting for complex survey design, 69% of the 14089 current smokers reported ever being advised to quit by a provider. Hispanics (50%) and African Americans (61%) reported receiving smoking counseling less frequently compared with Whites (72%, P<.01 for each). Ethnic minority status, lower education, and poorer health status remained significantly associated with lower rates of advice to quit after adjustment for number of cigarettes, time from last provider visit, income, comorbidities, health insurance, gender, and age. Smoking counseling differences between African Americans and Whites were greater among those with lower income and those without health insurance. Compared with Whites, differences for both Hispanics and African Americans were also greater among those with lower education. CONCLUSION: We found lower rates of smoking cessation advice among ethnic minorities. However, we also found complex interactions of ethnicity with socioeconomic factors.     

State Medicaid coverage for tobacco-dependence treatments--United States, 1994-2001

Tobacco use is the leading preventable cause of death in the United States. One of the national health objectives for 2010 is to increase insurance coverage of evidence-based treatment for nicotine dependence (i.e., total coverage of behavioral therapies and Food and Drug Administration [FDA]--approved pharmacotherapies) in Medicaid programs from 36 states to all states and the District of Columbia (DC) (objective 27.8). To increase both the use of treatment by smokers attempting to quit and the number of smokers who quit successfully, the Guide to Community Preventive Services recommends reducing the "out-of-pocket" cost of effective tobacco-dependence treatments (i.e., individual, group, and telephone counseling, and FDA--approved pharmacotherapies) for smokers. The 2000 Public Health Service (PHS) Clinical Practice Guideline supports expanded insurance coverage for tobacco-dependence treatments. In 2000, approximately 32 million low-income persons in the United States received their health insurance coverage through the federal-state Medicaid program; 11.5 million (36%) of these persons smoked (CDC, unpublished data, 2000). The amount and type of coverage for tobacco-dependence treatment offered by Medicaid has been reported for 1998 and 2000 from state surveys conducted by the Center for Health and Public Policy Studies (CHPPS) at the University of California, Berkeley. All states and DC were re-surveyed in 2001 about amount and type of coverage, and level of coverage since 1994. This report summarizes the results of the survey, which indicate that the number of Medicaid programs providing some coverage for tobacco-dependence counseling or medication increased from 34 in 2000 to 36 in 2001, but only one state offered coverage for all the counseling and pharmacotherapy treatments recommended by the 2000 PHS guideline. If the 2010 national health objective is to be achieved, Medicaid coverage for treatment of tobacco dependence should be increased dramatically.     

Use of smoking-cessation treatments in the United States

BACKGROUND: Health promotion efforts encourage smokers to quit and to use effective cessation treatments. Randomized controlled trials demonstrate that medications and behavioral treatments improve cessation rates, but retrospective surveys have been inconsistent. This study assessed frequency of quit attempts, use of treatments for cessation, and abstinence rates among treatment users and non-users. METHODS: Data were analyzed from the 2003 Tobacco Use Special Cessation Supplement to the Current Population Survey. Participants included 29,537 U.S. smokers aged > or =18 years who smoked daily 12 months before the survey. Outcome measures included past-year quit attempts; use of behavioral, pharmacologic, and alternative treatments; receipt of social support; and abstinence for > or =4 weeks at time of survey. RESULTS: Approximately 43.5% of smokers reported a quit attempt in the preceding year: 64.2% of attempters used no cessation treatments; 8.8% used behavioral treatment; 32.2% used medication; and 14.1% used more than one treatment. Social support was reported to have been received by 24.1%. More nicotine-dependent smokers were more likely to use medications (OR=3.58; 95% CI=3.04-4.20). At the time of the survey, 19.3% of attempters were abstinent > or =4 weeks. Smokers who sought treatment were less likely to be abstinent (OR=0.75; 95% CI=0.67-0.84), and those who sought multiple treatments were even less likely to be abstinent. CONCLUSIONS: Many U.S. smokers make quit attempts, but most do not use behavioral or pharmacologic treatments. More nicotine-dependent smokers were more likely to seek treatment. Smokers who sought treatment were less likely to report abstinence, probably due to biased self-selection and recall. Retrospective survey data are not well-suited to assess the effectiveness of treatment.     

Effects of physician counseling on the smoking behavior of asbestos-exposed workers

Physician antismoking advice has been shown to increase smoking cessation, particularly among patients who have medical problems or perceive themselves to be at risk. The present study tested three hypotheses: (a) providing 3 to 5 min of behavioral counseling regarding a cessation strategy would be more effective than simply warning the smoker to quit smoking; (b) smokers with abnormal pulmonary function would be more likely to comply with medical advice than would smokers with normal pulmonary function; and (c) that smokers with abnormal pulmonary function who receive behavioral counseling would be the group most likely to achieve prolonged abstinence. Asbestos-exposed smoking men undergoing screening in a mandated program for naval shipyard workers were categorized as having normal or abnormal pulmonary status on the basis of chest X ray and pulmonary function tests (PFT). They were then randomly assigned within PFT categories to receive either a simple warning or 3 to 5 min of behavioral cessation counseling from the physician who gave them the results of their pulmonary tests. Subjects' smoking status was evaluated at 3- and 11-month intervals following the physician intervention. Smokers who received behavioral counseling were more likely to quit and remain abstinent over the 11-month period (8.4% abstinent) than were smokers given a minimal warning (3.6% abstinent). Prolonged abstinence rates among abnormal PFT subjects (3.7%) did not differ from those of normals (5.9%). The group with normal PFT who received behavioral counseling achieved the highest level of abstinence (9.5%). Maintaining adequate physician compliance with the counseling protocol proved difficult; implications of this for future efforts are discussed.     

Adoption of the AHCPR Clinical Practice Guideline for Smoking Cessation: a survey of California's HMOs

OBJECTIVE: Our objective was to assess the degree to which health maintenance organizations (HMOs) and Medicaid managed care (MMC) plans in California have adopted the 1996 AHCPR Clinical Practice Guideline for Smoking Cessation. (AHCPR [U.S. Agency for Health Care Policy and Research] was renamed AHRQ [Agency for Healthcare Research and Quality] in 1999.) METHODS: A fax survey of 13 licensed HMOs and 21 MMC plans operating in California in 1999 with up to 10 follow-up contacts by telephone, mail, fax, and/or electronic mail. RESULTS: Awareness of the AHCPR guideline is widespread, and all HMOs in California in 1999 offered coverage for at least one treatment for smoking cessation. We found that 77% of the HMOs in California were aware of the AHCPR guideline, but less than half had used it to design benefits or distribute treatment guidelines to medical care providers in their networks. While only 23% of California HMOs covered the nicotine patch or gum, 69% covered at least one form of the pharmacotherapy and one type of counseling to treat tobacco dependence. In addition, a majority of the HMOs and MMC plans inform their members about coverage for smoking cessation treatments and inform providers about their role in helping smokers to quit. CONCLUSION: Considerable progress has been made in increasing access to effective smoking cessation treatments in California's managed care organizations over the last 10 years. Future efforts and research must concentrate on: (1) adopting the 2000 Public Health Service Clinical Practice Guideline on Treating Tobacco Use and Dependence, (2) increasing purchaser demand for coverage of tobacco dependence treatments, (3) increasing health plan documentation and monitoring of member smoking status, and (4) increasing provider provision of effective tobacco dependence treatments.     

Aids to quitting tobacco use: how important are they outside controlled trials?

BACKGROUND: Although there is good evidence that several pharmacotherapies and counseling can effectively facilitate smoking cessation, there is little information about the use or effectiveness of these or any other quit aids outside of controlled trials. METHODS: A mailed survey with phone follow-up documented the use of various quit aids among 3,122 health plan members who smoke. A multilevel statistical modeling technique controlled for potentially confounding variables. RESULTS: Nearly half (1,513) of these smokers reported a quit attempt during the preceding 6 months. Although 1,036 (33.2%) reported using some type of aid to quitting, primarily nicotine products or bupropion, 10-26% of these "users" did not report an actual quit attempt. Ninety percent of the medication users had a personal cost, averaging $53-$87. Fully 26.9% of those reporting a quit without any type of aid quit for at least 7 days. This rate equals that of users of all types of aids except for nicotine patches and bupropion, both of which had associated 7 or more day quit rates of about 46% (95% CI 39.3-52.2). CONCLUSIONS: Pharmacotherapeutic quit aids are being widely used, even in the absence of significant insurance coverage.     

Effect on cessation counseling of documenting smoking status as a routine vital sign: an ACORN study

PURPOSE Guidelines encourage primary care clinicians to document smoking status when obtaining patients’ blood pressure, temperature, and pulse rate (vital signs), but whether this practice promotes cessation counseling is unclear. We examined whether the vital sign intervention influences patient-reported frequency and intensity of tobacco cessation counseling.METHODS This study was a cluster-randomized, controlled trial conducted in the Virginia Ambulatory Care Outcomes Research Network (ACORN). At intervention practices, nurses and medical assistants were instructed to assess the tobacco use status of every adult patient and record it with the traditional vital signs. Control practices did not use any systematic tobacco screening or identification system. Outcomes were the proportion of smokers reporting clinician counseling of any kind and the frequency of 2 counseling subcomponents: simple quit advice and more intensive discussion.RESULTS A total of 6,729 adult patients (1,149 smokers) at 18 primary care practices completed exit questionnaires during a 6-month comparison period. Among 561 smokers at intervention practices, 61.9% reported receiving any counseling, compared with 53.4% of the 588 smokers at control practices, for a difference of 8.6% (P = .04). The effect was largely restricted to simple advice, which was reported by 59.9% of intervention patients and 51.5% of control patients (P=.04). There was no significant increase in more extensive discussion, with 32.5% and 29.3% of patients at intervention and control practices, respectively, reporting this type of counseling (P=.18).CONCLUSIONS The vital sign intervention promotes tobacco counseling at primary care practices through a modest increase in simple advice to quit. When implemented as a stand-alone intervention, it does not appear to increase intensive counseling.     

Effectiveness of smoking cessation interventions: review of evidence and implications for best practice in Australian health care settings

OBJECTIVE: To review the evidence of the effectiveness of various smoking cessation methods and appropriateness for use in Australian health care settings. METHODS: Cochrane and other existing reviews and meta-analyses of evidence were the basis for the review. Systematic literature searches were also conducted to identify relevant controlled trials published internationally between January 1999 and May 2002. The main inclusion criteria for studies were use of a controlled evaluation design and an outcome measure of continuous abstinence from smoking for at least five months. A three-tiered grading system for strength of evidence was used. RESULTS: Clinic and hospital systems to assess and document tobacco use and routine provision of cessation advice can double long-term quit rates. While brief intervention can achieve a significant effect at population level, at individual level there is a strong dose response between the number and length of sessions of tobacco cessation counselling and its effectiveness. Effective behavioural interventions can increase cessation rates by 50-100% compared with no intervention. Some pharmacotherapies are safe and also help to substantially increase cessation rates. CONCLUSIONS: Effective behavioural and pharmacological methods of tobacco cessation are available. IMPLICATIONS: Every smoker should be offered evidence-based advice and treatment to quit smoking. This includes pharmacotherapy, unless contra-indicated. Health professionals and health care settings can play a significant role in motivating and assisting smokers to quit.     

Tobacco use and quit attempts among methadone maintenance clients

OBJECTIVES: This study examined tobacco use prevalence, types of tobacco used, interest in quitting, and prior quit attempts among persons in methadone maintenance treatment. METHODS: Counselors collected surveys from 84% (550 of 655) of all clients in a 4-county metropolitan area. RESULTS: Most clients (77%) smoked cigarettes. Of the 59 former tobacco users, only 6 reported using a cessation pharmacotherapy to quit. Three quarters of the current smokers had attempted to quit at least once, with an average of 5 attempts. Most smokers (80%) were "somewhat" or "very" interested in quitting. CONCLUSIONS: The quit ratio among methadone maintenance treatment clients was 12%, compared with 50% nationwide. To reduce morbidity and mortality, cessation interventions must be developed and disseminated.     

Motivational Interviewing for encouraging quit attempts among unmotivated smokers: Study protocol of a randomized, controlled, efficacy trial

ABSTRACT: BACKGROUND: Although current clinical practice guidelines recommend Motivational Interviewing for use with smokers not ready to quit, the strength of evidence for its use is rated as not optimal. The purpose of the present study is to address key methodological limitations of previous studies by ensuring fidelity in the delivery of the Motivational Interviewing intervention, using an attention-matched control condition, and focusing on unmotivated smokers whom meta-analyses have indicated may benefit most from Motivational Interviewing. It is hypothesized that MI will be more effective at inducing quit attempts and smoking cessation at 6-month follow-up than brief advice to quit and an intensity-matched health education condition. METHODS: A sample of adult community resident smokers (N= 255) who report low motivation and readiness to quit are being randomized using a 2:2:1 treatment allocation to Motivational Interviewing, Health Education, or Brief Advice. Over 6 months, participants in Motivational Interviewing and Health Education receive 4 individual counseling sessions and participants in Brief Advice receive one brief in-person individual session at baseline. Rigorous monitoring and independent verification of fidelity will assure the counseling approaches are distinct and delivered as planned. Participants complete surveys at baseline, week 12 and 6-month follow-up to assess demographics, smoking characteristics, and smoking outcomes. Participants who decide to quit are provided with a self-help guide to quitting, help with a quit plan, and free pharmacotherapy. The primary outcome is self-report of one or more quit attempts lasting at least 24 hours between randomization and 6-month follow-up. The secondary outcome is biochemically confirmed 7-day point prevalence cessation at 6-month follow-up. Hypothesized mediators of the presumed treatment effect on quit attempts are greater perceived autonomy support and autonomous motivation. Use of pharmacotherapy is a hypothesized mediator of Motivational Interviewing's effect on cessation. DISCUSSION: This trial will provide the most rigorous evaluation to date of Motivational Interviewing's efficacy for encouraging unmotivated smokers to make a quit attempt. It will provide also provide effect-size estimates of MI's impact on smoking cessation to inform future clinical trials and inform the clinical practice guidelines. Trial registration ClinicalTrials.gov NCT01188018.     

Views on smoking cessation methods in ethnic minority communities: a qualitative investigation

OBJECTIVE: The purpose of this qualitative analysis is to increase our understanding of minority smokers' experiences and beliefs about guideline-recommended smoking cessation treatments. METHODS: We conducted sixteen focus groups (N=95) among current and former smokers from four ethnic minority communities in Minneapolis/St. Paul in 2005. Focus groups were conducted separately for American Indians, Vietnamese, Hmong and African Americans. RESULTS: Participants reported little experience with counseling and views on seeking help from physicians were mixed. African American and American Indian participants expressed feelings of mistrust and negative experiences with doctors. Hmong and Vietnamese smokers viewed doctors positively but did not regard them as an important resource to help with quitting, and especially for Vietnamese, the cultural value of mental control and self-determination was seen as most important to quit smoking. Across all the groups, pharmacotherapy was rarely utilized and participants had low knowledge and poor understanding of the benefits of pharmacotherapy. CONCLUSIONS: Personal beliefs, views toward doctors, and lack of knowledge are important determinants of the use of tobacco treatments among ethnic minority smokers. In order to increase minority smokers' utilization of evidence-based tobacco cessation treatments, effective strategies are needed to deliver accurate information about treatment from trusted sources.