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Original Investigation
October 30, 2017

Effect of Patient Navigation and Financial Incentives on Smoking Cessation Among Primary Care Patients at an Urban Safety-Net HospitalA Randomized Clinical Trial

Author Affiliations
  • 1Boston University, School of Medicine, Section of General Internal Medicine, Crosstown Center, Boston, Massachusetts
  • 2Boston University, School of Public Health, Department of Community Health Sciences, Crosstown Center, Boston, Massachusetts
  • 3Boston Medical Center, Section of General Internal Medicine, Crosstown Center, Boston, Massachusetts
  • 4Bridge Over Troubled Waters, Boston, Massachusetts
  • 5University of Massachusetts Medical School, Division of Preventive and Behavioral Medicine, Department of Medicine, Worcester
JAMA Intern Med. Published online October 30, 2017. doi:10.1001/jamainternmed.2017.4372
Key Points

Question  Does a multicomponent intervention with a patient navigator and financial incentives for biochemically confirmed smoking cessation improve smoking cessation rates at 12 months among underserved adult primary care smokers when compared with an enhancement of usual care alone?

Findings  In this randomized clinical trial that included 352 adults, the proportion with biochemically confirmed smoking cessation at 12 months was 11.9% with navigation and incentives vs 2.3% with an enhancement of usual care.

Meaning  Among smokers at an urban safety-net hospital, navigation and incentives for smoking cessation significantly increased smoking cessation rates.

Abstract

Importance  While the proportion of adults who smoke cigarettes has declined substantially in the past decade, socioeconomic disparities in cigarette smoking remain. Few interventions have targeted low socioeconomic status (SES) and minority smokers in primary care settings.

Objective  To evaluate a multicomponent intervention to promote smoking cessation among low-SES and minority smokers.

Design, Setting, and Participants  For this prospective, unblinded, randomized clinical trial conducted between May 1, 2015, and September 4, 2017, adults 18 years and older who spoke English, smoked 10 or more cigarettes per day in the past week, were contemplating or preparing to quit smoking, and had a primary care clinician were recruited from general internal medicine and family medicine practices at 1 large safety-net hospital in Boston, Massachusetts.

Interventions  Patients were randomized to a control group that received an enhancement of usual care (n = 175 participants) or to an intervention group that received up to 4 hours of patient navigation delivered over 6 months in addition to usual care, as well as financial incentives for biochemically confirmed smoking cessation at 6 and 12 months following enrollment (n = 177 participants).

Main Outcomes and Measures  The primary outcome determined a priori was biochemically confirmed smoking cessation at 12 months.

Results  Among 352 patients who were randomized (mean [SD] age, 50.0 [11.0] years; 191 women [54.3%]; 197 participants who identified as non–Hispanic black [56.0%]; 40 participants who identified as Hispanic of any race [11.4%]), all were included in the intention-to-treat analysis. At 12 months following enrollment, 21 participants [11.9%] in the navigation and incentives group, compared with 4 participants [2.3%] in the control group, had quit smoking (odds ratio, 5.8; 95% CI, 1.9-17.1; number needed to treat, 10.4; P < .001). In prespecified subgroup analyses, the intervention was particularly beneficial for older participants (19 [19.8%] vs 1 [1.0%]; P < .001), women (17 [16.8%] vs 2 [2.2%]; P < .001), participants with household yearly income of $20 000 or less (15 [15.5%] vs 3 [3.1%]; P = .003), and nonwhite participants (21 [15.2%] vs 4 [3.0%]; P < .001).

Conclusions and Relevance  In this study of adult daily smokers at 1 large urban safety-net hospital, patient navigation and financial incentives for smoking cessation significantly increased the rates of smoking cessation.

Trial Registration  clinicaltrials.gov Identifier: NCT02351609

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