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Original Investigation
February 2015

Proactive Tobacco Cessation Outreach to Smokers of Low Socioeconomic Status: A Randomized Clinical Trial

Author Affiliations
  • 1Division of General Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
  • 2Department of Social and Behavior Sciences, Harvard School of Public Health, Boston, Massachusetts
  • 3Harvard Medical School, Boston, Massachusetts
  • 4Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
  • 5Division of General Internal Medicine, Massachusetts General Hospital, Boston
  • 6Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
JAMA Intern Med. 2015;175(2):218-226. doi:10.1001/jamainternmed.2014.6674

Importance  Widening socioeconomic disparities in mortality in the United States are largely explained by slower declines in tobacco use among smokers of low socioeconomic status (SES) than among those of higher SES, which points to the need for targeted tobacco cessation interventions. Documentation of smoking status in electronic health records (EHRs) provides the tools for health systems to proactively offer tobacco treatment to socioeconomically disadvantaged smokers.

Objective  To evaluate a proactive tobacco cessation strategy that addresses sociocontextual mediators of tobacco use for low-SES smokers.

Design, Setting, and Participants  This prospective, randomized clinical trial included low-SES adult smokers who described their race and/or ethnicity as black, Hispanic, or white and received primary care at 1 of 13 practices in the greater Boston area (intervention group, n = 399; control group, n = 308).

Interventions  We analyzed EHRs to identify potentially eligible participants and then used interactive voice response (IVR) techniques to reach out to them. Consenting patients were randomized to either receive usual care from their own health care team or enter an intervention program that included (1) telephone-based motivational counseling, (2) free nicotine replacement therapy (NRT) for 6 weeks, (3) access to community-based referrals to address sociocontextual mediators of tobacco use, and (4) integration of all these components into their normal health care through the EHR system.

Main Outcomes and Measures  Self-reported past-7-day tobacco abstinence 9 months after randomization (“quitting”), assessed by automated caller or blinded study staff.

Results  The intervention group had a higher quit rate than the usual care group (17.8% vs 8.1%; odds ratio, 2.5; 95% CI, 1.5-4.0; number needed to treat, 10). We examined whether use of intervention components was associated with quitting among individuals in the intervention group: individuals who participated in the telephone counseling were more likely to quit than those who did not (21.2% vs 10.4%; P < .001). There was no difference in quitting by use of NRT. Quitting did not differ by a request for a community referral, but individuals who used their referral were more likely to quit than those who did not (43.6% vs 15.3%; P < .001).

Conclusions and Relevance  Proactive, IVR-facilitated outreach enables engagement with low-SES smokers. Providing counseling, NRT, and access to community-based resources to address sociocontextual mediators among smokers reached in this setting is effective.

Trial Registration Identifier: NCT01156610