A Proactive Smoking Cessation Intervention for Socioeconomically Disadvantaged Smokers: The Role of Smoking-Related Stigma.

Introduction: Smoking denormalization has been paralleled by reduced smoking prevalence, but smoking rates among socioeconomically disadvantaged populations remain high. The social unacceptability of smoking has also led to increased perceptions of smoking-related stigma. By examining how smoking stigma influences cessation intervention effectiveness, we can better tailor interventions to socioeconomically disadvantaged smokers. Aims and Methods: Data are from a randomized controlled trial evaluating the effectiveness of a proactive cessation intervention on abstinence. Current smokers enrolled in Minnesota Health Care Programs were randomized to proactive outreach (n = 1200) or usual care (n = 1206). The intervention included mailings, telephone outreach, counseling, and access to free cessation treatments. Using baseline measurements, groups with lower (n = 1227) and higher (n = 1093) perceived stigma were formed. Intervention, stigma, and their interaction term were added to a logistic regression modeling abstinence at 12 months. Results: Lower perceived smoking-related stigma was associated with less support for quitting, lower rates of physician quitting advice, and less motivation for quitting. A logistic regression modeling abstinence found a significant intervention × stigma interaction. The proactive intervention was more effective among smokers with lower perceived smoking-related stigma (odds ratio 1.94, 95% confidence interval, 1.29 to 2.92) than those with higher perceived smoking-related stigma (odds ratio 1.04, 95% confidence interval, 0.70 to 1.55). Discussion: Smokers with lower perceived smoking-related stigma had social environments that were conducive to smoking, received less physician advice to quit, and were less motivated to quit than higher stigma smokers. Despite these barriers, the intervention was more effective for lower stigma smokers, suggesting that proactive outreach is an efficient treatment for these hard-to-reach smokers. Implications: Smoking denormalization has led to increased perceptions of smoking-related stigma among many smokers; however, little is known about how this stigma influences the cessation process. In the present study, smokers with lower levels of perceived smoking-related stigma lived in social environments that were more conducive to smoking and were less motivated to quit than higher stigma smokers. Despite these barriers, our proactive outreach cessation intervention was more effective for lower stigma smokers, suggesting that interventions which utilize proactive outreach to stimulate interest in quitting and offer facilitated access to free cessation treatments are an effective treatment approach for these hard-to-reach smokers. These strategies may be particularly effective for motivating smokers enrolled in government-subsidized health insurance programs to take advantage of cessation resources.

Coevolution of Information Sharing and Implementation of Evidence-Based Practices Among North American Tobacco Cessation Quitlines.

OBJECTIVES: We examined the coevolution of information sharing and implementation of evidence-based practices among US and Canadian tobacco cessation quitlines within the North American Quitline Consortium (NAQC). METHODS: Web-based surveys were used to collect data from key respondents representing each of 74 participating funders of NAQC quitlines during the summer and fall of 2009, 2010, and 2011. We used stochastic actor-based models to estimate changes in information sharing and practice implementation in the NAQC network. RESULTS: Funders were more likely to share information within their own country and with funders that contracted with the same service provider. Funders contracting with larger service providers shared less information but implemented significantly more practices. Funders connected to larger numbers of tobacco control researchers more often received information from other funders. Intensity of ties to the NAQC network administrative organization did not influence funders' decisions to share information or implement practices. CONCLUSIONS: Our findings show the importance of monitoring the NAQC network over time. We recommend increased cross-border information sharing and sharing of information between funders contracting with different and smaller service providers.

Implementation of tobacco cessation quitline practices in the United States and Canada.

OBJECTIVES: We examined relationships between implementation of tobacco quitline practices, levels of evidence of practices, and quitline reach and spending. METHODS: In June and July 2009, a total of 176 quitline funders and providers in the United States and Canada completed a survey on quitline practices, in particular quitline-level implementation for the reported practices. From these data, we selected and categorized evidence-based and emerging quitline practices by the strength of the evidence for each practice to increase quitline efficacy and reach. RESULTS: The proportion of quitlines implementing each practice ranged from 3% (text messaging) to 92% (providing a multiple-call protocol). Implementation of practices showing higher levels of evidence for increasing either reach or efficacy showed moderate but significant positive correlations with both reach outcomes and spending levels. The strongest correlation was between reach outcomes and spending levels (r=0.80; P<.01). CONCLUSIONS: The strong relationship between quitline spending and reach reinforces the need to increase quitline funding to levels commensurate with national cessation goals.

Culture, acculturation and smoking use in Hmong, Khmer, Laotians, and Vietnamese communities in Minnesota.

BACKGROUND: Southeast Asian communities in the United States have suffered from high rates of tobacco use and high rates of chronic diseases associated with firsthand and secondhand smoking. Research is needed on how best to reduce and prevent tobacco use and exposure to secondhand smoke in these communities. The objective of this study was to examine how tobacco use patterns in Minnesota's Southeast Asian communities have been shaped by culture, immigration, and adjustment to life in America in order to inform future tobacco control strategies. METHODS: The study consisted of semi-structured interviews with 60 formal and informal leaders from Minnesota's Hmong, Khmer (Cambodian), Lao, and Vietnamese communities and incorporated principles of community-based participatory research. RESULTS: Among Khmer, Lao and Vietnamese, tobacco in the homeland was a valued part of material culture and was used to signify social status, convey respect, and support social rituals among adult men (the only group for whom smoking was acceptable). Among the Hmong, regular consumption of tobacco was unacceptable and rarely seen until the civil war in Laos when a number of Hmong soldiers became smokers. In Minnesota, social norms have begun to shift, with smoking becoming less acceptable. Although older male smokers felt social pressure to quit, smoking functioned to reduce the stress of social isolation, economic hardship, prior trauma, and the loss of power and status. Youth and younger women no longer felt as constrained by culturally-rooted social prohibitions to smoke. CONCLUSIONS: Leaders from Minnesota's Southeast Asian communities perceived key changes in tobacco-related attitudes, beliefs, and behaviors which were embedded in the context of shifting power, status, and gender roles within their communities. This has practical implications for developing policy and interventions. Older Southeast Asians are likely to benefit from culturally-tailored programs (e.g., that value politeness and the importance of acting in ways that benefit the family, community, and clan) and programs that work with existing social structures, as well as initiatives that address smokers' psychological distress and social isolation. Leaders remained uncertain about how to address smoking uptake among youth, pointing to a need for additional research.

Assessing the preconditions for communication influence on decision making: the North American Quitline Consortium.

The network of North American quitlines is a loose confederation of telephone-based smoking cessation professionals, including smoking cessation counseling providers, funders, researcher and policy advocates. Each quitline has some leeway in the types of services it provides, and the purpose of this article is to identify factors that explain such choices. Representatives from quitline organizations responded to a survey regarding the importance of several items that were hypothesized to influence general intentions to adopt and implement new cessation methods. Results indicate that internal (to the quitline) constraints are positively associated with consensus processes and that implementation of practices in general was more likely if consensus processes were used. Unilateral decision making (one person within an organization makes decisions for the quitline on his/her own) was unrelated to either internal or external constraints and was negatively associated with adoption of quitline practices. Discussion focuses on factors that influence consensus decision-making processes beyond those investigated in the article.

Large-system transformation in health care: a realist review.

CONTEXT: An evidence base that addresses issues of complexity and context is urgently needed for large-system transformation (LST) and health care reform. Fundamental conceptual and methodological challenges also must be addressed. The Saskatchewan Ministry of Health in Canada requested a six-month synthesis project to guide four major policy development and strategy initiatives focused on patient- and family-centered care, primary health care renewal, quality improvement, and surgical wait lists. The aims of the review were to analyze examples of successful and less successful transformation initiatives, to synthesize knowledge of the underlying mechanisms, to clarify the role of government, and to outline options for evaluation. METHODS: We used realist review, whose working assumption is that a particular intervention triggers particular mechanisms of change. Mechanisms may be more or less effective in producing their intended outcomes, depending on their interaction with various contextual factors. We explain the variations in outcome as the interplay between context and mechanisms. We nested this analytic approach in a macro framing of complex adaptive systems (CAS). FINDINGS: Our rapid realist review identified five "simple rules" of LST that were likely to enhance the success of the target initiatives: (1) blend designated leadership with distributed leadership; (2) establish feedback loops; (3) attend to history; (4) engage physicians; and (5) include patients and families. These principles play out differently in different contexts affecting human behavior (and thereby contributing to change) through a wide range of different mechanisms. CONCLUSIONS: Realist review methodology can be applied in combination with a complex system lens on published literature to produce a knowledge synthesis that informs a prospective change effort in large-system transformation. A collaborative process engaging both research producers and research users contributes to local applications of universal principles and mid-range theories, as well as to a more robust knowledge base for applied research. We conclude with suggestions for the future development of synthesis and evaluation methods.

The comparative effectiveness of clinic, work-site, phone, and Web-based tobacco treatment programs.

INTRODUCTION: Tobacco treatment programs may be offered in clinical settings, at work-sites, via telephone helplines, or over the Internet. Little comparative data exist regarding the real-world effectiveness of these programs. This paper compares the reach, effectiveness, and costs of these different modes of cessation assistance. METHODS: This is an observational study of cohorts of participants in Minnesota's QUITPLAN programs in 2004. Cessation assistance was provided in person at 9 treatment centers, using group counseling at 68 work-sites, via a telephone helpline, or via the Internet. The main outcomes of the study are enrollment by current smokers, self-reported 30-day abstinence, and cost per quit. Reach was calculated statewide for the helpline and Web site, regionally for the treatment centers, and for the employee population for work-site programs. RESULTS: Enrollment was greatest for the Web site (n = 4,698), followed by the helpline (n = 2,351), treatment centers (n = 616), and work-sites (n = 479). The Web site attracted younger smokers. Smokers at treatment centers had higher levels of nicotine dependence. The helpline reached more socially disadvantaged smokers. Responder 30-day abstinence rates were higher for the helpline (29.3%), treatment centers (25.8%), and work-sites (19.6%) compared with the online program (12.5%). These differences persisted after controlling for baseline differences in participant characteristics and use of pharmacological therapy. The cost per quit was lowest for the Web site program ($291 per quit, 95% CI = $229-$372). DISCUSSION: Treatment center, work-site, helpline, and Web site programs differ in their reach, effectiveness, and estimated cost per quit. Each program plays a part in assisting populations of tobacco users in quitting.

Exploring the relationship between acculturation and smoking behavior within four Southeast Asian communities of Minnesota.

OBJECTIVES: This study sought to measure the prevalence of smoking among the Hmong, Vietnamese, Lao, and Cambodian communities of Minnesota and explore the relationship between smoking and acculturation within these communities. METHODS: A community-based participatory research framework was used through all phases of this study. Standard as well as community-developed measures of acculturation were used. Data were obtained by face-to-face and telephone interviews with 1,628 respondents from July 2006 to March 2007. RESULTS: Vietnamese and Cambodian men smoke at higher rates than men in the U.S. general population (35% and 58% compared with 20%, respectively). Most men across the Vietnamese, Cambodian, and Lao populations started smoking prior to immigration to the United States, although most former smokers quit smoking after immigration to the United States. Most male Hmong respondents started smoking after immigration. Education was predictive of smoking status across genders, with less education associated with greater odds of being a smoker. Logistic regression found some acculturation measures to be predictive of smoking status across both genders: Less acculturated male respondents and more acculturated female respondents are more likely to be smokers. DISCUSSION: Results of this study suggest that the role of acculturation in tobacco use may not be straightforward as has been presented previously. Other factors, such as social norms and cultural or linguistic isolation, may also be playing a role in tobacco use patterns and may play different roles for different subgroups. Further research is needed within each population and subgroups within those populations to understand these relationships and how they affect smoking behavior.

They Came, But Will They Come Back? An Observational Study of Re-Enrollment Predictors for the Oklahoma Tobacco Helpline.

PURPOSE: Although quitlines reach 1% to 2% of tobacco users annually, additional efforts are needed to increase their impact. We hypothesized that offering less intensive services would increase the rate of re-enrollment in any service, as well as re-enrollment in more intensive services. This study describes the enrollment patterns and identifies re-enrollment predictors for Oklahoma Tobacco Helpline (OTH) participants. DESIGN: This study used a comparative observational design. SETTING: The setting for this study was the OTH, a telephone-based cessation program funded by the Oklahoma Tobacco Settlement Endowment Trust. The OTH participants could select either a multicall telephone-based cessation program (MC) or one or more individual services (IS), including a 2-week nicotine replacement therapy (NRT) starter kit, e-mail or text-based support, and a printed quit guide. PARTICIPANTS: A total of 35 648 first-time adult OTH participants eligible for the multicall program from October 2015 through September 2018 were included. MEASURES: Demographic and tobacco use variables and initial quitline service selection were collected at intake. Additional service utilization was tracked for 6 months following initial registration. ANALYSIS: Pearson chi-square and t tests were used to test for significant differences between groups. Multinomial logistic regression was used to examine predictors of re-enrollment. RESULTS: Individual services were more frequently selected (n = 17 266) than MC (n = 14 326), despite all users being eligible for MC. A much higher proportion of IS registrants re-enrolled than MC registrants (16% vs 3%, P < .0001) Among the IS cohort, those who received an NRT follow-up call were 14.7 times more likely to re-enroll in IS, and 7.8 times more likely to re-enroll in MC, than those who were not reached by phone. CONCLUSIONS: Access to free NRT without a telephone-coaching requirement is a draw for tobacco users, especially those with lower income and the uninsured. The results suggest the value of increasing use of nonphone services in an effort to increase interest in quitting and reach.

A cross-sectional study of the relationship of proximal smoking environments and cessation history, plans, and self-efficacy among low-income smokers.

INTRODUCTION: Proximal environments could facilitate smoking cessation among low-income smokers by making cessation appealing to strive for and tenable. AIMS: We sought to examine how home smoking rules and proximal environmental factors such as other household members' and peers' smoking behaviors and attitudes related to low-income smokers' past quit attempts, readiness, and self-efficacy to quit. METHODS: This analysis used data from Offering Proactive Treatment Intervention (OPT-IN) (randomized control trial of proactive tobacco cessation outreach) baseline survey, which was completed by 2,406 participants in 2011/12. We tested the associations between predictors (home smoking rules and proximal environmental factors) and outcomes (past-year quit attempts, readiness to quit, and quitting self-efficacy). RESULTS: Smokers who lived in homes with more restrictive household smoking rules, and/or reported having 'important others' who would be supportive of their quitting, were more likely to report having made a quit attempt in the past year, had greater readiness to quit, and greater self-efficacy related to quitting. CONCLUSIONS: Adjustments to proximal environments, including strengthening household smoking rules, might encourage cessation even if other household members are smokers.

Online advertising as a public health and recruitment tool: comparison of different media campaigns to increase demand for smoking cessation interventions.

BACKGROUND: To improve the overall impact (reach x efficacy) of cessation treatments and to reduce the population prevalence of smoking, innovative strategies are needed that increase consumer demand for and use of cessation treatments. Given that 12 million people search for smoking cessation information each year, online advertising may represent a cost-efficient approach to reach and recruit online smokers to treatment. Online ads can be implemented in many forms, and surveys consistently show that consumers are receptive. Few studies have examined the potential of online advertising to recruit smokers to cessation treatments. OBJECTIVE: The aims of the study were to (1) demonstrate the feasibility of online advertising as a strategy to increase consumer demand for cessation treatments, (2) illustrate the tools that can be used to track and evaluate the impact of online advertising on treatment utilization, and (3) highlight some of the methodological challenges and future directions for researchers. METHODS: An observational design was used to examine the impact of online advertising compared to traditional recruitment approaches (billboards, television and radio ads, outdoor advertising, direct mail, and physician detailing) on several dependent variables: (1) number of individuals who enrolled in Web- or telephone-based cessation treatment, (2) the demographic, smoking, and treatment utilization characteristics of smokers recruited to treatment, and (3) the cost to enroll smokers. Several creative approaches to online ads (banner ads, paid search) were tested on national and local websites and search engines. The comparison group was comprised of individuals who registered for Web-based cessation treatment in response to traditional advertising during the same time period. RESULTS: A total of 130,214 individuals responded to advertising during the study period: 23,923 (18.4%) responded to traditional recruitment approaches and 106,291 (81.6%) to online ads. Of those who clicked on an online ad, 9655 (9.1%) registered for cessation treatment: 6.8% (n = 7268) for Web only, 1.1% (n = 1119) for phone only, and 1.2% (n = 1268) for Web and phone. Compared to traditional recruitment approaches, online ads recruited a higher percentage of males, young adults, racial/ethnic minorities, those with a high school education or less, and dependent smokers. Cost-effectiveness analyses compare favorably to traditional recruitment strategies, with costs as low as US $5-$8 per enrolled smoker. CONCLUSIONS: Developing and evaluating new ways to increase consumer demand for evidence-based cessation services is critical to cost-efficiently reduce population smoking prevalence. Results suggest that online advertising is a promising approach to recruit smokers to Web- and telephone-based cessation interventions. The enrollment rate of 9.1% exceeds most studies of traditional recruitment approaches. The powerful targeting capabilities of online advertising present new opportunities to reach subgroups of smokers who may not respond to other forms of advertising. Online advertising also provides unique evaluation opportunities and challenges to determine rigorously its impact and value.

Utilization of smoking cessation informational, interactive, and online community resources as predictors of abstinence: cohort study.

BACKGROUND: The association between greater utilization of Web-assisted tobacco interventions and increased abstinence rates is well recognized. However, there is little information on how utilization of specific website features influences quitting. OBJECTIVE: To determine the association between utilization of informational, interactive, and online community resources (eg. bulletin boards) and abstinence rates, with the broader objective to identify potential strategies for improving outcomes for Web-assisted tobacco interventions. METHODS: In Spring 2004, a cohort of 607 quitplan.com users consented to participate in an evaluation of quitplan.com, a Minnesota branded version of QuitNet.com. We developed utilization measures for different site features: general information, interactive diagnostic tools and quit planning tools, online expert counseling, passive (ie, reading of bulletin boards) and active (ie, public posting) online community engagement, and one-to-one messaging with other virtual community members. Using bivariate, multivariate, and path analyses, we examined the relationship between utilization of specific site features and 30-day abstinence at 6 months. RESULTS: The most commonly used resources were the interactive quit planning tools (used by 77% of site users). Other informational resources (ie, quitting guides) were used more commonly (60% of users) than passive (38%) or active (24%) community features. Online community engagement through one-to-one messaging was low (11%) as was use of online counseling (5%). The 30-day abstinence rate among study participants at 6 months was 9.7% (95% Confidence Interval [CI] 7.3% - 12.1%). In the logistic regression model, neither the demographic data (eg, age, gender, education level, employment, or insurance status) nor the smoking-related data (eg, cigarettes per day, time to first morning cigarette, baseline readiness to quit) nor use of smoking cessation medications entered the model as significant predictors of abstinence. Individuals who used the interactive quit planning tools once, two to three times, or four or more times had an odds of abstinence of 0.65 (95% Confidence Interval [CI] 0.22 - 1.94), 1.87 (95% CI 0.77 - 4.56), and 2.35 (95% CI 1.0 - 5.58), respectively. The use of one-to-one messages (reference = none vs 1 or more) entered the final model as potential predictor for abstinence, though the significance of this measure was marginal (OR = 1.91, 95% CI 0.92 - 3.97, P = .083). In the path analysis, an apparent association between active online community engagement and abstinence was accounted for in large part by increased use of interactive quitting tools and one-to-one messaging. CONCLUSIONS: Use of interactive quitting tools, and perhaps one-to-one messaging with other members of the online community, was associated with increased abstinence rates among quitplan.com users. Designs that facilitate use of these features should be considered.

Networks as systems.

Purpose The purpose of this paper is to present a case study of the World Health Organization's Global Healthcare Workforce Alliance (GHWA). Based on a commissioned evaluation of GHWA, it applies network theory and key concepts from systems thinking to explore network emergence, effectiveness, and evolution to over a ten-year period. The research was designed to provide high-level strategic guidance for further evolution of global governance in human resources for health (HRH). Design/methodology/approach Methods included a review of published literature on HRH governance and current practice in the field and an in-depth case study whose main data sources were relevant GHWA background documents and key informant interviews with GHWA leaders, staff, and stakeholders. Sampling was purposive and at a senior level, focusing on board members, executive directors, funders, and academics. Data were analyzed thematically with reference to systems theory and Shiffman's theory of network development. Findings Five key lessons emerged: effective management and leadership are critical; networks need to balance "tight" and "loose" approaches to their structure and processes; an active communication strategy is key to create and maintain support; the goals, priorities, and membership must be carefully focused; and the network needs to support shared measurement of progress on agreed-upon goals. Shiffman's middle-range network theory is a useful tool when guided by the principles of complex systems that illuminate dynamic situations and shifting interests as global alliances evolve. Research limitations/implications This study was implemented at the end of the ten-year funding cycle. A more continuous evaluation throughout the term would have provided richer understanding of issues. Experience and perspectives at the country level were not assessed. Practical implications Design and management of large, complex networks requires ongoing attention to key issues like leadership, and flexible structures and processes to accommodate the dynamic reality of these networks. Originality/value This case study builds on growing interest in the role of networks to foster large-scale change. The particular value rests on the longitudinal perspective on the evolution of a large, complex global network, and the use of theory to guide understanding.

A Good Idea May Not Be Good Enough: Stakeholder Buy In to QuitConnect, a National Smokers' Registry.

PURPOSE: To examine interest and concerns among those who fund and operate state-run smoking cessation helplines (quitlines) about the concept of creating a centralized smokers' registry that could be used to reengage smokers after they receive initial quitline support services. DESIGN: We conducted 3, hour-long focus groups with stakeholders, covering the perceived benefits and barriers to creating a smokers' registry. SETTING: The focus groups were conducted via telephone. PARTICIPANTS: Three groups participated: quitline service providers (n = 14), quitline funders (n = 9), and national quitline partners (n = 8). METHOD: Data collection: Focus groups were recorded, transcribed, and coded for major relevant themes. Analysis Strategies: We used a grounded theory approach. RESULTS: Stakeholders were generally positive about the concept of a centralized smokers' registry (ie, QuitConnect), especially with its potential to link relapsed smokers to ongoing research studies designed to help smokers achieve abstinence from tobacco. However, stakeholders expressed concern about QuitConnect duplicating services already offered by state quitlines. CONCLUSION: Despite a common goal, many state quitline stakeholders had strong reservations about the creation of a centralized smokers' registry unless they could see clear evidence that the registry added value and was not duplicative of their existing services.

Impact of a statewide Internet-based tobacco cessation intervention.

BACKGROUND: An increasing number of people have access to the Internet, and more people are seeking tobacco cessation resources online every year. Despite the proliferation of various online interventions and their evident acceptance and reach, little research has addressed their impact in the real world. Typically, low response rates to Internet-based follow-up surveys generate unrepresentative samples and large confidence intervals when reporting results. OBJECTIVES: The aim of this study was to achieve a high response rate on follow-up evaluation in order to better determine the impact of an Internet-based tobacco cessation intervention provided to tobacco users in Minnesota, United States. METHODS: Participants included 607 men and women aged 18 and over residing in Minnesota who self-reported current tobacco use when registering for an Internet-based tobacco cessation program between February 2 and April 13, 2004. Participants were given access to an interactive website with features including social support, expert systems, proactive email, chat sessions, and online counselors. Mixed-mode follow-up (online survey with telephone survey for online nonrespondents) occurred 6 months after registration. RESULTS: Of the study participants, 77.6% (471/607) responded to the 6-month follow-up survey (39.4% online and 38.2% by telephone). Among respondents, 17.0% (80/471, 95% CI = 13.6%-20.4%) reported that they had not smoked in the past 7 days (observed rate). Assuming all nonrespondents were still smoking (missing=smoking rate), the quit rate was 13.2% (80/607, 95% CI = 10.5%-15.9%). CONCLUSIONS: This mixed-mode follow-up survey of an online smoking cessation program achieved a high response rate and provides a more accurate estimate of long-term cessation rates than has been previously reported. Quit rates for the Internet-based tobacco cessation program were higher than those expected for unassisted quit attempts and are comparable to other evidence-based behavioral interventions. The similarities between quit rates demonstrates that an Internet-based cessation program may have as great an impact as, and can have wider reach than, other cessation programs such as those delivered by telephone. With over 100000 people having visited the website and over 23000 having registered, a 6-month self-reported quit rate of 13.2% suggests that the quitplan.com program helped over 3000 Minnesotans remain tobacco free for at least 6 months. Results of this study suggest that an Internet-based cessation program is a useful tool in states' efforts to provide comprehensive cessation tools for smokers.

Treatment barriers among younger and older socioeconomically disadvantaged smokers.

OBJECTIVES: Underutilization of smoking cessation treatments contributes to high rates of smoking in socioeconomically disadvantaged populations. Guided by a conceptual framework, the present study explored how healthcare provider factors, social environment characteristics, and cessation beliefs influence treatment utilization among low-income smokers and whether these associations vary by age. STUDY DESIGN: Analyses were conducted on baseline data from 2406 participants enrolled in a randomized controlled trial that evaluated the effectiveness of a proactive outreach cessation intervention among a sample of younger (18-34 years) and older (35-64 years) smokers enrolled in public healthcare assistance programs. METHODS: Multivariable logistic regression models predicted past year cessation treatment utilization (CTU) among younger and older smokers. Independent variables included measures of healthcare provider barriers, social environment characteristics, and cessation beliefs. RESULTS: Younger smokers were less likely to have CTU than older smokers (27.2% vs 36.2%; P <.001). In both groups, number of cigarettes per day, more problems accessing healthcare, receiving medication-related cessation advice, and readiness to quit were positively associated with CTU (P <.05). Among younger smokers, living with another smoker was associated with lower odds of CTU while receipt of cessation advice was associated (P = .033) with higher odds of CTU. CONCLUSIONS: In this sample of low-income smokers, interest in quitting was high but treatment utilization was low. Increasing utilization of cessation treatments via interventions that target issues specific to low-income smokers, including healthcare provider access and advice, the home environment, and motivation to quit, is an important step toward reducing smoking rates in this population.

Engagement and attrition in Internet smoking cessation interventions: Insights from a cross-sectional survey of "one-hit-wonders".

INTRODUCTION: Internet interventions can reach large numbers of individuals. However, low levels of engagement and high rates of follow-up attrition are common, presenting major challenges to evaluation. This study investigated why registrants of an Internet smoking cessation intervention did not return after joining ("one hit wonders"), and explored the impact of graduated incentives on survey response rates and responder characteristics. METHODS: A sample of "one hit wonders" that registered on a free smoking cessation website between 2014 and 2015 were surveyed. The initial invitation contained no incentive. Subsequent invitations were sent to random subsamples of non-responders from each previous wave offering $25 and $50 respectively. Descriptive statistics characterized respondents on demographic characteristics, reasons for not returning, and length of time since last visit. Differences were investigated with Fisher's Exact tests, Kruskal-Wallis, and logistic regression. RESULTS: Of 8779 users who received the initial invitation, 132 completed the survey (1.5%). Among those subsequently offered a $25 incentive, 127 (3.7%) responded. Among those offered a $50 incentive, 97 responded (5.7%). The most common reasons endorsed for not returning were being unable to quit (51%), not having enough time (33%), having forgotten about the website (28%), and not being ready to quit (21%). Notably, however, 23% reported not returning because they had successfully quit smoking. Paid incentives yielded a higher proportion of individuals who were still smoking than the $0 incentive (72% vs. 61%). Among $0 and $25 responders, likelihood of survey response decreased with time since registration; the $50 incentive removed the negative effect of time-since-registration on probability of response. CONCLUSIONS: One third of participants that had disengaged from an Internet intervention reported abstinence at follow-up, suggesting that low levels of engagement are not synonymous with treatment failure in all cases. Paid incentives above $25 may be needed to elicit survey responses, especially among those with longer intervals of disengagement from an intervention.

A time-responsive tool for informing policy making: rapid realist review.

BACKGROUND: A realist synthesis attempts to provide policy makers with a transferable theory that suggests a certain program is more or less likely to work in certain respects, for particular subjects, in specific kinds of situations. Yet realist reviews can require considerable and sustained investment over time, which does not always suit the time-sensitive demands of many policy decisions. 'Rapid Realist Review' methodology (RRR) has been developed as a tool for applying a realist approach to a knowledge synthesis process in order to produce a product that is useful to policy makers in responding to time-sensitive and/or emerging issues, while preserving the core elements of realist methodology. METHODS: Using examples from completed RRRs, we describe key features of the RRR methodology, the resources required, and the strengths and limitations of the process. All aspects of an RRR are guided by both a local reference group, and a group of content experts. Involvement of knowledge users and external experts ensures both the usability of the review products, as well as their links to current practice. RESULTS: RRRs have proven useful in providing evidence for and making explicit what is known on a given topic, as well as articulating where knowledge gaps may exist. From the RRRs completed to date, findings broadly adhere to four (often overlapping) classifications: guiding rules for policy-making; knowledge quantification (i.e., the amount of literature available that identifies context, mechanisms, and outcomes for a given topic); understanding tensions/paradoxes in the evidence base; and, reinforcing or refuting beliefs and decisions taken. CONCLUSIONS: 'Traditional' realist reviews and RRRs have some key differences, which allow policy makers to apply each type of methodology strategically to maximize its utility within a particular local constellation of history, goals, resources, politics and environment. In particular, the RRR methodology is explicitly designed to engage knowledge users and review stakeholders to define the research questions, and to streamline the review process. In addition, results are presented with a focus on context-specific explanations for what works within a particular set of parameters rather than producing explanations that are potentially transferrable across contexts and populations. For policy makers faced with making difficult decisions in short time frames for which there is sufficient (if limited) published/research and practice-based evidence available, RRR provides a practical, outcomes-focused knowledge synthesis method.

Experience of smokers and recent quitters with smokefree regulations and quitting.

BACKGROUND: Bans on smoking in public areas have increased as knowledge of secondhand smoke dangers has grown. Restrictions on smoking in public areas may lead to less smoking and increased quitting. PURPOSE: This study examines the experiences of smokers and recent quitters with local smokefree regulations to better understand the possible mechanisms by which smokefree regulations affect individual tobacco users' patterns of tobacco consumption and quitting. METHODS: Fifteen in-depth interviews and thirteen focus groups were conducted with tobacco users and recent quitters formerly enrolled in cessation programs provided by ClearWay Minnesota(SM). Data were collected 3 months after smokefree legislation was adopted in the Minneapolis/St. Paul metropolitan area in 2006, and were stratified by tobacco use status and strength of regulation. Essential themes were extracted using NVivo 8 software in 2011. RESULTS: Study participants reported that smokefree legislation forced them to confront their addiction. They experienced apprehension, frustration, and panic anticipating smoking restrictions. This motivated some to attempt to quit, whereas others felt punished by and angry at government intrusion. Both current and former tobacco users felt smokefree regulations contributed to stigmatizing smokers. They also reported smokefree legislation reduced the temptation to smoke. The physical absence of cigarette smoke in bars and restaurants appeared to support quit attempts. The inconvenience of smoking outside was reported to have a similar effect. CONCLUSIONS: Essential mechanisms by which bans influenced patterns of tobacco use and quitting include confronting addiction, temptation, inconvenience, and social norms. These findings highlight the success of tobacco control advocates in denormalizing tobacco use, and suggest that some tobacco users may be internalizing negative messages about tobacco.

Outcomes and cost-effectiveness of two nicotine replacement treatment delivery models for a tobacco quitline.

Many tobacco cessation quitlines provide nicotine replacement therapy (NRT) in the U.S. but consensus is lacking regarding the best shipping protocol or NRT amounts. We evaluated the impact of the Minnesota QUITPLAN(®) Helpline's shift from distributing NRT using a single eight-week shipment to a two-shipment protocol. For this observational study, the eight week single-shipment cohort (n = 247) received eight weeks of NRT (patches or gum) at once, while the split-shipment cohort (n = 160) received five weeks of NRT (n = 94), followed by an additional three weeks of NRT if callers continued with counseling (n = 66). Patient satisfaction, retention, quit rates, and cost associated with the three groups were compared. A higher proportion of those receiving eight weeks of NRT, whether in one or two shipments, reported that the helpline was "very helpful" (77.2% of the single-shipment group; 81.1% of the two-shipment group) than those receiving five weeks of NRT (57.8% of the one-shipment group) (p = 0.004). Callers in the eight week two-shipment group completed significantly more calls (3.0) than callers in the five week one-shipment group (2.4) or eight week single-shipment group (1.7) (p < 0.001). Using both responder and intent-to-treat calculations, there were no significant differences in 30-day point prevalence abstinence at seven months among the three protocol groups even when controlling for demographic and tobacco use characteristics, and treatment group protocol. The mean cost per caller was greater for the single-shipment phase than the split-shipment phase ($350 vs. $326) due to the savings associated with not sending a second shipment to some participants. Assuming no difference in abstinence rates resulting from the protocol change, cost-per-quit was lowest for the five week one-shipment group ($1,155), and lower for the combined split-shipment cohort ($1,242) than for the single-shipment cohort ($1,350). Results of this evaluation indicate that while satisfaction rates increase among those receiving more counseling and NRT, quit rates do not, even when controlling for demographic and tobacco use characteristics.