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ATTC Messenger October 2015: Smoking among Vulnerable Populations: Tailoring Approaches to Change Attitudes and Behavior

October 2015

Smoking in Vulnerable Populations: Tailoring Approaches to Change Attitudes and Behavior

Maureen Fitzgerald
Communications Coordinator
ATTC Network Coordinating Office

This month’s National Conference on Tackling Tobacco Use in Vulnerable Populations, hosted by the Central East ATTC and the Danya Institute, brings together researchers, policy makers, and behavioral health and health care professionals to discuss the challenges and opportunities for reducing tobacco use among vulnerable populations.

While smoking rates have declined since the Surgeon General’s Report in 1964, dropping from 42% to 17.8% among U.S adults, smoking remains the single largest preventable cause of death (U.S. Department of Health and Human Services, CDC, 2014).

Smoking Rates are Higher Among Certain Populations*

29.2% of people living below poverty level smoke, compared to 16.2% who are at or above poverty level.

26.6% of LGBT individuals smoke, compared with 17.6% of heterosexuals.

24.2% of people with less than a high school education smoke, compared to 5.6% with a post graduate degree.

Adults with mental illness or substance use disorder account for 40% of all cigarettes smoked. (SAMHSA, NSDUH Report, 2013)

Approximately 10% of women report smoking during the last three months of pregnancy.

Every day in the United States, an additional 2,100 youth and young adults become daily smokers.

*CDC, 2014

Dr. Bruce Christiansen, Senior Scientist at the University of Wisconsin Center for Tobacco Research and Intervention (UW-CTRI) is among the experts presenting findings at the National Conference. Dr. Christiansen leads the Wisconsin Nicotine Treatment Integration (WiNTiP) project, and his work with UW-CTRI has focused on helping low-income people and people with severe mental illness quit smoking.

Health disparities in tobacco use have grown over recent decades within the larger scheme of public health, says Dr. Christiansen.

The CDC reports that in 2013, 24.2% of people with less than high school education smoked compared to 5.6% with a post graduate degree. (CDC, 2014.)

One reason for this gap, explains Dr. Christiansen, is that public health efforts such as smoke-free laws, advertising restrictions, lawsuits against tobacco companies, raising cigarette taxes, anti-smoking marketing, and new medications for smoking cessation have generally been more effective at reaching people with more resources and higher education.

“People with more resources are more likely to have access to health care and generally in a better position to respond to public health efforts targeting smoking.”

Dr. Christiansen describes his “niche” as working to motivate low-income people and those with severe and persistent mental illness to quit smoking. He collaborates with community partners such as the Salvation Army that have a mission to support and help the poor.

“Low-income people who smoke have less access to primary care and rely more on Emergency Departments for health care, which is not the optimal setting to address smoking behavior. They also rely on community organizations for help with basic needs.”

Measuring and addressing beliefs about smoking and quitting

One of Christiansen’s studies measured and addressed beliefs that people have about smoking and quitting. In survey in a poor neighborhood in Milwaukee, respondents perceived 73% of Wisconsin adults as smokers—whereas the reality is 20 to 30%.

“If you perceive smoking as the norm, then there’s no reason to quit,” says Christiansen. “We also asked people questions about smoking cessation medications, and found that most people thought they were more harmful than smoking.”

Another belief was that the best way to quit smoking was to do it alone, cold turkey, using only will power. “No amount of medication or coaching support is going to help someone who doesn’t think they have the needed will power and if the smoker believes they have enough will power, then additional help isn’t needed,” says Christiansen.

The majority of people surveyed in this neighborhood did not know about the Wisconsin Tobacco Quit Line or that it provides free medication and counseling.

As a follow-up to address these beliefs, low SES smokers from two Wisconsin Salvation Army locations were recruited to test a brief intervention. Salvation Army staff use brief, 20- minute scripted interventions to counteract some of these deeply entrenched beliefs and see if the result would be increased use of the Wisconsin Quit Line.

“For example, we’d ask, “Did you know that your willpower is like a muscle that you can train every day to get stronger?” Then we’d say that getting support from a coach to quit smoking would help build that willpower muscle. The script for medicine was that medication helps will power last longer because it reduces smoking urges. We found that the people who received that intervention were more likely to call the tobacco-quit line and use other supports: 17.8% of the intervention subjects self-reported calling the quit line compared to 7.3% of the controls.”

Another approach Christiansen used with the Salvation Army in six Wisconsin communities borrowed a technique from motivational interviewing: the decisional balanced worksheet.

“The goal was to draw out a smoker’s ambivalence about quitting by listing all the good reasons to quit or continue smoking,” explains Christiansen. After completing the worksheet, the Salvation Army staff person turned the focus to change talk, asking the smoker to identify the most important reasons for quitting or not quitting.

“We find that most smokers would go to the long-term consequences and talk about wanting see their daughter get married or to avoid dying from a debilitating disease. When the staff person points out that continuing to smoke is inconsistent with these long-term goals, smokers showed more willingness to call the Wisconsin Tobacco QuitLine.”

The PREP to Quit Project

In this project Christiansen partnered with the NAMI Wisconsin (National Alliance for the Mentally Ill) to work with people with severe mental illness. It included 12 Community Support Programs, where the state pays counties to provide intense outpatient programs for people with severe mental illness. Smoking rates among this population can be as high as 70-80 percent.

This project, called PREP to Quit, involved four visits with people who did not want to quit smoking.

“In the control group, the staff person gave messages about the health effects of smoking. The intervention group used the decisional support worksheet and participants also were asked to practice quitting—to cut their smoking by half one week and go 24 hours without smoking the next. This group was also provided the nicotine patch. We found that having people practicing the skills to quit really increased their confidence and motivation to quit.”

The project did show the effectiveness of the intervention.

Participants were offered an additional four sessions. In the control group, only 10 % agreed to continue, compared to 52% in the intervention arm. Importantly, follow-up three months later found that 8% of intervention participants stopped smoking vs. 1% of the control participants.

However, intervention participants were no more likely to call the Wisconsin Tobacco Quit Line than control participants.

“I’ve come to understand that people with serious mental illness may be slow to trust others, for good reason, and therefore may be more reluctant than others to pick up the phone and talk to a stranger,” says Christiansen.

Tailoring treatments

There has been tremendous progress reducing the rate of smoking in the general population. As a result, smoking is now concentrated is specific populations.

As Dr. Christiansen explains, “The challenge is to either find better ways to reach these populations with evidence-based treatments, and/or find ways to tailor those treatments to boost their effectiveness with these populations.”

View slides from Dr. Christiansen’s August 2015 presentation for Central East ATTC Tobacco Cessation Tuesday Webinar Series: Reaching, Motivating, and Treating Low SES Smokers.

To read more of Dr. Christiansen’s research:

Christiansen B, Reeder K, TerBeek E, Fiore MC, Baker TB. Motivating Low Socioeconomic Status Smokers to Accept Evidence-Based Smoking Cessation Treatment: A Brief Intervention for the Community Agency Setting. Nicotine and Tobacco Research. 2015 July;17(8):1002-1011.

Christiansen BA, Reeder K, Fiore MC, Baker TB. Changing Low Income Smokers’ Beliefs about Tobacco Dependence Treatment. Substance Use and Misuse. Epub 2014 Feb 6. [Full text]

Christiansen BA, Reeder K, Hill M, Baker TB, Fiore MC. Barriers to Effective Tobacco Dependence Treatment for the Very Poor. The Journal of Studies on Alcohol and Drugs. 2012; 73(6):874-84. [Abstract]

Christiansen BA. What Does It Cost To Change Behavior? Editorial. Annals of Family Medicine 10(3):197-198. [Full Editorial]

Christiansen BA, Brooks M, Keller PA, Theobald WE, Fiore MC. Closing Tobacco-related Disparities: Using Community Organizations to Increase Consumer Demand. American Journal of Preventive Medicine. 2010 Mar;38(3 Suppl):S397-402. [Abstract]