9.6 Tailored and targeted interventions for low socioeconomic groups

Last updated:  June 2022

Suggested citation: Greenhalgh, EM, & Scollo, MM. 9.6 Tailored and targeted interventions for low socioeconomic groups. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2022.  Available from: http://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/9-6-tailored-and-targeted-interventions-for-low-socioeconomic-groups

 

In Australia, the prevalence of smoking remains substantially higher among those with low educational attainment and lower income levels compared with the population as a whole (see Section 9.1). Smoking exacerbates financial stress and poverty both for adults,1 and children2—see Section 9.4. Australian socioeconomically disadvantaged smokers have reported frequent experiences of deprivation and financial stress caused by their smoking, such as going without meals, substituting food choices and paying bills late in order to purchase cigarettes.3 Several studies have found that increases in income support/wages among socioeconomically disadvantaged smokers are associated with increases in smoking cessation.4,5 Subsidised cessation medications are also associated with increased use among disadvantaged groups6 (see Section 9.9).

Social (e.g., low social support for quitting), psychological (e.g., low self-efficacy) and physical factors (e.g., greater nicotine dependence) all contribute to the higher tobacco use among socially disadvantaged populations7 (see Section 9.7). Qualitative research in Australia has found that socially disadvantaged populations may be resistant to cessation interventions and feel a lack of control over their smoking and the stressful life circumstances that sustain it. 8 Feelings of guilt, shame and stigma can impede help-seeking among low-socioeconomic status (low-SES) smokers in Australia.9 Nonetheless, the most disadvantaged smokers in Australia are equally likely to make a quit attempt (albeit with less success), and equally or more likely to use quit aids, as those more socioeconomically advantaged.10

The development of interventions that address smoking among low-SES groups is a high clinical and economic priority to reduce health inequalities and improve life expectancies,11 and to reduce the financial burden of smoking.2 However, a systematic review of research into cessation among low-SES and other disadvantaged groups concluded that the current research output is not ideal or optimal for guiding design of policies and programs to decrease smoking rates.11 Nonetheless, a recent review found consistent evidence that individual-level smoking cessation interventions in socioeconomically disadvantaged groups are effective.12 Examples of such interventions are outlined below. For a discussion of whether individual-level interventions increase (or decrease) disparities in smoking prevalence between low-SES and more advantaged groups, see Section 9.9. Population-wide strategies, including tax increases and narrative mass media campaigns, are also effective at reducing smoking among low-SES groups—see Section 9.8 for a detailed discussion.

9.6.1 Financial incentives

Several studies have examined the potential of offering low-SES smokers financial incentives to quit. A study in the US assessed two strategies (direct mail and opportunistic telephone referrals) that offered financial incentives to low-income smokers for being connected to a quitline. Both strategies successfully connected smokers to the Quitline and encouraged quit attempts and continuous smoking abstinence.13 Another US study similarly found that financial incentives encouraged Quitline use among socioeconomically disadvantaged smokers.14 There is evidence supporting the effectiveness of financial incentives that are large,15 and also modest incentives,16 as well as those that are not contingent on outcomes,17 for increasing engagement and quitting behaviours among low-income smokers.

See Section 7.17 for a detailed discussion of financial incentives for smoking cessation.

9.6.2 Telephone and Internet-based interventions

Studies have supported the use of the Quitline to support and promote quitting among low-SES smokers. A brief intervention comprising counselling, referral to the Quitline, and free nicotine replacement therapy resulted in quit attempts and successful quitting among low-income smokers visiting an emergency department.18 A trial in the US found that greater use of Quitline services was associated with higher abstinence in low-income smokers.19 While research in the US has suggested there may be barriers to using the Quitline among low-SES smokers such as not having access to a phone 20 and the cost of making the call from a mobile,21 low-SES smokers in Australia appear to be just as or more likely to contact the Quitline10, 22 (see Section 9.8). Australian research has also suggested that text messaging-based9 and internet-based interventions23 have potential for reducing smoking among low-SES smokers.

See Section 7.14 for a broader discussion of these interventions.

9.6.3 Role of healthcare providers and community organisations

Integrating interventions into community programs holds promise for promoting cessation among low-SES smokers.24-27 In the UK, stop-smoking services appear to reduce inequalities in smoking through increased relative reach through targeting services to low-SES smokers.28, 29 For example, one UK study found that a mobile, drop-in, community-based stop smoking service effectively increased reach to disadvantaged smokers.30 Two studies in the US have examined interventions among Salvation Army client smokers: one that showed that a brief, targeted motivational intervention increased the initiation of an evidence-based tobacco cessation treatment,31 and another that challenged beliefs about the effectiveness of various quit methods, which was associated with greater smoking reduction and greater likelihood of contacting the Quitline.32 Disadvantaged smokers in Australia report being open to receiving information and support to quit from community service organisations.33 Peer support interventions also appear to have potential to address the high prevalence of smoking in vulnerable populations, particularly among disadvantaged groups who experience fewer opportunities to access such support informally.7, 26, 34

Healthcare professionals can also play an important role in reducing smoking among disadvantaged populations by integrating cessation interventions into routine care.29 In Australia, GPs and other healthcare providers are a known and trusted source of cessation information and advice for disadvantaged people who smoke,33 and low-SES smokers are just as likely as mid-high-SES smokers to report being advised to quit by their doctor (see Section 9.8). Such interventions can promote and assist smoking cessation – see Section 7.10 for a broader discussion.

9.6.4 Increasing the effectiveness of cessation interventions

Tailoring and adapting evidence-based cessation treatments to address the needs of socioeconomically disadvantaged groups has been suggested as a pathway to increasing their effectiveness; however a recent review found that while individual-level interventions were effective, there were no differences in the effectiveness of socioeconomic-position-tailored and non-tailored cessation interventions for reducing smoking among disadvantaged groups. The authors suggesting that multifaceted approaches and improvements in current tailored interventions may be needed to reduce disparities.12 Several reviews have concluded that multicomponent cessation interventions are needed for low socioeconomic populations,35, 36 and have highlighted the importance of social support, employing community-based participatory approaches to develop tailored approaches, effective combination pharmacotherapies (varenicline and NRT),36 incentives, and peer facilitators.35

Despite being just as likely to make quit attempts, low-SES smokers experience less success in sustaining cessation.10 Increasing the likelihood that quit attempts are successful is therefore an important step in reducing smoking prevalence and smoking-related disparities. Low-income smokers are more likely to discontinue treatment early (see Section 9.9.2.2); therefore interventions that increase compliance may help to increase the success of quit attempts. 37 For example, interventions that enhance resilience,38 motivation, and self-efficacy39 and address life stressors.40 Providing greater choice/sampling of NRT41-43 can also help to promote adherence and cessation among low-SES smokers.

9.6.5 Increasing engagement with cessation interventions

Disadvantaged smokers have traditionally been a hard-to-reach group, and researchers have examined factors that could promote engagement with cessation interventions among socioeconomically disadvantaged populations. Targeting interventions in areas with high numbers of low SES smokers by healthcare and community organisations can help compensate for low SES smokers’ relatively low quit rate, thereby reducing health disparities.29 In Victoria, Quit is geotargeting several low-SES Local Government Areas with high numbers of smokers, with strategies including additional campaign messaging in outdoor and shopping locations, geotargeted messaging on social and digital media, and community organisations amplifying Quit’s messages. The project aims to increase smokers’ self-efficacy to quit and maintain cessation, as well as to educate and encourage those surrounding them (health professionals, family, friends) to provide support.44

To increase recruitment for smoking cessation trials, studies have found that mailed invitations and follow-up from health professionals,45 and in-person field-based methods,46, 47 appear to be effective strategies. Among disadvantaged smokers in Australia, one trial found that retention was higher among those with higher motivation to quit, more recent quit attempts, increased age, higher level of education and for those recruited through Quitline or newspaper advertisements.48 Proactively contacting smokers and offering cessation support, regardless of their interest in quitting, can also be effective in promoting quitting among socioeconomically disadvantaged smokers.14,49

 

Relevant news and research

For recent news items and research on this topic, click  here.( Last updated November 2022 )

 

References

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