Dataset Information

Tobacco Cessation on Prescription as a primary health care intervention targeting a context with socioeconomically disadvantaged groups in Sweden: A qualitative study of perceived implementation barriers and facilitators among providers.

ABSTRACT:

Background

A new intervention, Tobacco Cessation on Prescription (TCP), has been developed in the Swedish primary health care (PHC) setting to address inequalities in health caused by tobacco use. It consists of counseling for at least 10 minutes, an individualized prescription of tobacco cessation treatment and follow-up on at least one occasion. TCP is currently being tested in clinical practice for the first time but there is a lack of knowledge about how it is perceived by health care providers.

Aim

To explore PHC provider's perceived barriers and facilitators of implementing TCP as an intervention targeting a context with socioeconomically disadvantaged groups in Sweden.

Methods

Directed content analysis of transcripts from eight semi-structured interviews and one focus group interview with PHC providers with personal experience of TCP as informants. Data collection and analysis was guided by The Consolidated Framework for Implementation Research.

Results

Perceived facilitators of implementing TCP were increased self-efficacy among the informants and involvement in the treatment among patients, which led to more intensive counseling and advice being taken more seriously by patients. Lack of resources, routines, and collaboration to work with tobacco cessation and lack of knowledge, motivation and self-efficacy among colleagues were perceived as barriers. Motivation and self-efficacy to quit was perceived as low among some patients, which was explained by low social support to quit, negative attitude and low adherence to treatment and tobacco being used as a coping strategy for life stress. Access to treatment for patients was limited by cost of treatment, long waiting times and focus on face-to-face counseling.

Conclusion

TCP was perceived positively by the informants but access to treatment for patients was partly limited by how tobacco cessation services were organized. Lack of structural support, resources and differing attitudes among PHC providers need to be addressed to facilitate its implementation.

SUBMITTER: Leppanen A

PROVIDER: S-EPMC6383914 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundTobacco Cessation on Prescription (TCP) is a new intervention that is being evaluated in socioeconomically disadvantaged areas in Swedish primary health care (PHC). Patients' perceptions of TCP are important to understand as this may have implications for the acceptability and adherence to treatment and explain cessation outcomes. Patients' general experiences of tobacco cessation are also important to explore to improve cessation support in this setting.AimTo explore experiences of tobacco cessation and TCP among patients in Swedish PHC focusing on socioeconomically disadvantaged areas.MethodsInductive content analysis of transcripts from eight semi-structured interviews with patients recruited from the intervention group in a randomized controlled trial evaluating the effectiveness of TCP in socioeconomically disadvantaged areas in PHC in Stockholm.ResultsTwo themes were identified: needing individualized support to quit, taking differences in patients' experiences of tobacco use and cessation into account, acknowledging individual factors such as impact of health and wellbeing on tobacco use and differing attitudes towards tobacco and cessation and needing a supportive environment to facilitate tobacco cessation, taking contextual factors like professional support from the health care system, the importance of the social environment and supportive societal structures into account. Regarding TCP, the prescription form was perceived as useful for providers but did not appear to have a direct impact on tobacco cessation from the informants' perspective. However, individualized counseling from a tobacco cessation specialist, an empathetic approach in the treatment and long-term follow-up was considered important.ConclusionA holistic approach may be needed in cessation treatment, combined with interventions outside the health care system, to facilitate tobacco cessation among patients in socioeconomically disadvantaged areas in Swedish PHC. The TCP prescription form may be helpful for PHC providers but counseling and follow-up appear to be the most important components of TCP for patients in this setting.

Project description:BACKGROUND:Socioeconomic disadvantage is associated with a reduced likelihood of smoking cessation. Smartphone ownership is increasing rapidly, including among low-income adults, and smartphone interventions for smoking cessation may increase access to smoking cessation treatment among socioeconomically disadvantaged adults. OBJECTIVE:This study aimed to evaluate the feasibility of an automated smartphone-based approach to delivering financial incentives for smoking cessation. METHODS:Socioeconomically disadvantaged adults initiating tobacco cessation treatment were followed from 1 week before a scheduled quit attempt through 26 weeks after the quit date. Participants received telephone counseling and nicotine replacement therapy. Smoking cessation was verified 5 times per week via smartphone prompts to self-report smoking status and submit a breath sample via a portable carbon monoxide (CO) monitor that was connected with participants' smartphones. Identity was verified during smoking status assessments using smartphone-based facial recognition software. When smoking abstinence and identity were verified, an automated credit card payment was triggered. Participants were incentivized for abstinence on the quit date and up to five days per week during the first 4 weeks after the scheduled quit date, with additional incentives offered during postquit weeks 8 and 12. In total, participants had the opportunity to earn up to US $250 in abstinence-contingent incentives over the first 12 weeks of the quit attempt. RESULTS:Participants (N=16) were predominantly female (12/16, 75%) and non-Hispanic white (11/16, 69%), black (4/16, 25%), or Hispanic of any race (1/16, 6%). Most participants (9/16, 56%) reported an annual household income of <US $11,000. During the first 4 weeks after the scheduled quit date, participants completed a median of 16 (out of 21; range 1-21) mobile smoking status assessments, and they earned a median of US $28 in abstinence-contingent incentives (out of a possible US $150; range US $0-US $135). Median earnings did not change during the 8- and 12-week incentivized follow-up periods (total median earnings over 12 weeks=US $28; range US $0-US $167). During the first 4 weeks after the scheduled quit date, participants abstained from smoking on a median of 5 (out of 21) assessment days (range 0-20). At the in-person follow-up visits, the expired CO-confirmed 7-day point prevalence abstinence rates were 19% (3/16) and 13% (2/16) at 12 and 26 weeks postquit, respectively. Overall, most participants reported that the system was easy to use and that they would recommend this treatment to their friends and family. CONCLUSIONS:Preliminary data suggest that this smartphone-based approach to verifying identity and smoking status and automating the delivery of abstinence-contingent incentives to a credit card is feasible for use among socioeconomically disadvantaged adults. However, continued refinement is warranted.

Project description:IntroductionSmoking 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 methodsData 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.ResultsLower 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).DiscussionSmokers 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.ImplicationsSmoking 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.

Project description:Importance:Limited evidence supports mobile phone-delivered cessation interventions for socioeconomically disadvantaged individuals. Objective:To assess the efficacy of mobile phone-delivered cessation interventions targeted to smokers at neighborhood sites serving racial/ethnic minority and socioeconomically disadvantaged individuals. Design, Setting, and Participants:This group-randomized clinical trial with neighborhood site serving as the sampling unit compared smoking cessation interventions that included (1) nicotine replacement therapy (NRT), (2) NRT plus text messaging, and (3) NRT plus text messaging plus proactive counseling via mobile phone. Recruitment took place at churches, public housing complexes, and community centers located throughout the Houston, Texas, area. A total of 624 current cigarette smokers 18 years or older were enrolled at neighborhood sites from August 13, 2011, through December 12, 2014. Final follow-up was completed on June 12, 2015, and data were analyzed from August 17, 2017, through May 10, 2018, based on intention to treat. Interventions:Nicotine replacement therapy consisted of transdermal nicotine patches; NRT plus text messages, transdermal nicotine patches and individually tailored mobile phone text messages; and NRT plus text plus call, transdermal patches, individually tailored mobile phone text messages, and proactive counseling via mobile phone. Main Outcomes and Measures:The primary outcome was smoking abstinence at 6 months, defined as (1) biochemically verified smoking abstinence (calculated among a subgroup of 377 participants) as determined by saliva cotinine level; and (2) self-reported 30-day abstinence (calculated among all 624 participants). Results:The study sample included 624 current cigarette smokers (50.6% female; mean [SD] age, 45.8 [12.8] years). Among the 377 participants eligible for biochemical verification, 127 self-reported 30-day abstinence and were asked to provide saliva samples. Of these, 98 samples were returned (participants who did not return samples were coded as smoking). Biochemically verified abstinence rates were 12.0% for NRT, 12.0% for NRT plus text, and 25.5% for NRT plus text plus call. Participants in the NRT plus text plus call group were 2.11 (95% CI, 1.00-4.48) times more likely to be biochemically verified as abstinent compared with the NRT group. No differences in biochemically verified abstinence between the NRT plus text group and the NRT group were observed. Similar associations were observed with the self-report cessation outcomes. Conclusions and Relevance:Findings indicate that assignment to an intervention consisting of text messaging alone may not increase cessation rates for socioeconomically disadvantaged smokers. However, text messaging plus proactive counseling may be an efficacious option. Trial Registration:ClinicalTrials.gov identifier: NCT00948129.