Smoking Cessation Clinical Trial
Official title:
Financial Incentives and Proactive Calling for Reducing Barriers to Tobacco Treatment Among Socioeconomically Disadvantaged Populations: A Factorial Randomized Trial
Improved strategies and scalable interventions to engage low-socioeconomic status (SES) smokers in tobacco treatment are needed. The investigators tested an intervention designed to connect low-SES smokers to treatment services, implemented through Minnesota's National Breast and Cervical Cancer Early Detection Program (Sage) in 2017. Participants were female smokers from Sage (N=3,365). Using a factorial design, participants were randomized to six intervention groups consisting of a proactive call (no call vs call) and/or a financial incentive offered for being connected to treatment services (three levels of incentives). All individuals received direct mail and could opt for cessation support through Minnesota's population-based cessation services. The primary outcome was confirmed connection via phone to the free quit-line.
Individuals were randomized to one of six conditions. The design was a two-factor,
three-by-two factorial design: three levels of financial incentives, and two levels of
proactive calls (yes, no). All groups received direct mail and free tobacco treatment
services.
The intervention was implemented from June 2017 to October 2017. National Breast and Cervical
Cancer Early Detection Programs serve uninsured women with household incomes at or below 250%
of the U.S. federal poverty level; subsequently, the sample was strictly female, and the
investigators included individuals for whom self-reported smoking status was available (from
2014 to 2017). Smoking status was determined using Sage data, which come from clinics and
Sage's call center. Using a uniform measure ("Does the participant currently smoke
cigarettes?"), smoking status was based on cigarette use at the time of contact with the Sage
program (i.e., clinic visit or contact with the call center). Data on smoking intensity were
not available. There were 3,723 smokers who met selection criteria.
All participants received two rounds of direct mail. Mailers consisted of a folded card,
which contained messages and graphics rooted in a loss-frame approach. Following previous
research, the loss-frame approach was designed to indicate that certain behaviors lead to
unhealthy outcomes, and the investigators paired the message with a clear articulation of
behavioral steps.
Sage has a call center staffed by patient navigators. When participants called Sage's number,
patient navigators followed a script, recorded callers' promotion code, determined callers'
desire to participate, and made connections to the quit-line for willing participants. After
two rounds of direct mail, patient navigators placed proactive outreach calls to eligible
participants. Phone numbers were retrieved from the Sage database. Using a script, navigators
reminded participants of the direct mail piece and the program offer. Each participant
received one proactive call. One call attempt was made; navigators left a voicemail for
participants who were unavailable. Proactive calling lasted three months.
Both the mailer and navigators referred participants to Minnesota's free population-based
cessation services. The quit-line is funded and administered by an independent nonprofit
organization. Participants can enroll in services either by phone or online. Tobacco users
can choose telephone counseling or one or more individual services.
Our primary outcome was phone-only treatment connection, which was defined as a confirmed
connection between participants and quit-line staff via three-way calls conducted by patient
navigators. For willing participants, patient navigators called quit-line staff and confirmed
that a patient would be connected via a three-way call. Navigators remained on the line until
communication between participants and quit-line staff was established. Once connected,
trained operators from the quit-line were responsible for administering cessation-related
services.
A secondary measure captured connections to online services. This measure combined both phone
and web connections. The web connection assessed whether participants entered their
individual promotion codes (provided via direct mail) on a unique online landing page. Once
participants entered their individual codes, they were directly connected to the cessation
webpage where they entered their personal information and chose tailored treatment services.
Direct transfers to the online services counted as a connection; each code was counted only
once. The investigators used the confirmed phone connection as our primary outcome as it was
a more conservative measure of connection to tobacco treatment services. The investigators
used the measure that combined phone and web connections in secondary analyses.
Intervention components. The investigators used dummy variables to assess levels of financial
incentives (for all three measures: 1=yes, 0=no). The proactive calling measure was assessed
using a dichotomous measure (1=proactive calling, 0=no proactive calling). The investigators
assessed the components' combined effect by generating interaction terms.
Covariates. The investigators examined whether randomized groups differed according to age
(continuous measure ranging from 20 to 88), race/ethnicity (five dichotomous measures: white,
African American, Hispanic, American Indian, and other races/ethnicities), whether
participants spoke Spanish or not (1=yes, 0=no), whether respondents lived with a fellow
smoker (1=yes, 0=no), time since last contact with Sage (four dichotomous variables: 2014,
2015, 2016, or 2017), and urban residence (1=metro region, 0=other).
Using a per-protocol approach, the investigators eliminated all individuals with bad
addresses. Descriptive statistics were used to compare connection rates and demographics
across intervention arms. The investigators ran a logistic regression model that included
dichotomous measures for all six possible treatment conditions in order to run
post-estimation pairwise comparisons.
Logistic regression is the optimal method for examining unbalanced factorial designs with a
binary outcome. The investigators ran four logistic regression models for the primary
analysis. The investigators examined: (1) the association between incentive levels and
phone-only quit-line connections, (2) the association between proactive calling and
phone-only quit-line connections, (3) the direct effects of financial incentives and
proactive calling, and the interaction between incentive levels and proactive calling, and
(4) the effect of intervention components adjusted for covariates. For the logistic
regression models, the main effects for the incentive and proactive call are interpreted as
the effect when all other variables equal zero, and the interaction coefficients are
interpreted as the test for whether the relationship between proactive calling and
connections to the quit-line depended on receiving an incentive. For the secondary analyses,
the investigators report in the text any differences between the phone-only measure and the
combined measure that combined telephone and web connections.
For cost-effectiveness analysis, the investigators assessed the average cost-effectiveness
ratio, which is the increase in costs by each intervention group compared with the no
incentive, no call group, divided by the increase in connections within each intervention
group compared with the no incentive, no call group. The investigators also examined the
incremental cost-effectiveness ratios, which is the change in cost compared to an adjacent
condition divided by the change in connections compared to the adjacent condition. The
investigators included costs associated with printing, postage, incentives, labor, and the
creation and maintenance of the landing page. Costs were in 2017 US dollars and based on
receipts and labor hours; hourly rates were based on national averages for respective
positions.
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