Tobacco control efforts have reduced smoking prevalence in the U.S. from 40% in 1964 to 20.6% currently. However the benefits of this achievement are not spread evenly. Smokers with other substance abuse problems smoke more heavily, are less successful in their attempts to quit smoking, and more often die from smoking-related causes than from other substance-related causes. Compared to a 20.6% smoking prevalence in the general population, smoking prevalence among persons in addiction treatment programs is about 76%. Despite high smoking prevalence reported for this population, addiction treatment programs usually do not address smoking. Clinical trials testing smoking cessation interventions with persons in addictions treatment often yield disappointing quit rates, and broader policy interventions show limited impacts on patient smoking. Based on the literature and on our own prior work, we conclude that policy and organizational interventions are necessary but not sufficient to reduce smoking in addictions treatment, and additional individual motivational strategies are needed.
This project is designed to develop a new intervention, called the Tobacco Treatment Readiness Intervention (TTRI) by combining two interventions that have been shown effective in previous research. One intervention is a computerized and self-administered e-heath intervention, called Expert Systems, which helps patients develop their internal motivation to quit smoking. The second intervention is called motivational incentives, which uses small financial rewards (e.g., gift cards) as a way to promote healthy behaviors. In this study, we will combine the internal motivational strategies of Expert Systems with the external motivation provided by motivational incentives, to address smoking in a population where it is highly prevalent and also recalcitrant to change.
After developing the TTRI intervention, this study will test TTRI against standard Expert Systems in a small randomized clinical trial. While a small trial cannot be definitive, it will tell us about the feasibility and acceptability of the new intervention, and it will help us estimate how effective the new intervention is in promoting smoking cessation. This type of information is always required before launching a larger and more definitive clinical trial.
This application responds to the TRDRP priority to prevent and reduce the use of tobacco products and tobacco-related health disparities in California’s disproportionately impacted populations. In California, 162,000 persons enroll in publicly-funded addictions treatment each year, and most are smokers. The annual smoking-attributable healthcare cost for those smokers is $386 million. Tobacco control, public health, and addiction treatment systems have convergent interests in addressing smoking in these treatment programs. Our clinical partner is Haight-Ashbury Free Clinic-Walden House (HAFC-WH), one of the largest providers of behavioral healthcare to poor and uninsured Californians. HAFC-WH integrates substance abuse, mental health and primary care, foreshadowing the likely structure of addiction treatment under the Affordable Care Act (ACA). By partnering with HAFC-WH residential treatment programs in San Francisco this application addresses smoking in a high prevalence population, and in collaboration with a leading California behavioral health provider. Across multiple HAFC-WH addiction treatment programs, 45% of patients are African American, so this application supports TRDRP’s aim to expand research on African American smokers in California.
The short term goal of this research is to develop, implement and pilot test interventions to increase patient motivation to quit smoking, in a population where smoking is extremely high. The long term goal is to develop the most effective strategies for reducing the pernicious effects of smoking among persons in addictions treatment.