Low-Income and Blue-Collar Populations

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Low-Income and Blue-Collar Populations

• Elizabeth Barbeau, ScD, MPH
• Dana-Farber Cancer Institute
• Harvard School of Public Health

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Question

• What are effective strategies for increasing
  consumer demand for and use of proven
  individually oriented cessation treatments among
  low-income and blue-collar populations?

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Key points

1. Compared to smokers in higher socioeconomic
   groups, those in low socioeconomic groups are
   just as likely to attempt to quit, but less
   likely to use proven treatments and less likely
   to succeed in quitting
2. Insurance-based coverage of smoking cessation
   treatments increases use of treatments (Medicaid
   and labor-management funds)
3. Little empirical evidence on effectiveness of
   various strategies to promote use of treatments
   suggestions for future research directions

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Social class and smoking

• Dimensions of social class
• Income
• Occupation
• Education
• Related but not identical constructs
• Providing evidence of their independent effects
  on smoking, analyses on NHIS 2000 data indicated
  that odds ratios for current smoking were
  attenuated but remained statistically significant
  for education, occupation, and income when
  jointly included in a multivariable model.
  (Barbeau et al, 2004)

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Key points

1. Compared to smokers in higher socioeconomic
   groups, those in low socioeconomic groups are
   just as likely to attempt to quit, but less
   likely to use proven treatments and less likely
   to succeed in quitting
2. Insurance-based coverage of smoking cessation
   treatments increases use of treatments (Medicaid
   and labor-management funds)
3. Little empirical evidence on effectiveness of
   various strategies to promote use of treatments
   suggestions for future research directions

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Key point 1

• Low SES groups try to quit as often as higher SES
  groups, BUT
• Low SES groups are less likely to succeed in quit
  attempts
• And less likely to use proven cessation treatments

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Smoking behaviors by education (NHIS 2000)
Source Trosclair et al, 2002
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Smoking behaviorsby income (NHIS 2000)
Source Trosclair et al, 2002
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Smoking behaviorsby occupation (NHIS 1997)
Source Giovino et al, 2002
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Use of tobacco cessation aids by education (NHIS
2000) (n3,218)
Source V. Cokkinides, 2005, personal
communication
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Use of tobacco cessation aidsby income (NHIS
2000)
Source V. Cokkinides, 2005, personal
communication
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Insurance-based coverage for smoking cessation
treatments

• Out-of-pocket expenditures can be a barrier to
  use of counseling and/or pharmacotherapy
• Insurance (private and public)
• Limitation Not reaching uninsured

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Key points

1. Compared to smokers in higher socioeconomic
   groups, those in low socioeconomic groups are
   just as likely to attempt to quit, but less
   likely to use proven treatments and less likely
   to succeed in quitting
2. Insurance-based coverage of smoking cessation
   treatments increases use of treatments (Medicaid
   and labor-management funds)
3. Little empirical evidence on effectiveness of
   various strategies to promote use of treatments
   suggestions for future research directions

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Key point 2

• HMO-based study found that the use of all
  cessation services was greater with full coverage
  than with cost-sharing plans (11.6 vs.
  3.5-3.7). Curry et al, 1998
• RCT (n1,204 smokers) found higher use of NRT
  among those receiving fully-covered benefits for
  NRT and counseling (25) vs. self-help kit (14)
  p0.001. Schauffler et al, 2001
• RCT (n1,266 smokers) found higher use of
  treatments among those in the fully-covered
  benefits arm (10.8) vs. no coverage arm (4.1)
  (OR2.8, 95 CI 1.8-4.7). Kaper et al, 2005

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Insurance and low SES smokers

• Medicaid
• 36 of Medicaid recipients smoke
• Across 20 US communities, among low-income
  smokers, nicotine patch use was significantly
  higher among those who lived in a state where
  Medicaid included the patch as a benefit (12.1
  vs. 7.7)When full coverage for NRT patch
  provided, use increased by 57. Cummings et al,
  1997
• 37 states cover at least one evidence-based
  treatment
• Labor-management health welfare (Taft-Hartley)
  funds
• Coverage is suspected to be low Barbeau et al,
  2000
• Pilot study of coverage demonstrated 13 use of
  treatments. Ringen et al, 2002

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What we know Insurance-based coverage works

• Small but convincing literature indicates that
  insurance coverage for full costs of treatments
  increases their use.
• Medicaid and labor-management insurance vehicles
  important for low SES groups.

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What we dont know New research directions

• Need to identify effective intervention
  strategies
• Purchasers, benefits administrators, insurance
  consultants
• Plan participants

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Key points

1. Compared to smokers in higher socioeconomic
   groups, those in low socioeconomic groups are
   just as likely to attempt to quit, but less
   likely to use proven treatments and less likely
   to succeed in quitting
2. Insurance-based coverage of smoking cessation
   treatments increases use of treatments (Medicaid
   and labor-management funds)
3. Little empirical evidence on effectiveness of
   various strategies to promote use of treatments
   suggestions for future research directions

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Key point 3

• Channels Where can we best reach low SES
  smokers?
• Message What to say? How to say it?
• Messenger Who should say it?

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Potential channels for reaching low SES smokers

• Worksites employing blue-collar and service
  workers
• Labor unions (largely represent blue-collar and
  service workers)
• Vocational/trade schools and GED programs
• Public assistance programs (e.g., WIC)
• Telephone quitlines
• Take a page from the tobacco industry
• Bars and night clubs, concerts, car races
• Internet

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Blue-collar smokers Promising channels and
messages

• WellWorks-2
• MassBUILT

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WellWorks-2Research question

• Does an intervention integrating health promotion
  with occupational health and safety result in
  increases in smoking cessation compared to a
  standard health promotion intervention?
• Secondary aim of evaluating participation levels
  in two conditions
• RCT worksites randomized to HP/OHS vs. HP-only

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Adjusted 6-month quit rates at final by
intervention and job type (cohort of smokers at
baseline n880)
Quit rates
Sorensen et al, Cancer Causes and Control, 2002
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WellWorks-2Participation results
Participation HP Only Integrated OSH/HP
Participation in worksite-wide activities 14 21
Mean worker exposure to intervention 15 minutes 33 minutes
Number of management contacts 9 25
Hunt et al 2005
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massbuilt
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massBUILTResearch question

• Feasibility and effect of incorporating smoking
  cessation intervention into health and safety
  training for building trades apprenticeship
  programs
• Pilot study
• Baseline smoking prevalence of 41 (n330).
• 19.4 quit rate immediately post-intervention
  (Barbeau et al, 2006)
• RCT underway

massbuilt
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Channels and messages State quitlines

• Demonstrated effectiveness
• Telephone-based quitlines create theoretically
  equal access to cessation counseling
• How can we drive more traffic to quitlines?
• Could promotions be targeted to low SES groups?

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Channels and messagesInternet

• Digital divide is narrowing
• Among smokers, those who use web for cessation
  assistance are more highly educated and earn
  higher incomes than those who do not. Stoddard
  and Augustson.
• Research challenges
• Interventions to reduce digital divide and
  increase capacity to access health information
  via internet
• Creating websites and testing effectiveness of
  attracting low SES smokers and enabling
  successful quits

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Summary

• Low SES smokers are just as likely to attempt to
  quit as higher SES smokers, but less likely to
  use proven treatments and to succeed.
• Insurance-based coverage of treatments works, but
  need additional research on ways to increase
  coverage and use of services through Medicaid,
  labor-management funds.
• Research is needed to identify effective
  messages, channels, and messengers to stimulate
  increased demand for and use of treatments among
  low SES smokers.