The Call it Quits trial: A community welfare service case-worker delivered smoking cessation intervention

Billie Bonevski

University of Newcastle

Faculty of Health

School of Medicine and Public Health

Newcastle2

The Call it Quits Team

• The University of Newcastle: Laura Twyman, Chris Paul, Cate D’Este, Jamie Bryant

• University College London: Robert West

• University of Nebraska: Mohammad Siapush

• Illawarra Translational Cancer Research Unit: Afaf Girgis

3

Overview

1. Rationale for tackling tobacco amongst socially disadvantaged

2. Describe the Tackling Tobacco Program formative research• What are the opportunities and barriers?

• Is data collected in this setting accurate?

• Do clients smoke and do they want to quit?

• Is a smoking intervention feasible?

• Is a smoking intervention effective?

3. Baseline results from the Call it Quits Trial

4

Smoking rates over time by SEIFA quintile

5

Changes in smoking prevalence (daily and occasional) from 1998 to 2010 by socioeconomic quintile (1 - most disadvantaged, to 5 - least disadvantaged: AIHW National Drug Household Surveys 1998, 2001, 2004, 2007, 2010

Smoking rates 2010 - group comparisons 6

27.6%

19.6%

24.6%

12.5%

37.60%

17.40%

0%

5%

10%

15%

20%

25%

30%

35%

40%

General population (15.1%)

Smoking prevalence in the Australian general population compared with selected disadvantaged groups: AIHW National Drug Household Survey 2010

Smoking and disadvantage

• Compared to more advantaged groups, disadvantaged smokers:– are more addicted1

– report lower self efficacy for quitting1

– smoke more cigarettes per day (17.9 vs. 10.9 for least disadvantaged)2

– are less likely to make a quit attempt 3, 4

– are less likely to plan a quit attempt in the next 6 months 4

– are less likely to receive health provider advice to quit smoking5

7

1. Siahpush, McNeill, Borland, 2006; 2. AIHW, 2004; 3. Siahpush, Yong, Borland, Reid, Hammond, 2009; 4. Reid, Hammond, Boudreau, Fong, Siahpush, 2010; 5. Browning, Ferketich, Salsberry, Wewers, 2008.

Addressing smoking amongst disadvantaged groups

• National Preventive Health Taskforce recommendations:

– “tailor services for indigenous smokers and other highly disadvantaged groups”

– “resources for professionals to encourage and assist smokers in psychiatric and correctional facilities”

– “Implement programs to subsidise nicotine replacement therapy for people who are homeless and other highly disadvantaged people in financial stress”

8

9Tackling Tobacco

• Led by the Cancer Council NSW• Reduce smoking among most disadvantaged population groups

in NSW by engaging with the non-government community service sector– Reframe smoking as a social justice issue

– Make the provision of quit support part of routine care

• Research driven

Why the community social service sector?

• Access and reach– More than 5,000 services in Australia

– More than 4 million instances of service

– Single parents 12 times more likely to use, Indigenous Australians 6.5 times more likely to use

• Holistic approach• Personalised and tailored support• Sustainable and cost effective• Being recognised internationally as a novel and potentially

suitable setting (Christiansen et al., 2010, American Journal of Preventive Medicine)

10

11Tackling Tobacco Research

Focus groups with clients

Cross sectional client survey

Focus groups with staff

Call it Quits

RCT Pilot Study

Cancer Council NSW Tackling Tobacco Program

What are the barriers and opportunities? 12

Bryant, Bonevski, Paul, et al. Delivering smoking cessation support to disadvantaged groups: A qualitative study of the potential of community welfare organisations. Health Education Research, 2010 25(6):979-990.

Bryant, Bonevski Paul et al. Developing cessation interventions for the social and community service setting: A qualitative study of barriers to quitting among disadvantaged Australian smokers BMC Public Health 2011, 11:493

Bonevski B, Bryant J, Paul C. Encouraging smoking cessation in socially disadvantaged groups: a qualitative study of the financial aspects of cessation. Drug and Alcohol Review, 2010, 30(4):411-418.

Staff Focus Groups (n = 43) • Willingness to address smoking• Appropriateness with role• Brief intervention approaches preferred

“We provide an access point for them and a place where they feel comfortable and safe to go, rather than having to go somewhere strange with different people”

• Barriers– Addressing smoking often not a priority– Inadequate time, skills, and confidence

“I don’t know how well skilled I am, how confident I would feel giving advice about stopping smoking.”

13

Client focus groups (n = 32)

“I reckon it would be alright as long as we weren’t feeling like we were getting pestered”

“Yep. I reckon it’s good. At least it’s [quit support] there instead of them not supporting it at all”

“Yeah, it would be alright, they could ask…”

Barriers to quitting:– Lack of support and services– Financial cost of quitting (eg, NRT)

14

Is data collected in this setting accurate?

• 383 clients completed a 60-item touch screen computer survey and CO breathanalysis (69% consent rate)

• Touch screen computer smoking survey and CO breathanalysis as gold standard– Sensitivity = 94%– Specificity = 93%

• Computer survey was easy to complete (88%)• Computer survey was enjoyable (79%)

Bryant J, Bonevski B, Paul C. Assessing smoking status in disadvantaged populations: Is computer administered self report an accurate and acceptable measure? BMC Medical Research Methodology 2011, 11:153

15

April 22, 2023

16

Do clients smoke and do they want to quit?• Smoking variables

– 53.5% daily smoking– 7.9% occasional smoking– 17 cigarettes per day– $46 per week

• Of current smokers:– 56.6% were ‘very’ or ‘quite’ interested in quitting– 70% intended to quit in next 6 months– 52.8% wanted support from staff at the SCSO to quit smoking

Bryant J, Bonevski B, Paul C. A survey of smoking prevalence and interest in quitting among social and community service organisation clients: a unique opportunity for reaching the highly disadvantaged. BMC Public Health 2011, 2011, 11:827

17

Is a quit support intervention feasible?

• Pre-post pilot study

1. Test feasibility and acceptability of integrating the delivery of smoking cessation support into usual care at a community service organisation

2. Assess the impact of the program on client smoking

• One SCSO providing a Personal Helpers and Mentors program.

• N = 20 clients

Bryant J, Bonevski B, Paul C, Hull P, O’Brien J. Implementing a smoking cessation program in social and community service organisations: A feasibility and acceptability trial. Drug and Alcohol Review, 2011, DOI: 10.1111/j.1465-3362.2011.00391.x

18

Intervention

• One day staff training + booster session– Rationale for incorporating smoking cessation into usual care– Heaviness of smoking index– 5A’s brief intervention– Brief motivational interviewing– NRT

• Free NRT

• Quit ‘Buddy’ system

• Brief advice and motivational interviewing at every visit or where deemed appropriate

19

Acceptability to Clients 20

Strongly Agree or

Agree

%

Neutral

%

Strongly Disagree /Disagree

%

Talking to my support worker about my smoking was helpful

92 8 0

Talking to my support worker about my smoking made me think about quitting

90 10 0

I did not like being asked about my smoking by my support worker

0 10 90

Cessation Results

• (70%) of clients initiated NRT use during the program

• At 6 months follow-up

– No participants reported seven day point prevalence abstinence

– Significant reduction in the number of cigarettes smoked - from 20.5 cigarettes per day at baseline to 15 cigarettes per day (p= 0.04).

– Non-significant reduction in dollars spent on tobacco from $70.95 at baseline to $60.69.

21

Next Steps

• Support workers are interested in training and willing to provide support

• Clients of SCSO are interested in quitting and willing to be involved in a cessation program

• May decrease smoking behaviours

• A methodologically rigorous and powered randomised controlled trial is needed to determine effectiveness

22

Call it Quits – A RCT of a case worker delivered intervention

• Aim: Evaluate the efficacy of a caseworker-delivered cessation intervention at increasing smoking cessation rates

– Clients randomised to intervention or usual care control – Intervention group to receive 2 face-to-face counselling sessions, free NRT,

‘Quit Buddy’, telephone follow-up

• Primary outcome: CO validated continuous abstinence at 6 months follow up

Bonevski B, Paul C, D’Este C, Sanson-Fisher R, West R, Girgis A, Siahpush M, Carter R. RCT of a client-centred, case worker delivered smoking cessation intervention for a socially disadvantaged population. BMC Public Health 2011, 11:70

23

Call it Quits – Progress to date24

CiQ Study Participants (n = 384)

Sociodemographic Variables n (%)

Gender

Female 188 (49)

Age

Mean (SD) 38 years (11)

Indigenous Status

Indigenous Australian 58 (15)

Education

Completed Year 10 or below 245 (64)

Housing

Supported Accommodation/no home/street living 207 (54)

Income level

$400 per week or less 307 (80)

Income source

Centrelink 364 (95)

25

CiQ – Psycho-social variables (n = 384)

Psychosocial variables n (%)

Financial stress

Scores ≥ 4 343 (89)

Depression

Scores ≥ 10 228 (59)

Anxiety

Scores ≥ 3 216 (56)

Resilience

Mean (SD) 2.9 (1)

Social support (family & friend contact)

No/Less than once a month 115 (30)

26

Prevalence rates in current sample n (%)

Tobacco use (both daily and occasional)

384 (74)

Risky alcohol users 242 (63)

Concurrent users 190 (46)

27CiQ Trial – tobacco and alcohol use (n= 384)

28

CiQ Trial – Quit attempts (total n = 384)

n (%)

Smokers - ever made a quit attempt n = 384

Yes 334 (87)

Smokers - quit attempt in the last 12 months n = 334

Min, Max 0 – 24

Median 1

Mean (SD) 1.8 (2.1)

Two or more quit attempts 167 (50)

Zero or one quit attempt 167 (50)

Next steps

• Continued recruitment to December 2013

• Continued analysis of baseline data

• 1 Month outcomes

• Trial concludes July 2014

• Main 6 month outcomes

29

THANK YOU

Cancer Council NSW:Jon O’Brien, Phil Hull

Anglicare clients and staff

Funding:•Cancer Council NSW•Cancer Institute NSW•NHMRC•University of Newcastle•HMRI