A behavioral economic intervention for low-income smokers

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PROJECT SUMMARY People with low income are three times more likely to smoke than people with high income. The income disparity in tobacco use has persisted over the past 50 years—in part because there have been limited efforts to design cessation interventions that address the sociocontextual determinants of smoking among low-income adults. Tobacco use not only causes extreme health consequences for low-income people, but it can also exacerbate their financial strain by using funds on tobacco that could go towards essentials. Low-income smokers also face unique barriers to cessation, including high levels of financial distress and other social needs, which results in the use of smoking as a coping mechanism. Behavioral economics further finds that people experiencing financial strain have an increased focus on immediate needs at the expense of delayed goals (such as the long- term health benefits of cessation)—resulting in limited cognitive “bandwidth” to attend to smoking cessation. Interventions that alleviate financial stress and help low-income smokers attend to the benefits of quitting may improve quit rates in this vulnerable population. We previously conducted a randomized study testing a novel intervention that integrates financial coaching into a smoking cessation program for low-income smokers. At follow-up, intervention participants were more likely to have quit smoking, report lower levels of financial stress, and report higher levels of financial satisfaction than a minimal usual care control group. Our goal with the proposed R01 is to leverage the successes of the prior study and conduct a large randomized controlled trial (RCT) comparing the effectiveness, mechanisms, and costs of the integrated intervention against standard intensive cessation treatment. We have the following Specific Aims: (1) Compare the effectiveness of the integrated intervention to standard cessation counseling on long-term abstinence; (2) Identify the significant mechanisms of action of the integrated intervention; and (3) Estimate the cost and cost-effectiveness of the integrated intervention compared to standard counseling. To accomplish these aims, we will conduct a two-arm, parallel-group, RCT. We will recruit and randomize 900 smokers (n=450 per arm) to either: (1) Control: Standard Smoking Cessation Counseling or (2) Intervention: Integrated Financial-Smoking Cessation Counseling. Both groups will receive 8 weeks of nicotine replacement therapy. We will survey participants at baseline, 6 months, and 12 months to assess outcomes and mechanisms, and biochemically verify self-reported abstinence at 12 months (our primary outcome). We will assess and compare the cost-per-quit in the two treatment arms.