Mi­nori­ties strug­gle to quit smok­ing

A new study hopes to find ways that will make it eas­ier for blacks, His­pan­ics

The Capital - - BUSINESS - By Aneri Pat­tani The Philadel­phia In­quirer

PHILADEL­PHIA — Black and His­panic Amer­i­cans are less likely to smoke cig­a­rettes than white Amer­i­cans. Yet once they’ve started, they’re more likely to stay hooked. Na­tional data show they suc­cess­fully quit only about half as of­ten as white smok­ers.

These com­mu­ni­ties of­ten have less ac­cess to nico­tine-re­place­ment ther­apy and coun­sel­ing that can help them quit.

But ex­perts say that’s only one piece of a much larger is­sue.

Black and His­panic Amer­i­cans, es­pe­cially those with low in­come and ed­u­ca­tion lev­els, of­ten work or live in places with­out smoke-free laws, said Stella Bialous, an as­so­ciate pro­fes­sor of so­cial be­hav­ioral sciences at the Univer­sity of Cal­i­for­nia, San Fran­cisco. Be­ing around oth­ers who smoke makes it more dif­fi­cult to quit.

Higher lev­els of stress ex­pe­ri­enced by these com­mu­ni­ties also can make them more likely to turn to cig­a­rettes for the re­lief nico­tine can of­fer, said David Wil­liams, a pub­lic health pro­fes­sor at Har­vard Univer­sity who stud­ies racial health dis­par­i­ties.

Given such ob­sta­cles, what could help these smok­ers quit?

The fed­eral Pa­tien­tCen­tered Out­comes Re­search In­sti­tute has awarded $11 mil­lion to a team of re­searchers, led by the Univer­sity of Penn­syl­va­nia, to an­swer that ques­tion.

The study will in­clude 3,200 smok­ers who are black, His­panic, live in a ru­ral area, or have a low in­come or ed­u­ca­tion level — all groups for whom data show smok­ing ces­sa­tion is most chal­leng­ing. They will be re­cruited dur­ing lung can­cer screen­ings at the Univer­sity of Penn­syl­va­nia Health Sys­tem in Philadel­phia, Geisinger Health Sys­tem in north­east­ern and cen­tral Penn­syl­va­nia, Kaiser Per­ma­nente in South­ern Cal­i­for­nia and Henry Ford Health Sys­tem in Detroit.

An­nual lung can­cer screen­ings are rec­om­mended for heavy smok­ers over the age of 55 who cur­rently smoke or have quit within the last 15 years. Many screen­ing pro­grams are re­quired to of­fer smok­ing-ces­sa­tion ser­vices to their pa­tients.

“But most are scram­bling to fig­ure out what pro­grams to of­fer,” said Scott Halpern, lead re­searcher of the study and pro­fes­sor of medicine at Penn. “It’s en­tirely un­clear what ap­proaches work best among peo­ple pre­sent­ing for lung can­cer screen­ing, let alone which work best among un­der­served pop­u­la­tions.”

It’s a missed op­por­tu­nity, he said. Pa­tients un­der­go­ing screen­ing are of­ten more con­cerned about their health. A study from the Univer­sity of Texas found lung can­cer screen­ing par­tic­i­pants are three to four times more likely to quit suc­cess­fully than other smok­ers.

Study par­tic­i­pants in each health sys­tem will be ran­domly as­signed to one of four in­ter­ven­tions to help them quit smok­ing.

The first group will re­ceive the stan­dard ap­proach em­ployed at lung can­cer screen­ings now: Clin­i­cians ask pa­tients about their de­sire to quit, ad­vise them to quit, and re­fer them to re­sources such as hot­lines or sup­port groups.

It’s a pas­sive sys­tem that of­ten puts the bur­den on pa­tients to fol­low through on re­fer­rals, said Stan­ton Glantz, di­rec­tor of the UCSF Cen­ter for To­bacco Con­trol Re­search and Ed­u­ca­tion.

The sec­ond group will re­ceive the stan­dard ap­proach plus free ac­cess to nico­tine patches and gum, as well as FDA-ap­proved drugs to help with quit­ting.

The third group will be re­ferred to sup­port re­sources, re­ceive free nico­tine-re­place­ment aids, and a mo­bile health app that will text par­tic­i­pants per­son­al­ized re­minders of what they will gain by quit­ting.

The fourth group will re­ceive all those ser­vices and will be paid up to $600 for suc­cess­fully quit­ting. Pre­vi­ous re­search has shown fi­nan­cial in­cen­tives are one of the most ef­fec­tive strate­gies to help peo­ple quit.

Though this ap­proach has an up­front cost, Halpern said, it saves money in the long run by de­creas­ing the like­li­hood that pa­tients will de­velop lung can­cer or heart dis­ease.

All four in­ter­ven­tions will be of­fered for six months, then re­searchers will fol­low up with pa­tients for an­other year. The trial is set to start in 2020 and end in 2022.

“We’re con­fi­dent that if we suc­ceed in pro­duc­ing this ev­i­dence, health sys­tems and pay­ers will re­spond,” Halpern said.

Smok­ing-ces­sa­tion ex­perts cau­tion that help­ing smok­ers in un­der­served pop­u­la­tions quit is a com­plex chal­lenge.

A com­mon myth is that pay­ing for nico­tine-re­place­ment prod­ucts will solve the prob­lem, said Glantz, of UCSF. But stud­ies show that gums and patches don’t work well with­out coun­sel­ing.

In fact, Glantz ex­plained in a 2017 es­say for the Amer­i­can Jour­nal of Pub­lic Health, many pa­tients end up us­ing them in ad­di­tion to cig­a­rettes rather than as a re­place­ment.

Coun­sel­ing is cru­cial to ad­dress the un­der­ly­ing stress that drives peo­ple to smoke, said Wil­liams, of Har­vard.

“You’re look­ing at a pop­u­la­tion with fewer al­ter­na­tives to cope,” he said. “That makes it harder for them to give up that aid.”

The new study will not re­quire pa­tients to un­dergo coun­sel­ing, though they can choose to pur­sue re­sources pro­vided by clin­i­cians.

En­vi­ron­ment is an­other po­ten­tial bar­rier to suc­cess, said Bialous, of UCSF. “Peo­ple who don’t see cig­a­rette ads, who don’t shop in places that sell cig­a­rettes,” she said, “have an eas­ier time quit­ting.”

Re­search shows that peo­ple of lower in­come are more likely to live in neigh­bor­hoods with high rates of to­bacco re­tail­ers.

In Philadel­phia, which has the high­est rate of adult smok­ers among the na­tion’s 10 largest cities, al­most half of all to­bacco re­tail­ers are lo­cated in low­in­come com­mu­ni­ties, ac­cord­ing to the city De­part­ment of Pub­lic Health.

That’s no co­in­ci­dence, Glantz said. “While smok­ing has come down in the gen­eral pop­u­la­tion, the to­bacco in­dus­try has been fo­cus­ing more and more on hold­ing onto peo­ple with less ed­u­ca­tion and lower in­come,” he said. Such ef­forts have in­cluded hand­ing out cig­a­rettes in hous­ing projects, is­su­ing to­bacco coupons with food stamps, and fight­ing at­tempts at reg­u­la­tion.

The FDA re­cently moved to re­strict e-cig­a­rette sales at most gas sta­tions and con­ve­nience stores be­cause it said they were en­cour­ag­ing more youth to start smok­ing than adults to quit. The agency also an­nounced plans to ban men­thol cig­a­rettes, which are dis­pro­por­tion­ately pop­u­lar among African-Amer­i­cans.

That may pre­vent fu­ture smok­ers, Bialous said. But it’s only one side of the is­sue.

“It’s im­por­tant to un­der­stand how we can elim­i­nate the dis­par­ity in quit­ting, just as we try to elim­i­nate the dis­par­ity in start­ing,” she said.


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