A randomized trial of assertive intervention approaches with non treatment seeking 18 to 24 year old tobacco users: 3 month tobacco cessation outcomes

Purpose – Tobacco use is a leading contributing cause of mortality and morbidity among low income individuals. Tobacco use also contributes to lower social and economic functioning and secondhand smoke negatively impacts the health of young children. Tobacco use remains highest among young adults especially those with lower incomes, lower education, and who lack healthcare access. Within the U.S. 70% of tobacco users report that they are interested in quitting smoking, although fewer than 5% quit annually. Low quit rates are associated with underutilization of evidence based cessation programs, which range in effectiveness from 24% to 36% among treatment seeking tobacco users. Thus an important public health need is to motivate the vast majority of tobacco users who want to quit smoking to successfully engage in evidence based tobacco cessation programs. The study aims were to: (1) assess if assertive intervention could motivate non treatment seeking tobacco users to participate in evidence based quit programs; and (2) to determine if there were outcome differences between two commonly utilized intervention approaches.

Methods – The study was implemented in six rural counties. Inclusion/exclusion criteria included: age (18 to 24); non college graduates; and having smoked at least 1 cigarette in the past month. Recruitment was conducted by six tobacco cessation counselors at recruitment booths set up at local businesses or through street outreach. A convenience sample of 192 clients was recruited and block randomized to one of two conditions: (1) referral to a national tobacco cessation Quitline (N=90) or (2) direct cessation intervention provided by the counselor (N=102). Participants completed the “Panel Tobacco User Survey”, a commonly utilized assessment of tobacco use practices and were followed 3 months post baseline. Tobacco use status was validated through random saliva testing at the 3-month follow-up.

Results - Overall 78% of the participants completed the 3 month follow-up and 16.3% quit smoking. A 2X2 chi-square test was conducted in which the first factor was condition assignment and the second factor was 3 month smoking status (no tobacco use in the past 30 days vs. any tobacco use). The results found that 20.7% of the tobacco users in the direct intervention condition quit compared to 10.2% in the Quitline (chi-square=2.8, df=1, p=.09). A logistic regression analysis found that condition assignment was the strongest predictor of quitting and that participants in the direct intervention condition were statistically (p=.03) more likely to quit after controlling for other factors.

Implications – Assertive intervention is an effective social work practice designed to assist non treatment seeking tobacco users to enroll in commonly utilized tobacco cessation services. Further, randomization to direct intervention resulted in slightly more than a 100% increase in quit rates than referral to the national tobacco cessation Quitline. These results are even more encouraging when compared to the estimated 5% of adults who quit without formal intervention. Application of assertive intervention to specific populations could be an important social work intervention protocol designed to reach the highest proportion of tobacco users, especially those with lower incomes and education to quit smoking.