Treatment Barriers Among Younger and Older Socioeconomically Disadvantaged Smokers

A conceptual framework was used to examine the influence of healthcare provider and psychosocial barriers on treatment utilization among younger and older socioeconomically disadvantaged smokers.
Published Online: September 29, 2017
Patrick J. Hammett, MA; Steven S. Fu, MD, MSCE; Diana J. Burgess, PhD; David Nelson, PhD; Barbara Clothier, MS, MA; Jessie E. Saul, PhD; John A. Nyman, PhD; Rachel Widome, PhD, MHS; and Anne M. Joseph, MD, MPH

Objectives: Underutilization of smoking cessation treatments contributes to high rates of smoking in socioeconomically disadvantaged populations. Guided by a conceptual framework, the present study explored how healthcare provider factors, social environment characteristics, and cessation beliefs influence treatment utilization among low-income smokers and whether these associations vary by age.

Study Design: Analyses were conducted on baseline data from 2406 participants enrolled in a randomized controlled trial that evaluated the effectiveness of a proactive outreach cessation intervention among a sample of younger (18-34 years) and older (35-64 years) smokers enrolled in public healthcare assistance programs.

Methods: Multivariable logistic regression models predicted past year cessation treatment utilization (CTU) among younger and older smokers. Independent variables included measures of healthcare provider barriers, social environment characteristics, and cessation beliefs.

Results: Younger smokers were less likely to have CTU than older smokers (27.2% vs 36.2%; P <.001). In both groups, number of cigarettes per day, more problems accessing healthcare, receiving medication-related cessation advice, and readiness to quit were positively associated with CTU (P <.05). Among younger smokers, living with another smoker was associated with lower odds of CTU while receipt of cessation advice was associated (P = .033) with higher odds of CTU.

Conclusions: In this sample of low-income smokers, interest in quitting was high but treatment utilization was low. Increasing utilization of cessation treatments via interventions that target issues specific to low-income smokers, including healthcare provider access and advice, the home environment, and motivation to quit, is an important step toward reducing smoking rates in this population.

Am J Manag Care. 2017;23(9):e295-e302
Takeaway Points

Underutilization of cessation treatments contributes to high rates of smoking in socioeconomically disadvantaged populations. A conceptual framework was developed to assess the influence of healthcare provider factors, social environment characteristics, and beliefs about cessation treatment among younger (18-34 years) and older (35-64 years) low-income smokers. Regression models using variables from our conceptual framework predicted baseline cessation treatment utilization (CTU) among younger and older smokers enrolled in a proactive outreach tobacco treatment randomized controlled trial. Results indicate that cessation advice from healthcare providers, characteristics of the home environment, and cessation beliefs predict treatment use and that these predictors are consistent across age groups. 
  • Younger and older socioeconomically disadvantaged smokers share common predictors of CTU. 
  • Difficulty accessing healthcare, receipt of medication-related cessation advice, and readiness to quit are positively associated with CTU. 
  • Bolstering rates of physician-delivered cessation treatment may reduce socioeconomic disparities in smoking prevalence.
Among US adults younger than 65 years, 30% of the medically uninsured and Medicaid enrollees are current cigarette smokers compared with 15% of adults with private health insurance.1 Smokers with lower incomes are less likely to use evidence-based smoking cessation treatments, like pharmacotherapy and counseling, than smokers with higher incomes.2-4 In an analysis of the 2010 National Health Interview Survey, among smokers who were attempting to quit, only 29.9% of Medicaid enrollees used a cessation aid compared with 37.1% of individuals with private health insurance.3 The low rate of smoking cessation treatment utilization (CTU) among low-income smokers likely contributes to the socioeconomic disparity in smoking prevalence among US adults.

Socioeconomically disadvantaged smokers experience barriers to CTU at the healthcare provider and psychosocial levels. The present study organizes these barriers to CTU in a conceptual framework informed by elements of Social Cognitive Theory (SCT),5,6 the Transtheoretical (Stages of Change) Model,7 and the Biopsychosocial Model of Perceived Discrimination (Figure).8 Drawing from SCT, the framework emphasizes the influence of healthcare provider and psychosocial factors on CTU. The Stages of Change Model highlights the roles that precontemplation, contemplation, and action play in enacting behavior change. The Biopsychosocial Model of Perceived Discrimination elucidates how perceptions of healthcare provider bias influence CTU.

Healthcare providers often lack the time or motivation to discuss smoking cessation treatments with their patients.9 Competing treatment demands may play an especially important role with socioeconomically disadvantaged patients.10 A lack of knowledge regarding insurance coverage for cessation treatment in this population and skepticism about treatment effectiveness11 likely contribute to underadministration of treatment. Furthermore, healthcare providers’ lack of competence to discuss smoking cessation treatments in a culturally sensitive manner can contribute to low CTU rates.12

Social environment characteristics also influence smokers’ propensity to utilize cessation treatment. Indeed, smokers who live with another smoker are less likely to utilize cessation treatments than those not living with a smoker.13 It is hypothesized that other characteristics of smokers’ social environments, including perceived social support and social norms, also influence CTU. Other data show that psychosocial factors pertaining to cessation beliefs, including readiness to quit and self-efficacy for quitting, influence smokers’ CTU.14,15 Smokers who believe that they will stop smoking in the next year are more likely to utilize treatment than those who do not believe they will quit in the next year.16

Although the conceptual framework asserts that socioeconomically disadvantaged smokers share many common barriers to CTU, it is hypothesized that the influence of these barriers may vary as a function of age. Younger smokers engage in frequent quit attempts,17 but they use cessation treatments at lower rates than older smokers.16,18-21 This age disparity in CTU could be due to age-related differences in nicotine dependence, use of healthcare resources, social environment, and cessation-related beliefs.17,22

As such, examining the factors that influence CTU separately for younger and older smokers may inform more effective cessation interventions for these smokers. The primary aim of the present study was to examine the predictors of CTU among smokers enrolled in publicly subsidized healthcare programs, with a focus on healthcare provider and psychosocial barriers. A secondary objective was to determine whether the predictors of CTU differ by age. Analyses are intended to inform future interventions designed to increase CTU in socioeconomically disadvantaged populations and to elucidate how healthcare provider factors influence the propensity with which these smokers utilize cessation treatment.


Study Design

We used baseline data from a randomized controlled trial evaluating the effectiveness of a proactive care tobacco cessation outreach intervention in a sample of adult smokers enrolled in Minnesota Health Care Programs (MHCP).23 MHCP is a state-funded health insurance plan for low-income Minnesota residents comprising 2 publicly subsidized healthcare programs: Medicaid and MinnesotaCare. The study population sample was stratified by age group (18-24, 25-34, and 35-64 years), gender, and healthcare program (Medicaid and MinnesotaCare). Institutional review board approval for the study was obtained from the University of Minnesota and the Minnesota Department of Human Services.

Study Setting and Participants

Eligibility criteria included: 1) a valid home address, 2) proficiency in English, and 3) current cigarette smoking (having smoked a cigarette in the past 30 days, even as little as 1 puff). Baseline surveys were mailed to 21,181 prospective participants aged 18 to 64 years who were MHCP clients. A total of 9362 baseline surveys were returned. Of these, 6826 individuals did not meet study inclusion criteria and 130 declined to participate. The remaining smokers (n = 2406) were enrolled in the study and randomized to proactive outreach or usual care.

Conceptual Framework: Predictors of Smoking Cessation Treatment Utilization

To conform to the proposed conceptual framework, distinct blocks of variables relating to healthcare provider factors and psychosocial characteristics were formed on the basis of their underlying constructs. Blocks assessing demographics and smoking history were also formed to enable block adjustment for known predictors of CTU. The demographic factors assessed were insurance type, gender, race/ethnicity, education, employment status, and income. In terms of smoking history, the California Tobacco Survey24 and the CDC Behavioral Risk Factor Surveillance System25 assessed lifetime duration of smoking, time until first cigarette upon waking, and quit attempts in the past year.

Healthcare Provider Barriers

Access to healthcare. A composite variable measuring healthcare access was created by summing 5 items pertaining to cost of care, transportation, and ease of access. Each item was assessed on a 3-point scale, with higher scores indicating greater healthcare provider barriers. Participants also indicated whether they had a regular doctor.

Healthcare provider cessation advice. Healthcare Effectiveness Data and Information Set tobacco performance measures26 were used to assess participants’ past year healthcare experiences, including the receipt of advice to quit, to use cessation medications, to use ways (besides products) to help with quitting, and the receipt of any cessation-related care.

Healthcare provider bias/cultural competence. A composite variable measuring healthcare provider bias was created by taking the mean of 3 items from the Physician Bias and Interpersonal Cultural Competence Measures Scale.27 Each item was assessed on a 5-point scale, with higher values indicating greater physician bias.

Psychosocial Barriers: Social Environment

Social support. A composite variable measuring perceived social support for cessation was created by taking the mean of 2 support-related variables.28 Another composite variable measuring overall social support was created by taking the mean of 6 general social support-related variables, pertaining to issues like help with housework, monetary assistance, and emotional support. Both of these variables were assessed on a 5-point scale, with higher scores indicating greater support.

Social norms. Participants reported the proportion of their close friends and family who smoke.

Home environment. Participants reported whether they lived with a child younger than 18 years, whether they lived with another smoker, and smoking rules within their home.

Psychosocial Barriers: Cessation Beliefs

Self-efficacy. Self-efficacy for quitting was measured on a scale from 1 to 10, with higher values indicating greater confidence in quitting.28

Readiness to quit. Readiness to quit on a scale from 1 to 10 was assessed using the Contemplation Ladder (CL), with higher values indicating greater readiness to quit.29

Treatment utilization. Items assessed past-year use of nicotine replacement therapy (NRT) products, prescription cessation medications, and behavioral counseling.

Statistical Analysis

The 2 younger age strata (18-24 and 25-34 years) were merged into a single group (n = 1320) due to similarities with respect to the independent variables of interest and to increase the power of the regression analyses; the older age group (35-64 years; n = 1086) was not altered. The younger and older groups were compared across baseline demographics, smoking history, healthcare provider barriers, social environment characteristics, and cessation beliefs using t tests and χ2 tests.

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