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Treatment Barriers Among Younger and Older Socioeconomically Disadvantaged Smokers
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
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Treatment Barriers Among Younger and Older Socioeconomically Disadvantaged Smokers

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
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.
With respect to individual predictors, participants who received any form of cessation care from their healthcare provider had higher odds of CTU than those who had not received cessation care (aOR, 1.87; 95% CI, 1.19-2.94; P = .007). Participants whose healthcare provider had discussed smoking cessation medications had higher odds of CTU than those who indicated that their healthcare provider had not discussed these medications (aOR, 3.90; 95% CI, 2.46-6.20; P <.001). Surprisingly, difficulty of healthcare access was associated with higher odds of CTU (aOR, 1.12; 95% CI, 1.04-1.20; P = .004). Participants who live with another smoker had lower odds of CTU than those who do not live with another smoker (aOR, 0.69; 95% CI, 0.49-0.97; P = .033). Higher CL scores were associated with higher odds of CTU (aOR, 1.27; 95% CI, 1.17-1.37; P <.001) (Table 4).

Evaluating the conceptual model in the older age group, access to healthcare and physician cessation advice were significantly associated with CTU (all P <.05). Readiness to quit was also significantly associated with CTU (P <.001) (Table 3).

With respect to the individual predictors, participants whose healthcare provider had discussed smoking cessation medications had higher odds of CTU than those who indicated that their healthcare provider had not discussed these medications (aOR, 4.24; 95% CI, 2.70-6.67; P <.001). Higher CL scores were associated with higher odds of CTU (aOR, 1.38; 95% CI, 1.27-1.50; P <.001). Unexpectedly, higher scores on difficulty of healthcare access were associated with higher odds of CTU (aOR, 1.11; 95% CI, 1.03-1.19; P = .008) (Table 4).


Although many socioeconomically disadvantaged smokers in our sample were interested in quitting smoking and reported a recent quit attempt, the majority had not used NRT products, prescription cessation medications, or behavioral counseling in the past year. Older smokers were more likely to have utilized cessation treatments in the past year than younger smokers; this result is consistent with past findings.16,18-21

A conceptual framework was developed to identify potential predictors of CTU (Figure). This framework describes the influence of healthcare provider and psychosocial barriers on the likelihood of utilizing cessation treatment among socioeconomically disadvantaged smokers. In evaluating the framework, it was found that access to healthcare, receipt of cessation advice from one’s healthcare provider, and readiness to quit were significantly associated with CTU in both age groups. In the younger group, the presence of another smoker in the home was significantly associated with CTU.

We had posited that predictors of CTU would vary by age; however, the results for the 2 age groups are largely consistent with respect to aORs and CIs. This suggests that socioeconomically disadvantaged smokers, regardless of age, experience many common barriers to treatment access and utilization, particularly with respect to healthcare provider access and advice, as well as cessation beliefs.

Among socioeconomically disadvantaged smokers, knowledge regarding the availability and effectiveness of cessation treatments, like NRT and counseling, are positively associated with their use.11 As such, breaking down barriers to healthcare access and cessation advice is critical for bolstering CTU. In the present study, this is evidenced by the pronounced effect of physician-delivered cessation advice on CTU. In the younger age group, receipt of cessation-related care from a healthcare provider was positively associated with CTU. Furthermore, in both age groups, smokers whose healthcare providers discussed the use of cessation medications had approximately 4 times higher odds of CTU than smokers whose healthcare providers did not discuss these medications.

However, for both age groups it was also found that greater difficulty accessing healthcare was associated with higher odds of CTU. This may be the result of the fact that in our sample, smokers who experience more barriers to healthcare tend to have poorer overall health and are greater consumers of healthcare resources (ie, to have a regular doctor and to have seen a doctor in the past year) as a result. Thus, the increased odds of CTU among smokers who experience greater difficulty accessing healthcare may be explained by the fact that these smokers are in more regular contact with a physician and therefore are more likely to receive cessation-related advice. With respect to psychosocial factors, it was found that readiness to quit was positively associated with CTU in both age groups, suggesting that being more motivated to quit results in a greater propensity to take concrete steps toward this goal.

Among younger smokers, having another smoker in the home was associated with lower odds of CTU. This finding is consistent with research showing that residing with another smoker is negatively associated with CTU13 and suggests that the immediate home environment may influence CTU to a greater extent than perceived social support and smoking-related social norms. Although not significant, similar estimates were found for the older age group.

Past research suggests that counseling and medication-based cessation interventions are feasible and effective for smokers of all ages.30,31 Results of our study can inform both cessation interventions and healthcare provider practices for low-income smokers, which are vital steps toward reducing smoking rates in this population. Indeed, the discussion of cessation medications by one’s healthcare provider was a very strong predictor of CTU in this study. As such, bolstering rates of physician-delivered cessation advice, particularly regarding evidence-based cessation treatments, is a public health priority. It was also found that smokers in our study demonstrated a high readiness to quit and high rates of quit attempts. Therefore, it may be helpful to normalize the experience of multiple quit attempts in order to help smokers retain interest in engaging in future quit attempts, particularly those that include a cessation aid. Among younger smokers, living with another smoker was associated with lower odds of CTU. In light of this finding, interventions that stress the importance of the immediate home environment may be particularly effective for younger smokers.

Limitations and Strengths

Dependent and independent variables were measured at the same time so temporal relationships among these variables are unknown. Additionally, participants who consented to be in the trial may not be representative of the general population of smokers on state-funded insurance plans. A strength of the study is that we were able to study a sample of low-income smokers with health insurance that provided access to at least some evidence-based cessation treatment. Given current tobacco use disparities, information on these groups is needed in order to guide interventions.


Socioeconomically disadvantaged populations have a far higher prevalence of smoking compared with the general US population. One way to address this disparity is to increase the use of evidence-based tobacco treatments, which improve the likelihood that a smoker will be successful in their quit attempt. Increasing interest in or access to these treatments via interventions that target issues specific to these smokers, including healthcare access, provider-delivered cessation advice, the home environment, and cessation beliefs, could facilitate this process. As the majority of socioeconomically disadvantaged smokers do want to quit,32 it is imperative that healthcare providers and policy makers develop ways of promoting and delivering cessation strategies that lead to success.


This work was supported by the National Cancer Institute (1R01CA141527-01), National Institutes of Health. This work was also supported by the Minneapolis VA Center for Chronic Disease Outcomes Research. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

Author Affiliations: VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System (PJH, SSF, DJB, DN, BC), Minneapolis, MN; Department of Medicine, University of Minnesota Medical School (PJH, SSF, DJB, DN, AMJ), Minneapolis, MN; Division of Epidemiology and Community Health (PJH, RW), and Division of Health Policy and Management (JAN), University of Minnesota School of Public Health, Minneapolis, MN; North American Quitline Consortium (JES), Phoenix, AZ; Division of Health Care Policy & Research, Mayo Clinic (MVR), Rochester, MN.

Source of Funding: This work was supported by the National Cancer Institute (1R01CA141527-01), National Institutes of Health.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (SSF, DN, JAN, AMJ); acquisition of data (SSF, DJB, BC, RW); analysis and interpretation of data (PJH, SSF, DN, BC, JES, RW, AMJ); drafting of the manuscript (PJH, DJB, JES, RW); critical revision of the manuscript for important intellectual content (SSF, DJB, DN, JES, JAN, AMJ); statistical analysis (PJH, BC); provision of patients or study materials (SSF); obtaining funding (SSF, DN, AMJ); administrative, technical, or logistic support (SSF); and supervision (SSF). 

Address Correspondence to: Patrick J. Hammett, MA, VA Medical Center (152), 1 Veterans Dr, Minneapolis, MN 55417. E-mail: 

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