Cigarette smoking is the leading preventable cause of cancer and many other deadly diseases, and the burden
of tobacco use is greatest among those with limited socioeconomic resources. Although we have driven down
population smoking rates, and with them, cancer rates, roughly 28% of the socioeconomically disadvantaged
still smoke regularly. Low-income (L-I) smokers also develop cancer at higher rates and struggle more to quit
than do higher-income smokers. These disparities in tobacco use and its burdens must be addressed. Highly
effective cessation treatment services that can be delivered remotely, flexibly, and conveniently with few cost
or logistical barriers have the potential to achieve this aim. Tobacco quitline and SmokefreeTXT services are
such treatment resources with demonstrated attractiveness and reach among L-I smokers. The current
proposal will use an efficient factorial design to evaluate 4 smoking cessation interventions with vast reach and
dissemination potential. The target population will be N=1,408 Medicaid-eligible or uninsured smokers who
have recently enrolled in the Wisconsin Tobacco Quit Line (WTQL), but who report continued smoking 4-
months following engagement in standard WTQL services. These treatment non-responders will be invited to
participate in an experiment that will randomize them to 1 of 2 levels of each of the following 4 factors in a
2X2X2X2 design: WTQL counseling intensity (1 session vs. 4 sessions), medication intensity (2-week nicotine
patch monotherapy vs. 4-week nicotine patch and lozenge combination therapy), a supportive text messaging
program (SmokefreeTXT vs. none), and financial incentives (rewards of up to $150 for treatment engagement
vs. no treatment incentives). The primary outcome will be 26-week biochemically confirmed point-prevalence
abstinence. Analyses will examine the main and interactive effects of these 4 treatment components on 26-
week and secondary abstinence outcomes to identify the components and combinations of components that
significantly enhance success in quitting in this high-risk population. This experiment will identify especially
effective combinations of highly scalable interventions of modest cost and few barriers that could be
disseminated nationally to reduce socioeconomic disparities in smoking cessation among those seeking to
quit. Additional analyses will: compare intervention components and promising component combinations in
terms of cost-effectiveness, examine whether or not treatment engagement differs across component
combinations, examine baseline variables that may moderate treatment response, and identify mediators of
treatment effects on abstinence outcomes. Because delivery of the study interventions can be centralized
through established and efficient services (WTQL and SmokefreeTXT), the potential for both scalable
dissemination and cost-effectiveness of the interventions tested is great. The proposed research will help
identify ways to reduce tobacco cessation disparities in L-I smokers who have tried to quit smoking but
relapsed and may benefit from improved assistance.
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