Methods
Electronic databases were searched to get relevant literature for this review. Keywords were joined using Boolean operators including “AND’, “OR” and “NOT” and used during the search. The keywords are smoking, tobacco, cessation, quit, disadvantaged, socioeconomically disadvantaged, and low socioeconomic status. These search terms were combined and altered to yield many results. The search results were limited to English publications, last five years, and search terms. Besides, the search was limited to peer-reviewed and scholarly articles. The search results were hand reviewed for relevancy, duplication, and possible errors.
The reasons for including/excluding articles for the review and the pertinence and quality of the papers included
The criterion of including and excluding papers in this review was based on various fundamental factors. Only studies that focused on disadvantaged populations were included. In this context, disadvantaged populations include people living in low socioeconomic status (SES), unemployed individuals and those earning low incomes. All papers that did not define the target population or focused on the broad populations were excluded from this review. In addition, the review included studies that present both pharmacological and non-pharmacological smoking cessation interventions. Importantly, some studies detailed pharmacological trails only while others focused on non-pharmacological cessation interventions only. Papers, whereby the therapy is administered by peers such as friends or family members and unqualified individuals, are excluded. In essence, the papers that include nurses, medical professionals, nurses, cessation counselors, and qualified social workers are included in the review.
The selection criterion also considered the kinds of interventions detailed in the papers. In this regard, the papers that were included focused on nicotine replacement therapy, behavioral therapy, Mindfulness Training for Smokers, and financial incentives. The papers used different population sizes in their trials in an effort to determine the effectiveness and effect of smoking cessation attributes. The review excluded studies that focused on group therapies such as group counseling. Evidently, the review wanted to determine the effectiveness or effect of individual cessation therapies. Papers were excluded in case they were not original accounts of therapies developed to support smoking quitting efforts, failed to include peer support components in the interventions or failed to analyze the peer support components of the interventions. Eventually, ten papers were selected as suitable for the review.
In Australia, the prevalence of smoking is 23 per cent for individuals in the lowest socioeconomic quintile and 10 per cent within the highest socioeconomic quintile (Twyman et al., 2018, p.170). Recent research has found that the use of cessation aids as well as lower odds of experiencing financial stress cause people to quit smoking (Twyman et al., 2018, p.170). According to Guillaumier et al. (2016, p.118), a majority of socially disadvantaged smokers in Australia have normalized the dangers associated with smoking. Besides, many of these smokers have “skeptic” beliefs about smoking (Guillaumier et al., 2016, p.118). The barriers to smoking cessation among disadvantaged populations include smoking to manage stress, inadequate support from service providers and acceptance of smoking among the vulnerable communities (Twyman et al., 2014, p.e006414). Indigenous populations are also likely to smoke because of their historical and cultural norms (Twyman et al., 2014, p.e006414). As a result, the literature details the effectiveness of various smoking cessation techniques designed for disadvantaged populations.
Results
The effectiveness of nicotine replacement therapy (NRT) in Australia has been studied comprehensively. The government-subsidised NRT for disadvantaged populations mainly indigenous Australians is relatively ineffective (Paul et al., 2015, p.786). In fact, the evidence of effectiveness for NTR is weak. One randomised study involving a sample population of 431 disadvantaged smokers in Australia found that free NRT is ineffective in achieving tobacco abstinence (Bonevski et al., 2018, p.38). However, the intervention increased intentions and attempts to quit smoking and even resulted in a decrease in the number of cigarettes smoked in a day.
The combination of NRT with other non-pharmacological smoking cessation techniques is effective for low socioeconomic status (SES). Courtney et al. (2014, p.1602) assert that the integration of NTR with financial education is an ideal intervention for low SES Australian smokers. Similarly, Fu et al. (2016, p.446) designed a study to determine the effectiveness of free NRT and telephone counseling for disadvantaged populations. Based on the findings, the use of population-based therapy increases engagement rates and is practical for long-term tobacco cessation among low SES smokers (Fu et al., 2016, p.446).
Behavioral interventions have also been designed to enhance smoking cessation among disadvantaged groups. Hiscock et al. (2013, p.2787) explored the effectiveness of behavioral therapy for tobacco cessation among socioeconomically disadvantaged and wealthy smokers using records of 202,084 individuals. The authors found that affluent smokers are more likely to quit smoking if exposed to behavioral therapy than socioeconomically disadvantaged smokers (Hiscock et al., 2013, p.2787). These findings suggest that socioeconomically disadvantaged smokers are not motivated to quit even after attending smoking cessation programmes. Kendzor et al. (2015, p.1198) did a randomised study involving 146 disadvantaged smokers to determine the effectiveness of financial incentives for smoking quitting. Based on the findings, financial incentive tends to increase smoking abstinence rates among economically disadvantaged populations (Kendzor et al., 2015, p.1198). Further, Mindfulness Training for Smokers (MTS) has been found to be successful in enhancing tobacco quitting among disadvantaged groups (Davis et al., 2014, p.571). In essence, different smoking cessation therapies have been designed for disadvantaged populations.
Conclusions from the evidence
Less affluent populations are more likely to smoke than wealthy individuals because of various factors such as smoking to manage stress and acceptance of smoking behaviors. In this case, indigenous populations have higher chances of being smokers than the non-indigenous populations. The evidence shows that a single intervention is less likely to improve smoking cessation rates among disadvantaged populations. Ideally, a combination of interventions has a high possibility of increasing cessation rates. Smoking cessation therapies should address inherent factors that increase smoking intentions within the target population. A practical cessation program should focus on skeptic beliefs that sustain smoking intentions.
Discussion
The evidence further implies that free smoking cessation programs might be less effective because the population is not motivated to attend the sessions or seek quit services. In this case, subsidised cessation programs might be more effective for disadvantaged groups. An important question is whether a combination of pharmacological and non-pharmacological interventions is effective in improving cessation rates. The evidence suggests that interventions that engage the population are more likely to yield positive results than cessation programs that do not engage the target population. Conclusively, a combination of NTR and behavioral therapy has a high possibility of increasing cessation rates among disadvantaged populations.
The primary objective is to establish whether the wealthy and socioeconomically disadvantaged smokers have similar intentions to quit smoking. This objective has been proposed because certain cessation techniques are more effective for the affluent smokers than disadvantaged populations. Another objective is to determine whether socioeconomically disadvantaged populations adopt smoking cessation programs and their level of engagement during such programs. Importantly, the level of adoption of such programs as well as the level of engagement tends to predict cessation rates. In this regard, a high adoption level and engagement might increase quit rates among disadvantaged smokers.
The other objective arising from the evidence is to investigate how the delivery of smoking cessation programs affects quit rates. This objective is inspired by the fact that there are different methods of delivery such as telephone, one-on-one, and online therapies. In addition, the professional or provider administering the therapy may influence its success level. Therefore, it is important to determine whether the skills or competency of the professional influence the effectiveness of the cessation interventions. The focus, in this case, will be the nurses, counselors and other social workers who are involved in cessation programs. In essence, these objectives will provide comprehensive information on smoking cessation among disadvantaged populations.
Bonevski, B., Twyman, L., Paul, C., D’Este, C., West, R., Siahpush, M., Oldmeadow, C. and Palazzi, K. (2018). Smoking cessation intervention delivered by social service organisations for a diverse population of Australian disadvantaged smokers: A pragmatic randomised controlled trial. Preventive medicine, 112, pp.38-44.
Courtney, R.J., Bradford, D., Martire, K.A., Bonevski, B., Borland, R., Doran, C., Hall, W., Farrell, M., Siahpush, M., Sanson?Fisher, R. and West, R. (2014). A randomized clinical trial of a financial education intervention with nicotine replacement therapy (NRT) for low socio?economic status A ustralian smokers: a study protocol. Addiction, 109(10), pp.1602-1611.
Davis, J.M., Goldberg, S.B., Anderson, M.C., Manley, A.R., Smith, S.S. and Baker, T.B. (2014. Randomized trial on mindfulness training for smokers targeted to a disadvantaged population. Substance Use & Misuse, 49(5), pp.571-585.
Fu, S.S., Van Ryn, M., Nelson, D., Burgess, D.J., Thomas, J.L., Saul, J., Clothier, B., Nyman, J.A., Hammett, P. and Joseph, A.M. (2016). Proactive tobacco treatment offering free nicotine replacement therapy and telephone counselling for socioeconomically disadvantaged smokers: a randomised clinical trial. Thorax, 71(5), pp.446-453.
Guillaumier, A., Bonevski, B., Paul, C., D’Este, C., Twyman, L., Palazzi, K. and Oldmeadow, C. (2016). Self-exempting beliefs and intention to quit smoking within a socially disadvantaged Australian sample of smokers. International journal of environmental research and public health, 13(1), p.118.
Hiscock, R., Murray, S., Brose, L.S., McEwen, A., Bee, J.L., Dobbie, F. and Bauld, L. (2013). Behavioural therapy for smoking cessation: the effectiveness of different intervention types for disadvantaged and affluent smokers. Addictive behaviors, 38(11), pp.2787-2796.
Kendzor, D.E., Businelle, M.S., Poonawalla, I.B., Cuate, E.L., Kesh, A., Rios, D.M., Ma, P. and Balis, D.S. (2015). Financial incentives for abstinence among socioeconomically disadvantaged individuals in smoking cessation treatment. American journal of public health, 105(6), pp.1198-1205.
Paul, C., Wolfenden, L., Tzelepis, F., Yoong, S., Bowman, J., Wye, P., Sherwood, E., Rose, S. and Wiggers, J. (2016). Nicotine replacement therapy as a smoking cessation aid among disadvantaged smokers: What answers do we need?. Drug and alcohol review, 35(6), pp.785-789.
Twyman, L., Bonevski, B., Paul, C. and Bryant, J. (2014). Perceived barriers to smoking cessation in selected vulnerable groups: a systematic review of the qualitative and quantitative literature. BMJ open, 4(12), p.e006414.
Twyman, L., Bonevski, B., Paul, C., Bryant, J., West, R., Siahpush, M., D’este, C., Oldmeadow, C. and Palazzi, K. (2018). What factors are associated with abstinence amongst socioeconomically disadvantaged smokers? A cross?sectional survey of use of cessation aids and quitting approach. Drug and alcohol review, 37(2), pp.170-179.
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