1. Translating Effective Cessation to Underserved Populations: What Barriers? Matthew J. Carpenter, PhD, Marvella E. Ford, PhD, Kathleen Cartmell, MPH, Anthony Alberg, PhD, MPH Hollings Cancer Center, Medical University of South Carolina, Charleston, SC Background: Disparities in quitting success among ever-smokers: Many smokers unaware of effective cessation tools Survey of 616 smokers in Ontario 1 : - 20% failed to recall any proven pharmacotherapy aid - 24% cited at least 1 unproven cessation strategy (e.g., hypnosis) - 78% stated that, if motivated to quit, they would be as successful on their own as with help Nicotine Replacement Therapy (NRT) well documented to improve quitting success Underuse of proven cessation strategies is a big problem, particularly among minority smokers - 2000 NHIS data: 78% of smokers who tried to quit in past year did so unaided 2 Not just about cost: - In VA (equal access health system) – 34% of AA smokers, 26% of Hispanic smokers, and 50% of Caucasian smokers ever used NRT 3 Likely barriers: perceived efficacy, perceived safety While studies have examined barriers to NRT use, few have used a qualitative approach to capture detailed information about beliefs or examined beliefs across race/ethnic groups This study examines individual factors by race / ethnicity that may inhibit the use of NRT into widespread public health benefit Acknowledgments: Funding provided through the American Cancer Society (IRG-97-219-08). The authors wish to thank Jason Roberson for assistance in conducting focus groups and Lindy McQuinn with assistance with data analysis. Correspondence: Matthew Carpenter: carpente@musc.edu. Specific Aims: To examine qualitative and detailed perspectives on NRT across and within groups of smokers using focus group methodology Predominant Themes Among African Americans Strong Suspicion of Pharmaceutical Industry / Government (FDA): “I’m thinking ‘are you sure that’s not a placebo you wear’ - they’re telling you that it’s used to cut back the nicotine craving. Is there actual medication in there or is it something like a test, where you have some of the people getting the active pills and there’s no medication in the others” “sometimes they slip somebody a little money under the table to put this stuff on the market and before you know it somebody done croaked and they either recall or get sued” “some of these research programs- people are going to cover up in order to get their products [out], but it’s the drug companies that are paying to get there products out there on the market” “with everything else they could just go around the authorities” “Are the cigarette companies selling those (NRT products)? When the price of cigarettes goes up, the price of NRT goes up too. The cigarette company is probably selling that product too” “It’s all part of the government. Everyone gets part of the reward from the sale of cigarette tobacco. If there’s something they could do to stop, they would stop, but they don’t want to do that because the change is going to affect a lot of people” Power of Doctor’s Advice: “the doctor is going to know what type of health condition you have, to determine whether you should be taking any one of those NRTs” “the doctor knows your health and whether you can handle the medication, or whether the other medication you’re taking (is going to react)” “If my doctor gave it to me, then I would use it. Because he knows my background” “I think I would want my doctor to take my body’s metabolism and my physical health and connect it to whatever one he feels is best for me. And to be straight up front as to what that the effects could be” “I think you should see your physician before you start anything. You know because some things just don’t combine. You know it may have chemical reactions” Supremacy of ‘Cold Turkey’: “Cause you don’t have to worry about being addicted to those stuff, that nasal spray out there, or using the gum all day” “[using NRT is] adding on the problem. If you take that, you’re just going to stop for a while, then you’re going right back at it” Conclusions: General lack of knowledge of NRT effects, efficacy; moderate knowledge on mechanism Universal concerns about NRT safety; EA smokers more likely to endorse addictive potential Among AA smokers  strong suspicion of pharmaceutical industry & government oversight Reliance on ineffective strategies: “at least with cold turkey its free & you’re not hurting yourself” More education needed with regard to NRT development, process of testing: safety / efficacy AA smokers could be educated through trusted physicians Methods: Six focus groups conducted homogeneous to race - 3 with European Americans (EA), 3 with African Americans (AA) - 7 to 12 members per group; total N=53 (27 AAs and 26 EAs) Groups heterogeneous with regard to prior NRT use Locations in public libraries Individuals recruited in person & through flyers at local community businesses Moderators race-matched & trained on focus group methodology Exclusive focus on NRT – rationale based on ubiquity of NRT (OTC status) Adjunctive survey on smoking history, attitudes about NRT $75 reimbursement (2-3 hour total) Data analyzed through Qualitative Data Analysis (NVivo): - transcripts coded and organized for thematic nodes Focus Group Topics: 1) consequences of continued smoking 2) what NRT is, its mechanism, and the rationale for using it 3) perceived efficacy of NRT for smoking cessation & comparisons to “cold turkey” 4) side effects and indirect consequences of NRT use 5) actual cost and cost/benefit 6) knowledge of NRT development and regulatory oversight Common Themes Across All Groups (AA and EA) Primacy of motivation: “they have to want to quit smoking for those to be effective” “if you don’t really want to quit you could try all of that stuff but if you don’t really want to quit, it ain’t going to happen” “I don’t think that they really help though because it is the individual alone who has to quit the smoking” Concerns about safety: “NRT could affect other medications you’re taking” “You’re taking a chance. Because you already know what’s going to happen when you smoke, but with the patch, or the pill, or all those things, you don’t know what’s going to happen. You’re really taking a chance” “there could be something in me, that I am allergic to, and it could cause problems” “Isn’t the nicotine that causes cancer?” “Well, it’s a poison, if you over use it, like anything else, it’s going to be harmful“ Need for more information / Openness to learn more: “My question is will it kill me to smoke a cigarette while using the products” “You know more about cigarette studies and how they’ll kill you than you know on the stuff to save you. You know, how many people stopped this month?” “If you are prescribed a certain amount of doses of a capsule and you miss a dose by mistake or are not able to get the dose, what harm can it cause to your body?” “We don’t know what is in them. There could be something in them that could cause cancer” “As far as the commercials alone I can’t determine a success rate on the product itself. Maybe it works” Doubts of Efficacy / Concerns of Cost: “I’m not going to spend $42 for them to sit in my medicine chest b/c it’s not going to work” Citations: 1 Hammond, et al. (2004). Addiction, 99, 1042-1048. 2 Cokkinides, et al. (2005). Am J Prev Med, 28, 119-122. 3 Fu, et al. (2005). Am J Health Promotion, 20, 108-116. Related Survey Data: AAEAp Ever use of NRT: 26%56%;.03 Nicotine is cause of cancer (% agree):83%65%n.s. Nicotine is cause of heart attacks68%69%n.s. NRT products help people quit31%72%.003 There is risk for becoming dependent42%78%.01