The Call it Quits trial: A community welfare service case-worker delivered smoking cessation intervention Billie Bonevski University of Newcastle Faculty of Health School of Medicine and Public Health

Newcastle

The Call it Quits Team The University of Newcastle: Laura Twyman, Chris Paul, Cate D’Este, Jamie Bryant University College London: Robert West University of Nebraska: Mohammad Siapush Illawarra Translational Cancer Research Unit: Afaf Girgis

Overview Rationale for tackling tobacco amongst socially disadvantaged Describe the Tackling Tobacco Program formative research What are the opportunities and barriers? Is data collected in this setting accurate? Do clients smoke and do they want to quit? Is a smoking intervention feasible? Is a smoking intervention effective? Baseline results from the Call it Quits Trial During this presentation: I will use smoking prevalence data to provide a rationale for targeting sub-groups of the population many of whom experience various forms of disadvantage. Outline some of the advantages for reaching the high smoking prevalence sub-groups through the social and community services sector. Then I’ll describe The Tackling Tobacco Program and the main components of research we have been conducting in partnership with the community services sector looking at What the opportunities for and barriers to addressing smoking in this setting are. Whether data collected in this setting is accurate. Do clients smoke and do they want to quit? Is a smoking cessation intervention in this setting feasible? Is it effective?

Smoking rates over time by SEIFA quintile This graph shows the most recent smoking prevalence data according to the SEIFA index or measure of disadvantage which uses area-level measures of socioeconomic position. As you can see.....those with the highest socioeconomic position (quintile 5) tend to have lower smoking prevalence rates compared to those with the lowest socioeconomic position (quintile 1) who demonstrate highest smoking rates. The graph also illustrates that the difference in smoking rates according to socioeconomic position appears to be getting larger over time - it is not narrowing. This appears to be due to falls in smoking rates amongst those from the higher socioeconomic position while there appears to be no or little change in smoking rates over the last 12 years in those with lower socioeconomic status. Changes in smoking prevalence (daily and occasional) from 1998 to 2010 by socioeconomic quintile (1 - most disadvantaged, to 5 - least disadvantaged: AIHW National Drug Household Surveys 1998, 2001, 2004, 2007, 2010

Smoking rates 2010 - group comparisons There is a social gradient in smoking rates in Australia. This means that the prevalence of tobacco use is highest among individuals who are disadvantaged relative to individuals who are advantaged. Whichever way you define social disadvantage, the disparity is present. The dashed line is the smoking prevalence rates amongst the general adult population in Australia of 15.1%. Large discrepancies are evident between the employed (19.6%) and unemployed (27.6), highest (12.5%) and lowest socioeconomic position (24.6%), and Aboriginal Australians (37.6) and Non-Aboriginal Australians (17.4). Smoking prevalence in the Australian general population compared with selected disadvantaged groups: AIHW National Drug Household Survey 2010

Smoking and disadvantage Compared to more advantaged groups, disadvantaged smokers: are more addicted1 report lower self efficacy for quitting1 smoke more cigarettes per day (17.9 vs. 10.9 for least disadvantaged)2 are less likely to make a quit attempt 3, 4 are less likely to plan a quit attempt in the next 6 months 4 are less likely to receive health provider advice to quit smoking5 In addition The lower your socioeconomic position, The higher the rates of heavy nicotine dependence....... 1. Siahpush, McNeill, Borland, 2006; 2. AIHW, 2004; 3. Siahpush, Yong, Borland, Reid, Hammond, 2009; 4. Reid, Hammond, Boudreau, Fong, Siahpush, 2010; 5. Browning, Ferketich, Salsberry, Wewers, 2008.

Addressing smoking amongst disadvantaged groups National Preventive Health Taskforce recommendations: “tailor services for indigenous smokers and other highly disadvantaged groups” “resources for professionals to encourage and assist smokers in psychiatric and correctional facilities” “Implement programs to subsidise nicotine replacement therapy for people who are homeless and other highly disadvantaged people in financial stress” As a result the most disadvantaged in society carry the highest burden of disease due to smoking as well as social and financial burden. Recognising tobacco-related disparities, a number of peak health organisations in Australia and overseas have called for increased efforts to try to address the inequities. For example............... However, there is limited evidence demonstrating what is effective. A recent meta-analysis showed that behavioural smoking cessation interventions, with or without nicotine replacement therapy, have the potential to reduce smoking rates in some disadvantaged groups, however, reaching high numbers of smokers from disadvantaged groups remains a challenge.

Tackling Tobacco Led by the Cancer Council NSW Reduce smoking among most disadvantaged population groups in NSW by engaging with the non-government community service sector Reframe smoking as a social justice issue Make the provision of quit support part of routine care Research driven In 2006 the Cancer Council NSW identified the social gradient in smoking rates as a policy priority and launched its Tackling Tobacco Program. It is a collaborative program of work that seeks to work with social service agencies with the central objective being a reduction in smoking-related harm among the most disadvantaged groups in NSW. It aims to do this using a variety of strategies. Using a top down approach including meetings with CEOs and managers of social service organisations it is working to reframe smoking as a social justice issue. Its also using seminars, staff training, policy development tools, and development of case-work resources to facilitate the uptake of quit support for clients as usual care provision within services. It is a research-driven agenda and I’ll describe some of the research informing the Tackling Tobacco Program to date.

Why the community social service sector? Access and reach More than 5,000 services in Australia More than 4 million instances of service Single parents 12 times more likely to use, Indigenous Australians 6.5 times more likely to use Holistic approach Personalised and tailored support Sustainable and cost effective Being recognised internationally as a novel and potentially suitable setting (Christiansen et al., 2010, American Journal of Preventive Medicine) Very briefly – why the community and social service sector. Working with community social services is a novel approach as it represents a move away from health settings for addessing smoking. This is in line with the Cancer Coucil’s aim to re-frame smoking as not just a health issue but a social justice issue. Social and community service organisations are non-government, not-for-profit organisations that provide welfare services to individuals and families in need. They are common across rural and metropolitan areas of Australia and see large number of people experiencing financial, housing, employment, legal, or social challenges. Disadvantaged groups are over-represented amongst clients for example, Aboriginal people are nearly 6.5 times more likely to access community services than their representation in the community would suggest. Over 90% of clients are Centrelink income recipients, most clients have some type of mental illness or other co-morbidity. Most of these services follow principles of empowering individuals to ‘get back on their feet’ and they use whole of person, individualised approaches. Changing service provision to incorporate quit support has the potential to be sustainable in the long term and cost-effective. Its also something that is picking up momentum overseas.

Tackling Tobacco Research Cancer Council NSW Tackling Tobacco Program Focus groups with staff Pilot Study Call it Quits RCT Focus groups with clients So given these advantages, we designed a program of research, ‘action research’ which involved participation by the CCNSW and social and community service organisations which included formative research, pilot studies leading to a randomised controlled trial. Cross sectional client survey

What are the barriers and opportunities? The first step in our formative research was 11 focus groups with six major social and community service organisations to explore what some of the barriers to introducing smoking cessation care in these services would be and what the opportunities were. Focus groups were conducted with both clients and staff of services. A range of service types were represented including family welfare and counselling, outreach homelessness services and community care drop-in centres. Bryant, Bonevski, Paul, et al. Delivering smoking cessation support to disadvantaged groups: A qualitative study of the potential of community welfare organisations. Health Education Research, 2010 25(6):979-990. Bryant, Bonevski Paul et al. Developing cessation interventions for the social and community service setting: A qualitative study of barriers to quitting among disadvantaged Australian smokers BMC Public Health 2011, 11:493 Bonevski B, Bryant J, Paul C. Encouraging smoking cessation in socially disadvantaged groups: a qualitative study of the financial aspects of cessation. Drug and Alcohol Review, 2010, 30(4):411-418.

Staff Focus Groups (n = 43) Willingness to address smoking Appropriateness with role Brief intervention approaches preferred “We provide an access point for them and a place where they feel comfortable and safe to go, rather than having to go somewhere strange with different people” Barriers Addressing smoking often not a priority Inadequate time, skills, and confidence “I don’t know how well skilled I am, how confident I would feel giving advice about stopping smoking.” In summary, the staff focus groups showed a willingness to address smoking, agreement for the appropriateness of their role in supporting clients to quit, and a preference for brief interventions. The main barriers included competing priorities – due to clients often being in a crisis situation that needed to be addressed immediately and lack of confidence, skills and time.

Client focus groups (n = 32) “I reckon it would be alright as long as we weren’t feeling like we were getting pestered” “Yep. I reckon it’s good. At least it’s [quit support] there instead of them not supporting it at all” “Yeah, it would be alright, they could ask…” Barriers to quitting: Lack of support and services Financial cost of quitting (eg, NRT) Discussions with clients revealed a willingness and motivation to quit and agreement that their case-worker was an appropriate, even preferred source of quit support. They also talked about difficulties of quitting including no social support or service they can easily access, and the financial cost of quitting, for example they’d rather spend their money on another packet of cigarettes than on NRT. These data provided us with information we could use to develop an intervention, delivered through clients case-workers, who we would train in cessation support strategies, which would include brief intervention, social support component for clients and free NRT addressing any cost barriers.

Is data collected in this setting accurate? 383 clients completed a 60-item touch screen computer survey and CO breathanalysis (69% consent rate) Touch screen computer smoking survey and CO breathanalysis as gold standard Sensitivity = 94% Specificity = 93% Computer survey was easy to complete (88%) Computer survey was enjoyable (79%) Bryant J, Bonevski B, Paul C. Assessing smoking status in disadvantaged populations: Is computer administered self report an accurate and acceptable measure? BMC Medical Research Methodology 2011, 11:153 Another question we wanted to answer throughout our formative research was whether data we collected was accurate and data collection methods feasible to ensure long term evaluation. To do this we conducted a cross-sectional survey assessing the self reported smoking status using a simple touch screen computer program against carbon monoxide breathanalysis. The results showed that the computer administered self report survey of smoking status was highly accurate at identifying smokers and non-smokers and in addition, clients found it easy and enjoyable to use.

This is an example of a screen that a participant would see on the touchscreen computer. April 19, 2017

Do clients smoke and do they want to quit? Smoking variables 53.5% daily smoking 7.9% occasional smoking 17 cigarettes per day $46 per week Of current smokers: 56.6% were ‘very’ or ‘quite’ interested in quitting 70% intended to quit in next 6 months 52.8% wanted support from staff at the SCSO to quit smoking Bryant J, Bonevski B, Paul C. A survey of smoking prevalence and interest in quitting among social and community service organisation clients: a unique opportunity for reaching the highly disadvantaged. BMC Public Health 2011, 2011, 11:827 Now that we were confident that the survey was providing accurate results, we conducted a baseline survey exploring smoking prevalence rates, quit intentions and interest, preferences for types of support and a variety of other smoking and quitting items. We found that smoking prevalence was high..................

Is a quit support intervention feasible? Pre-post pilot study Test feasibility and acceptability of integrating the delivery of smoking cessation support into usual care at a community service organisation Assess the impact of the program on client smoking One SCSO providing a Personal Helpers and Mentors program. N = 20 clients Bryant J, Bonevski B, Paul C, Hull P, O’Brien J. Implementing a smoking cessation program in social and community service organisations: A feasibility and acceptability trial. Drug and Alcohol Review, 2011, DOI: 10.1111/j.1465-3362.2011.00391.x So based on the formative research, we have designed a smoking cessation intervention for use in the community social service setting, and we have mechanisms for accurately and acceptably evaluating the intervention. The next step of the research program was to test the feasibility and acceptability of the intervention delivered by case-workers to clients and to explore whether it has any impact on smoking behaviours. PHAMS – strengths based outreach service aimed to help individuals with a mental illness develop independence.

Intervention One day staff training + booster session Free NRT Rationale for incorporating smoking cessation into usual care Heaviness of smoking index 5A’s brief intervention Brief motivational interviewing NRT Free NRT Quit ‘Buddy’ system Brief advice and motivational interviewing at every visit or where deemed appropriate The intervention was developed using the focus group results to address barriers and optimise on opportunities. Support workers involved in determining the structure and content of the program which needed to be Flexible and easily integrated into usual care with minimal burden. NRT type and strength determined based on client preferences and manufacturer recommendations.

Acceptability to Clients Strongly Agree or Agree % Neutral Strongly Disagree /Disagree Talking to my support worker about my smoking was helpful 92 8 Talking to my support worker about my smoking made me think about quitting 90 10 I did not like being asked about my smoking by my support worker

Cessation Results (70%) of clients initiated NRT use during the program At 6 months follow-up No participants reported seven day point prevalence abstinence Significant reduction in the number of cigarettes smoked - from 20.5 cigarettes per day at baseline to 15 cigarettes per day (p= 0.04). Non-significant reduction in dollars spent on tobacco from $70.95 at baseline to $60.69.

Next Steps Support workers are interested in training and willing to provide support Clients of SCSO are interested in quitting and willing to be involved in a cessation program May decrease smoking behaviours A methodologically rigorous and powered randomised controlled trial is needed to determine effectiveness The results of this research showed that social and community service organisation staff are willing to provide quit support and interested in receiving training clients of social and community service organisations are interested in quitting and willing to be involved in a cessation program And that a cessation intervention may be effective at reducing smoking by clients These results suggest that a methodologically rigorous trial of a smoking cessation intervention in social services is warranted

Call it Quits – A RCT of a case worker delivered intervention Aim: Evaluate the efficacy of a caseworker-delivered cessation intervention at increasing smoking cessation rates Clients randomised to intervention or usual care control Intervention group to receive 2 face-to-face counselling sessions, free NRT, ‘Quit Buddy’, telephone follow-up Primary outcome: CO validated continuous abstinence at 6 months follow up Bonevski B, Paul C, D’Este C, Sanson-Fisher R, West R, Girgis A, Siahpush M, Carter R. RCT of a client-centred, case worker delivered smoking cessation intervention for a socially disadvantaged population. BMC Public Health 2011, 11:70 We’re currently in the data collection phase of a randomised controlled trial of a case worker delivered smoking cessation intervention for SCSO clients. 400 clients are being randomised to either receive the intervention or be in a usual care control group. Data collection is due to be completed by the end of the year, which will provide some evidence regarding the effectiveness of quit support in community social services

Call it Quits – Progress to date 574 clients case-worker to RA for more information about participating 562 completed baseline survey 361 eligible to participate in CiQ trial 275 consent (76%) and randomise to: Intervention: 122/ Control: 160 1 month: 227 (80%) 6 month: 89 (57%)

CiQ Study Participants (n = 384) Sociodemographic Variables n (%) Gender Female 188 (49) Age Mean (SD) 38 years (11) Indigenous Status Indigenous Australian 58 (15) Education Completed Year 10 or below 245 (64) Housing Supported Accommodation/no home/street living 207 (54) Income level $400 per week or less 307 (80) Income source Centrelink 364 (95) Poverty line as at Dec 2012 for a single person is about $480 – most of our sample is living below the poverty line.

CiQ – Psycho-social variables (n = 384) Financial stress Scores ≥ 4 343 (89) Depression Scores ≥ 10 228 (59) Anxiety Scores ≥ 3 216 (56) Resilience Mean (SD) 2.9 (1) Social support (family & friend contact) No/Less than once a month 115 (30)

CiQ Trial – tobacco and alcohol use (n= 384) Prevalence rates in current sample n (%) Tobacco use (both daily and occasional) 384 (74) Risky alcohol users 242 (63) Concurrent users 190 (46) The majority of tobacco users were daily smokers (66%) and the majority of participants who had had an alcoholic drink in the past 12 months were risky users (89%).

CiQ Trial – Quit attempts (total n = 384) Smokers - ever made a quit attempt n = 384 Yes 334 (87) Smokers - quit attempt in the last 12 months n = 334 Min, Max 0 – 24 Median 1 Mean (SD) 1.8 (2.1) Two or more quit attempts 167 (50) Zero or one quit attempt Of our 309 smokers, 268 participants had ever made a quit attempt. These 268 participants were then asked about the number of quit attempts they had made in the previous year.

Next steps Continued recruitment to December 2013 Continued analysis of baseline data 1 Month outcomes Trial concludes July 2014 Main 6 month outcomes

THANK YOU Cancer Council NSW: Jon O’Brien, Phil Hull Anglicare clients and staff Funding: Cancer Council NSW Cancer Institute NSW NHMRC University of Newcastle HMRI