California Smokers Research Articles

Cost-effectiveness analysis of e-cigarettes compared to nicotine replacement therapy for smoking cessation among Medicaid users in California.

Smoking is the leading preventable cause of death and disability in the United States (US). A 2019 randomized controlled trial found e-cigarettes are more effective than nicotine replacement therapy (NRT) in achieving abstinence when both are combined with behavioral counselling. Few cost-effectiveness studies have been performed regarding e-cigarettes as an adjunct to cessation efforts, and none in a US context. This study evaluated the cost-effectiveness of e-cigarettes compared to NRT, both with counselling, as cessation aids for Medicaid smokers in California. A cost-effectiveness analysis from a US societal perspective comparing e-cigarettes with NRT was constructed. Using a lifetime horizon, smokers were followed to different health states to their expected lifespan. Costs were expressed in 2020 US dollars and health outcomes in quality-adjusted life years. All costs and outcomes were discounted at a 3% annual rate and model findings were assessed with a series of sensitivity analyses. Using US willingness-to-pay thresholds, e-cigarettes were more cost-effective than NRT, with an incremental cost-effectiveness ratio of $11,454 per additional QALY gained over smokers' lifetimes. Results were sensitive to smokers' healthcare costs, model start ages, discount rate, and QALY weights. E-cigarettes used as a cessation treatment by smokers are more cost-effective relative to NRT. However, e-cigarettes as a treatment are currently unapproved by the Food and Drug Administration (FDA). Despite lack of FDA approval, e-cigarettes are a popular choice among smokers trying to quit. Policymakers should consider whether providing financial support for e-cigarettes as a harm reduction strategy is worth pursuing. As e-cigarettes grow in popularity and are an increasingly preferred choice of smoking cessation aid among smokers attempting to quit, it is important to examine the inclusion of these products in tobacco policy, research, and practice. Several countries have now adopted or are in the process of adopting e-cigarettes as a medically licensed and regulated smoking cessation aid. Future smoking cessation strategies by US policymakers may consider the adoption of e-cigarettes as a cost-effective harm reduction tool for use by current smokers seeking to quit.

Tax noncompliance: The role of tax morale in smokers' behavior

AbstractMeasuring and predicting compliance with tax obligations is an important but challenging task. Survey data from California smokers show that several forms of tax avoidance and evasion were common. The analysis shows that 43% of smokers avoided taxes by purchasing cigarettes from out‐of‐state sources in the past year, 15% admitted to evading taxes through cross‐border purchases, and 26% reported purchasing likely or certainly untaxed cigarettes in the state in the past month. Attitudinal factors related to tax morale explain much more of the variance in compliance rates than demographic or law‐and‐economics factors. The implications for policy are discussed.

Psychological network analysis of the relations between beliefs about smoking for smokers with and without a recent quit attempt

Objective Psychological network analysis was used to evaluate the relations between beliefs about cigarette smoking in current smokers with and without a recent quit attempt and determine if these networks differed in global strength (how strongly beliefs are related) or global structure (which beliefs are related). Design Using two publicly available datasets, the California Smokers’ Cohort (CSC; N = 933) and Wave 1 of the Population Assessment of Tobacco and Health (PATH; N = 7855), we evaluated differences in global strength and global structure of the beliefs held by current smokers with and without a recent quit attempt. Main Outcome Measures Strength and structure of networks generated for current smokers with and without a recent quit attempt. Results In the CSC dataset there were differences between smokers with and without a recent quit attempt in global structure and marginal differences in global strength; the PATH dataset suggested small differences in global strength and structure. Conclusion The present study suggests that consideration of relations among smoking beliefs may be a valuable contribution to characterizing smoking beliefs when assessing smoking quit attempts.

Tax evasion and illicit cigarettes in California: prevalence and demand-side correlates

Unlike some areas of crime, participation in illicit tobacco markets is not rare and spans most sociodemographic groups. Measurement of the scale of illicit trade in cigarettes usually is for markets with recently increased (or continually increasing) excise taxes. This study examines survey data from adult cigarette smokers in California at a time when prices and taxes had been fairly stable for many years. Even with no recent price shocks in the market, the results indicate that one-third of cigarette packs may lack a valid tax stamp and that between 18 and 25% of smokers avoided taxes by bringing cigarettes into the state from elsewhere in the past month (36% in the past year). Over 10% of packs were purchased for a suspiciously low price and 24–32% of smokers think they might have bought untaxed cigarettes in the past month. Furthermore, 20% think they may have consumed counterfeit cigarettes in the past month. There is a low incidence of illegal sales of single cigarettes. Men, smokers who roll their own cigarettes, e-cigarette users, younger smokers, and those with more income and education are all more likely to engage in at least some of the suspect market behaviors examined. The results show that many smokers from all segments of society participate in the illicit market for cigarettes—wittingly or not—which complicates efforts to reduce illicit trade.

Assessing cigarette smoking levels of intensity among Californian adults

This study assessed the prevalence of cigarette smoking by demographic characteristics. We conducted interactions between gender and race/ethnicity, and one's smoking status. We utilised secondary data comprised of 22,160 participants. Multinomial logistic regression was conducted to predict the probability of participants' level of smoking intensity. Majority were non-smokers (93.1%), majority were female (51.2%). Many had a bachelor's degree (23.9%) or some college, or an associate degree (22.8%). Many participants (59.8%) were married/living with a partner, and (25.7%) were single. Most participants spoke English (55.4%) and the largest race/ethnic groups were White (40.2%) followed by Latinos (21.8%). Age distribution was: 18 to 29-year-olds (22.9%), 30 to 39-year-olds (17.6%) and 40 to 49-year-old (16.2%). Findings suggest that one's demographics characteristics do play a role in smoking levels. Hence, public health efforts should create evidence-based interventions that fit each group to reduce disparities among smokers in California.

Quality Improvement Approach to Increase Inpatient Pediatric Secondhand Smoke Exposure Screening.

Secondhand smoke exposure (SHSe) is highly prevalent among children and has numerous adverse health effects. Consistent screening for SHSe is an essential first step to helping families break the toxic cycle of smoking. With this quality improvement project, we evaluated a SHSe screening and cessation resource distribution protocol in a general pediatrics inpatient unit of a safety-net hospital. Our primary outcome measure was the percent of admissions screened for SHSe, with a goal of increasing our documented rate of SHSe screening from 0% to 70% within 6 months of implementation. Our secondary outcome measure was the percent of those who screened positive for SHSe who were offered smoking cessation resources. Process measures included tracking nurse confidence in screening and compliance with new workflow training. Balancing measures were nurse satisfaction and brevity of screening. From May 1, 2019, to April 30, 2020, nurses screened 97.2% of the 394 patients admitted to the pediatric unit for SHSe. Of the patients screened, 15.7% were exposed to cigarettes or other tobacco products, 5.6% to e-cigarettes, and 6.5% to marijuana. Nurses documented offering "Quit Kits" with cessation materials to 45 caregivers (72.6% of positive screen results) and offering 33 referrals to the California Smokers' Helpline (53.2% of positive screen results). In this project, we successfully implemented a screening protocol for SHSe to tobacco, e-cigarettes, and marijuana and a workflow for cessation resource distribution in an inpatient pediatric setting that far exceeded goals. Requiring minimal maintenance and using just a simple paper-based format, the workflow could be adopted at other institutions.

Understanding health disparities affecting utilization of tobacco treatment in low-income patients in an urban health center in Southern California

Tobacco use disproportionately affects low-income communities. Prevalence among patients in Federally Qualified Health Centers (FQHCs) is higher (29.3%) than the general population (20%). Little is known about the rates of referrals to cessation services and cessation pharmacotherapy practices in FQHCs. This study will examine referral and prescribing patterns based on patient characteristics at a large FQHC in Southern California. We conducted a retrospective analysis of EHR data from 2019. Patients who were ≥ 18 years old and had “tobacco use” as an active problem were included in analyses. We characterized the proportion of 1) those who were referred to California Smokers’ Helpline (CSH), 2) referred to smoking cessation counseling (SCC) at the FQHC clinic, or 3) received pharmacotherapy. Associations of demographic characteristics and comorbidities with referral types and uptake of services were evaluated using mixed-effects multinomial and logistic regressions. Of the 20,119 tobacco users identified, 87% had some cessation intervention: 66% were advised to quit and given information to contact CSH, while 21% were referred to SCC. Patients were least likely to get referred to cessation services if they had more medical, psychiatric, or substance use comorbidities, were in the lowest income group, were uninsured or were Hispanic. Although EHR systems have enhanced the ease of screening, most patients do not receive more than brief advice to quit during a PCP visit. Most (70%) low-income smokers see their PCPs at least once a year, making FQHCs excellent settings to promote smoking cessation initiatives in low-income populations.

Real-world exposure to graphic warning labels on cigarette packages in US smokers: The CASA randomized trial protocol

BackgroundThe US lags behind >120 countries in implementing graphic warning labels (GWLs) on cigarette packs. US courts prevented implementation of FDA's 2012 rule requiring GWLs citing the need for more evidence on effectiveness. After more research, in 2020, the FDA proposed a revised rule mandating GWLs. This trial will test how the introduction of GWLs influence cognitions and behavior in US smokers. MethodTo investigate the “real-world” impact of GWLs in US smokers, we are conducting a randomized trial involving a 3-month intervention and 8-month follow-up. The study recruited California smokers between September 2016 through December 2019 and randomly assigned them into 3 groups (1) Blank Pack devoid of any cigarette branding; (2) GWL Pack featuring 1 of 3 rotating images added to blank pack; or (3) their usual Standard US Pack. Throughout the 3-month intervention, participants purchased study-packaged cigarettes and reported daily cognitions and behavior through ecological momentary assessments. We will validate self-reported tobacco use with saliva cotinine concentrations following the 3-month intervention and 8-month follow-up. ResultsThe trial enrolled 359 participants (average age 39 years; average cigarette consumption half a pack/day). The 3 study groups were balanced on age, gender, race-ethnicity, education and income (17% low income) as well as on smoking related variables. ConclusionsThis 3-month real-world randomized trial will test the effect of repackaging cigarettes from standard US packs to GWL plain packs on smokers' perceptions of the risks of smoking, their perception of the appeal of their cigarettes, and on their smoking behavior.

Implementation of a Comprehensive Tobacco-Cessation Policy in Medicaid Managed Care Plans in California

In 2016, the California Department of Health Care Services issued All Plan Letter 16-014 to the Medi-Cal Managed Care plans to provide information on requirements for comprehensive tobacco-cessation services. Researchers at the University of California, San Diego set out to (1) examine Medi-Cal's Managed Care plans' progress in implementing each section of All Plan Letter 16-014, (2) understand various factors related to implementation of the All Plan Letter, and (3) make recommendations to improve implementation. Researchers surveyed health educators within California's 25 Medi-Cal Managed Care plans to document each one's smoking-cessation services and policies in 2018. Data were collected for 24 of the 25 Medi-Cal Managed Care plans (96%) through 3 methods, including: (1) a web-based survey, (2) an in-depth phone interview, and (3) collection of smoking cessation-relevant documents. Managed Care plans demonstrate low levels of full implementation, with only 1 fully implementing all 20 provisions of the All Plan Letter. On average, Managed Care plans implemented 13 of the 20 provisions. Managed Care plans had the highest implementation rates for provisions related to requirements for coverage of the 7 U.S. Food and Drug Administration-approved medications for tobacco cessation, in which 12 (55%) fully implemented all related required provisions. Managed Care plans had lowest implementation rates for provisions related to data collection, with only 4 (18%) fully implementing all 3 requirements. Although All Plan Letter 16-014 was successful in creating more comprehensive and consistent benefits across Managed Care plans, 95% of Managed Care plans have not fully implemented it. Further guidance from the Department of Health Care Services and integration with the California Smokers' Helpline may be needed to achieve full implementation.

American Indian/Alaska Native Smokers' Utilization of a Statewide Tobacco Quitline: Engagement and Quitting Behaviors From 2008 to 2018.

The objective of this study was to examine access, engagement, and quitting behaviors of American Indian/Alaska Native (AIAN) callers to the California Smokers' Helpline. Telephone counseling is the primary function of the quitline. The overarching theoretical framework for California's quitline is social cognitive theory, although it also utilizes motivational interviewing and cognitive-behavioral strategies. AIAN (n = 16 089) and White (n = 173 425) California quitline callers from 2009 to 2018 were compared on their characteristics, engagement, and quitting behaviors. Quitline callers responded to a telephone survey at intake. A random selection was called for evaluation 7 months later (White n = 8194, AIAN n = 764). Data from the 2009 to 2017 California Health Interview Survey (CHIS) were used as a reference point for AIANs (AIAN n = 1373). The quitline and CHIS had similar proportions of AIANs (4.6% vs. 4.3%, respectively). AIAN smokers were more likely than White smokers to report physical (53.6% vs. 44.9%) and mental (65.7% vs. 57.8%) health conditions at intake. AIANs were more likely to participate in counseling than White callers (67.1% vs. 65.7%). Among those who received counseling, AIANs had greater odds than White smokers of making a quit attempt (adjusted odds ratio = 1.39 [1.06, 1.81]) and similar odds of quitting for 180 days (adjusted odds ratio = 0.95 [0.69, 1.31]). Rates of access, engagement, and quitting suggest that individualized quitline counseling was as effective with AIANs as it was with White smokers. Increasing efforts to refer AIANs to existing state quitlines can help more smokers quit. This study showed that AIAN smokers were well represented among California quitline callers, even without a targeted campaign. It also found that AIAN smokers engaged in quitline services and were as able to quit as their White counterparts were, even after adjusting for other baseline characteristics. One implication is that public health programs can promote quitlines using broad-based campaigns knowing that they will still motivate AIAN smokers to seek help. Another implication is that a standard, individualized counseling protocol delivered by culturally competent quitline staff can effectively help AIAN smokers to quit.

Disparities in knowledge and use of tobacco treatment among smokers in California following healthcare reform.

The Affordable Care Act (ACA) promised to narrow smoking disparities by expanding access to healthcare and mandating comprehensive coverage for tobacco treatment starting in 2014. We examined whether two years after ACA implementation disparities in receiving clinician advice to quit and smokers' knowledge and use of treatment resources remained.We conducted telephone interviews in 2016 with a stratified random sample of self-reported smokers newly enrolled in the Kaiser Permanente Northern California's (KPNC) integrated healthcare delivery system in 2014 (N = 491; 50% female; 53% non-white; 6% Spanish language). We used Poisson regression with robust standard errors to test whether sociodemographics, insurance type, comorbidities, smoking status in 2016 (former, light/nondaily [<5 cigarettes per day], daily), and preferred language (English or Spanish) were associated with receiving clinician advice to quit and knowledge and use of tobacco treatment. We included an interaction between smoking status and language to test whether the relation between smoking status and key outcomes varied with preferred language.Overall, 80% of respondents received clinician advice to quit, 84% knew that KPNC offers cessation counseling, 54% knew that cessation pharmacotherapy is free, 54% used pharmacotherapy, and 6% used counseling. In multivariate models, Spanish-speaking light/nondaily smokers had significantly lower rates of all outcomes, while there was no association with other demographic and clinical characteristics.Following ACA implementation, most smokers newly enrolled in KPNC received clinician advice to quit and over half used pharmacotherapy, yet counseling utilization was low. Spanish-language outreach efforts and treatment services are recommended, particularly for adults who are light/nondaily smokers.

Similar softening across different racial and ethnic groups of smokers in California as smoking prevalence declined

Smoking prevalence differs among different racial/ethnic groups. Previous research found that as smoking prevalence declined in the U.S., remaining smokers made more quit attempts and smoked fewer cigarettes per day (CPD), indicating so-called softening. We examined California, a state with a highly diverse population, to assess whether there is differential softening among remaining smokers in different racial/ethnic groups. We used the California Tobacco Survey (1990–2008, N: 145,128). We ran logistic and linear regressions for smoking prevalence, CPD, quit attempts and time to first cigarette (30 min) as a function of race/ethnicity (non-Hispanic White, Hispanic, African American, Japanese, Chinese, Filipino, Korean, other Asian/Pacific Islander, American Indian/Alaska Native) controlling for other demographics. Overall prevalence fell from 21.1% in 1990 to 12.3% in 2008 (p < 0.01), showing similar declining trends across all racial/ethnic groups (p = 0.44), albeit from different baseline prevalence levels. In terms of softening indicators the proportion with at least one quit attempt in the past 12 months increased from 46.2% to 59.3%, a factor of 1.25 per decade (95%CI = 1.17, 1.34) in the adjusted model. CPD declined from 16.9 to 10.9, by −2.95 CPD per decade (95%CI = −3.24, −2.67) in the adjusted model. There were no significant changes in the time to first cigarette. Interactions of race/ethnicity and time show similar trends among all subgroups expect Hispanics, whose CPD remained stable rather than declining. Although from different baseline levels, tobacco control policies have benefitted all subgroups of California smokers, exhibiting similar softening as prevalence fell. Interventions are still needed to reduce the baseline differences.

Racial/Ethnic Differences in the Response to Incentives for Quitline Engagement

Certain racial and ethnic minorities have lower utilization of tobacco cessation services, such as Helpline counseling and cessation medications. The goal of the California Medicaid (Medi-Cal) Incentives to Quit Smoking Program was to facilitate successful cessation by promoting modest financial and cessation medication-related incentives to increase engagement with the California Smokers' Helpline counseling services. Differences in the response to incentives and outreach on engagement with Helpline services among racial/ethnic groups within the Medi-Cal population were examined. Analysis of Helpline caller data. African American (n=18,656); English-speaking Latinx (n=12,792); Spanish-speaking Latinx (n=3,254); and white (n=45,907) Medi-Cal callers. The Medi-Cal Incentives to Quit Smoking team conducted statewide and community-based outreach and facilitated direct-to-member all-household mailings about the Medi-Cal Incentives to Quit Smoking program to engage with Medi-Cal callers and promote Helpline services between March 2012 and July 2015 (analyzed 2017/2018). Medi-Cal callers could ask for a $20 gift card incentive after having completed a counseling session; in September 2013, callers were offered free nicotine replacement therapy. Three behavioral outcomes are reported that reflect activated callers and callers who engaged in treatment that is proven to improve chances of quitting smoking: receipt of the $20 incentive, receipt of nicotine replacement therapy, and receipt of counseling. African Americans and English-speaking Latinx had higher engagement with the financial incentive than whites (African American APR=1.66, 95% CI=1.59, 1.73, English-speaking Latinx APR=1.29, 95% CI=1.22, 1.36). Spanish-speaking Latinx had lower initial engagement with the financial incentive (APR=0.75, 95% CI=0.66, 0.85), but higher engagement with Medi-Cal's all-household mailing (Spanish-speaking Latinx 30.6% vs whites 18.2%, p<0.001). Although African Americans and English-speaking Latinx had similar rates of completing counseling and receiving nicotine replacement therapy as whites, Spanish-speaking Latinx had higher rates than whites. The promotion of modest financial and cessation medication incentives through multiple outreach channels increased callers' engagement with the Helpline and appeared to promote ethnic and linguistic equity with respect to the receipt of counseling and nicotine replacement therapy. Targeted community-based outreach may resonate particularly for African Americans, and language-concordant Medi-Cal insurance plan mailings may have reached newly covered Spanish-speaking Latinx. This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Building and Scaling-up California Quits: Supporting Health Systems Change for Tobacco Treatment

The California Tobacco Control Program is the longest standing, publicly funded tobacco control program in the U.S. California's adult smoking rate declined from 23.7% (1989) to 11% (2016) but California still has more than 3 million smokers dispersed over 58 counties, requiring a coordinated approach to further tobacco control. Early California Tobacco Control Program success is rooted in public health policy strategies and a statewide media campaign that shifted social norms. In 2009, concepts for a coordinated approach were introduced by the California Tobacco Control Program in the state's first tobacco quit plan. The state quit plan called for public health's tobacco control programs to engage healthcare systems and insurers to work more directly with the California Smoker's Helpline (Helpline). With California's Medicaid (Medi-Cal) program expansion and the implementation of electronic medical record systems, health care plans and providers received additional support for system changes. Simultaneous with these changes, coordinated tobacco control efforts began, including California's Medi-Cal Incentives to Quit Smoking project (2012-2015). In the Medi-Cal Incentives to Quit Smoking project, safety-net providers and Medi-Cal plans were outreached and engaged to promote incentives for Medi-Cal members to utilize Helpline services. In another effort, UC Quits (2013-2015), the five University of California health systems used electronic medical record tools to promote tobacco treatments and electronic referrals to the Helpline. Now, as tobacco prevention is increasingly prioritized for quality improvement, California Tobacco Control Program is funding CA Quits, a statewide tobacco-cessation learning collaborative and technical assistance resource to promote integration of tobacco treatment services and quality improvement activities into safety-net health systems. CA Quits, in coordination with the Helpline, will connect public health departments, Medi-Cal plans, and safety-net providers to accelerate health systems change for tobacco-cessation treatment throughout the state. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Direct-to-Member Household or Targeted Mailings: Incentivizing Medicaid Calls for Quitline Services

Innovative methods are needed to promote tobacco cessation services. The Medi-Cal Incentives to Quit Smoking project (2012-2015) promoted modest financial and medication incentives to encourage Medi-Cal smokers to utilize the California Smokers' Helpline (Helpline). This article describes the implementation and impact of two different direct-to-member mailing approaches. Medi-Cal Incentives to Quit Smoking promotional materials were mailed directly to members using two approaches: (1) household mailings: households identified through centralized membership divisions and (2) individually targeted mailings: smokers identified by medical codes from Medi-Cal managed care plans. Mailings included messaging on incentives, such as gift cards or nicotine patches. Number of calls per month, calls per unit mailed, and associated printing costs per call were compared during and 1 month after mailings. Activated caller response was based on reporting a household mailing promotional code or based on requesting financial incentives for individually targeted mailings. Analyses were conducted in 2018. Direct-to-member mailings, particularly with incentive messaging, demonstrated an increase in call volumes during and 1 month after mailing, and increased Medi-Cal calls to the Helpline per unit mailed. Mailings with only counseling messages had the lowest percentage of activated calls per unit mailed, whereas the incentive messaging mailings were consistently higher. Although household mailings demonstrated lower printing costs per call, individually targeted mailings had a higher percentage of activated calls per unit mailed. Household and individually targeted mailings are feasible approaches to increase Medi-Cal calls to the Helpline, particularly with incentive messaging. Choosing an approach and messaging depends on available resources, timing, and purpose. This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Outreach to California Medicaid Smokers for Asian Language Quitline Services

Asian male immigrants have high smoking rates. This article describes outreach approaches in the Medi-Cal Incentives to Quit Smoking project to incentivize California Medicaid (Medi-Cal) calls to the California Smokers' Helpline (Helpline) Asian-language lines. Outreach efforts adapted Medi-Cal Incentives to Quit Smoking materials for the Asian-language lines. Community-based efforts included outreach at ethnic supermarkets and distribution through community networks. Leveraging the Helpline's Asian print media campaign, three press releases promoted Medi-Cal Incentives to Quit Smoking with Lunar New Year or community physician messaging. Medi-Cal all-household mailings with tracking codes also included the Asian-language lines. Helpline caller characteristics and trends were examined for project period 2012-2015. Analyses were conducted in 2018. Among 4,306 Asian American Pacific Islander Medi-Cal callers, there were 37% Asian-speaking Asian Americans (9.5% Chinese, 17.2% Vietnamese, and 10.5% Korean); 44% English-speaking Asian Americans; 9% Pacific Islanders; and 10% Asian American Pacific Islander not otherwise specified. Almost 10% of Asian-speaking Asian Americans were activated by the financial incentive and this was similar for all-household mailings, although this was lower than the other groups. Medi-Cal calls to the Asian-language lines increased, from an average of 18 calls/month to 47 calls/month (162% increase) in the first and last 12 project months respectively. Community outreach was limited by timing and sustainability. The 3-month call totals before and after the Asian-language press releases were significantly greater for Asian-speaking calls than for English-speaking calls (Cochran-Mantel-Haenszel p<0.001, OR=1.70, 95% CI=1.45, 1.99). Whereas community outreach is challenging, promising population-based methods for in-language, culturally tailored outreach can include press releases with ethnic media and direct-to-member mailings. This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

The Growing Proportion of Smokers in Medicaid and Implications for Public Policy

This study examined survey data from before and after California expanded its Medicaid program under the Affordable Care Act. It assessed changes in the insurance status of smokers, the proportion of smokers in Medicaid, and the health and well-being of those smokers relative to their counterparts in other insurance groups. The study compared two data sets from the California Health Interview Study, the 2011-2012 (N=42,935) and 2016 (N=21,055) surveys. Measures include health insurance status, smoking status, chronic health conditions, frequency of doctors' visits, and psychological distress. Data were analyzed in 2018. From 2011-2012 to 2016, the estimated number of California smokers in Medicaid nearly doubled from 738,113 to 1,447,945, and the proportion of smokers covered by Medicaid increased from 19.3% to 41.5%. Compared with those with private insurance, smokers in Medicaid were more likely to have chronic disease, have made five or more doctors' visits in the past year, and be in severe psychological distress. In 2016, a total of 51.4% of all adult smokers with chronic disease conditions and 57.8% of those in severe psychological distress were covered by Medicaid. With Medicaid covering a much higher proportion of smokers, especially of those smokers with chronic disease and in psychological distress, state Medicaid programs and plans must make tobacco cessation a top priority. They should encourage clinicians to ask, advise, and assist all smokers, track progress in reducing smoking prevalence, employ mass communication strategies to drive quit attempts, improve access to medications, and develop or expand programs to help smokers quit. This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Medi-Cal Incentives to Quit Smoking Program: Reach to Pregnant and Parenting Women

In California, half of pregnant women and children are on California's Medicaid (Medi-Cal). The Medi-Cal Incentives to Quit Smoking program provided incentives to adults on Medi-Cal to call the California Smokers Helpline (Helpline) from March 2012 to July 2015. This analysis examined reach of the Medi-Cal Incentives to Quit Smoking program among pregnant and parenting women. This study examined caller data from the Helpline from 2010 to 2015 among women of reproductive age (18-45 years) enrolled in Medi-Cal (n=32,691; analyzed in 2017/2018). The authors calculated the annual percentage of the target population reached who called the Helpline by pregnancy status and used adjusted prevalence ratios to examine the associations between Medi-Cal Incentives to Quit Smoking incentive period, pregnancy/parenting status, Medi-Cal Incentives to Quit Smoking incentives ($20 gift card and nicotine patch), and counseling. Over the study period, the percentage of the target population reached increased for women of reproductive age (2.1% in 2011 to 3.0% in 2014) and pregnant women (2.1% in 2011 to 3.3% in 2014). The percentage of women who asked for the $20 gift card (13.6%) was not substantially different by pregnancy status, and WIC and nonprofits were important referral sources. Pregnant women were less likely to receive nicotine patches, but there was a 3- to 4-fold increase during the Medi-Cal Incentives to Quit Smoking incentive period for both pregnant and nonpregnant women. Among nonpregnant women, counseling decreased 14% during the Medi-Cal Incentives to Quit Smoking incentive period. Results suggest that the nicotine patch incentives motivated women to call the Helpline, even pregnant women who needed a physician's approval consistent with current American College of Obstetricians and Gynecologists cautions about the appropriateness of the patch during pregnancy. This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Incentives and Patches for Medicaid Smokers: An RCT

Most successful trials of financial incentives for smoking cessation have offered large rewards contingent on outcomes. This study examines whether more modest incentives to encourage engagement, non-contingent on outcomes, also increase cessation; whether sending medications directly to participants boosts quitting; and whether these strategies are effective in Medicaid. Three-group RCT of usual care (UC); nicotine patch (NP); and NP and financial incentive (NP+FI). Medicaid beneficiaries calling the California Smokers' Helpline, 2012-2013 (N=3,816). Data were analyzed in 2017. All participants enrolled in evidence-based, multisession telephone counseling. All received proof of enrollment with which they could obtain free quitting aids at their pharmacy. NP and NP+FI also received nicotine patches sent to their homes. NP+FI received up to $60 for completing counseling calls. Quit attempt rate, 7-day and 30-day abstinence at 2 and 7 months, and 6-month prolonged abstinence (primary outcome). In both complete-case and intention-to-treat analyses, outcomes trended upward from UC to NP to NP+FI. Differences between NP and UC were generally nonsignificant. By contrast, the NP+FI group significantly outperformed the other groups on all measures. In intention-to-treat analysis, compared with UC, NP+FI was more likely to make a quit attempt (68.4% vs 54.3%, p<0.001); be abstinent for 7 days at 2 months (36.1% vs 25.5%, p<0.001) and 7 months (21.2% vs 16.1%, p=0.002); be abstinent for 30 days at 2 months (30.0% vs 18.9%, p<0.001) and 7 months (21.5% vs 16.7%, p=0.004); and achieve 6-month prolonged abstinence (13.2% vs 9.0%, p=0.001). Financial incentives increased treatment engagement and short- and long-term smoking cessation, despite being modest and non-contingent on outcomes. The study found that incentives can be effective in a Medicaid population, and can feasibly be integrated into existing quitline services. The trial is registered at www.clinicaltrials.gov NCT01502306. This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

E-cigarettes versus nicotine patches for perioperative smoking cessation: a pilot randomized trial.

IntroductionCigarette smoking by surgical patients is associated with increased complications. E-cigarettes have emerged as a potential smoking cessation tool. We sought to determine the feasibility and acceptability of e-cigarettes, compared to nicotine patch, for perioperative smoking cessation in veterans.MethodsPreoperative patients were randomized to either the nicotine patch group (n = 10) or the e-cigarette group (n = 20). Both groups were given a free 6-week supply in a tapering dose. All patients received brief counseling, a brochure on perioperative smoking cessation, and referral to the California Smokers’ Helpline. The primary outcome was rate of smoking cessation on day of surgery confirmed by exhaled carbon monoxide. Secondary outcomes included smoking habits, pulmonary function, adverse events, and satisfaction with the products on day of surgery and at 8-weeks follow-up.ResultsBiochemically verified smoking cessation on day of surgery was similar in both groups. Change in forced expiratory volume in one second (FEV1) was 592 ml greater in the e-cigarette group (95% CI [153–1,031] ml, p = 0.01) and change in forced expiratory volume in one second to forced vital capacity ratio (FEV1/FVC ratio) was 40.1% greater in the e-cigarette group (95% CI [18.2%–78.4%], p = 0.04). Satisfaction with the product was similar in both groups.DiscussionE-cigarettes are a feasible tool for perioperative smoking cessation in veterans with quit rates comparable to nicotine replacement patch. Spirometry appears to be improved 8-weeks after initiating e-cigarettes compared to nicotine patch, possibly due to worse baseline spirometry and more smoking reduction in the e-cigarette group. An adequately powered study is recommended to determine if these results can be duplicated.