Contingency management to promote smoking cessation in people experiencing homelessness: Leveraging the electronic health record in a pilot, pragmatic randomized controlled trial

Abstract

Background Cigarette smoking is disproportionately high among people experiencing homelessness (PEH). Contingency management (CM) is a strategy that has shown considerable efficacy for smoking cessation and has been used in short-term studies of smoking abstinence in PEH. We describe a pilot, pragmatic randomized controlled trial protocol, which leverages an electronic health record (EHR) infrastructure to assess the feasibility and acceptability of an extended CM intervention to improve long-term abstinence in PEH. Methods We will conduct the study at three safety-net clinics in San Francisco among 90 adults experiencing homelessness who smoke cigarettes currently and have a desire to quit. We will encourage all participants to receive smoking cessation services that include behavioral counseling and pharmacotherapy through their clinics. We will randomly assign participants to an extended CM intervention group with escalating incentives contingent on abstinence or to a control group with fixed incentives for attending study visits. We will use the EHR to recruit participants, track receipt of counseling and pharmacotherapy during clinical care, and communicate with providers on participants’ progress. CM participants will get escalating incentives for demonstration of carbon monoxide-verified abstinence over 6 months, with a total possible earnings of $475. Control participants will receive a fixed incentive of $5 for attending study visits, totaling $125. We will conduct the carbon-monoxide verified abstinence assessments—which will determine CM incentive amounts—daily during week 1, bi-weekly through week 4, weekly through week 13, and monthly through week 24. Measures of feasibility and acceptability, both quantitative and qualitative, will include assessments of screening and recruitment, adherence to study visits, engagement in smoking cessation clinical care, retention, and participant satisfaction. One of the primary clinical outcomes will be biochemically verified 7-day point prevalence abstinence at 6 months. We will measure secondary outcomes, which will include 7-day point prevalence abstinence at 2 weeks, 3 and 12 months. Discussion This trial will allow us to assess the feasibility and acceptability of a CM cessation intervention among PEH. The protocol’s clinical setting and use of EHRs gives it significant potential for scalability. If found to be feasible, acceptable, and subsequently efficacious in a larger trial, the intervention could reduce tobacco-related health disparities by increasing long-term smoking abstinence among this vulnerable population. Trial registration ClinicalTrials.gov NCT04982952. Registered on July 29, 2021.

Financial Incentives for Smoking Cessation Among Socioeconomically Disadvantaged Adults

“…The present findings add to the substantial body of research demonstrating that incentive-based interventions are effective for promoting smoking cessation. 26 Primarily pilot studies have focused on socioeconomically disadvantaged populations, including patients from safety-net hospitals, 27 , 44 people experiencing homelessness, 45 , 46 , 47 , 48 , 49 adults with low income, 50 and economically disadvantaged pregnant women. 27 , 45 , 46 , 47 , 49 , 50 , 51 In a full-scale randomized trial with patients from a safety net hospital, Lasser et al 44 reported that enhanced UC (ie, smoking cessation brochure, list of cessation resources), patient navigation (eg, connection with resources, brief counseling, facilitation of medication access), and incentives for biochemically confirmed abstinence at 6 ($250) and 12 months (≤$500) after enrollment increased long-term cessation rates relative to enhanced UC alone.…”

“… 26 Primarily pilot studies have focused on socioeconomically disadvantaged populations, including patients from safety-net hospitals, 27 , 44 people experiencing homelessness, 45 , 46 , 47 , 48 , 49 adults with low income, 50 and economically disadvantaged pregnant women. 27 , 45 , 46 , 47 , 49 , 50 , 51 In a full-scale randomized trial with patients from a safety net hospital, Lasser et al 44 reported that enhanced UC (ie, smoking cessation brochure, list of cessation resources), patient navigation (eg, connection with resources, brief counseling, facilitation of medication access), and incentives for biochemically confirmed abstinence at 6 ($250) and 12 months (≤$500) after enrollment increased long-term cessation rates relative to enhanced UC alone. Their study used less intensive treatment and provided relatively large incentives for longer-term abstinence, which may have practical benefits at the system level (eg, greater reach, simplicity, fewer required treatment resources).…”