NIH funding opportunities (2) – Improving Smoking Cessation in Socioeconomically Disadvantaged Populations via Scalable Interventions (R01, R21)

April 29, 2016 by School of Medicine Webmaster

The description below was taken from the R01 version of this FOA:

This FOA encourages innovative research to improve our understanding of how to increase quit attempts and cessation rates among socioeconomically disadvantaged populations, with an emphasis on interventions that have the potential to be scalable, implementable, and sustainable in real-world settings. Interventions to be tested can include individual-, systems-, or population-based treatment approaches with smoking cessation as the primary outcome. Applicants may propose projects that develop and test novel cessation interventions with the potential to be scaled up, as well as projects that focus on enhancing the effectiveness, quality, accessibility, utilization, and cost-effectiveness of currently scaled smoking cessation interventions. The long-term goal of this FOA is to facilitate a significant reduction in smoking prevalence among socioeconomically disadvantaged populations, thereby reducing the excess disease burden of tobacco use within these groups and decreasing the prevalence of smoking in the United States (U.S.) as a whole.

Socioeconomic Disparities in Smoking Prevalence

Comprehensive tobacco control efforts have produced several decades of steady declines in smoking prevalence in the general U.S. population; however, this progress has not occurred equally across socioeconomic strata. The observed declines in cigarette smoking have occurred disproportionately among those with more education, better health status, skilled jobs, and higher household incomes. Smoking is increasingly concentrated among adults with the lowest levels of income, educational attainment, and occupational status, as well as those occupying other positions of socioeconomic disadvantage within society. For example, in 2014, 26.3% adults living below the poverty level were current smokers, compared with 15.2% of adults living above the poverty level; 43% of adults with a General Educational Development (GED) certificate were current smokers, compared with 7.9% of adults with an undergraduate college degree; and, 27.9% of uninsured adults and 29.1% of adults on Medicaid, respectively, were current smokers, compared with 12.9% of adults with private insurance. Socioeconomically disadvantaged smokers are also more likely to smoke heavily, relative to smokers in the general population, leading to greater amounts of tobacco exposure over their lifetime.

Socioeconomic Disparities in Smoking-Related Harm

Smoking contributes to substantial health inequalities in socioeconomically disadvantaged populations, including marked disparities in cancer incidence and mortality. Approximately 1 out of every 3 cancer deaths in the US is caused by smoking, and smoking has been implicated in cancers of the lung, trachea, bronchus, esophagus, oral cavity, lip, nasopharynx, nasal cavity, larynx, stomach, bladder, pancreas, kidney, liver, cervix, colon, rectum, and acute myeloid leukemia. Socioeconomically disadvantaged populations experience a disproportionate burden of cancer incidence and death, as well as excess morbidity and mortality from other smoking-related diseases such as diabetes, cardiovascular disease, and respiratory disease. A better understanding of how to reduce these smoking-related health disparities represents a critical area of need within the field of tobacco control.

Socioeconomic Disparities in Smoking Cessation  

Low smoking cessation rates among socioeconomically disadvantaged populations are a major contributor to smoking-related health disparities. Quit ratios (i.e., the percentage of ever smokers who have quit) in the US population are lower among adults with lower educational attainment and adults living below the poverty level, compared with quit ratios observed in the general adult population. Individuals in socioeconomically disadvantaged populations have less access to smoking cessation treatment and encounter more obstacles to both engaging in and maintaining behavioral change, which undoubtedly contributes to greater difficulty in quitting smoking. Furthermore, socioeconomically disadvantaged smokers are less likely to use proven cessation treatments such as counseling and/or pharmacotherapy compared to those with higher incomes and more education. Achieving greater progress in reducing smoking-related health disparities will require identifying, developing, and testing cessation interventions, especially those that can be scaled up to the population level.

Scalable Interventions for Smoking Cessation

Scalability is generally defined as the ability of a health intervention shown to be efficacious on a small scale and/or under controlled conditions to be expanded under real-world conditions to reach a greater proportion of the eligible populations, while maintaining efficacy. Many existing evidence-based smoking cessation treatments have limited scalability, due to their high cost, high delivery burden, and/or complexity. Cessation interventions with the potential to be scaled up and packaged for broad use represent a promising avenue to more efficiently and effectively reduce the population prevalence of smoking, particularly in subgroups that continue to smoke at high rates. For example, evidence supports the use of telephone-based (e.g., smoking cessation quitlines) and mobile health (e.g., SMS text-based cessation interventions) interventions as individually focused treatments in socioeconomically disadvantaged populations.  System-focused interventions, such as those that change community networks or health care delivery, may also enhance cessation rates among socioeconomically disadvantaged smokers.  Although promising, the success rates of these treatment approaches are modest and there is a need to develop and test improved protocols. Addressing important research gaps related to scalable interventions would greatly expand the reach, efficiency, and sustainability of cessation interventions targeted to socioeconomically disadvantaged populations.

Research Objectives

Applications submitted to this FOA should focus on developing and testing scalable treatment approaches for promoting smoking cessation among socioeconomically disadvantaged smokers. Applicants may propose projects that develop and test novel cessation interventions with the potential to be scaled up (i.e., those that include treatment components, tools, and/or protocols that could be readily packaged for broad use in real-world settings). Applicants may also propose projects that focus on identifying and testing enhancements to currently scaled cessation interventions.

It is expected that the proposed research will attend to efficacy, reach, and adoption; intervention delivery; accessibility; engagement; resources; costs; contextual factors and appropriate evaluation approaches so as to promote the quality and usability of research available to policy makers and to improve uptake and expansion of promising programs. Applicants must develop a compelling scientific rationale for how the proposed intervention approach is expected to specifically improve cessation outcomes in socioeconomically disadvantaged populations. As scalability is a central feature of this FOA, investigators must consider how scalability and packaging of the intervention for real-world implementation would occur, and must propose a hypothesis that tests scalability (for non-scaled interventions) or enhancements to scalability (for currently scaled interventions). In addition, because the costs of developing, implementing, and sustaining a large-scale intervention can be substantial, all projects are required to include an economic evaluation element to quantify the overall economic impact of the intervention.

Research projects that target specific subpopulations of socioeconomically disadvantaged smokers are appropriate for this announcement and encouraged.  These subpopulations include, but are not limited to: individuals with low income (at or below the federal poverty level); individuals with low levels of education (less than 12 years of education or GED); individuals who are unemployed or underemployed; individuals who are uninsured and underinsured; racial/ethnic populations living in low-resource communities; individuals living in affordable housing and multi-unit housing; food insecure and food stamp eligible individuals; individuals living in rural communities; and other disadvantaged groups with high rates of smoking (e.g., veterans, blue collar workers, homeless individuals, incarcerated individuals, individuals with co-morbid psychiatric conditions or physical disabilities).

Applicants are expected to utilize study designs that are maximally efficient for testing study hypotheses, and where applicable incorporate innovative strategies (e.g., hybrid effectiveness-implementation designs, pragmatic trials, mixed methodologies, key informant interviews, needs assessments of systems where the intervention would be scaled) for appropriate testing of scalability hypotheses. Fractional factorial designs, mediational analyses, and other analytic approaches should be considered, where appropriate, to isolate the additional effects of novel intervention components, above and beyond the effects produced by standard care treatments. Biochemical verification of smoking status is encouraged where feasible and not cost-prohibitive, but not required.

It is anticipated that each award will support multidisciplinary project teams composed of scientists with expertise to enable all the specific aims to be addressed. A range of disciplines is likely to be needed; for example, teams may include public health, clinical, behavioral, and social scientists, statisticians, economists, technology developers, and others. Given that scalability is a central feature of the FOA, it is expected that teams will include researchers with expertise in dissemination and implementation science, or related scientific domains.

Research questions of interest include, but are not limited to, the following:

  • How might individual, quitline, mobile health, and/or health care system-based treatments of tobacco dependence be personalized for socioeconomically disadvantaged smokers to enhance treatment efficacy?
  • In what ways can scalable interventions be developed or modified to increase engagement with treatment and enhance long-term behavioral change among socioeconomically disadvantaged smokers?
  • What strategies might be used to systematically increase access to and utilization of cessation services in socioeconomically disadvantaged populations?
  • How might available infrastructures that provide services to socioeconomically disadvantaged populations be utilized to also deliver smoking cessation interventions?

Deadlines for both FOAs:  October 11, 2016; June 13, 2017; October 11, 2017; June 13, 2018; October 11, 2018, June 13, 2019


Filed Under: Funding Opportunities