摘要：Objectives. We compared participant characteristics and abstinence outcomes of smokers who chose in-person or telephone tobacco dependence treatment. Methods. We provided the same treatment content to 7267 smokers in Arkansas between 2005 and 2008 who self-selected treatment modality; examined demographic, clinical, environmental, and treatment utilization differences between modalities; and modeled outcomes and participants’ choice of modality with logistic regression. Results. At end of treatment, in-person participants were more likely to be abstinent than telephone participants, and smokers of higher socioeconomic status (SES) were more likely to be abstinent with telephone treatment than lower-SES smokers. Long term, modality had no effect on treatment outcomes. Higher-SES smokers and smokers exposed to more treatment content were more likely to achieve long-term abstinence, regardless of modality. Men and more recalcitrant smokers were more likely to choose in-person treatment; lower-SES, ethnic minority, and more dependent smokers were more likely to choose telephone treatment. Conclusions. Treatment modality attracts different groups of smokers, but has no effect on long-term abstinence. Multiple treatment modalities are needed to provide treatment to a heterogeneous population of smokers. More research is needed to understand the influences on treatment choice. Providing treatment of tobacco dependence is a vital component of comprehensive tobacco control programs. 1 Cognitive–behavioral treatment (CBT) for tobacco dependence delivered through various modalities (in person and over the telephone) is well-validated 2 and widely available in the United States, United Kingdom, and Canada, but there is a dearth of information about the comparative effectiveness among modalities especially in the context of providing treatment to a heterogeneous population of smokers in real-world settings. Because tobacco use is a leading contributor to socioeconomic health disparities, understanding the effects of socioeconomic status (SES) on treatment modality effectiveness as well as the choice of treatment modality is a priority. 3–5 In the United States, those with household incomes of $15 000 or less smoke at nearly 3 times the rate of those with incomes of $50 000 or more. 6 Although quit attempts demonstrate no socioeconomic gradient, successful cessation demonstrates a considerable socioeconomic disparity, 7–10 which is broadening over time. 5,11 In-person and telephone treatment modalities each have obvious strengths and limitations; however, it remains unclear how these modalities compare in terms of effectiveness for and their ability to attract lower-SES smokers. In-person CBT is the traditional behavioral treatment modality. Telephone CBT provided through proactive “quitlines” is a promising and practical innovation in treatment delivery. 12,13 Proactive quitlines provide CBT to callers with scheduled contacts over several weeks, similar to in-person treatment. Quitlines are widely available in the United States, Canada, and the United Kingdom, albeit of varying types and intensities. 13 Regardless of modality, CBT has a clear dose–response curve, with the most effective CBT including at least 4 contacts augmented with medication. 2 Telephone treatment is purported to be more desirable and accessible to lower-SES smokers than in-person treatment because it decreases logistical barriers to treatment, requiring less effort on the part of smokers, 12 but there are little data to support this contention. In fact, some quitlines attract a greater proportion of higher-SES than lower-SES smokers, maintaining existing smoking-related socioeconomic disparities. 14,15 Moreover, some lower-SES and ethnic minority smokers experience significant barriers to using proactive telephone treatment effectively (e.g., private access to a landline, available free cellular minutes, trust in a treatment provider located elsewhere). 16 In addition, quitline promotion often uses extensive TV and radio media promotions 13,17 that do not reach some lower-SES and ethnic minority communities. 14,16 In-person treatment programs are purported to reach fewer smokers than telephone treatment because of geographic limitations 18 ; however, they almost exclusively rely on less-extensive promotional methods (e.g., local word-of-mouth and health care provider referrals). 7,19–22 These factors make it difficult to compare the ability of treatments to attract lower-SES smokers. The 2 existing comparisons between in-person and telephone treatment have significant limitations 21,22 ; however, evidence suggests that smokers served by in-person and telephone programs have many similarities and differences. Both modalities attract urban and rural lower-SES smokers and, compared with the general population of smokers, a greater proportion of women. 7,19–21,23–25 In-person participants are more likely to be older and more highly dependent 21,22 and callers are more likely to be younger, more dependent, and more ready to quit 22 than the general population of smokers. The most recent and most direct comparison between in-person and telephone treatment found no difference in treatment outcomes. 21 The comparisons made in this study are limited, however, because the modalities offered different treatment content; there were systematic biases in treatment modality eligibility (e.g., insurance status, readiness to quit); and geographic proximity to in-person treatment was unaccounted for as were a wide range of demographic, clinical, environmental, and treatment utilization factors. 21,22 Nonetheless, these findings suggest that each modality provides services for populations not reached by the other. 21,22 To date, there are no direct comparisons of in-person and telephone treatments offering the same content and accounting for geographic proximity to in-person treatment as well as accounting for differences in participant demographic, clinical, environmental, and treatment utilization characteristics. From 2005 to 2008, the Arkansas state-funded tobacco dependence treatment program provided a unique opportunity to account for proximity to in-person treatment and directly compare in-person and telephone treatment outcomes and participant characteristics with the same treatment content delivered in both modalities. The large sample size, the extensive amount of data collected, and the heterogeneity of participants allowed us to account for demographic, clinical, environmental, and treatment utilization factors; proximity to in-person treatment; and the interaction between SES and treatment modality. We hypothesized that our results would support preliminary findings. We expected treatment modality to have no effect on treatment outcomes, and higher SES and increased treatment utilization to be associated with a greater likelihood of long-term abstinence. We expected both (modalities to attract a similarly large proportion of women, but telephone treatment to attract a higher proportion of lower-SES and ethnic minority smokers. We also expected smokers with higher dependence and greater motivation levels to be more likely to choose in-person treatment.
