Financial Incentives and Proactive Calling for Reducing Barriers to Tobacco Treatment Among Socioeconomically Disadvantaged Populations: A Factorial Randomized Trial

Individuals were randomized to one of six conditions. The design was a two-factor, three-by-two factorial design: three levels of financial incentives, and two levels of proactive calls (yes, no). All groups received direct mail and free tobacco treatment services.

The intervention was implemented from June 2017 to October 2017. National Breast and Cervical Cancer Early Detection Programs serve uninsured women with household incomes at or below 250% of the U.S. federal poverty level; subsequently, the sample was strictly female, and the investigators included individuals for whom self-reported smoking status was available (from 2014 to 2017). Smoking status was determined using Sage data, which come from clinics and Sage's call center. Using a uniform measure ("Does the participant currently smoke cigarettes?"), smoking status was based on cigarette use at the time of contact with the Sage program (i.e., clinic visit or contact with the call center). Data on smoking intensity were not available. There were 3,723 smokers who met selection criteria.

All participants received two rounds of direct mail. Mailers consisted of a folded card, which contained messages and graphics rooted in a loss-frame approach. Following previous research, the loss-frame approach was designed to indicate that certain behaviors lead to unhealthy outcomes, and the investigators paired the message with a clear articulation of behavioral steps.

Sage has a call center staffed by patient navigators. When participants called Sage's number, patient navigators followed a script, recorded callers' promotion code, determined callers' desire to participate, and made connections to the quit-line for willing participants. After two rounds of direct mail, patient navigators placed proactive outreach calls to eligible participants. Phone numbers were retrieved from the Sage database. Using a script, navigators reminded participants of the direct mail piece and the program offer. Each participant received one proactive call. One call attempt was made; navigators left a voicemail for participants who were unavailable. Proactive calling lasted three months.

Both the mailer and navigators referred participants to Minnesota's free population-based cessation services. The quit-line is funded and administered by an independent nonprofit organization. Participants can enroll in services either by phone or online. Tobacco users can choose telephone counseling or one or more individual services.