Tobacco use is a leading contributor to racial and socioeconomic health disparities in the US primarily due to an unequal burden of tobacco-related disease from a disproportionate share of smokers in lower socioeconomic (SES) groups in which minorities, particularly African Americans, are disproportionately represented.1-5 Although deemed effective for all smokers,6 the standard cognitive-behavioral treatment for tobacco dependence is significantly less effective for lower SES smokers.7-15 Tobacco dependence treatment, however, has the potential to reduce racial and socioeconomic disparities in achieving long-term abstinence by proactively providing our most at-risk smokers with the specific treatment components they need to achieve abstinence through the existing extensive treatment delivery system.16, 17 Our preliminary studies indicate that in addition to several socio-cultural barriers to engaging in treatment,18 there are several key factors associated with socioeconomic disparities in relapse rates and thus treatment outcomes. These factors include: stress, negative affect, smoking in response to negative affect, delay discounting, locus of control, impulsiveness, exposure to smokers in the environment, and treatment utilization (see Table 1).19, 20 Based on this and other evidence, our overall goal is to revise the standard treatment with specific, evidence-based, cognitive-behavioral strategies to address these key factors as well as target and tailor the approach to more fully meet the needs of lower SES and minority smokers, thereby reducing treatment outcome disparities. We expect: 1) The revised treatment (RT) to reduce socioeconomic disparities in treatment outcomes, and 2) Participants treated with the RT to demonstrate more improvement on each of the key factors associated with disparities than those treated with standard treatment (ST).
The specific aims i nclude: 1) Complete a revised draft of a widely utilized standard treatment manual that addresses each of the key factors with treatment components.
This aim i s partially accomplished (see Appendix for preliminary draft). 2) Using the PEN-3 Model,21-23 target and tailor the daft RT to more fully represent the experiences of smokers who are of lower SES and /or of minority status, particularly African American smokers. 3) Pilot test the targeted/tailored draft RT with three treatment groups (n=5-10 per group) to assess understandability and acceptability and to ensure that it can be delivered in the same timeframe as the ST. 4) Compare the effects of SES on treatment outcomes with socioeconomically and racially diverse participants treated with ST (n=110) and RT (n=110) in a randomized treatment design. 5) Compare the effects of treatment condition on each of the key factors. This innovative approach refines, improves upon, and applies theoretically derived and empirically supported concepts and strategies. If effective at reducing treatment outcome disparities, the manual-driven RT will be easily disseminable as a """"""""new"""""""" standard, having a sustained and powerful impact on the field and contributing to a reduction in the magnitude of the present tobacco-related racial and socioeconomic health disparities.

Public Health Relevance

Tobacco use is a leading contributor to racial and socioeconomic health disparities in the US primarily due to an unequal burden of tobacco-related disease from a disproportionate share of smokers in African American and lower socioeconomic (SES) groups. Unlike many other health risk behaviors, tobacco-related health disparities are increasing despite a large treatment network of free telephone and in-person counseling services, perhaps due to significant disparities in treatment outcomes. The goal of this project is to revise the standard treatment for tobacco dependence to address key factors associated with treatment outcome disparities and more fully meet the needs of lower SES and African American smokers thereby reducing socioeconomic disparities in tobacco dependence treatment outcomes, halting the alarming increase in tobacco-related health disparities, and reducing a leading cause of racial and socioeconomic health disparities in the US.

National Institute of Health (NIH)
National Institute on Minority Health and Health Disparities (NIMHD)
Research Project (R01)
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Special Emphasis Panel (ZMD1)
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Dankwa-Mullan, Irene
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City College of New York
Public Health & Prev Medicine
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New York
United States
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Bickel, Warren K; Mellis, Alexandra M; Snider, Sarah E et al. (2018) 21st century neurobehavioral theories of decision making in addiction: Review and evaluation. Pharmacol Biochem Behav 164:4-21
Sheffer, Christine E; Bickel, Warren K; Franck, Christopher T et al. (2017) Improving tobacco dependence treatment outcomes for smokers of lower socioeconomic status: A randomized clinical trial. Drug Alcohol Depend 181:177-185
Sheffer, Christine E; Mackillop, James; Fernandez, Arislenia et al. (2016) Initial examination of priming tasks to decrease delay discounting. Behav Processes 128:144-52
Evans, Shenell D; Sheffer, Christine E; Bickel, Warren K et al. (2015) The Process of Adapting the Evidence-Based Treatment for Tobacco Dependence for Smokers of Lower Socioeconomic Status. J Addict Res Ther 6:
Bickel, W K; Moody, L; Quisenberry, A J et al. (2014) A Competing Neurobehavioral Decision Systems model of SES-related health and behavioral disparities. Prev Med 68:37-43