When you explore interventions to quit smoking, you might see programs that claim to be “tailored” or specially designed for certain groups or populations. But are these programs more effective in enrolling and engaging individuals?
As a councilmember of the Society for Research on Nicotine and Tobacco’s Health Equity Network, I am deeply committed to making sure quit smoking programs work equally well for all tobacco users. As the managing director of research for the EX Program, I also keep my finger on the pulse of the latest research.
So, let’s explore what the research shows.
What exactly is “tailoring”?
As a grounding, it’s important to have a shared understanding of what tailoring means.
Tailoring in behavior change interventions involves using information about someone to customize the program they receive. Most often this involves delivering content based on an individual’s answers to questions about the underlying drivers of the intervention.
For example, self-efficacy (a.k.a. confidence) is a key construct in many behavior change interventions. Someone who lacks confidence to change their diet to better control their diabetes would receive different content than someone who has a high level of confidence.
The theory is that tailored programs feel more personally relevant and salient to the receiver (“it’s designed for me”), and that this relevance and salience lead to deeper processing of the information.
There is strong evidence that this kind of tailoring works.
What is cultural tailoring?
Also called cultural adaptation, cultural tailoring involves reviewing and changing the structure of a program or practice to fit the needs and preferences of a particular cultural group. The intent is to ensure a program is culturally responsive to the group it serves.
This kind of tailoring may involve adapting the way an intervention is delivered, the context around how it’s delivered, and even who may deliver it. One example of cultural tailoring would be to focus on the concept of familismo—the importance of family that is central in Latino culture—in a smoking cessation campaign designed for Hispanic tobacco users.
Another example is a study that compared regular quitline services to a quitline service plus a culturally specific video intervention designed for African American smokers. This study found the video arm had better cessation outcomes after 6 months.
So, does this mean we need different interventions for each cultural group? A recent systematic review that synthesized the results of many studies sheds light on this question.
Culturally adapting digital health interventions “might not be worth the effort”
The systematic review in npj Digital Medicine—one of the prestigious Nature journals—found that culturally adapted internet- and mobile-based interventions did not have better health behavior outcomes compared to non-adapted programs.
The review included 13 randomized controlled trials that investigated culturally adapted digital health promotion interventions across a range of behaviors. While some of the included studies did show better outcomes with cultural tailoring, overall, the evidence didn’t support that tailored programs led to better effectiveness.
The authors noted that their findings should be considered preliminary but concluded, based on the evidence and cost of cultural adaptations, that such approaches “may not be worth the effort”.
Interestingly, a recent study showed that adapting a smoking cessation program for low income smokers made it less effective. A specialized tobacco quitline intervention was designed for low-income smokers that included specialized training for quitline coaches, a tailored quit guide that was easier to read, and longer standard call times for better rapport building with the caller.
In addition, a “social needs navigation” intervention was designed to help participants address the unique stressors in their lives (e.g., food insecurity, transportation, childcare) by connecting them with relevant resources. Findings showed that the specialized quitline combined with the “social needs navigation” component made the standard quitline intervention less effective.
What does work to address needs of different smokers?
If a full adaptation of an evidence-based intervention to quit smoking is not necessary, how can we address the needs of different smokers?
Here are 4 things to look for in a tobacco cessation program to make sure it meets the needs of a diverse group of tobacco users:
Prioritizing Access and Accessibility
In a study led by colleagues at the University of Maryland, we are testing the feasibility of delivering EX Program to hospitalized smokers with serious mental illness. The goal is to bridge the treatment gap that occurs following hospital discharge when most patients return to smoking.
We consulted with psychiatrists and psychologists who had experience working with this patient population and former smokers living with serious mental illness themselves to determine what kinds of adaptation might be needed.
The consensus among these stakeholder groups was that specific changes to the program itself weren’t necessary. They felt that smokers with serious mental illness could benefit from the same strategies and tools as other smokers. However, they did recommend introducing the program during the hospital stay and providing additional guidance to encourage ongoing engagement with the program following hospital discharge.
As a result, instead of changing EX, we created a bridge program to help smokers with serious mental illness access EX after they left the hospital. Ensuring easy and equitable access to proven tobacco cessation treatments was noted as a priority in the latest U.S. Surgeon General’s Report on Smoking Cessation.
Ensuring Diversity in Representation and Service Delivery
While it may not be necessary to completely customize a cessation program for all different groups of people, efforts should still be made so end users feel like a program they use is still “for them.” EX Program achieves this by:
- Ensuring imagery used in our digital program is diverse and representative of a wide variety of tobacco users;
- Making the program fully available in Spanish, in all our content and in our coaching staff;
- Hiring coaching staff to reflect the diversity of tobacco users;
- Training coaching staff in diversity, equity, and inclusion and social determinants of health so they are prepared to coach tobacco users of various backgrounds; and,
- Confirming accessibility to all users by adhering to the latest Web Content Accessibility Guidelines (WCAG).
Acknowledging Lived Experience
Tobacco use and cessation don’t occur in a vacuum. It’s important for a quit-tobacco program to acknowledge what a user has gone through, such as experiencing stigma, discrimination, financial distress, and living with chronic conditions.
Our coaches are trained to be welcoming, non-judgmental, and open so that every user knows they are connecting with a real person who understands their individual experiences of quitting.
EX Program also weaves these considerations throughout our entire program rather than creating a customization that siloes content for specific populations.
Improving Access to Proven Treatment
Lastly, it’s essential to focus on actions that will have the biggest impact.
Research highlighted above suggests that the key to achieving health equity in quitting tobacco is making it easier for everyone, regardless of their background, to access programs that work.
Employers and health plans can play a pivotal role in reducing tobacco use by spreading awareness about available programs and making it easier for everyone to use them. And to help employers and health plans do this, we provide comprehensive communications led by strategic Client Success Managers.