Tobacco treatment clinics
We established clinics at two housing units in Baltimore City in 2019. The clinics were staffed on-sight with an advanced healthcare provider (physician or a nurse) and a tobacco treatment specialist. Each clinic session was 90 min long, allowing for 20 min with each tenant. Housing unit staff helped to advertise the clinics and identify active smokers of combustible tobacco. Further, the housing unit staff identified private space for interaction between healthcare professionals and the tenants. Tenants participated in the clinic voluntarily. The Institutional Review Board at Johns Hopkins School of Medicine approved the study, and all actions undertaken by the authors were in accordance with the Declaration of Helsinki.
Housing units were identified through existing partnerships. Our aim was to hold a clinical session once every two weeks. Both housing units are located in socioeconomically disadvantaged neighborhoods, as identified by their respective area deprivation index (ADI), a composite score based on census-tract level variables . The ADI ranges from 1 to 100 (the higher the number, the more socioeconomically disadvantaged a neighborhood): Housing Unit 1’s ADI is 92, and Housing Unit 2’s ADI is 99. Clinical session dates were subject to cancellation by weather or holidays. Housing Unit 1 had significant construction throughout 2019, which limited tenant presence on-site.
Tenants were encouraged to come to as many clinical sessions as possible. The initial session characterized participants and their tobacco-dependence phenotypes. At the end of the first visit, tenants were introduced to current Food and Drug Administration (FDA) approved pharmacological interventions for smoking cessation and encouraged to come to additional clinical sessions. Additional clinical sessions provided ongoing tobacco-centered counseling and motivational interviewing principles established by the tobacco treatment specialist and physician. Further, at each clinical session, tenants reported whether they were current smokers or quit smoking. A tenant’s positive self-identification of actively smoking defined them as a “current smoker” . Participants listed in the “quit smoking” group were defined as those who reported not smoking for more than 24-h and planned to refrain from future tobacco use .
If the tenant selected pharmacological agents, we encouraged obtaining the medications through two methods, with the tenant’s permission. We notified the state’s Quitline to provide nicotine replacement therapies currently available over the counter. For medications requiring a prescription, we notified the tenant’s primary care physician. Medications were dichotomized as 24-h medications, known as controllers (bupropion, nicotine replacement therapy transdermal, and varenicline), or as needed medications, known as relievers (nicotine replacement therapy gum, lozenges, inhaler, or nasal spray).
All participants were called 3-months and 6-months after their initial clinical session to discuss their smoking status and asked if they required additional resources.
Data collected during the clinical session included age, race, and gender. Tobacco dependence-related variables included: the brand of cigarettes currently using, the age at which a tenant began to smoke, and what triggers a tenant to smoke. Triggers were identified as intrinsic (stress, boredom) and extrinsic (time of the day, social, meals). Time of the day is defined as the tenant’s reported time of use over 24 h (e.g., cigarette used during the morning or right before bed) as part of their routine. All participants were called every 4 weeks for 6 months to assess their smoking status (“quit smoking” or “current smoker”).
The primary outcome was a change in smoking status to “quit smoking” by or at the 3-month or 6-month mark. Secondary outcomes included the number of clinical sessions attended and the type of pharmacological interventions selected (e.g., only one medication or two or more medications; utilizing a controller and a reliever).
Continuous variables were expressed as medians and interquartile ranges (IQR) or mean + standard deviation. Categorical variables were summarized as counts and percentages. For missing data, no imputation was made. Since participants in the cohort were not randomly selected, all statistics were deemed descriptive. Statistical analyses were conducted with R software (V.0.99.903).