Mobile health contingency management for smoking cessation among veterans experiencing homelessness: A comparative effectiveness trial

Abstract

Tobacco cessation is reduced in U.S. military veterans experiencing homelessness. Mobile contingency management (mCM) is a promising treatment for tobacco use among populations experiencing homelessness, but past CM studies have largely been small, have relied on in-person follow-up, and/or lacked long-term biochemically verified abstinence measures. Veterans who smoked and were experiencing homelessness (N = 127) were randomly assigned to mCM treatment (4 weeks of mCM, 5 weeks of telehealth counseling, and the option of 12 weeks of pharmacotherapy) or VA standard care (3 biweekly group sessions and clinically appropriate pharmacotherapy), and all participants were randomly assigned to a $100 longer-term financial incentive for abstinence at 3-month follow-up. Participants were followed at 3-, 6-, and 12-months post-randomization, with the a priori main outcome designated as biochemically verified prolonged abstinence (with lapses) at 6-month follow-up. At 6-months, participants in the mCM group were significantly more likely to meet criteria for prolonged abstinence (OR = 3.1). Across time points, veterans in the mCM group had twice the odds of prolonged abstinence as those in the standard care group. However, by the 12-month follow-up, there was no statistically significant group difference in abstinence. Cost-effectiveness analysis indicated a modest increase in cost ($1,133) associated with an increase of one quality-adjusted life year saved for the intervention compared to standard care. mCM is a cost-effective approach to smoking cessation among veterans experiencing homelessness. Considering waning potency of this and other tobacco cessation interventions at 12-month follow-up, it is crucial to implement strategies to sustain abstinence for individuals experiencing homelessness.

Keywords: Contingency management; Financial incentives; Homelessness; Insecure housing; Mobile health; Smoking cessation; Veterans.

Fig. 1

CONSORT Diagram, Smoking Cessation Randomized Trial among U.S. Military Veterans Experiencing Homelessness, Baseline through 12 Months Post-Randomization.

Fig. 2

Proportion of U.S. Military Veteran Participants with Biochemically Verified Prolonged Smoking Abstinence (with Lapses) by Treatment Group at 3, 6, and 12 Months Post-Randomization. † p =.05, * p <.05 ^a Across time points, the mCM group had significantly higher biochemically verified smoking abstinence, OR = 2.34 (95% C.I. 1.18–4.61), p <.01].

Fig. 3

Proportion of U.S. Military Veteran Participants with Biochemically Verified Seven-Day Point Prevalence Smoking Abstinence by Treatment Group at 3, 6, and 12 Months Post-Randomization. ^a Across time points, there was no significant difference in seven-day point prevalence abstinence between groups (OR = 1.25, 95% CI [0.74–2.13], p =.40).