Differences in the effectiveness of individual-level smoking cessation interventions by socioeconomic status
- PMID: 39868569
- PMCID: PMC11770844
- DOI: 10.1002/14651858.CD015120.pub2
Differences in the effectiveness of individual-level smoking cessation interventions by socioeconomic status
Abstract
Background: People from lower socioeconomic groups are more likely to smoke and less likely to succeed in achieving abstinence, making tobacco smoking a leading driver of health inequalities. Contextual factors affecting subpopulations may moderate the efficacy of individual-level smoking cessation interventions. It is not known whether any intervention performs differently across socioeconomically-diverse populations and contexts.
Objectives: To assess whether the effects of individual-level smoking cessation interventions on combustible tobacco cigarette use differ by socioeconomic groups, and their potential impact on health equalities.
Search methods: We searched the Cochrane Database of Systematic Reviews from inception to 1 May 2023 for Cochrane reviews investigating individual-level smoking cessation interventions. We selected studies included in these reviews that met our criteria. We contacted study authors to identify further eligible studies.
Selection criteria: We included parallel, cluster or factorial randomised controlled trials (RCTs) investigating any individual-level smoking cessation intervention which encouraged complete cessation of combustible tobacco cigarette use compared to no intervention, placebo, or another intervention in adults. Studies must have assessed or reported smoking quit rates, split by any measure of socioeconomic status (SES) at longest follow-up (≥ six months), and been published in 2000 or later.
Data collection and analysis: We followed standard Cochrane methods for screening, data extraction, and risk of bias assessment. We assessed the availability of smoking abstinence data by SES in lieu of selective reporting. The primary outcome was smoking cessation quit rates, split by lower and higher SES, at the longest follow-up (≥ six months). Where possible, we calculated ratios of odds ratios (ROR) with 95% confidence intervals (CIs) for each study, comparing lower to higher SES. We pooled RORs by intervention type in random-effects meta-analyses, using the generic inverse-variance method. We subgrouped by type of SES indicator and economic classification of the study country. We summarised all evidence in effect direction plots and categorised the intervention impact on health equality as: positive (evidence that the relative effect of the intervention on quit rates was greater in lower rather than higher SES groups), possibly positive, neutral, possibly neutral, possibly negative, negative, no reported statistically significant difference, or unclear. We evaluated certainty using GRADE.
Main results: We included 77 studies (73 from high-income countries), representing 127,791 participants. We deemed 12 studies at low overall risk of bias, 13 at unclear risk, and the remaining 52 at high risk. Included studies investigated a range of pharmacological interventions, behavioural support, or combinations of these. Pharmacological interventions We found very low-certainty evidence for all the main pharmacological interventions compared to control. Evidence on cytisine (ROR 1.13, 95% CI 0.73 to 1.74; 1 study, 2472 participants) and nicotine electronic cigarettes (ROR 4.57, 95% CI 0.88 to 23.72; 1 study, 989 participants) compared to control indicated a greater relative effect of these interventions on quit rates in lower compared to higher SES groups, suggesting a possibly positive impact on health equality. CIs for both estimates included the possibility of no clinically important difference and of favouring higher SES groups. There was a lower relative effect of bupropion versus placebo on quit rates in lower compared to higher SES groups, indicating a possibly negative impact on health equality (ROR 0.05, 95% CI 0.00 to 1.00; from 1 of 2 studies, 354 participants; 1 study reported no difference); however, the CI included the possibility of no clinically important difference. We could not determine the intervention impact of combination or single-form nicotine replacement therapy on relative quit rates by SES. No studies on varenicline versus control were included. Behavioural interventions We found low-certainty evidence of lower quit rates in lower compared to higher SES groups for print-based self-help (ROR 0.85, 95% CI 0.52 to 1.38; 3 studies, 4440 participants) and text-messaging (ROR 0.76, 95% CI 0.47 to 1.23; from 3 of 4 studies, 5339 participants; 1 study reported no difference) versus control, indicating a possibly negative impact on health equality. CIs for both estimates included the possibility of no clinically important difference and of favouring lower SES groups. There was very low-certainty evidence of quit rates favouring higher SES groups for financial incentives compared to balanced intervention components. However, the CI included the possibility of no clinically important difference and of favouring lower SES groups (ROR 0.91, 95% CI 0.45 to 1.85; from 5 of 6 studies, 3018 participants; 1 study reported no difference). This indicates a possibly negative impact on health equality. There was very low-certainty evidence of no difference in quit rates by SES for face-to-face counselling compared to less intensive counselling, balanced components, or usual care. However, the CI included the possibility of favouring lower and higher SES groups (ROR 1.26, 95% CI 0.18 to 8.93; from 1 of 6 studies, 294 participants; 5 studies reported no difference), indicating a possibly neutral impact. We found very low-certainty evidence of a greater relative effect of telephone counselling (ROR 4.31, 95% CI 1.28 to 14.51; from 1 of 7 studies, 903 participants; 5 studies reported no difference, 1 unclear) and internet interventions (ROR 1.49, 95% CI 0.99 to 2.25; from 1 of 5 studies, 4613 participants; 4 studies reported no difference) versus control on quit rates in lower versus higher SES groups, suggesting a possibly positive impact on health equality. The CI for the internet intervention estimate included the possibility of no difference. Although the CI for the telephone counselling estimate only favoured lower SES groups, most studies narratively reported no clear evidence of interaction effects.
Authors' conclusions: Currently, there is no clear evidence to support the use of differential individual-level smoking cessation interventions for people from lower or higher SES groups, or that any one intervention would have an effect on health inequalities. This conclusion may change as further data become available. Many studies did not report sufficient data to be included in a meta-analysis, despite having tested the association of interest. Further RCTs should collect, analyse, and report quit rates by measures of SES, to inform intervention development and ensure recommended interventions do not exacerbate but help reduce health inequalities caused by smoking.
Trial registration: ClinicalTrials.gov NCT01553084 NCT01983150 NCT00448344 NCT00345891 NCT01812278 NCT02096029 NCT00608426 NCT00775944 NCT00786149 NCT00683839 NCT00282009 NCT01156610 NCT01526265 NCT02351609 NCT02693626 NCT02416011 NCT02844595 NCT02301403 NCT01487642 NCT02730260 NCT00128375 NCT02521662 NCT02539875 NCT02497339 NCT00301145 NCT01867983 NCT00086385 NCT00297453 NCT00365508 NCT01047527 NCT00503230 NCT02859142.
Copyright © 2025 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Conflict of interest statement
AT holds a PhD scholarship from the Society for the Study of Addiction, graduate scholarships from St Catherine's College at the University of Oxford, and Global Grants from The Rotary Foundation to support DPhil studies. The funders had no role in the design, conduct, or publication of the review.
JSA is chair of the scientific advisory board and equity owner in a US start‐up company, Qnovia (formerly Respira Technologies), which is developing a nicotine‐based smoking cessation prescription medication working with the US Food and Drug Administration (FDA). In 2024, the medication will enter early Phase I trials. As part of this role, JSA declares consultancy fees from Qnovia (personal payment). JSA is affiliated with the Society for Research on Nicotine and Tobacco, who have declared an opinion on the topic. JSA was a Principal Investigator of a study which was eligible for inclusion in this review: Helping African American Light Smokers Quit, supported by the National Cancer Institute at the National Institutes of Health (NIH R01 CA91912). The trial was conducted at University of Kansas Medical Center, USA. JSA was not involved in assessing eligibility, extracting data, assessing risk of bias or grading the certainty of the evidence for this study (performed independently by AT, EL, JHB and NL). JSA also discloses the following travel expense fees: Global Tobacco Nicotine Forum 2021, 2022, 2023 (funded by the conference), Tobacco Science Research Conference 2022 (funded by the conference), Food and Drug Law Institute 2021, 2022, 2023 (funded by FDLI, a non‐profit); all personal payments.
NL has received payment for lectures on systematic review methodology from Oxford University Hospitals NHS Foundation Trust (employment; personal payment). NL has been an applicant and principal investigator on project funding to carry out research in the area of tobacco control from the NIHR Evidence Synthesis programme, Cancer Research UK (charity), Clarion Futures (charity), Oxfordshire County Council and the NIHR Oxfordshire and Thames Valley ARC, and Greater Manchester NHS Integrated Care, all of whom have interests in people stopping smoking; all paid to institutions but NL benefitted. NL has written pieces for The Conversation on the findings of Cochrane reviews assessing the effects of treatments for smoking cessation. These are evidence‐based and not based on personal opinion. NL was involved with the Preloading trial funded by NIHR HTA, and the Rapid Reduction Trial, funded by the British Health Foundation. These RCTs were carried out at the University of Birmingham and the University of Oxford. NL was not involved in assessing eligibility, extracting data, assessing risk of bias or grading the certainty of the evidence for these studies (performed independently by AT, AH, LH, and JHB).
ET, ADW, CS, ARB, AH and JT have no conflicts of interest to declare.
TRF declares a grant from the NIHR Community Healthcare MedTech and In Vitro Diagnostics Co‐operative at Oxford Health NHS Foundation Trust (MIC‐2016‐018) and the NIHR Applied Research Collaboration Oxford and Thames Valley at Oxford Health NHS Foundation Trust. These funds are all paid to the University of Oxford; however, TRF benefits in the form of a salary.
EL is a Clinical Psychology Fellow, University of Kansas Health System. She declares a grant from the National Institutes of Health (K01DA054995), which supports her salary and research studies, paid to the institution.
JHB is a Cochrane Editor. She was not involved in the editorial process for this review. JHB declares that she writes regularly for The Conversation and is interviewed in the media on the topic of e‐cigarettes and smoking. She has been an applicant and principal investigator on project funding to carry out research in the area of tobacco control from the NIHR Evidence Synthesis programme, Cancer Research UK (charity), the National Cancer Institute, and the US Food and Drug Administration; all paid to institutions. She has received consultancy payments from the Truth Initiative, the National Cancer Institute, and the US Food and Drug Administration.
LH works as a General Practitioner in the UK NHS.
NN has received grants from the National Institutes of Health (R01DA046576, R01DA03181, R01DA055999, and R01MD018123). Pfizer provided medication for trials R01DA046575 and R01DA031815 but Pfizer was not involved in the design, execution, analysis or reporting of results. None of these declared grants were included in the Cochrane review. NN was a Co‐Investigator of a study which was eligible for inclusion in this review: Helping African American Light Smokers Quit, supported by the National Cancer Institute at the National Institutes of Health (NIH R01 CA91912). The trial was conducted at University of Kansas Medical Center, USA. NN was not involved in assessing eligibility, extracting data, assessing risk of bias or grading the certainty of the evidence for this study (performed independently by AT, EL, JHB and NL). NN is a member of the scientific advisory board for Qnovia (formerly Respira Technologies), which is developing a nicotine‐based smoking cessation prescription medication working with the FDA. NN declares consultancy fees as part of this role (personal payment).
Update of
- doi: 10.1002/14651858.CD015120
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References to studies excluded from this review
An 2008 {published data only}
Aveyard 2003 {published data only}
Bailey 2010 {published data only}
Bergen 2013 {published data only}
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