Efficacy of a Gender-Relevant Smoking Cessation Intervention Among Women in Brazil: Findings from a Group Randomized Controlled Trial
Publication: Journal of Women's Health
Volume 31, Issue Number 11
Abstract
Background: There is scarcity of smoking cessation programs that take gender into account during its development, implementation, and evaluation. We evaluated the efficacy of a theory-based, culturally, and gender-relevant smoking cessation intervention delivered by Community Health Workers (CHWs) among Brazilian women that augments the smoking cessation program offered through the public health system (PHS).
Materials and Methods: A total of 328 women current smokers (100% cigarette smokers) were recruited across 8 towns in a tobacco producing state in Brazil between 2014 and 2017. Four towns were randomly assigned to the intervention (12 home visits by a CHW and a scheduled appointment to attend the smoking cessation program at the PHS) and four towns to the control condition (scheduled appointment to attend the cessation program at the PHS). The primary outcome was self-reported 7-day smoked tobacco abstinence at 7-month follow-up with biochemical verification.
Results: Retention at 7-month follow-up was 80.7% (intervention) and 85.1% (control). Using intention-to-treat analysis, abstinence at 7-month-follow-up was 20% in the intervention arm versus 11% in the control arm. Multivariable modeling showed that participants in the intervention arm had 1.88 times the odds of self-reported smoking cessation than control participants after adjustment for depressive symptomatology, self-efficacy, and having someone in the house who smokes. Besides the intervention, only self-efficacy remained significant in the full model as a predictor of cessation. Replication of these analyses using the objective measure of carbon monoxide at a cutoff score of 8 ppm yielded similar results.
Conclusions: A theory-based, culturally, and gender-relevant intervention, delivered by CHWs, can successfully promote smoking cessation among women.
Clinical Trial Registration No. NCT03845413.
Get full access to this article
View all available purchase options and get full access to this article.
References
1. GBD 2015 Tobacco Collaborators. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: A systematic analysis from the Global Burden of Disease Study 2015. Lancet 2017;389:1885–1906.
2. American Cancer Society. The Tobacco Atlas—Brazil, 2020. Available at: https://tobaccoatlas.org/country/brazil/ Accessed May 28, 2020.
3. Scarinci IC, Bittencourt L, Person S, et al. [Prevalence of tobacco use and associated factors among women in Parana State, Brazil]. Cad Saude Publica 2012;28:1450–1458.
4. Malta DC, Oliveira MR, Moura EC, et al. [Prevalence of risk health behavior among members of private health insurance plans: Results from the 2008 national telephone survey Vigitel, Brazil]. Cien Saude Colet 2011;16:2011–2022.
5. Bardach A, Perdomo HA, Gándara RA, et al. [Income and smoking prevalence in Latin America: A systematic review and meta-analysis]. Rev Panam Salud Publica 2016;40:263–271.
6. Amos A, Greaves L, Nichter M, et al. Women and tobacco: A call for including gender in tobacco control research, policy and practice. Tob Control 2012;21:236–243.
7. Bottorff JL, Haines-Saah R, Kelly MT, et al. Gender, smoking and tobacco reduction and cessation: A scoping review. Int J Equity Health 2014;13:114.
8. Higgins ST, Kurti AN, Redner R, et al. A literature review on prevalence of gender differences and intersections with other vulnerabilities to tobacco use in the United States, 2004–2014. Prev Med 2015;80:89–100.
9. Piper ME, Cook JW, Schlam TR, et al. Gender, race, and education differences in abstinence rates among participants in two randomized smoking cessation trials. Nicotine Tob Res 2010;12:647–657.
10. Pederson A, Greaves L, Poole N. Gender-transformative health promotion for women: A framework for action. Health Promot Int 2015;30:140–150.
11. World Health Organization. WHO framework convention on tobacco control, 2020. Available at: https://www.who.int/fctc/en/ Accessed January 14, 2020.
12. Perkins KA, Scott J. Sex differences in long-term smoking cessation rates due to nicotine patch. Nicotine Tob Res 2008;10:1245–1250.
13. Smith PH, Bessette AJ, Weinberger AH, et al. Sex/gender differences in smoking cessation: A review. Prev Med 2016;92:135–140.
14. Berlin I, Singleton EG, Pedarriosse AM, et al., The Modified Reasons for Smoking Scale: Factorial structure, gender effects and relationship with nicotine dependence and smoking cessation in French smokers. Addiction 2003;98:1575–1583.
15. Aguirre CG, Bello MS, Andrabi N, et al. Gender, ethnicity, and their intersectionality in the prediction of smoking outcome expectancies in regular cigarette smokers. Behav Modif 2016;40:281–302.
16. Pang RD, Zvolensky MJ, Schmidt NB, et al. Gender differences in negative reinforcement smoking expectancies. Nicotine Tob Res 2015;17:750–754.
17. Baker TB, Fraser DL, Kobinsky K, et al. A randomized controlled trial of financial incentives to low income pregnant women to engage in smoking cessation treatment: Effects on post-birth abstinence. J Consult Clin Psychol 2018;86:464–473.
18. duPont NC, Mahoney MC, Kahn LS, et al. Developing a smoking cessation intervention for low income and minority women. J Womens Health Care 2016;5:309.
19. Coleman-Cowger VH, Mark KS, Rosenberry ZR, et al. A pilot randomized controlled trial of a phone-based intervention for smoking cessation and relapse prevention in the postpartum period. J Addict Med 2018;12:193–200.
20. Bradizza CM, Stasiewicz PR, Zhuo Y. et al. Smoking cessation for pregnant smokers: Development and pilot test of an emotion regulation treatment supplement to standard smoking cessation for negative affect smokers. Nicotine Tob Res 2017;19:578–584.
21. Bloom EL, Wing RR, Kahler CW, et al. Distress tolerance treatment for weight concern in smoking cessation among women: The WE QUIT Pilot Study. Behav Modif 2017;41:468–498.
22. Gordon JS, Armin J, Hingle MD, et al. Development and evaluation of the See Me Smoke-Free multi-behavioral mHealth app for women smokers. Transl Behav Med 2017;7:172–184.
23. Giacobbi P Jr, Hingle M, Johnson T, et al. See Me Smoke-Free: Protocol for a research study to develop and test the feasibility of an mHealth app for women to address smoking, diet, and physical activity. JMIR Res Protoc 2016; 5:e12.
24. Mishra GA, Kulkarni SV, Majmudar PV, et al. Community-based tobacco cessation program among women in Mumbai, India. Indian J Cancer 2014;51 Suppl 1:S54–S59.
25. Wewers ME, Ferketich AK, Harness J, et al. Effectiveness of a nurse-managed, lay-led tobacco cessation intervention among ohio appalachian women. Cancer Epidemiol Biomarkers Prev 2009;18:3451–3458.
26. Ministério da Saúde. Portaria #442/SAS/MS, 2004. Available at: ftp://ftp.cve.saude.sp.gov.br/doc_tec/cronicas/portsas442_ago04.pdf Accessed July 17, 2018.
27. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med 2008;35:158–176.
28. Bittencourt L, Scarinci IC. Is there a role for community health workers in tobacco cessation programs? Perceptions of administrators and health care professionals. Nicotine Tob Res 2014;16:626–631.
29. Noticias Agrícolas. Região Sul é responsável por 98% da produção de tabaco no Brasil, 2018. Available at: https://www.noticiasagricolas.com.br/noticias/agronegocio/209105-regiao-sul-e-responsavel-por-98-da-producao-de-tabaco-no-brasil.html#.XFXZ8PZFzIU Accessed February 2, 2019.
30. Gomis B, Lee K, Botero NC, et al. “We think globally”: The rise of Paraguay's Tabacalera del Este as a threat to global tobacco control. Global Health 2018;14:110.
31. Glanz KRB, Lewis FM. Health behavior and health education: Theory, research, and practice. San Francisco, CA: Wiley & Sons, 2002.
32. Kienen ND, Wiltenburg TSDF, Bittencourt L, et al. Development of a gender-relevant tobacco cessation intervention for women in Brazil-an intervention mapping approach to planning. Health Educ Res 2019;34:505–520.
33. Bittencourt L, Cruz RC, Scarinci IC. Tobacco cessation program selection and training in the Unified Health System: Manager and health care professional perspectives in the state of Paraná, Brazil. Epidemiologia e Serviços de Saúde 2014;23:645–654.
34. Scarinci I, Bittencourt L. Diagnosis of the tobacco cessation program delivered through the public health system in Paraná. In: Guimarães A, Sapienza G, Dallo L, Cruz RC, eds. Tobacco control: Research, reflexions, and rexperiences. Curitiba, Paraná, Brazil: CRV, 2017: 73–84.
35. Kienen N, Bittencourt L, Pelloso SM, et al. Cervical cancer screening among underscreened and unscreened Brazilian women: Training community health workers to be agents of change. Prog Community Health Partnersh 2018;12:111–119.
36. Bittencourt L, Scarinci IC. Training Community Health Workers to promote breast cancer screening in Brazil. Health Promot Int 2019;34:1439–1449.
37. Kienen N, Bittencourt L, Wiltenburg TD, et al. Behavior change and tobacco cessation among women: An experience in the capacity building of Community Health Workers. Interação em Psicologia (Portuguese) 2019;23:404–415.
38. Heatherton TF, Kozlowski LT, Frecker RC, et al. The Fagerstrom test for nicotine dependence: A revision of the Fagerstrom Tolerance Questionnaire. Br J Addict 1991;86:1119–1127.
39. Velicer WF, Diclemente CC, Rossi JS, et al. Relapse situations and self-efficacy: An integrative model. Addict Behav 1990;15:271–283.
40. Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385–401.
41. Carmo J, Pueyo AA. Adaptation into Portuguese for the Fagerstrom test for nicotine dependence (FTND) to evaluate the dependence and tolerance for nicotine in Brazilian smokers. Rev Bras Med 2002;59:73–80.
42. Batistoni SS, Neri AL, Cupertino AP. [Validity of the Center for Epidemiological Studies Depression Scale among Brazilian elderly]. Rev Saude Publica 2007;41:598–605.
43. COVITA. Smokelyzer, 2018. Available at: https://www.covita.net/smokerlyzer.html Accessed July 16, 2018.
44. Ismail AA, Gill GV, Lawton K, et al. Comparison of questionnaire, breath carbon monoxide and urine cotinine in assessing the smoking habits of Type 2 diabetic patients. Diabet Med 2000;17:119–123.
45. SRNT Subcommittee on Biochemical Verification. Biochemical verification of tobacco use and cessation. Nicotine Tob Res 2002;4:149–159.
46. Bellg AJ, Borrellil B, Resnick B, et al. Enhancing treatment fidelity in health behavior change studies: Best practices and recommendations from the NIH Behavior Change Consortium. Health Psychol 2004;23:443–451.
47. Stead LF, Carroll AJ, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database Syst Rev 2017;3:CD001007.
48. Webb MS, deYbarra DR, Baker EA, et al. Cognitive-behavioral therapy to promote smoking cessation among African American smokers: A randomized clinical trial. J Consult Clin Psychol 2010;78:24–33.
49. Tabachnick BG, Fidell LS. Using multivariate statistics, 7th ed. New York: Pearson, 2019.
50. Kauermann G, Carroll RJ. A note on the efficiency of sandwich covariance matrix estimation. J Am Stat Assoc 2001;96:1387–1396.
51. Dharmaratne ADVTT, Sooriyarachchi MR. Methods for analyzing binary repeated measures: The small sample case. Am J Appl Math Stat 2017;5:80–89.
52. Wewers ME, Shoben A, Conroy S, et al. Effectiveness of two community health worker models of tobacco dependence treatment among community residents of Ohio Appalachia. Nicotine Tob Res 2017;19:1499–1507.
53. Scarinci IC, Garcés-Palacio IC, Morales-Alemán MM, et al. Sowing the seeds of health: Training of community health advisors to promote breast and cervical cancer screening among Latina Immigrants in Alabama. J Health Care Poor Underserved 2016;27:1779–1793.
54. Harris-Luna ML, Badr LK. Pragmatic Trial to evaluate the effect of a Promotora Telephone Intervention on the duration of breastfeeding. J Obstet Gynecol Neonatal Nurs 2018;47:738–748.
55. Jeet G, Thakur JS, Prinja S, Singh M. Community health workers for non-communicable diseases prevention and control in developing countries: Evidence and implications. PLoS One 2017;12:e0180640.
56. Louwagie GM, Okuyemi KS, Ayo-Yusuf OA. Efficacy of brief motivational interviewing on smoking cessation at tuberculosis clinics in Tshwane, South Africa: A randomized controlled trial. Addiction 2014;109:1942–1952.
57. Brooks DR, Burtner JL, Borrelli B, et al., Twelve-month outcomes of a group-randomized community health advocate-led smoking cessation intervention in public housing. Nicotine Tob Res 2018;20:1434–1441.
58. Jiang N, Siman N, Cleland CM, et al. Effectiveness of village health worker delivered smoking cessation counseling in Viet Nam. Nicotine Tob Res 2019;21:1524–1530.
59. Manfredi C, Cho YI, Crittenden KS, et al. A path model of smoking cessation in women smokers of low socio-economic status. Health Educ Res 2007;22:747–756.
60. Patrick DL, Cheadle A, Thompson DC, et al. The validity of self-reported smoking: A review and meta-analysis. Am J Public Health 1994;84:1086–1093.
Information & Authors
Information
Published In
Journal of Women's Health
Volume 31 • Issue Number 11 • November 2022
Pages: 1620 - 1629
PubMed: 35580140
Copyright
Copyright 2022, Mary Ann Liebert, Inc., publishers.
History
Published online: 9 November 2022
Published in print: November 2022
Published ahead of print: 17 May 2022
Topics
Authors
Authors' Contributions
I.C.S.—Conceptualization of the study, overall supervision for the study, primary writing of the article.
N.K.—Conceptualization of the study, overall supervision of CHWs, and assistance with overall writing of the article.
T.D.W.—Treatment fidelity, and assistance with overall writing of the article.
L.B.—Data management and assistance with overall writing of the article.
S.D.P.—Statistical analysis, and primary writing of the statistical analysis section and results.
All authors conceptualized the article, contributed to and have approved the final version of the article.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
Funding for this study was provided by the Fogarty International Center (FIC)/National Cancer Institute (NCI), Grant No. R01TW09272. FIC/NCI had no role in the study design, collection, analysis, or interpretation of the data, writing the article, or the decision to submit the article for publication.
Metrics & Citations
Metrics
Citations
Export Citation
Export citation
Select the format you want to export the citations of this publication.
View Options
Get Access
Access content
To read the fulltext, please use one of the options below to sign in or purchase access.⚠ Society Access
If you are a member of a society that has access to this content please log in via your society website and then return to this publication.