1. A Randomised Controlled Trial of Nicotine Replacement Therapy for Low-Income Smokers Valerie Sedivy, Caroline Miller and Jacqueline Hickling

2. RCT of subsidised NRT for low-income smokers Overview  Background and aims  Study design  NRT redemption  Quitting outcomes  Cost analysis  Conclusions and implications

3. RCT of subsidised NRT for low-income smokers Background  Smoking restrictions in workplaces and hospitality venues  Desire to support smokers to quit (especially disadvantaged groups)  Request for trial from Minister for Health

4. RCT of subsidised NRT for low-income smokers Aims  The study was designed to assess: –Demand for subsidised NRT in SA –Quit rates achieved by adding subsidised NRT to the Quitline –Cost per quitter

5. RCT of subsidised NRT for low-income smokers Study design Intervention invitations n=150,000 Approach Control invitations n=150,000 n=1000n=377 Recruited Follow-up n=863/832/672n=329/305/257 Intervention Subsidised NRT + Quitline counselling Quitline counselling only

6. RCT of subsidised NRT for low-income smokers Smoking behaviour at baseline Intervention (n=1000) Control (n=377) Years smoked 30.8 31.7 No. of cigarettes smoked/day*24.923.5 Smoke within 30 minutes*87%83% Quit attempt in past year*50%56% * statistically significant at p≤0.05

7. RCT of subsidised NRT for low-income smokers Use of NRT at 3 months InterventionControl Among all participants*58%22% Among those who quit or attempted to quit* 89%43% * statistically significant at p≤0.05

8. RCT of subsidised NRT for low-income smokers Voucher redemption at 3 months (intervention)  98.5% received vouchers  80.9% redeemed one or more vouchers  Used an average of 5 vouchers  37% of all vouchers redeemed

9. RCT of subsidised NRT for low-income smokers Reasons for not using vouchers (intervention)  No vouchers (n=162): –31% never attempted to quit –25% decided to quit without NRT –19% trouble with redemption  Fewer than 10 vouchers (n=571): –30% relapsed –23% still using –18% quit before using them all

10. RCT of subsidised NRT for low-income smokers Participation in callback program at 3 months InterventionControl Received 1+ callbacks96%95% Mean number of calls*6.65.8 * statistically significant at p≤0.05

11. RCT of subsidised NRT for low-income smokers Perceptions of the Quitline at 3 months Intervention (n=863) Control (n=329) Very helpful*63%56% Very friendly 95% 96% Not at all intrusive 73% 71% * statistically significant at p≤0.05

12. RCT of subsidised NRT for low-income smokers Quit attempts and cessation at 3, 6 and 12 months # Analyzed by intention to treat * statistically significant difference Figure 3 : Quit attempts and quit rates #

13. RCT of subsidised NRT for low-income smokers Cost analysis at 12 months  Costs included  Cost per quitter / per client  Relative contribution of NRT / counselling to costs

14. RCT of subsidised NRT for low-income smokers Costs included in analysis  Staff time  Telephone  NRT and voucher booklets  Resources sent  Excluded trial-related infrastructure and recruitment

15. RCT of subsidised NRT for low-income smokers Cost per quitter / per client at 12 months Intervention (n=1000) Control (n=377) Additional cost (Intervention over control) Cost per quitter $622$185 $436 Cost per client $139$35 $104

16. RCT of subsidised NRT for low-income smokers Cost of service versus NRT at 12 months

17. RCT of subsidised NRT for low-income smokers Overall conclusions  Offer of NRT increased demand for the Quitline  Encouraged 2-3 times as many smokers to call  63% first time callers  Reached higher-risk group: NRT callers more dependent on smoking

18. RCT of subsidised NRT for low-income smokers Overall conclusions  Statistically significant effects of subsidising NRT for low-income smokers are limited to short term  But overall quit rates higher among NRT group than among general Quitline callers

19. RCT of subsidised NRT for low-income smokers Implications Long-term quitting outcomes not improved statistically significantly by NRT subsidy Offer increased demand among disadvantaged group Cost should be weighed against benefits of reaching this group – currently being reviewed