Recent analyses by the World Health Organization and the U.S. Centers for Disease Control and Prevention (CDC) suggest an association between smoking and the severity of COVID-19 in hospitalized patients. CDC data also show that African Americans are experiencing a disproportionate number of COVID-19 cases, hospitalizations and deaths compared with other racial and ethnic groups. These findings further raise the visibility of both racial health disparities in the United States and the importance of quitting smoking, two issues that intertwine in a way that compounds the risk of poor health outcomes among African American communities.
Despite similar rates of smoking prevalence, African Americans have higher mortality rates associated with smoking, including lower cancer survival rates, than white Americans (U.S. Department of Health and Human Services, 2020). Moreover, data from a variety of clinical trial, cross-sectional and population-based studies reliably converge to demonstrate that African Americans are less likely to quit smoking than white Americans even though they are equally motivated to quit and may make more quit attempts (Fagan, 2016, in Health Disparities in Respiratory Medicine).
A recent prospective study identified several social determinants of health (SDoH)—conditions in which we are born, grow, live, work and age), including but not limited to lack of homeownership, lower income and increased neighborhood disadvantages—to be significant contributing factors to racial disparity in smoking cessation (Nollen et al., 2019). Additionally, increased subjection to high-risk environmental factors, such as the elevated presence of tobacco-selling retailers and housing that permits smoking, increases smoking initiation and exposure to secondhand smoke, making it more challenging to quit. Also, limited access to quality health care coverage can reduce access to prescription cessation therapies and other evidence-based approaches.
ADDRESSING CULTURAL ISSUES
As with many other societal issues, COVID-19 disparities result from various factors, including discrimination, reduced access to and utilization of health care; occupation; education; income and wealth gaps; crowded housing; and homelessness (Centers for Disease Control and Prevention, 2021). Recent studies indicate that discrimination, wealth, and neighborhood problems are the primary drivers of disparity (Nollten et al., 2019). Particularly with respect to smoking, socioeconomically disadvantaged communities are plagued with a greater degree of tobacco retail outlets, increasing exposure and risk for both initiation and relapse (Kirchner, 2013).
It is important to recognize that racial disparities in smoking cessation occur in the context of more significant cultural issues and reflects the mistrust that many Black Americans have for the medical system. This mistrust is primarily a consequence of the medical community’s historical bias toward addressing white Americans’ health needs, often at the expense of Black Americans’ health and well-being. This bias is reflected in the lack of diversity in clinical trials and the medical system’s failure to address health needs that are more prevalent and cause more deaths in Black communities, such as tobacco-related cancer mortality.
This lack of trust, access, and socioeconomic factors can drive Black smokers to choose less-effective over-the-counter (OTC) smoking cessation therapies rather than prescription options. The former allows them to have direct control over their health care choices and does not require a physician’s office visit. It is therefore essential to develop culturally tailored communications and address unique barriers to smoking cessation therapy (Webb et al., 2017).
Effectively addressing racial cessation disparities requires new approaches that are more effective for the physiologic and psychologic aspects of tobacco addiction and tailored to African American specific challenges. Mobile technology-based approaches may have particular utility in addressing racial disparities. Data from a Pew study suggest that African Americans are more likely to access health information on their phones compared with whites. The National Cancer Institute has a text-based messaging program, SmokefreeTXT, to support smoking cessation, which has demonstrated improved completion rates but lower quit rates for African Americans compared with whites (Robinson et al., 2020).
While many of these are societal issues that must be addressed holistically, novel cessation methods and mobile health (mHealth) apps can empower members of at-risk populations, including African Americans, to overcome barriers to quitting. A potential benefit of mobile health (mHealth) apps designed to support smoking cessation is their ability to integrate context sensing (e.g., GPS) information with patient-provided data about where they smoke. This enables the system to send alerts when an individual approaches a location where he or she is likely to smoke, helping to support smoking cessation. Alerts include reminders to use a nicotine lozenge or gum before arriving at a smoking trigger and sends messages that encourage and motivate them to adhere to smoking cessation goals.
Importantly, mHealth approaches also have the potential to provide mechanisms for standardizing and harmonizing SDoH assessments and providing real-time, actionable recommendations that can enhance SDoH interventions. This could be particularly helpful in reducing demand on overburdened community health centers and health providers while also enabling data collection and integration to inform precision population health care. Automated data integrations that have the capacity to generate actionable recommendations can enhance patient-provider efficiency, trust and clinical experience, collectively increasing the likelihood for treatment engagement and positive health outcomes (Heckman et al, 2015). These complementary data-driven approaches are necessary steps towards health equity–informed precision population health care.
QuitBuddy is the first mHealth app to offer precision population health care by integrating established theories of relapse risk; evidence-based treatment; smartphone/GPS technology, and SDoH. As such, it offers high-impact solutions to address health disparities across a wide range of tobacco-related chronic diseases that disproportionately affect underserved populations. This novel app is undergoing pilot testing and will also be evaluated for its ability to promote smoking abstinence and prevent relapse through the delivery of just-in-time adaptive interventions, as well as to augment SDoH intervention effectiveness for smoking cessation and relapse.
The development of additional prescription smoking cessation therapies may also help address barriers that make it less likely for African Americans to quit smoking. Current prescription smoking cessation therapies, while effective, may cause side effects decreasing treatment engagement, regardless of race. Cytisinicline, a plant-based, naturally occurring alkaloid structurally similar to nicotine, has been shown to aid in smoking cessation. Cytisinicline has been used for decades in Eastern Europe and Asia because of its safety, tolerability, efficacy and cost-effectiveness. It is currently being evaluated in a phase III clinical trial in the United States. If approved, its potential for improved tolerability could provide an important new and more accessible therapy.
In addition to mHealth apps and additional pharmaceutical smoking cessation therapies, developing culturally tailored modes of cognitive behavioral therapy that address barriers to cessation common in the African American community is also critical to improving quit rates for this population (Webb et al., 2017).
EVIDENCE-BASED OPTIONS ARE CRITICAL FOR SUCCESS
Evidence-based options, whether technological, pharmacologic or psychological, lead to increased quit rates. The importance of new approaches is especially critical for people who have been unable to quit with existing pharmacologic therapy, as studies show that cessation rates are higher when these individuals switch to a new therapy rather than trying again with a therapy that didn’t result in long-term abstinence (Heckman et al., 2017). Ensuring African Americans have effective, evidence-based smoking cessation options requires that they and their needs play a central role in the studies used to generate the base of evidence. Recognizing and addressing the distinct needs and challenges of African Americans seeking to quit smoking is essential for improving their quit rates—which is a key component in reducing racial disparities in various health outcomes and optimizing health equity.
This is an opinion and analysis article; the views expressed by the author or authors are not necessarily those of Scientific American.
ABOUT THE AUTHOR(S)Bryan W. Heckman, Ph.D., is an associate professor and the founding director of the Center for the Study of Social Determinants of Health at Meharry Medical College.
Anne Davis is director of communications at the Center for the Study of Social Determinants of Health at Meharry Medical College.
James E.K. Hildreth, Ph.D., M.D., is the president and chief executive officer of Meharry Medical College.