Innovative partnership helps low-income tobacco users quit

A partnership between Kick It California, a tobacco cessation line operated by the University of California San Diego, and local resource and referral agencies resulted in more than 55,000 new referrals for smoking cessation services between 2021 and 2023, UC San Diego researchers report Herbert Wertheim School for Public Health and Human Longevity Sciences and UC San Diego Moores Cancer Center.

The results, published in Nicotine and tobacco researchdemonstrate how quitlines and 211 agencies can work together effectively to address socioeconomic disparities in tobacco use.

“We already knew that 211 agencies primarily serve people in economic hardship, and we also knew that tobacco use is most concentrated among low-income populations,” said Shu-Hong Zhu, Ph.D., professor at the Herbert Wertheim School of Public Health and senior author of the study. “We thought that with a little push and a modest incentive, many clients who use tobacco would accept a referral to the quitline to access the services they need to quit.”

According to a 2024 report According to the US Surgeon General, smoking is more than twice as common among men and women living in poverty than among people who do not live in poverty. Quitlines are an essential public health tool to reduce the threat of tobacco-related disease and death, and they provide telephone counseling to help people quit smoking, vaping or other tobacco use. Although quitline services are free, they are often underutilized.

211 services, on the other hand, have a much greater reach. In 2022 alone, Californians accessed 211 services more than 2.1 million times to connect to vital health and human services. By working with thirteen 211 agencies across the state, the research team was able to identify 211 clients who use tobacco and refer them to Kick It California. The 211 agencies also offered callers a $20 reward for completing a counseling session.

The main findings of the study were:

• Between April 2021 and December 2023, 55,151 individuals were referred to Kick it California through this incentive program.
• 211 referred participants were more than twice as likely to enroll in quitline services compared to those referred from a health care clinic. They were also more likely to complete an initial counseling session.
• On average, 211 referred participants completed the same number of sessions as clinic-referred and self-referred participants, with no further incentives beyond the initial $20.
• All three groups had similar success rates when it came to actually quitting.

“This showed us that 211 participants weren’t just in it for the money,” Zhu said. “Once they started the counseling and quitting process, they were just as active as the other participants and just as many were successful at quitting.”

In addition to low-income tobacco users, the program was also able to reach other populations disproportionately affected by tobacco use. Comparing 211 participants with those referred from health care clinics and those who called themselves, researchers found that 211 participants were more likely to be female, LGBTQ, Black or multiracial, younger, less educated, and insured by Medicaid. They were also more likely to have mental illness, use cigarettes with other forms of tobacco, and use tobacco and cannabis together.

“Working with 211 not only enabled the Quitline to reach large numbers of tobacco users,” Zhu said. “It has also helped us reach many groups disproportionately affected by tobacco. For example, 7 in 10 of those referred to the quitline had a mental health condition, such as depression or anxiety, which can make it much more difficult for people to stop.”

The findings show how quitlines and 211 agencies can work together effectively to help low-income tobacco users quit. The researchers estimate that if 211 agencies in the United States referred their tobacco-using clients at the same rate as the agencies in this study, approximately 64,000 additional individuals would receive smoking cessation treatment each year.

“211 agencies exist to help people access social services, so it should come as no surprise that they can help people access evidence-based smoking cessation services,” Zhu said. “In the long term, this could be an incredibly powerful strategy to reduce the burden of tobacco use in the United States.”

Other authors of the study include Emily Aughinbaugh, Andrea Pratt, Yue-Lin Zhuang, Ding Wang, Antonio Mayoral and Christopher Anderson of the UC San Diego Moores Cancer Center, and Tonia Hagaman of the California Tobacco Prevention Program of the California Department of Public Health.