ABSTRACT Cigarette smoking is the leading preventable cause of cancer and many other deadly diseases, and the burden of tobacco use is greatest among those with limited socioeconomic resources. Although we have driven down population smoking rates, and with them, cancer rates, roughly 28% of the socioeconomically disadvantaged still smoke regularly. Low-income (L-I) smokers also develop cancer at higher rates and struggle more to quit than do higher-income smokers. These disparities in tobacco use and its burdens must be addressed. Highly effective cessation treatment services that can be delivered remotely, flexibly, and conveniently with few cost or logistical barriers have the potential to achieve this aim. Tobacco quitline and SmokefreeTXT services are such treatment resources with demonstrated attractiveness and reach among L-I smokers. The current proposal will use an efficient factorial design to evaluate 4 smoking cessation interventions with vast reach and dissemination potential. The target population will be N=1,408 Medicaid-eligible or uninsured smokers who have recently enrolled in the Wisconsin Tobacco Quit Line (WTQL), but who report continued smoking 4- months following engagement in standard WTQL services. These treatment non-responders will be invited to participate in an experiment that will randomize them to 1 of 2 levels of each of the following 4 factors in a 2X2X2X2 design: WTQL counseling intensity (1 session vs. 4 sessions), medication intensity (2-week nicotine patch monotherapy vs. 4-week nicotine patch and lozenge combination therapy), a supportive text messaging program (SmokefreeTXT vs. none), and financial incentives (rewards of up to $150 for treatment engagement vs. no treatment incentives). The primary outcome will be 26-week biochemically confirmed point-prevalence abstinence. Analyses will examine the main and interactive effects of these 4 treatment components on 26- week and secondary abstinence outcomes to identify the components and combinations of components that significantly enhance success in quitting in this high-risk population. This experiment will identify especially effective combinations of highly scalable interventions of modest cost and few barriers that could be disseminated nationally to reduce socioeconomic disparities in smoking cessation among those seeking to quit. Additional analyses will: compare intervention components and promising component combinations in terms of cost-effectiveness, examine whether or not treatment engagement differs across component combinations, examine baseline variables that may moderate treatment response, and identify mediators of treatment effects on abstinence outcomes. Because delivery of the study interventions can be centralized through established and efficient services (WTQL and SmokefreeTXT), the potential for both scalable dissemination and cost-effectiveness of the interventions tested is great. The proposed research will help identify ways to reduce tobacco cessation disparities in L-I smokers who have tried to quit smoking but relapsed and may benefit from improved assistance.

NARRATIVE This experiment will identify scalable interventions that can be delivered to low-income smokers, a high-risk group with high smoking and low smoking-cessation rates, by phone or through the mail to help them quit smoking after a recent failed attempt to quit smoking. This research will suggest ways to most efficiently combine convenient interventions to improve success in quitting among low-income smokers who bear a disproportionate burden of tobacco use, relative to higher-income smokers.