Using Text Messaging for Tobacco Cessation in Rural Populations

December 15, 2023|Jason Jean

Thank you to Jason R. Jean, DNP, APRN, RN for this resource-full article on tobacco cessation and text messaging programs.

Tobacco cessation is one of the critical strategies to reduce the risk for cardiovascular and other diseases, yet it is one of the most challenging behaviors for individuals to change. Using text messaging to reduce nicotine use in rural populations—and other groups—has been shown to improve success rates in individuals who are seeking to cease the use of tobacco products.

The Associated Problem of Nicotine Use

Cigarette smoking remains the leading cause of preventable disease, disability, and death in the United States, and work still needs to be done to reduce the utilization of both combustible and non-combustible forms of nicotine intake. An estimated 50.6 million American adults (21% of the American population) use tobacco products.1

Nicotine use is directly associated with cardiovascular disease, cancer, and teratogenesis, impacting fetal development. Unfortunately, the use of tobacco products remains high in vulnerable populations such as those receiving Medicaid insurance benefits, mental health services, and individuals from ethnic and racial minorities. An additional risk factor that is common among tobacco users is linked to where a person geographically lives – primarily, a rural community.

The Rural Population Impact & Significance of Nicotine Use

Americans who live in rural areas are the most prevalent tobacco users (28.5%) when compared to urban dwellers (25.1%).1,2 The United States Census Bureau defines rural communities as those that “encompass all [of the] population, housing, and territory not included within an urban area.”3 In comparison, an urban area is defined as having at least 2,000 housing units or a population of at least 5,000.3 The socioeconomic status of rural areas is generally lower than in urban areas,4 and the life expectancy is lower when comparing rural and urban communities.5

For those living in rural areas, resources to address the prevention of cardiovascular disease (CVD) can be a challenge since rural health infrastructures are commonly underdeveloped and not as readily accessible as those in urban areas. For example, 2,000 U.S. counties are classified as rural; more than 170 counties lack an in-county critical access hospital, Federally Qualified Health Center, or rural health clinic.6 Some rural residents are required to travel hundreds of miles to receive healthcare. Notably, there are a limited number of healthcare providers to staff these facilities since the clinician labor force is not evenly distributed by specialty or geography in America.7

Advances in technology have bridged the gap in under-resourced communities, and the list of interventions continues to grow. According to a recent Cochrane review, there is moderate-certainly evidence that automated text message-based smoking cessation interventions improve cessation rates by 50-60% for six months or longer,8 which can help reduce nicotine’s direct effect on acquiring CVD9 and improving patient outcomes.

cigarette smoking

The Detrimental Effects of Nicotine Upon Human Physiology

The two-hour half-life of nicotine, a stimulant, causes a natural rise in heart rate and blood pressure, along with a strong inotropic-contractility response. Over time, devastating physiological events occur, such as myocardial infarction, cerebrovascular accidents, and the potential development of peripheral limb ischemia.10

According to Gallucci et al.,11, the physiological mechanisms of exogenous nicotine stimulant exposure should, theoretically, be managed by the human body. The effects of stimulants are often countered through the release of nitric oxide, a vasodilator that reduces blood pressure at the endothelial alpha receptor sites of the vasculature. However, when nicotine is absorbed buccally or through the pulmonary bronchus (both vascular-rich tissues), nitric oxide is suppressed. Suppressing nitric oxide creates a thriving environment that can cause harm across the cardiovascular system.

Additionally, Galucci & colleagues11 state that vascular resistance is potentiated by nicotine exposure in individuals who use and are exposed secondarily to nicotine (i.e., “second-hand smoking” or “side-stream smoking”). Physiologically, nicotine exposure elevates blood pressure, a phenomenon known as vascular resistance. The vascular-resistant environment can cause disease, such as heart attack, stroke, or claudication.

Furthermore, nicotine exposure creates an inflammatory ecosystem, which leads to the upregulation of cellular inflammatory expression through sudden rises in c-reactive protein and cytokines. The pro-inflammatory environment activates prothrombin, which is directly linked to intravascular fibrin clot development, and thus may facilitate a life-threatening situation–akin to what many of us may have experienced clinically or personally, to be the dreaded ST-elevation myocardial infarction. 11

Implications & Interventions for Cardiovascular Nurses

Did you know frequent and brief nursing interactions can motivate patients to quit smoking?12,13 Yet, screening for nicotine and tobacco use remains low in hospitals, where only 1 in 4 patients are screened.12 In contrast, ambulatory clinics demonstrated better screening rates but lack the prevention-centered cessation techniques to improve quit rates.14

Consistency is the key to motivating patients to quit. Therefore, tobacco assessment should be as critical as routine capture of vital signs during clinic and hospital encounters.

The first step toward improving nicotine cessation is to screen for use. To improve screening rates, the Agency for Healthcare Quality and Research (AHRQ) developed the 5A framework, a simple screening tool to determine someone’s readiness to quit nicotine.15 Utilization of these five steps improved cessation attempts from 19% to 70%.16

The five steps include:

  • Ask the patient to document their nicotine use (smokeless, non-combustible (e-cigarette), and combustible forms) at every visit.
  • Advise the patient in a personalized tone to quit using nicotine products at every visit.
  • Assess if the patient is willing to quit using nicotine products.
  • Assist the patient in obtaining successful interventions like the automated text message program, which ideally should be done during or shortly after provider and patient interactions.
  • Arrange a scheduled personalized follow-up by telephone or in person, preferably in one, two, and four weeks. 15

Efficacy of Text Messaging in Tobacco Cessation

Whittaker and colleagues8 synthesized 26 studies that reviewed mobile-based cessation support through text messaging applications. They found that this intervention is simple and affordable and provides a unique opportunity for those living in rural communities.

The benefits of text messaging included:

  • Ease of use for the participant
  • Cost-effectiveness
  • Personalization of messaging
  • Automation of messages to the consumer
  • Capability to distribute messaging to those who live in underserved and/or rural areas

Boland et al.17 determined that mobile-based text interventions were preferred in lower socio-economic communities and designed in ways that meet patient needs.

Resources for Tobacco Cessation Text Messaging

The TruthInitiative.org18 is a non-profit organization that has partnered with Kaiser Permanente and the American Heart Association. Two free text messaging programs are designed for specific age groups, and more than 500,000 people have successfully ceased their nicotine use. Both programs can be used for both combustible and non-combustible forms of tobacco. Between 12 and 15 text messages a week are sent to those who sign up, and each has interactive tools to ensure success.

Another resource, the Every Try Counts campaign, was developed by the Food and Drug Administration and has reached over 45 million adult smokers.19 Interestingly, the campaign has specific programs designed to reach diverse populations, such as Spanish and LGBQT groups. A smartphone application can be downloaded from the Google and Apple application stores, which can assist the user in tracking their craving times, coping with stress, and monitoring progress. This program actively promotes nicotine replacement therapy, which has been documented to reduce the use of nicotine in vulnerable populations, i.e., rural dwellers, by 24%.20

Clinical Takeaways

  • The pathological effects of nicotine are devastating to the cardiovascular system.
  • Rural-dwelling persons use tobacco products more often and experience disparate rates of tobacco-associated chronic conditions.
  • Nurses can help address the public health crisis of tobacco use. As the most trusted profession, the largest healthcare group globally, and the individuals within healthcare who are most engaged in patient support, nurses can identify tobacco cessation resources to share with patients.
  • Text message-based tobacco cessation interventions can help rural-dwelling persons access preventive healthcare more readily.
  • A triad approach to tobacco assessment should be encouraged:
    • Use the 5A’s framework
    • Assist the patient in enrolling in tobacco cessation behavior modification text messaging applications.
    • Recommend the use of nicotine replacement and cessation-approved medications.

References

  1. Cornelius ME, Wang TW, Jamal A, Loretan C, Neff L. Tobacco product use among adults – United States, 2019. Morbidity & Mortality Weekly Report. 2020;69(46):1736-1742. doi:10.15585/mmwr.mm6946a4
  2. Substance Abuse and Mental Health Services Administration (SAMHSA): Center for Behavioral Health Statistics and Quality. 2016 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD. 2017. Accessed May 26, 2022.
  3. United States Census Bureau [USCB]. 2020 census urban and rural classification. Federal Register, document 87 FR 16706, docket number 220228-0062, document number 2022-06180, p. 16706 – 16715. 2020, March 24. Accessed June 9, 2023.
  4. Bishaw A, Posey, K. Comparison of rural and urban America: Household income and poverty. Census Blogs. 2016. Accessed June 8, 2023.
  5. Rural Health Information Hub. (2022). Rural data explorer: Life expectancy 2010 – 2014. 2022. Accessed June 8, 2023.
  6. Kaufman BG, Thomas SR, et al. The rising rate of rural hospital closures. Journal of Rural Health. 2016;32(1):35-43.
  7. Health Resources & Services Administration [HRSA]. Council on graduate medical education: Rural health policy brief 1, special needs in rural America: implications for healthcare workforce education, training, and practice. 2020, July. Accessed June 9, 2023.
  8. Whittaker R, McRobbie H, Bullen C, et al. Mobile phone text messaging and app-based interventions for smoking cessation. Cochrane Database of Systematic Reviews. 2019;11(10). doi: 10.1002/14651858.CD006611.pub5
  9. Roth G, Forouzanfar M, Moran A, et al. Demographic and epidemiologic drivers of global cardiovascular mortality. The New England Journal of Medicine. 2015;372(14):1333–1341.
  10. Barua RS, Ambrose JA. Mechanisms of coronary thrombosis in cigarette smoke exposure. Arteriosclerosis, thrombosis, and vascular biology. 2013:33(7):1460–1467. https://doi.org/10.1161/ATVBAHA.112.300154
  11. Gallucci G, Tartarone A, Lerose R, Lalinga A, Capobianco A. Cardiovascular risk of smoking and benefits of smoking cessation. Journal of Thoracic Disease. 2020;12(7):3866- 3876. doi: 10.21037/jtd.2020.02.47
  12. Jamal A, Dube SR, King BA. Tobacco use screening and counseling during hospital outpatient visits among US adults, 2005-2010. Preventing chronic disease. 2015;12.
  13. Price S, Studts J, Hamann H. Tobacco use assessment and treatment in cancer patients: A scoping review of oncology care clinician adherence to clinical practice guidelines in the U.S. The Oncologist. 2019;24(2):229-238. https://doi.org/10.1634/theoncologist.2018-0246
  14. Rice VH, Heath L, Livingstone-Bank, J, Hartmann-Boyce J. Nursing interventions for smoking cessation. The Cochrane Database of Systematic Reviews. (2017):12(12). CD001188.
  15. Agency for Healthcare Quality and Research [AHRQ]. Five major steps to intervention (The “5 A’s”). Agency for Healthcare Research and Quality, Rockville, MD. 2012, December. Accessed June 8, 2023.
  16. Moody-Thomas S, Celestin M, Tseng T, Horswell R. Patient tobacco use, quit attempts, and perceptions of healthcare provider practices in a safety-net healthcare system. The Ochsner Journal. 2013;13(3):367–374.
  17. Boland V, Mattick R, McRobbi, H, Siahpush M, Courtney R. I‘m not strong enough; I’m not good enough. I can’t do this, I’m failing- A qualitative study of low-socioeconomic status smokers’ experiences with accessing cessation support and the role for alternative technology-based support. International Journal for Equity in Health. 2017;16(1), 196.
  18. The Truth Initiative. 2021, May. Accessed June 9, 2023.
  19. Every Try Counts. 2018, May. Accessed June 9, 2023.
  20. Dahne J, Wahlquist A, Smith T, Carpenter M. The differential impact of nicotine replacement therapy sampling on cessation outcomes across established tobacco disparities groups. Preventive Medicine. 2020:136:106096.

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