Impact of Opt-Out Versus Opt-In Recruitment on Engagement of FDNY WTC-Exposed Responders in a Tobacco Cessation Intervention.

Abstract

Background: World Trade Center (WTC)-exposed Fire Department of the City of New York (FDNY) rescue/recovery workers have an elevated risk of smoking-related morbidity. Despite access to free tobacco cessation treatment, some individuals in this population continue to smoke. In other settings, opt-out treatment approaches increase treatment initiation, but effectiveness in occupational health programs is unclear. Accordingly, we (1) assessed whether an opt-out strategy increases engagement with a Tobacco Cessation Program and (2) identified factors associated with engagement.

Methods: This was a randomized trial among FDNY firefighters and Emergency Medical Service (EMS) who self-reported smoking and were eligible for the WTC Health Program Lung Cancer Screening Program. 1:1 randomization occurred prior to contact for opt-out recruitment with Enhanced Care treatment (Opt-Out/Enhanced) or opt-in recruitment with Standard Care treatment (Opt-In/Standard). Opt-Out/Enhanced included proactive outreach and tailored biofeedback during counseling; Opt-In/Standard included participant-initiated engagement and standard counseling. Both groups were offered identical no-cost pharmacotherapy (varenicline). Engagement was defined as: consented enrollment (expressed interest and provided informed consent) and treatment initiation (attendance at ≥1 counseling session). Engagement differences were evaluated using logistic regression; sociodemographic and health-related factors were characterized descriptively without formal testing due to small numbers.

Results: Overall, 312 individuals were randomized (Opt-Out/Enhanced, n = 156 and Opt-In/Standard, n = 156). Engagement was low (7.4%). Consented enrollment (n = 23; OR = 3.05; 95% CI = 1.11-9.72) and treatment initiation (n = 18; OR = 2.08; 95% CI = 0.72-6.73) were higher in Opt-Out/Enhanced versus Opt-In/Standard. Treatment initiators had a median age of 60.5 (vs 65.0 years among non-initiators); 38.9% were EMS (vs 18.0%), 22.2% were female (vs 6.9%), 77.8% had a prior cessation attempt (vs 23.5%), and 55.6% had abnormal lung function (vs 32.9%). Participants were too few to analyze cessation outcomes in depth.

Conclusions: Despite low engagement overall, opt-out treatment had higher engagement with tobacco cessation treatment. This supports other work that has found opt-out treatment to be encouraged for hard-to-reach populations.