Trash the ash

"Project SCUM." That was the name of R.J. Reynolds's plan to market cigarettes to gays and homeless people in San Francisco, according to documents released as part of a 1998 legal settlement. The "Subculture Urban Marketing" plan was to lure young men to Red Kamel cigarettes with logo-emblazoned beach towels and flashy product displays in the Castro district's head shops. To reach homeless people in the Tenderloin district, the company reduced prices on its Doral brand and brought counter displays to bodegas.

Though R.J. Reynolds stood out for its apparent contempt for its customers, the company wasn't alone in targeting the lesbian, gay, bisexual and transgender community, low-income people and many other marginalized groups, said Katherine Pruitt, of the American Lung Association, at APA's Strengthening Psychology's Role in Reducing Tobacco Health Disparities meeting, Dec. 11–12 in Washington, D.C.

"The tobacco industry has very astute marketers," Pruitt said. "We, too, need deep reach into priority communities so that we can move the needle on health disparities."

The APA conference brought together "an all-star cast of speakers from the government, academe, nonprofits and community groups to discuss the best practices for reducing disparities and helping chart an agenda for APA," said APA CEO Norman B. Anderson, PhD.

That's an important goal because smoking rates remain high in many of the groups targeted by tobacco manufacturers, though tobacco use is declining in the overall population. For instance, members of the LGBT community smoke at about double the rate of the U.S. general population, according to the American Lung Association. Low-income people, those with mental illness and rural populations also have high levels of tobacco use, said keynote speaker H. Westley Clark, MD, JD, the director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration. Overall, blacks and Hispanics smoke less than the general population, but they are disproportionally affected by related diseases, Clark noted.

To fight the $13 billion spent annually on tobacco marketing in the United States, psychologists must redouble their efforts to reach out to these groups, said Clark.

"What we need from psychology is more targeted, specific strategies to help these communities," he said.

What works

Researchers have documented many effective measures for reducing tobacco use, said Shane Davis, PhD, of the Centers for Disease Control and Prevention. Comprehensive, smoke-free policies for workplaces, restaurants and bars are particularly effective, with research showing that such laws reduce smoking-related heart attacks and have no adverse economic impact on restaurants or bars. But even given this evidence, only 25 states have a comprehensive smoke-free air law, Davis said.

Government regulations can also reduce smoking by raising prices through tax increases, with every 10 percent price increase leading to a 4 percent drop in adult cigarette consumption. High prices are particularly effective in keeping adolescents from starting the habit, Davis said.

An effective way to encourage people to quit is to arouse strong negative emotions in smokers — a fact that has underpinned the CDC's hard-hitting $54 million advertising campaign, which showed former smokers coping with serious consequences of smoking such as paralysis from strokes, heart attacks and limb amputations. The number of calls to 1-800-QUIT-NOW, a free national tobacco cessation call center, doubled when the campaign ran last spring, Davis said.

At the same time, federal legislators must limit advertising by cigarette companies, she added. Cigarette companies have been targeting minority and low-income populations through direct mail, by sponsoring social and cultural events, and in display advertising — areas that are all largely unregulated, she noted.

Hard to reach groups

While these measures reduce smoking among the general population, they may not reach some of America's heaviest smokers: people with mental illness. Psychiatric patients smoke two to four times more than mentally healthy smokers, said Kim Hamlett-Berry, PhD, who directs the Tobacco and Health Policy Office in the Department of Veterans Affairs. As a result, those with psychiatric illness are more likely to die from smoking-related diseases than from complications from their mental illness or substance use disorders, she said.

People with alcohol dependence and other substance use disorders also smoke at higher rates. In fact, 50 percent of people treated for alcohol dependence end up dying from smoking-related diseases, researchers have found.

"Many clinicians believe that we can't be taking away smoking from these populations because they will replace them with more harmful substances," Hamlett-Berry said. However, research shows that combining smoking cessation with substance use treatment increases patients' likelihood of success by 25 percent.

To address these concurrent problems, VA treatment centers have instituted and integrated smoking-cessation programs into treatment for PTSD and other disorders, Hamlett-Berry said. The VA has also increased smoking-cessation training for health care providers, and will soon offer a free smartphone app to help quitters stay on track.

Smartphone apps have the potential to engage many difficult-to-reach populations, said Eric Augustson, PhD, a behavioral science researcher at the National Cancer Institute. Even homeless people increasingly have access to smart phones, or at least phones capable of receiving text messages, he said. African-Americans and teens are frequent texters, he said.

"Many of our most vulnerable populations are skipping over computers or laptops and using phones as the primary way they interact with the Internet," he said.

That's why the National Cancer Institute created an app called Smokefree TXT. Users set a quit date and the program sends them reminder messages. The program also checks in with participants, asking them about their cravings and moods and prompting them to text back a response. The program then shoots back a tip or encouraging words.

Since its launch in 2011, the app has attracted more than 15,000 subscribers and shown about a 13 percent success rate — comparable with other, more labor-intensive treatments.

The program, with its versions for young adults, teens and Spanish speakers, demonstrates the potential of adapting interventions for subgroups. But researchers must go even further adapting evidence-based interventions to needs of vunerable populations — a practice that is "the rule, rather than the exception," said Felipe Gonzalez Castro, PhD, a psychology professor and director of the health psychology program at the University of Texas at El Paso. "You must make what you're doing interesting and connect with your audience, so they really believe this is going to help them," he said.