Interventions to Reduce Tobacco-Related Health Disparities

A cluster-randomized trial of a brief multi-component intervention to improve tobacco outcomes in substance use treatment

BACKGROUND

Smoking prevalence is high among people in substance use disorder (SUD) treatment, and program interventions to address smoking are often complex and lengthy. This cluster-randomized trial tested whether a brief multi-component intervention impacted tobacco outcomes among staff and clients.

METHODS

Seven SUD treatment programs were randomly assigned to the multi-component intervention or to waitlist control. The 6-month intervention included a leadership motivation assessment, program incentives, 4 staff training sessions and a leadership learning community session. Survey data were collected from staff and clients at pre- and post-intervention. Outcomes were first compared across condition (intervention vs waitlist control), and then examined pre- to post-intervention with condition collapsed.

RESULTS

Staff in the intervention (n = 48) and control conditions (n = 26) did not differ at post-intervention on smoking prevalence, self-efficacy to help clients quit, or practices used to help clients quit smoking. Intervention clients (n = 113) did not differ from controls (n = 61) in smoking prevalence or receipt of tobacco services. Pre-post comparisons collapsed across condition showed a decrease in client and staff smoking prevalence, which could not be attributed to the intervention, and a decrease in client receipt of cessation medication.

CONCLUSION

The brief multi-component intervention did not support changes in smoking prevalence or in tobacco-related services received by clients. Other intervention features are needed to reduce smoking among SUD clients.

TRIAL REGISTRATION

Randomization occurred at the program level and outcomes measured are program-level measures. Accordingly, the trial is not registered.

The OaSiS trial: A hybrid type II, national cluster randomized trial to implement smoking cessation during CT screening for lung cancer

INTRODUCTION

When the Centers for Medicare and Medicaid Services announced coverage for low dose CT lung cancer screening, they also mandated that imaging centers offer smoking cessation services. We designed the Optimizing Lung Screening (OaSiS) trial to evaluate strategies to implement the Public Health Service Guidelines for Treating Tobacco Use and Dependence during CT screening for lung cancer.

METHODS AND DESIGN

OaSiS was implemented using a pragmatic effectiveness-implementation hybrid design in 26 imaging clinics across the United States affiliated with the National Cancer Institute's National Community Oncology Research Program (NCORP). The 26 sites selected for participation in the OaSiS trial were randomized to receive either a compendium of implementation strategies to add or enhance smoking cessation services during lung screening or to usual care. Usual care sites were given the option to receive the full compendium of implementation strategies at the conclusion of data collection. We have evaluated both the effectiveness of the implementation strategies to improve smoking cessation at six months among patients undergoing LDCT screening as well as the adoption and sustainability of evidence-based tobacco cessation strategies in imaging clinics.

DISCUSSION

The OaSiS trial was designed to identify opportunities for implementing evidence-based smoking cessation into LDCT lung cancer screening imaging facilities and to establish the effectiveness of these services. We report our study design and evaluation, including strengths of the pragmatic design and the inclusion of a diverse range of screening programs. Establishing these tobacco cessation services will be critical to reducing smoking related morbidity and mortality.

Impact of the Society for Research on Nicotine and Tobacco Health Disparities Network's Scholarship on Professional Development of Its Recipients

INTRODUCTION

Diversifying the workforce is an important strategy to reducing health disparities. Since 2007, the Society for Research on Nicotine and Tobacco (SRNT) Health Disparities Network has funded a travel scholarship to promote inclusion, professional development, and diversity among investigators interested in tobacco-related health disparities research. This study examined indicators of productivity among former scholarship recipients.Methods: Scholarship recipients between 2007 and 2014 were invited to complete a survey online. The survey assessed demographic characteristics, academic productivity, and perceived professional benefit resulting from the scholarship.Results: Of the 117 scholarships recipients, 89 (77%) responded. Respondents were 67% female and had a mean age of 37.8 years. Twenty eight percent were African American, 25% Asian American, and 17% Latino. Most respondents worked in academia (80%) and nearly three-quarters (74%) reported publishing manuscripts on tobacco-related disparities, with a mean of 3.8 (SD 4.4) disparities-related publications since receiving the scholarship. Respondents' work focused on a wide range of health disparities topics and nearly all respondents reported that the scholarship removed barriers to attending the meeting and reported professional benefit from receiving the travel scholarship. Following receipt of the SRNT travel scholarship, a diverse group of scientists demonstrated scholarly productivity, professional development, and advancement of health disparities research. Similar efforts are encouraged in other professional societies.

IMPLICATIONS

This study examines the productivity of early career recipients of the SRNT Health Disparities Scholarship. Results suggest that the investment in annual travel scholarships by a professional organization is an important support system for emerging scientists from diverse backgrounds. This investment may help to advance the science of health disparities and engage researchers in an area where there are critical gaps in the research workforce.

A pilot study to implement and sustain the US PHS clinical practice guidelines for treating tobacco use and dependence in free clinics, a safety net care setting for the uninsured

Introduction

Uninsured patients are more likely than the general population to use tobacco and less likely to quit.

Aims

To determine if the mode of delivering the PHS Guidelines influenced the effectiveness of smoking cessation among patients in a safety net setting.

Methods

Six free clinics were randomly assigned to a training program delivered by an academic physician or community partner plus video support. A repeated cross-sectional survey of patients was conducted at three waves to assess effectiveness to promote quitting.

Results

Tobacco use was triple the rate of the US population: 57.7% (Wave 1), 44.7% (Wave 2), and 48.9% (Wave 3). Patients were more likely to report receipt of at least one evidence-based strategy to promote quitting at Wave 2 (AOR = 2.33, 95% CI (1.18–4.58)). Patients treated in clinics trained by the community partner were significantly more likely to report receiving cessation assistance at Wave 2 (AOR 2.54, 95%CI 1.29–5.00) and the trend was similar, but not significant at Wave 3. Patients in the community partner-led arm were significantly less likely to report tobacco use at Wave 3 (AOR 0.59, 95% CI 0.35–0.99).

Conclusions

Implementation of the PHS Guidelines in free clinics demonstrates preliminary efficacy, with delivery by community partners offering greater scalability.

Tobacco product use and smoking frequency among US adults with intellectual and developmental disabilities

BACKGROUND

People with intellectual and developmental disabilities (IDD) have been overlooked in tobacco use research although they are likely to experience tobacco-related health disparities. This study examined tobacco product use and smoking frequency and amount among a sample of US Special Olympics athletes with IDD.

METHODS

Multiple regression analysis was used to test whether age, gender, body mass index, blood pressure, bone density, eating fruits and vegetables and family member tobacco use were correlated with the number of cigarettes smoked per day.

RESULTS

The sample of people with IDD who used tobacco (n = 501) were aged 18-75 (M = 33.37) and 76.4% were male. About 73.6% reported cigarette use only, 10.6% reported dual or poly use of cigarettes and other tobacco products (cigars, pipe, and chewing tobacco) and 15.8% reported using only tobacco products other than cigarettes. Men were more likely than women to use tobacco products other than cigarettes. Of the cigarette smokers, 79.6% were daily smokers, and their mean cigarettes per day was 10.08 (SD = 9.50). Special Olympics athletes who did not have low bone density and those who consumed fruits and vegetables less than daily reported higher numbers of cigarettes per day.

CONCLUSIONS

Although people with IDD are less likely to use tobacco than the general population, study results suggest that people with IDD who smoke cigarettes are just as likely as smokers in the general US population to smoke daily. Improving overall health behaviours may be important in helping smokers with IDD to reduce their tobacco use. Research is needed to understand longitudinal patterns of tobacco use and how to prevent tobacco use among people with IDD.

Smoking-related outcomes and associations with tobacco-free policy in addiction treatment, 2015-2016

OBJECTIVE

This study assessed changes in smoking-related outcomes in two cross-sectional samples of clients enrolled in addiction treatment and whether tobacco-free grounds policies were associated with smoking-related outcomes.

METHOD

Clients in 25 programs were surveyed in 2015 (N=1176) and 2016 (N=1055). The samples were compared on smoking prevalence, cigarettes per day (CPD), thinking of quitting, past year quit attempts, staff and clients smoking together, attitudes towards quitting, and tobacco-related services. Second, programs with (n=6) and without (n=17) tobacco-free grounds at both time points were compared on smoking-related outcomes. Last, we examined changes in these measures for two programs that adopted tobacco-free grounds between 2015 and 2016.

RESULTS

There was one difference across years, such that the mean score for the tobacco Program Service scale increased from 2.37 to 2.48 (p=0.043, effect size=0.02). In programs with tobacco-free grounds policies, compared to those without, both CPD and the rate of staff and clients smoking together were significantly lower. In the two programs where tobacco-free grounds were implemented during study years, client smoking prevalence decreased (92.5% v. 67.6%, p=0.005), the rate of staff and clients smoking together decreased (35.6% v. 4.2%, p=0.031), mean CPD decreased (10.62v. 8.24, p<0.001) and mean tobacco services received by clients increased (2.08v. 3.05, p<0.001).

CONCLUSION

Addiction treatment programs, and agencies responsible for licensing, regulating and funding these programs, should implement tobacco-free grounds policies.

Quitting smoking during substance use disorders treatment: Patient and treatment-related variables

Although individuals in substance use disorders (SUD) treatment continue to smoke at high rates, regulatory, policy and programming changes promoting tobacco cessation are being implemented and some patients quit successfully. We examined associations of smoking patterns, tobacco advertising receptivity, anti-tobacco message awareness, health risk perception, attitudes towards addressing smoking and availability of smoking cessation services with quitting smoking during SUD treatment. Surveys were completed by 1127 patients in 24 programs chosen randomly, stratified by program type (residential, methadone maintenance, outpatient), from among publicly funded, adult treatment programs within the National Drug Abuse Treatment Clinical Trials Network. Among respondents who had been in SUD treatment for at least one month, there were 631 current smokers and 52 former smokers who reported quitting smoking during treatment for at least one month prior to survey completion; these respondents comprised our sample (N=683). Results showed that participants who reported health concerns as a reason for quitting were 1.27 times more likely to have quit during treatment (p=0.015) than those reporting health concerns affected quitting a little or not at all. Additionally, participants who reported that smoking cessation was part of their personal treatment plan during SUD treatment were 1.08 times more likely to have quit during treatment (p<0.001). Participants in methadone treatment were 49% less likely to report successfully quitting during treatment than those in outpatient treatment (95%CI: 0. 35-0.75, p<0.001). Leveraging health concerns about smoking and including smoking cessation in an individualized treatment plan may help increase smoking cessation during SUD treatment.

Tobacco-Related Health Disparities Across the Cancer Care Continuum

BACKGROUND

Use of tobacco is the leading preventable cause of death in the United States. Racial/ethnic minorities and individuals of low socioeconomic status disproportionately experience tobacco-related disease and illness. Unique challenges and circumstances exist at each point in the cancer care continuum that may contribute to the greater cancer burden experienced by these groups.

METHODS

We reviewed tobacco-related disparities from cancer prevention to cancer survivorship. We also describe research that seeks to reduce tobacco-related disparities.

RESULTS

Racial/ethnic minorities and low-income individuals experience unique social and environmental contextual challenges such as greater environmental cues to smoke and greater levels of perceived stress and social discrimination. Clinical practice guidelines support the effectiveness of pharmacotherapy and behavioral counseling for racial and ethnic minorities, yet smoking cessation rates are lower in this group when compared with non-Hispanic whites. Superior efficacy for culturally adapted interventions has not yet been established.

CONCLUSIONS

To reduce health disparities in this population, a comprehensive strategy is needed with efforts directed at each point along the cancer care continuum. Strategies are needed to reduce the impact of contextual factors such as targeted tobacco marketing and social discrimination on smoking initiation and maintenance. Future efforts should focus on increasing the use of evidence-based cessation treatment methods and studying its effectiveness in these populations. Attention must also be focused on improving treatment outcomes by reducing smoking in diverse racial and ethnic patient populations.

Ever-Use and Curiosity About Cigarettes, Cigars, Smokeless Tobacco, and Electronic Cigarettes Among US Middle and High School Students, 2012-2014

Introduction

Among young people, curiosity about tobacco products is a primary reason for tobacco experimentation and is a risk factor for future use. We examined whether curiosity about and ever-use of tobacco products among US middle and high school students changed from 2012 to 2014.

Methods

Data came from the 2012 and 2014 National Youth Tobacco Surveys, nationally representative surveys of US students in grades 6 through 12. For cigarettes, cigars, smokeless tobacco, and e-cigarettes (2014 only), students were classified as ever-users or never-users of each product. Among never-users, curiosity about using each product was assessed by asking participants if they had “definitely,” “probably,” “probably not,” or “definitely not” been curious about using the product.

Results

From 2012 to 2014, there were declines in ever-use of cigarettes (26% to 22%; P = .005) and cigars (21% to 18%; P = .003) overall and among students who were Hispanic (cigarettes, P = .001; cigars, P = .001) or black (cigarettes, P = .004; cigars, P = .01). The proportion of never-users reporting they were “definitely not” curious increased for cigarettes (51% to 54%; P = .01) and cigars (60% to 63%; P = .03). Ever-use and curiosity about smokeless tobacco did not change significantly from 2012 to 2014. In 2014, the proportion of young people who were “definitely” or “probably” curious never-users of each product was as follows: cigarettes, 11.4%; e-cigarettes, 10.8%; cigars, 10.3%; and smokeless tobacco, 4.4%.

Conclusion

The proportion of US students who are never users and are not curious about cigarettes and cigars increased. However, many young people remain curious about tobacco products, including e-cigarettes. Understanding factors driving curiosity can inform tobacco use prevention for youth.

Tobacco Use among Foster Youth: Evidence of Health Disparities

Youth aging out of foster care face a challenging road to independence. Following exposure to myriad risk factors such as abuse, neglect, parental substance use, and severe housing mobility, supportive services decrease upon exit from care, often increasing risk for substance use, homelessness, and unemployment. Although tobacco use is also highly prevalent, little attention has been paid to screening, assessment, and treatment of tobacco use in this vulnerable group. The current study (N = 116) reports on tobacco use prevalence, consequences, and co-occurrence with other substances in a sample of youth (ages 18 to 19) exiting the foster care system. In the face of an overall decrease in tobacco use among general population adolescents and young adults, results suggest disproportionate levels of lifetime, recent, and daily use among foster youth. Prevalence of recent tobacco use (46%) is nearly triple national rates, while daily smoking (32%) is almost four times that of general population young adults. Tobacco users were more likely than non-users to drink (70% vs. 40%) and to smoke marijuana (72% vs. 25%). We strongly encourage researchers and practitioners to increase attention to this tobacco-related health disparity.