Healthcare providers' treatment of college smokers

Disparities in knowledge and use of tobacco treatment among smokers in California following healthcare reform

The Affordable Care Act (ACA) promised to narrow smoking disparities by expanding access to healthcare and mandating comprehensive coverage for tobacco treatment starting in 2014. We examined whether two years after ACA implementation disparities in receiving clinician advice to quit and smokers' knowledge and use of treatment resources remained. We conducted telephone interviews in 2016 with a stratified random sample of self-reported smokers newly enrolled in the Kaiser Permanente Northern California's (KPNC) integrated healthcare delivery system in 2014 (N = 491; 50% female; 53% non-white; 6% Spanish language). We used Poisson regression with robust standard errors to test whether sociodemographics, insurance type, comorbidities, smoking status in 2016 (former, light/nondaily [<5 cigarettes per day], daily), and preferred language (English or Spanish) were associated with receiving clinician advice to quit and knowledge and use of tobacco treatment. We included an interaction between smoking status and language to test whether the relation between smoking status and key outcomes varied with preferred language. Overall, 80% of respondents received clinician advice to quit, 84% knew that KPNC offers cessation counseling, 54% knew that cessation pharmacotherapy is free, 54% used pharmacotherapy, and 6% used counseling. In multivariate models, Spanish-speaking light/nondaily smokers had significantly lower rates of all outcomes, while there was no association with other demographic and clinical characteristics. Following ACA implementation, most smokers newly enrolled in KPNC received clinician advice to quit and over half used pharmacotherapy, yet counseling utilization was low. Spanish-language outreach efforts and treatment services are recommended, particularly for adults who are light/nondaily smokers.

Associations of subjective social status with nondaily and daily smoking

OBJECTIVES

To explore associations between subjective social status (SSS) and smoking level among 2274 adult current smokers.

METHODS

Associations were investigated using a covariate-adjusted proportional odds cumulative logit model. Moderation (via race/ethnicity or sex) and mediation (via depressive symptoms, social/emotional support, or life satisfaction) were explored in additional models.

RESULTS

Higher SSS was associated with greater likelihood of nondaily versus light daily or moderate/ heavy daily smoking (p = .017). Life satisfaction partially mediated the association of SSS and smoking level (p = .003).

CONCLUSIONS

Higher SSS was associated with greater likelihood of nondaily relative to light daily or moderate to heavy smoking, potentially via greater life satisfaction. Additional studies are needed to confirm these findings.

Nicotine replacement therapy distribution to light daily smokers calling a quitline

BACKGROUND

With an increasing prevalence of lighter smokers presenting for cessation assistance, outcome-based recommendations are needed to inform nicotine replacement therapy (NRT) distribution protocols by quitlines.

METHODS

A quasi-experimental design was utilized to compare quit rates based on samples selected from the time period before and after NRT (gum or lozenge) was offered to light daily smokers (1-9 cigarettes) contacting the New York State Smokers' Quitline. Outcome measures included self-reported 7- and 30-day abstinence rates, numbers of daily cigarettes among continuing smokers, and cost per quit analyses.

RESULTS

Among responders to the follow-up survey, quit rates were higher for those given NRT compared with those not offered NRT at both 7 (33.0% vs. 27.2%; Relative Risk [RR] = 2.25 [95% CI: 1.15, 4.40; p < .05]) and 30 days (28.0% vs. 21.9%; RR = 2.63 [95% CI: 1.25, 5.54; p < .05]). Similar results were obtained based on intent-to-treat analyses for both 7 (13.4% vs. 11.3%; RR = 1.92 [95% CI: 1.08, 3.39; p < .05]) and 30 days (11.4% vs. 9.1%; RR = 2.29 [95% CI: 1.20, 4.40; p < .05]). Among continuing smokers, the mean number of cigarettes smoked per day increased from enrollment to follow-up in both groups, but less so in those receiving NRT. The additional cost associated with providing a 2-week free supply of nicotine replacement to smokers was $52 for gum and $74 for lozenge.

CONCLUSIONS

This study demonstrates that light daily smokers (1-9 cigarettes) who contact a telephone quitline are interested in using NRT if offered and are able to achieve higher quit rates compared with those not offered NRT.

Screening and brief intervention for tobacco use by student health providers on college campuses

OBJECTIVE

This study assessed college students' reports of tobacco screening and brief intervention by student health center providers.

PARTICIPANTS

Participants were 3,800 students from 8 universities in North Carolina.

METHODS

Web-based survey of a stratified random sample of undergraduates.

RESULTS

Fifty-three percent reported ever visiting their student health center. Of those, 62% reported being screened for tobacco use. Logistic regression revealed screening was higher among females and smokers, compared to nonsmokers. Among students who were screened and who reported tobacco use, 50% reported being advised to quit or reduce use. Brief intervention was more likely among current daily smokers compared to current nondaily smokers, as well as at schools with higher smoking rates. Screening and brief intervention were more likely at schools with lower clinic caseloads.

CONCLUSIONS

Results highlight the need to encourage college health providers to screen every patient at every visit and to provide brief intervention for tobacco users.

Evidence-based smoking cessation for college students

Despite a strong stance by the American College Health Association and years of prevention and control efforts on US college campuses, smoking and exposure to secondhand smoke remain a problem among college students. This article provides an overview of what is known about cigarette smoking in this population as well as existing interventions for smoking prevention, cessation, and exposure to secondhand smoke on college campuses. Strategies to reduce tobacco use are presented, many of which have been demonstrated to be effective in the short-term.

What Should We Do When Participants Report Dangerous Drinking? The Impact of Personalized Letters Versus General Pamphlets as a Function of Sex and Controlled Orientation

Research in which participants report potentially dangerous health-related behaviors raises ethical and professional questions about what to do with that information. Policies and laws regarding reportable behaviors vary across states and Institutional Review Boards (IRB). In alcohol research, IRBs often require researchers to respond to participants who report dangerous drinking practices. Researchers have little guidance regarding how best to respond in such cases. Personalized feedback or general nonpersonalized information may prove differentially effective as a function of gender and/or level of self-determination. This study evaluated response strategies for reducing peak blood alcohol concentration (BAC) among participants reporting dangerous BACs (≥ .35%) in the context of a two-year longitudinal intervention trial with 818 heavy drinking college students. After each assessment, participants who reported drinking to estimated BACs at or greater than .35% were sent either a personalized letter expressing concern and indicating their reported BAC or a nonpersonalized pamphlet that included general information about alcohol and other substances, referral information, and a BAC handout. Hierarchical linear modeling results revealed that both strategies were associated with reduced peak BAC when controlling for previous BAC. The personalized letter was more effective for women and for students who tend to regulate their behavior based on others' expectations and contingencies in the environment. This research provides some guidance for researchers considering appropriate responses to participants who report dangerous health behavior in the context of a research trial.

Smoking identities and behavior: evidence of discrepancies, issues for measurement and intervention

Although researchers and health care practitioners tend to use standard categories to classify smokers and nonsmokers, recent research suggests that individual smokers may use a variety of self-definitions regarding their smoking behavior. The purpose of this study was to examine smoking identity and smoking behavior among college students, specifically, the relationship between self-identifying as a smoker, nonsmoker, occasional smoker, or social smoker and number of days smoked in the past month. Data were obtained during a campuswide health assessment of randomly selected full-time students (N = 741). Results indicate discrepancy between smoking identity and cigarette use. Twenty percent of students who smoked in the past 30 days self-identified as nonsmokers. Such discrepancies have implications for data collection in research as well as on questionnaires and in health care interviews. Failure to understand actual smoking behavior may increase the risk that individuals will not receive effective smoking prevention and cessation interventions.

Differences between intermittent and light daily smokers in a population of U.S. military recruits

INTRODUCTION

Few studies have assessed differences between intermittent and light smokers, particularly among young adults. Exploring these differences promotes a systematic approach to research and treatment in low-level smokers. This study explored demographic, tobacco-related, and psychosocial predictors of intermittent nondaily smoking relative to light smoking among basic military training (BMT) recruits. The impact of smoking status on abstinence rates at follow-up was also assessed.

METHODS

Participants were 5,603 U.S. Air Force BMT intermittent nondaily (n = 3,134) or light daily (n = 2,469) smoking recruits participating in a population-based group randomized trial targeting tobacco use prevention and cessation (Klesges et al., 2006, Efficacy of a tailored tobacco control program on long-term use in a population of U.S. military troops. Journal of Consulting and Clinical Psychology, 74, 295-306.). Participants completed baseline measures assessing demographics; tobacco use and history; and common social, attitudinal, and behavioral risk factors for tobacco use. Flights of recruits were randomly assigned to a tobacco use intervention or health education control intervention. At the 1-year follow-up, participants reported 7-day point prevalence and continuous abstinence.

RESULTS

Intermittent nondaily smoking relative to light daily smoking was associated with lesser perceived addiction, intermittent and daily use of smokeless tobacco, nonsmoking male and female heads of household, lesser likelihood of smoking while stressed or while bored, and higher likelihood of intentions to quit smoking. Intermittent smokers were significantly more likely than light daily smokers to report abstinence at follow-up.

DISCUSSION

Intermittent and daily light smokers differ on several tobacco-related and psychosocial variables. Attending to these factors in prevention and cessation programs may enhance abstinence in both groups.

Cigarette smoking and associated health risks among students at five universities

INTRODUCTION

While most college students and other young adults who smoke fall into the light and intermittent smoking (LITS) category, they remain at risk for tobacco dependence and other adverse health effects from their smoking. This study examines smoking patterns, tobacco dependence, and other health variables among students at five universities to better understand how to identify and address tobacco use and related risks in a college health clinic setting.

METHODS

A health screening survey was completed by 2,091 college and graduate student volunteers seeking routine care at their university health centers or participating in a health class. Independent health variables were analyzed descriptively and in regression analyses with three levels of smoking (none, non-daily, and daily) and tobacco dependence to determine predictors and associated risks.

RESULTS

Nearly a quarter of students reported any current smoking, 41% of whom reported smoking less than 1 cigarette/day (cpd). Of the daily smokers, 80% smoked less than 10 cpd but 45% met criteria for tobacco dependence. Any smoking was associated with high-risk alcohol use, risky driving, relational abuse, depression, less exercise, and utilization of emergency and mental health services. In regression analyses, students who experienced depression had more than double the odds of being dependent smokers (odds ratio [OR] = 2.32), as did those who reported abuse (OR = 2.07) or sought mental health counseling (OR = 2.09).

DISCUSSION

Student health providers should be alerted to the multiple risks and comorbidities that occur among all smokers, including LITS, and intervene concurrently to help prevent or mitigate adverse outcomes that result from these conditions and behaviors.

Campus physicians' tobacco interventions with university students: a descriptive study of 16 Ontario university clinics

OBJECTIVE

About one-quarter of Canadian post-secondary students smoke cigarettes. We examined how physicians from Ontario university health clinics intervene with these young adult smokers.

METHOD

A convenience sample of 16 universities was identified and surveys were hand-delivered to all 228 physicians from these schools. A total of 125 doctors (54.82%) responded; 70 were from universities that were involved in a government-sponsored, coordinated, multi-campus, tobacco control initiative.

RESULTS

Twenty percent of doctors reported asking all or almost all patients about tobacco use; 25.22% asked fewer than half. Describing how they respond to patients identified as smokers, 96.00% of physicians advised cessation, 72.00% offered assistance, and 64.00% arranged for follow-up. Doctors discussed patients' tobacco use with 78.59% of smokers. Nicotine replacement therapies were rarely offered to patients wanting to quit. Doctors from universities involved in the tobacco control initiative were more likely to keep patient education materials in the examining room.

CONCLUSION

Because most doctors ask only some patients about tobacco use, they may be missing opportunities to provide appropriate advice and assistance to all smokers.

PRACTICE IMPLICATIONS

Physician education and support to the clinic are needed to improve the frequency and quality of physician-delivered smoking cessation services to post-secondary students.

Smoking-cessation counseling practices of college/university health-care providers--a theory-based approach

OBJECTIVE

The author's purpose in this study was to examine the relation between smoking cessation counseling self-efficacy, knowledge of smoking cessation counseling, motivation to counsel smokers, and barriers to performing smoking cessation counseling, relative to the smoking cessation counseling stage of change.

PARTICIPANTS AND METHODS

Members of The American College Health Association, who are health-care providers (N=296), completed a survey measuring the predictor variables of knowledge, motivation, self-efficacy and perceived barriers, and the members' readiness for conducting smoking-cessation counseling with students.

RESULTS

The majority reported that they were knowledgeable about smoking-cessation counseling practices, they were motivated to conduct counseling, and they had the confidence (self-efficacy) to perform smoking-cessation counseling effectively. Significant barriers to performing smoking cessation counseling included the lack of reimbursement for counseling, lack of training in smoking-cessation counseling, and lack of resources for follow-up. The author found a moderate negative correlation between self-efficacy for smoking-cessation counseling and barriers to performing smoking-cessation counseling.

CONCLUSION

The results suggest that researchers should address the barriers that prevent health-care providers from performing smoking-cessation counseling. Interventions on increasing healthcare providers' counseling self-efficacy may be instrumental in moving them further along the stage continuum and increase their readiness to perform smoking cessation counseling.