A qualitative feasibility study of a prototype patient-centered video intervention to increase uptake of cancer genetic testing among Black Americans

BACKGROUND

Health advances due to developments in genomic medicine are unequally experienced in the USA; racial differences in the uptake of genetic testing are one factor in this disparity. In collaboration with Black patients and diverse health care providers, we are developing a patient-centered video intervention to increase cancer genetic testing among eligible Black Americans. The objective of the pilot work is to explore the acceptability of and support for the intervention and key content components.

METHODS

In order to create a patient-centered video intervention prototype, we conducted a targeted, secondary analysis of 47 coded transcripts from video-taped qualitative interviews with people with a known genetic or inherited cancer risk. The review focused on decision-making, testing experiences, and perceived value of genetic testing. We subsequently generated a 15-min video montage of content from 9 diverse (age, gender, race) participants. We used the prototype video as prompt material for semi-structured interviews with 10 Black patients who had undergone genetic testing in the last 2 years and 10 racially diverse providers (genetic counselors, a nurse, and medical oncologists) who provide management recommendations for high-risk patients. Interviews sought to understand the acceptability of a video intervention to enhance informed decision-making by Black patients and key elements for intervention efficacy.

RESULTS

Study participants were generally positive about the prototype video and provided guidance for intervention development. Interviewed patients prioritized perceived authenticity and relatability of video participants. The presentation of patients' perspectives on testing, their experiences of testing, and the benefits of having test results were all seen as useful. The benefits of testing for self and family were identified as important considerations. Privacy concerns and science skepticism were identified as germane issues, with guidance to present barriers to testing alongside possible solutions. The inclusion of clinicians was seen as potentially useful but with caution that clinicians are not universally trusted.

CONCLUSIONS

Study findings provided critical input for the creation of a professionally produced, tailored intervention video for a randomized clinical trial with Black Americans to evaluate the influence on uptake of genetic testing. The interviews suggest the acceptability and potential utility of an authentic, realistic, and tailored, patient-centered video intervention to increase consideration and uptake of genetic testing.

Culturally specific health-related features on cigarette packs sold in China

BACKGROUND

China is the country with the highest burden of tobacco-caused disease. We characterised the extent to which cigarette pack marketing features (eg, imagery, text, pack color) could potentially mislead consumers by suggesting products are healthy.

METHODS

We used two methods: group concept mapping and content analysis. First, we used a group concept mapping approach to generate and sort Chinese consumer responses to an open-ended prompt asking what marketing features suggest a product is 'healthy' or 'good for you'. Second, based on the concept mapping results, we developed a codebook of health-related features on cigarette packs that were relevant to the unique cultural context of product marketing in China. Two trained coders who were native Chinese speakers double-coded a sample of 1023 cigarette packs purchased in 2013 (wave 1) and 2017 (wave 2). We examined differences in the presence of features overall and over time.

RESULTS

Overall, 83.5% (n=854) of Chinese cigarette packs in our sample contained at least one 'healthy' or 'good for you' feature, and the presence of health-related features on packs remained constant between wave 1 (83.5%, n=354) and wave 2 (83.5%, n=500; p=1.00). Across both waves, the most common categories of culturally specific health features present related to recycling symbols, rare animal imagery, bright colours (eg, bright yellow) and botanical imagery (eg, bamboo, mint).

CONCLUSION

Health-related features on cigarette packs sold in China are common. Enhanced policies to address tobacco packaging, labelling and branding could support and facilitate a reduction in the high tobacco burden in China.

Shared perceptions of flavored cigarette pack design among young adults who smoke in Mexico and the Philippines

INTRODUCTION

Tobacco industry documents reveal companies' knowledge of a similar young adult market across countries in terms of attitudes and lifestyle aspirations. Some tobacco companies, therefore, use similar marketing approaches across different jurisdictions. We examined young adults' perceptions of flavored cigarette packs, including those containing flavor capsules, in Mexico and the Philippines.

METHODS

We conducted a secondary analysis of five focus groups held in Mexico and four in the Philippines with young adults who smoke (aged 18-24 years), separated by gender, in which participants interacted with cigarette packs purchased locally. Transcribed and translated data were thematically analyzed and compared between countries.

RESULTS

Three major themes were identified: 1) Flavor capsules cigarettes are recognizable via pack design through imagery on the pack that is understood to signify capsules; 2) Colors signal flavor and make the pack attractive; and 3) Young adults who smoke identify the target audience for these products as young people and those who are beginning to smoke.

CONCLUSIONS

Young adults who smoke in Mexico and the Philippines interpreted flavored cigarette pack design similarly and thought that young people are the main audience for these products. This suggests a successful marketing approach creating shared perceptions of flavored cigarette packs in different world regions. It is likely that similar tactics are used in other countries around the world. Therefore, jurisdictions might use evidence from other jurisdictions to support the implementation of evidence-based tobacco control policies. These findings also support the implementation of plain and standardized packaging and flavor bans that would also limit product innovation such as capsules.

Tobacco companies' creation of additional communication space: a content analysis of cigarette pack inserts and onserts

OBJECTIVES

Pack inserts and onserts-removable items placed inside or on the outside of packs-are a communicative strategy used by tobacco companies that provide them with additional marketing space. A content analysis of these items was conducted across several years, countries and brands to assess how these items are used to communicate with consumers.

METHODS

Between 2013 and 2020, cigarette packs were systematically collected using the Tobacco Pack Surveillance System protocol. Packs with inserts or onserts (n=178) were identified from 11 low and middle-income countries. Packs were coded for tobacco company strategies, physical pack characteristics and imagery and lexical marketing appeals.

RESULTS

Of the 5903 packs, 3% (n=178) had an insert or onsert. 171 of these (96%) were inserts. While most (78%) pack exteriors were entirely in English, over half (51%) of the inserts/onserts were entirely in the local (non-English) language from where the pack was collected. The most common appeals on the inserts/onserts were product dependability (64%), luxury/aspirational (55%) and machinery/technology (37%). Product images were prevalent as well as images or words mentioning filters (22%). The most used appeals involved featuring aspects of a product (66%), addressing customers directly (52%) and informing customers about new aspects of a product (31%).

CONCLUSIONS

Cigarette pack inserts/onserts are unregulated in many countries and provide additional space for tobacco companies to extend and innovate their advertising. Tobacco advertising and packaging policies such as plain and standardised packaging should expand to address inserts/onserts to protect consumers more fully from industry promotion of deadly products.

The problematic use of cultural symbols on Chinese cigarette packs

INTRODUCTION

China is the world's largest tobacco-consuming nation. With minimal packaging regulations, the Chinese tobacco industry can use many appeals to promote their products, including calling upon traditions and culture to make positive connections between consumers and harmful products. We analyzed the nature and extent of cultural appeals on Chinese cigarette packs.

METHODS

A total of 610 unique cigarette packs were collected in 2017 from five major Chinese cities (Beijing, Guangzhou, Shanghai, Kunming, and Chengdu) following a systematic protocol. Two trained independent coders knowledgeable about Chinese culture and language coded the packs in accordance with a specially developed codebook encompassing important Chinese cultural symbols. The prevalence of identified elements was determined and interpreted.

RESULTS

Overall, 60.7% (n=370) of the analyzed Chinese cigarette packs in our sample contained at least one culturally specific appeal. The most common cultural appeals included written arts (n=131; 21.5%), celebratory red as the primary pack color (n=119; 19.5%), visual arts (n=70; 11.4%), and special occasions (n=60; 9.9%). There was a diverse range of cultural appeals present on the packs.

CONCLUSIONS

Cultural appeals are common on Chinese tobacco packaging, with over 60% of all analyzed packs containing at least one culturally specific element. With China's packaging policies requiring health warning labels to occupy only 35% of the pack, the tobacco industry is allowed plenty of package space to incorporate cultural elements among other appeals. A plain and standardized packaging policy would eliminate the ability for Chinese tobacco companies to use cultural appeals on their cigarette packs.

Colours, capsules and concept flavour names on cigarette packs appeal to youth in Mexico

BACKGROUND

Flavoured cigarettes are popular in Mexico. We examined how cigarette packaging design features used to communicate flavour influence perceptions of appeal, harm, perceived interest and pack preference among Mexico City residents.

METHODS

We conducted an experimental survey. Participants aged 13-34 years were randomly assigned to one of three conditions, viewed packs with systematically manipulated design features (colour, capsule image and flavour name) and answered questions on appeal, perceived harm, perceived interest and pack preference. Data were analysed using mixed effects and conditional logistic regression.

RESULTS

1500 adolescents and 950 adults participated. Regardless of flavour, cigarette packs with a background colour and capsule image were more appealing to adolescents (OR=13.19, 95% CI 11.53 to 15.10; OR=1.68, 95% CI 1.45 to 1.88) and adults (OR=4.18, 95% CI 3.73 to 4.69; OR=1.66, 95% CI 1.49 to 1.85) than packs without. Among adolescents, 'Tropical Burst' named packs were more appealing (OR=1.43, 95% CI 1.20 to 1.72) than packs without a flavour name and among adults, 'Arctic Air' named packs were more appealing (OR=1.20, 95% CI 1.02 to 1.14). Adolescents and adults reported a preference for trying packs that displayed a flavour name, background colour or capsule image (b=0.104, b=0.702, b=1.316, p<0.001 and b=0.126, b=0.619, b=0.775, p<0.001).

CONCLUSIONS

Colours and flavour capsule images appeal to adolescents and adults in Mexico. Mexico should consider adopting plain packaging to reduce appeal and interest.

Exploring the dynamics of the quality of HIV care experienced by female sex workers living in the Dominican Republic

Despite increased attention and efforts to improve HIV care among female sex workers (FSWs), they continue to have suboptimal HIV outcomes. Exploring the socio-structural dynamics related to the quality of HIV care received by FSWs is critical to further strengthen interventions to improve their HIV care continuum outcomes. In this study, we conducted two rounds of qualitative in-depth interviews with 20 FSWs living with HIV in the Dominican Republic to explore how healthcare experiences contributed to their quality of HIV care. Data was analyzed using a thematic analytic approach exploring diverse structural and relational aspects of the quality of HIV care affecting FSWs as they navigate the clinic environment. Results indicated that quality of HIV care was influenced by both structural and relational factors within clinics. At the structural level, insufficient stock of antiretroviral therapy and the financial burden created by HIV care related costs hindered FSWs' satisfaction with their current HIV care and presented a barrier in FSWs' ability to access HIV care services. Quality of care was also closely linked to relational aspects of the HIV care environment, including FSWs' relationship and communication with their clinical providers, as FSWs often expressed their satisfaction with HIV care experiences based on these interpersonal factors. Lastly, personal agency emerged as an important factor contributing to the quality of HIV care, specifically as FSWs' treatment literacy resulted in greater advocacy and demands for quality care. Programmatic efforts should be directed to improving the quality of HIV care experiences of FSWs in the clinic environment. These include addressing resource shortages, promoting positive and effective patient-provider relationships, and facilitating HIV treatment education opportunities for FSWs.

A study protocol to explore and implement community-based point-of-care COVID-19 testing for women who use drugs in Baltimore, Maryland: The CARE study

Women who use drugs (WWUD) experience structural vulnerabilities (e.g., housing, food insecurities) and comorbidities that elevate their susceptibility to more severe COVID-19 symptoms or fatality compared to similarly-aged women who do not use illicit drugs. Testing is a cornerstone of effective COVID prevention, however, entrenched barriers to healthcare utilization means that WWUD may have diminished accessing to COVID testing. The CARE (COVID Action Research Engagement) study first examines predisposing and enabling factors that predict COVID testing uptake over six months (baseline, 3-, and 6-month follow-up) among a cohort of WWUD (N = 250) in Baltimore, Maryland, providing a nuanced and holistic understanding of how to meaningfully engage WWUD in COVID testing. Then, point-of-care COVID testing will be implemented on a mobile outreach van affiliated with a local community-based organization primarily serving WWUD; anonymous surveys of mobile outreach guests (N = 100) will assess feasibility and acceptability of this integrated testing. The study is grounded in the Behavioral Model for Vulnerable Populations and the Theoretical Framework of Acceptability. We hypothesize that point-of-care COVID testing integrated into a low-barrier harm reduction service, such as a mobile outreach program, will be an enabling environment for COVID testing uptake in part by reducing structural impediments to testing and will be highly feasible and acceptable to participants. Strengths, limitations, and plans for results dissemination are discussed.

Multivariable analysis to determine risk factors associated with abortion in mares

Risk factors associated with equine reproductive efficiency have been identified along with those associated specifically with early pregnancy loss (EPL). In contrast, no studies have reported risk factors associated with abortion (loss between day 70 and 300 post-cover). Given the causes of abortion differ to those of EPL, likely too will the risk factors. A retrospective cohort study was carried out to identify risk factors associated with abortion in UK and Irish based Thoroughbreds, collecting data on 20 exposure variables over a five-year period. A generalized linear mixed model was utilized to evaluate the associations between exposure variables and abortion, with clustering of observations accounted for at the mare and farm level. Variables with a likelihood ratio test (LRT) p value <0.2 were entered into the model in a forward stepwise approach. Pregnancy outcome was available on 4,439 pregnancies from 2,510 mares. Having had two or more prior abortions (odds ratio (OR) 7.91, 95% confidence interval (CI) 2.86, 21.88), conceiving on the second or subsequent covered estrous cycle (OR 1.84, 95% CI 1.22, 2.78) and conceiving multiple conceptuses (OR 1.68, 95% CI 1.02, 2.76) were associated with an increased risk of abortion compared to null parous, first estrous cycle covers and singleton conceptions respectively. Increasing paternal age (OR 0.95, 95% CI 0.90, 0.99) was associated with a decreasing risk of abortion. Mare and farm variance were not significant in the final model, LRT p=0.43. These findings provide evidence-based data to inform Thoroughbred breeding management practices to help mitigate abortion risk.

Mild-moderate equine asthma: A scoping review of evidence supporting the consensus definition

Current consensus defines mild-moderate equine asthma (mEA; previously inflammatory airway disease) by a hierarchy of indicators of lung pathology: cough, poor performance, increased tracheobronchial mucus, inflammatory bronchoalveolar lavage (BAL) cytology and pulmonary dysfunction. Exclusion criteria include fever, systemic disease, or increased resting respiratory effort. The aim of this review was to inform future research by identifying gaps, strengths and weaknesses in the current body of evidence supporting this consensus-proposed definition. Objectives were to critique evidence supporting the inclusion of each diagnostic indicator in the case definition, by summarising and evaluating evidence for its association with higher-level indicators of lung inflammation. Searches of three databases identified 2275 articles relating to mEA or its diagnostic indicators, from which 298 full-text articles were screened and 45 reviewed in full. Studies (n = 44) had been performed worldwide in clinics, hospitals, racetracks, yards or research herds, in 6092 horses. Studies were predominantly opportunistic observational (n = 13/44: 29.5%) or cross-sectional (n = 11/44; 25%). The median number of horses per study was 74. Where breed and use were reported most were Thoroughbreds (58.2%; 2730/4688) and racehorses (72.8%; n = 3960/5439). Domains rated as high risk of bias in almost 50% of articles were 'study power' and 'masking'. Heterogeneity in clinical and laboratory measures precluded meta-analysis. Evidence was more consistent for certain pairwise relationships (e.g., between cough and tracheobronchial mucus) than others (e.g., BAL cytology and lung function). Findings highlight the need for increased standardisation of diagnostic methods and reporting to facilitate future systematic review and meta-analysis.

Beyond Gutka: Evidence of Illegal Smokeless Tobacco in Rural and Semi-urban Areas in India

INTRODUCTION

Gutka, a popular smokeless tobacco (SLT) product combining chewing tobacco, areca nut, and spices, was banned by states in India beginning in 2012. Gutka can be recreated by the user mixing twin packets of tobacco and spice mixtures. We examine the availability of premixed gutka, the sale of twin packets (chewing tobacco and spice mixture sold together but in separate packets) and whether SLT was sold without legally mandated health warning labels (HWLs), without the printed maximum retail price (MRP), and above the MRP.

AIMS AND METHODS

In October/November of 2017, unique SLT packets were purchased using a systematic protocol in 25 localities with populations under 50 000 across five Indian states. Purchase information (location, twin packets, price paid) and packaging information (SLT type, printed MRP, type of HWL) were used to assess legality.

RESULTS

Of the 240 purchases of unique SLT packets, three were premade gutka. Twin packets were half of the sample, sold in every state, and illegally sold in Maharashtra where they were banned. Over half (62%) of single packets and 27% of twin packets did not feature a legal HWL. While only 5% of packets did not have a printed MRP, 29% of single packets, and 38% of twin packets were sold illegally for more than the MRP.

CONCLUSIONS

SLT without the proper HWL or sold above the MRP were common. Twin packets were widely available. India should consider a country-wide restriction to ban single serving tobacco packets that would decrease affordability.

IMPLICATIONS

This study is the earliest and that first outside of Mumbai that we are aware of to present evidence of tobacco products being sold above the MRP in India. While finding little evidence of premade gutka being sold, we found twin packets (chewing tobacco and spice mixture packets sold together) are widely available even in Maharashtra, which has a policy in place to ban twin packets. This study also finds evidence of SLT products sold without the correct HWL and without a MRP listed which shows that implementation and enforcement of regulations are as important as passing regulations.

Claims of Reduced Odor on Tobacco Packs in Low- and Middle-Income Countries

INTRODUCTION

Cigarettes designed to have less smoke smell were developed by the tobacco industry to supposedly reduce negative qualities. Cigarettes with marketing claims communicating these designs have been sold in high-income countries and marketing of "less smoke smell" terms on cigarette packaging can promote cigarette use. It is unclear to what extent they have been marketed in low- and middle-income countries (LMICs).

AIMS AND METHODS

The Tobacco Pack Surveillance System (TPackSS) systemically collected tobacco packs available in 14 LMICs with high tobacco use between 2013 and 2017. We coded 4354 packs for marketing appeals, including claims related to smoke smell. We describe "less smoke smell" and similar claims found on these packs and compare across country and tobacco manufacturers.

RESULTS

Phrases communicating less smoke smell were present on packs purchased in nine of 14 LMICs, including Bangladesh, Brazil, China, India, Mexico, Philippines, Russia, Ukraine, and Vietnam. The most commonly (74.1%) used terminology was "less smoke smell," "LSS," or a combination of the two. Packs from Russia had the most prevalent use (11.8%) of such claims. Companies using these terms across 21 brands included Japan Tobacco International (JTI), British American Tobacco (BAT), Philip Morris International (PMI), and other smaller companies. JTI accounted for 70.9% of packs with such terms.

CONCLUSIONS

Some of the world's largest tobacco companies are communicating less smoke smell on packs in LMICs. Less smoke smell and similar phrases on packaging should be prohibited because they can enhance the appeal of cigarettes.

IMPLICATIONS

Tobacco companies are using "less smoke smell" and similar phrases on cigarette packs in LMICs. These claims have the potential to increase the appeal of smoking and promote cigarette use. Countries should consider policies to restrict attractive labeling claims, in accordance with the WHO Framework Convention on Tobacco Control (FCTC) Article 13 guidelines, which recommends restrictions on attractive design elements on tobacco packaging.

Exploring peer navigation and support in the quality of HIV care experiences of female sex workers in the Dominican Republic

Abstract

Background

Despite evidence on peer navigation’s association with positive HIV outcomes, such as engagement in HIV care and antiretroviral therapy (ART) initiation, the mechanisms through which peer navigation may influence these outcomes have been less explored. The purpose of this study is to describe the role of peer navigation and support on enhancing the quality of HIV treatment and care services experienced by female sex workers (FSWs).

Methods

Survey data was derived from a quantitative cohort (n = 211) of FSWs living with HIV in the Dominican Republic and complemented with data from two rounds of in-depth interviews (IDIs) from a qualitative subsample (n = 20 per round). Descriptive statistics and multivariable logistic regressions were used to explore the association between peer navigation and relational aspects of care and overall satisfaction of the quality of HIV treatment and care. Thematic analysis was employed to code and synthesize textual data from IDIs.

Results

41.2% of the participants reported having had contact with a peer navigator in the last 6 months. Qualitative data revealed that peer navigation and support was instrumental in assisting FSWs linkage to HIV care after diagnosis, elevating FSWs’ ability to access more comprehensive clinical care facilities, and promoting agency by improving FSWs’ skills to more strategically and effectively engage with the clinic environment and health care providers. Peer navigation was positively associated with experiencing more respectful treatment by clinic staff (AOR: 6.65, 95% CI: 2.32–19.02), and greater satisfaction with overall HIV care services (AOR: 2.57, 95% CI: 1.77–3.74).

Conclusion

Promoting the full integration of peer navigation into healthcare structures is a strategic approach to enhance the quality of HIV care experienced by FSWs and improve their HIV-related outcomes.

Straw cigarette branding: misleading descriptors and a new Marlboro man

BACKGROUND

Straw cigarettes are hand-rolled tobacco in a corn straw, common in Brazil and believed to be less harmful by consumers. Traditionally consumed in rural areas and by men, a recent increase in use among young people in urban areas was observed. This study assessed marketing appeals of straw cigarette packaging in Brazil.

METHODS

Following a systematic protocol, unique straw cigarette packs were purchased in 2013, 2016 and 2019 from three cities: Manaus, Salvador and São Paulo. Packs were double-coded for the absence/presence of marketing appeals (ie, luxury/quality, masculinity, classic/timeless, flavours and less harm).

RESULTS

The number of unique straw cigarette packs purchased as part of the overall sample increased in the most recent collection: 2.3% (n=3), 1.3% (n=2) and 15.5% (n=27) in 2013, 2016 and 2019, respectively. Across the years, all packs presented luxury/quality elements (eg, images of crests); 93.8% (n=30) included the word 'artisanal'. Masculine appeal (eg, images of men) was present on 56.3% (n=18) of packs. Almost half had classic/timeless elements, including the words 'tradition'/'original'. In 2019, 59.3% (n=16) of the packs were flavoured compared with none in previous years. Over a quarter of all packs presented a less harm appeal (eg, 'smooth').

CONCLUSION

We identified an increase in availability of unique straw cigarette packs, strong branding and use of misleading descriptors on the packs. The adoption of plain packaging and the implementation of Brazil's additive ban could help to reduce the appeal of straw cigarettes and curb the current increase in use among youth.

Feminine Appeals on Cigarette Packs Sold in 14 Countries

Objective: Limited research has examined feminine marketing appeals on cigarette packs in low-and middle-income countries (LMICs). We reviewed a systematically collected sample of cigarette packs sold across 14 LMICs in 2013 (Wave 1) and 2015–2017 (Wave 2).

Methods: Packs in Wave 1 (n = 3,240) and Wave 2 (n = 2,336) were coded for feminine imagery and descriptors (flowers, fashion, women/girls, color “pink”). We examined trends in feminine appeals over time, including co-occurrence with other pack features (slim or lipstick shape, flavor, reduced harm, and reduced odor claims).

Results: The proportion of unique feminine cigarette packs significantly decreased from 8.6% (n = 278) in Wave 1 to 5.9% (n = 137) in Wave 2 (p < 0.001). Among all feminine packs, flower-and fashion-related features were most common; a substantial proportion also used flavor and reduced odor appeals.

Conclusion: While there was a notable presence of feminine packs, the decline observed may reflect global trends toward marketing gender-neutral cigarettes to women and a general contempt for using traditional femininity to market products directly to women. Plain packaging standards may reduce the influence of branding on smoking among women.

Skin masses in dogs under 1 year of age: 2554 cases (2006-2013)

OBJECTIVES

To utilise a large histopathology database to ascertain the incidence and nature of skin masses in young dogs from 0 to 12 months of age.

MATERIALS AND METHODS

A total of 2554 submissions received for histopathology from dogs 0 to 12 months of age, clinically diagnosed with a skin mass between 2006 and 2013, were retrieved from the database of a large commercial diagnostic laboratory. The histological diagnosis and site of the lesion, together with age, breed and sex of the dog were recorded.

RESULTS

The most common skin mass found in this study was histiocytoma (n=2212, 86.6%). The majority of all submissions were neoplastic (n=2408, 94.3%), and most of those were benign (n=2372, 98.5%). Almost all of the benign neoplastic lesions were of round cell origin (n=2229, 94.0%) whereas most of the non-neoplastic lesions were derived from the epithelium (n=136, 93.8%). The five most commonly diagnosed skin masses in young dogs were histiocytoma, papilloma, dermoid cyst, follicular cyst and mast cell tumour. A male predisposition was shown for histiocytoma (odds ratio 1.72) and mast cell tumour (odds ratio 2.18) with a strong site predilection for the limb region (30.8% and 27.8% respectively). Dermoid cysts and follicular cysts were most commonly found in the skin of the abdomen (64.7% and 52.3% respectively) with boxers being predisposed (25.9% of dermoid cyst and 25.0% of follicular cyst).

CLINICAL SIGNIFICANCE

A large proportion of skin mass submissions in young dogs were neoplastic and benign. Also, the most common skin mass in young dogs was found to be histiocytoma. Tumours can occur in this age group and should be considered as a potential differential diagnosis also in young patients presenting with a skin mass.

Why do breast cancer survivors decline a couple-based intimacy enhancement intervention trial?

Recruitment challenges hinder behavioral intervention research in cancer survivors. The purpose was to examine the reasons for declining and intervention preferences of study-eligible breast cancer survivors declining a trial of a four-session couple-based Intimacy Enhancement intervention (refusers) and explore whether refusers differed from participants on key characteristics. Partnered, post-treatment breast cancer survivors reporting sexual concerns who were eligible for but declined participation in the intervention trial were approached to complete a standardized 5-min telephone survey assessing reasons for declining and support preferences. Demographic, clinical, and sexual concerns information were collected during screening. Trial participants and refusers were compared on key variables of age, race, hormone therapy use, time since treatment, level of sexual concerns, and recruitment method using t-tests or chi-square tests. Among the 31 women who declined the trial and completed the survey, the most common reasons for declining were time commitment (74%) and partner noninterest (32%). Most (61%) reported that the telephone format played little to no role in their refusal. Eighty-one percent wanted their partners involved in a program addressing sexual concerns. The two most preferred resources were informational websites (45%) and meeting with a professional (26%). Trial participants and refusers did not differ on any key factors examined. Developing intimacy interventions that are very brief, partner-optional, or that use stepped care may bolster uptake. The methods used to examine study-eligible candidates' needs and preferences could be employed in other health populations, thus having broader implications for research design.

Simplifying survivorship care planning: A randomized controlled trial comparing three care plan delivery approaches

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Background: Survivorship care plans (“plans”) have been promoted to smooth the transition from active cancer treatment to survivorship. However, the time and resources involved in plan completion and delivery have been barriers to implementation. This randomized controlled trial aimed to identify the simplest, most effective approach for implementing survivorship care planning. Methods: Stage 1-3 breast, colorectal, and prostate cancer patients aged 21+ who were completing acute treatment were recruited from one urban-academic and one rural-community cancer center. Participants were randomized, stratified by recruitment site and cancer type, 1:1:1 to (a) mailed plan (“mail”), (b) plan delivered during one-time transition visit (“one-visit”), or (c) plan delivered during transition visit plus a 6-month follow-up visit (“two-visit”). Health service use (visits, tests/procedures, non-oral medications) was collected from participants and medical records for 18 months and compared to the plan recommendations. Logistic regression, adjusting for cancer type and recruitment site, was used to evaluate the primary outcome of adherence to recommendations for all health service use categories by intervention arm. Descriptive analyses compared care receipt for each health service use category separately (i.e., visits, tests/procedures, non-oral medications). Results: Of 378 participants randomized (n = 126 mail; n = 125 one-visit; n = 127 two-visit), 316 (84%) were analyzable for the primary outcome (n = 107 mail; n = 105 one-visit; n = 104 two-visit): 164 (52%) recruited from the urban-academic and 152 (48%) from the rural-community site; 137 (43%) breast, 112 (35%) prostate, 67 (21%) colorectal cancer; mean age 62 years. For the primary outcome, there was no difference across arms in the proportion of participants who received all plan-recommended care: 45.2% mail, 50.5% one-visit, 42.7% two-visit (p = 0.60). We did not find significant interactions by recruitment site or cancer type. There were also no differences in receipt of recommended care by category of health service use. The proportion of participants who had the recommended number of visits was 53.4% mail, 54.8% one-visit, 53.7% two-visit (p = 0.99). The proportion undergoing recommended tests/procedures was 78.8% mail, 77.2% one-visit, 73.0% two-visit (p = 0.62). The proportion receiving recommended non-oral medications was 66.7% mail, 75.0% one-visit, 73.7% two-visit (p = 0.87). Conclusions: This study found no significant difference in receipt of recommended follow-up care by plan delivery approach. Across study arms, survivors were more likely to receive recommended tests/procedures and non-oral medications but less likely to have the recommended number of visits. Feasibility and other factors may determine the best survivorship care planning approach. Clinical trial information: NCT03035773.

The Market for Bidis, Smokeless Tobacco, and Cigarettes in India: Evidence From Semi-Urban and Rural Areas in Five States

Objectives: Compare the brand availability, pricing and presence of illicit products in semi-urban and rural areas in India across product types and states.

Methods: In late 2017, 382 unique tobacco products were purchased from localities with populations under 50,000 in the states of Assam, Karnataka, Maharashtra, Rajasthan, and Uttar Pradesh. Brand, printed maximum retail price, price paid, tax, and health warning labels (HWLs) were used to compare the market for bidis, smokeless tobacco (SLT), and cigarettes.

Results: Brand availability and pricing of SLT products was similar to cigarettes. Brand availability and pricing of bidis was consistent with having many small producers. Bidis and single serving SLT with spice mixtures were more affordable than cigarettes and SLT sold alone. 2% of SLT and 10% of cigarettes did not feature an India HWL.

Conclusion: The elimination of single serving SLT packets and the removal of tax exemptions for small producers, often exploited by bidi producers, could reduce their respective affordability. State differences in illegal and illicit products could indicate a greater need for enforcement in some states.

Analysis of wedding appeals on cigarette packs in China

Introduction

Exchanging or gifting cigarettes is a common practice in Chinese culture, often occurring during weddings to connote celebrations and happiness. We examined Chinese cigarette packs for wedding terminology and imagery to assess the extent to which packs are marketed for such occasions.

Methods

Cigarette packs were collected from Beijing, Guangzhou, Shanghai, Kunming and Chengdu in February 2017 using a systematic protocol designed to capture unique packs. Packs were coded by two independent coders for text and imagery of traditional Chinese wedding symbols, such as double happiness, dragon and phoenix, and other culturally specific phrases and images associated with weddings in China.

Results

From the sample of 738 unique cigarette packs, 68 (9.2%) contained either lexical and/or imagery appeals for wedding gifting. Of these 68 packs, 65 contained both lexical and imagery appeals, 1 pack had only a lexical appeal and 2 packs only included an imagery appeal. The most common appeal was ‘double happiness’ found on 56 packs (82.4%) for both lexical and imagery, followed by ‘dragon and phoenix’ found lexically on 12 packs (17.6%), and through imagery on 15 packs (22.1%).

Conclusions

Chinese tobacco manufacturers take full advantage of the cigarette gifting and sharing culture demonstrated by packs with imagery and terminology specific to weddings. With only a 35% text health warning label, manufacturers have much real estate to make packs attractive for gifting on such occasions. Implementing plain packaging policies may be effective in decreasing gifting attractiveness for cigarette packs.

Variations in recommended surveillance in colorectal cancer survivorship care plans

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Background: Survivorship care plans (SCPs) outline pertinent information about a cancer survivor’s treatment and follow-up care. We describe the content of colorectal cancer (CRC) SCPs, completed as part of a randomized controlled trial of SCPs, and evaluate whether follow-up recommendations are guideline concordant. Methods: We analyzed 74 CRC SCPs from an academic and community cancer center. Frequency distributions and descriptive statistics were calculated for the entire cohort and separately by recruiting site. Follow-up recommendations were compared to American Cancer Society (ACS), American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines (Table). Results: Content routinely provided in SCPs (>80%) included patient demographics, cancer diagnosis, treatment details (surgery, chemotherapy, radiation therapy) as well as treatment-related side effects. SCP content specified less frequently included cancer stage, cancer risk (predisposing conditions), and recommendations for genetic counseling/testing and health promotion. Nearly all SCPs from the community site provided uniform, guideline-concordant follow-up. At the academic site, on average, more than 15 follow-up recommendations were listed for each surveillance modality, except colonoscopy. Among the SCPs that specified the frequency of follow-up care, the rate of guideline-concordant recommendations was 15/42 (36%) for follow-up visits, 29/43 (67%) for imaging, 12/45 (27%) for laboratory and 39/39 (100%) for colonoscopy. Conclusions: SCPs consistently provided information about CRC diagnosis and treatment, but often omitted information about cancer risk, staging and prognosis. There was considerable variation between cancer centers in the follow-up recommendations suggested for CRC survivors. Future work to improve the consistency of SCP follow-up recommendations with guidelines may be needed. Clinical trial information: NCT03035773 . [Table: see text]

Smoke and Scan: A Content Analysis of QR Code-Directed Websites Found on Cigarette Packs in China

Introduction

Quick Response codes, or “QR” codes, are used widely in China—for mobile payment, marketing, public transportation, and various other applications. In this study, we examined the content of websites linked from QR codes on cigarette packs collected in China.

Aims and Methods

In February 2017, 738 unique cigarette packs were collected from five Chinese cities (Beijing, Guangzhou, Shanghai, Kunming, and Chengdu) using a systematic protocol. Cigarette packs were coded for presence of QR codes on packaging. Packs containing QR codes were then scanned using the WeChat app. Websites sourced from QR codes were coded for required verification, website type, age- and health-related statements, engagement strategies, and marketing appeals.

Results

From the sample of 738 unique packs, 109 packs (14.8%) had a QR code on the packaging. The QR codes were linked to 24 unique websites of which 23 could be analyzed. All 23 unique websites were either brand-specific or social media websites; none focused on health or quit information. Of the 23 websites, only three (13.0%) websites had age-restricted site access and just six (26.1%) had any mention of health-related risks associated with product usage. Engagement strategies and/or marketing appeals were found on 20 (87.0%) websites.

Conclusions

The Chinese tobacco industry uses QR codes on cigarette packaging to link to web-based marketing content including social media recruitment, contests and giveaways, and product advertisement. It is important to understand where packs send consumers online and what messages they receive, and to consider QR codes on packaging when drafting policy.

Implications

Scanning QR codes in China is a commonplace activity. The authors are aware of no published studies on the role QR codes play on the marketing of cigarette packs, in China or elsewhere. This study demonstrates QR codes on cigarette packs can expose users and nonusers to cigarette marketing on interactive websites and protobacco social media pages, mostly without restrictive access or health warnings. This is an area that health authorities can consider regulating, given that this is a channel through which the tobacco industry can communicate with current and potential consumers.

Patient-reported outcomes in RA care improve patient communication, decision-making, satisfaction and confidence: qualitative results

OBJECTIVE

To evaluate the impact of integrating patient-reported outcomes (PROs) into routine clinics, from the perspective of patients with RA, clinicians and other staff.

METHODS

We conducted a prospective cohort study using a mixed methods sequential explanatory design at an academic arthritis clinic. RA patients completed selected Patient-Reported Outcomes Measurement Information System measures on tablets in the waiting room. Results were immediately available to discuss during the visit. Post-visit surveys with patients and physicians evaluated topics discussed and their impact on decision making; patients rated confidence in treatment. Focus groups or interviews with patients, treating rheumatologists and clinic staff were conducted to understand perspectives and experiences.

RESULTS

Some 196 patients and 20 rheumatologists completed post-visit surveys at 816 and 806 visits, respectively. Focus groups were conducted with 24 patients, 10 rheumatologists and 4 research/clinic staff. PROs influenced medical decision-making and RA treatment changes (38 and 18% of visits, respectively). Patients reported very high satisfaction and treatment confidence. Impact on clinical workflow was minimal after a period of initial adjustment. PROs were valued by patients and physicians, and provided new insight into how patients felt and functioned over time. Reviewing results together improved communication, and facilitated patient-centred care, shared decision making, and the identification of new symptoms and contributing psychosocial/behavioural factors.

CONCLUSION

PRO use at RA visits was feasible, increased understanding of how disease affects how patients feel and function, facilitated shared decision-making, and was associated with high patient satisfaction and treatment confidence.

Global review of tobacco product flavour policies

OBJECTIVE

We determined which countries prohibit flavoured tobacco products and the details of those restrictions in order to identify possible gaps and opportunities for these and other countries to address.

METHODS

We reviewed the grey literature, scanned news articles and consulted with key informants and identified 11 countries and the European Union (EU) that ban or restrict tobacco product flavours. We reviewed policy documents for their stated policy rationale, terms and definitions of flavours, tobacco products covered and restrictions on the use of flavour imagery and terms on tobacco product packaging.

RESULTS

Countries with a tobacco product flavour policy include the USA, Canada, Brazil, Ethiopia, Uganda, Senegal, Niger, Mauritania, EU (28 Member States), Moldova, Turkey and Singapore. Most of the countries' policies provide a rationale of dissuading youth from taking up tobacco use. Ten of the 12 policies use the terms 'flavours' (n=6) or 'characterising flavours' (n=4). Six policies cover all products made entirely or partly of tobacco leaf. Countries consistently prohibit flavours associated with fruits, vanilla and spices. The USA and Niger make an exception for menthol, while Mauritania and Uganda do not specify the scope of flavours or ingredients covered by their policies. Eight policies make no specific reference to restricting flavour descriptors on tobacco product packaging.

CONCLUSION

Countries looking to implement policies restricting flavours in tobacco products can build on existing comprehensive policies. Future research could examine the implementation and impacts of these policies, to inform other countries interested in acting in this policy domain.

Menthol and flavor capsule cigarettes in the Philippines: A comparison of pack design

INTRODUCTION

Tobacco use is a major public health problem in the Philippines. Menthol flavored and flavor capsule cigarettes are independently associated with increased smoking initiation and appeal to youth and young adults. Packaging is an important tobacco marketing tool. We describe cigarette packs sold in the Philippines market and describe products’ flavor and capsule inclusion.

METHODS

Tobacco packs were systematically collected in the Philippines in 2016 and categorized as non-flavored non-capsule, menthol non-capsule, menthol capsule, and non-menthol capsule. Structural elements (e.g. pack type, shape) and graphic components (e.g. imagery, descriptors, color) of the packs were compared.

RESULTS

Menthol capsule packs were significantly more likely to be hard packs than menthol non-capsule. Menthol packs were more likely to be colored green than non-flavored packs. Non-menthol capsule packs were more likely to display the term ‘fresh’ than non-capsule packs. Capsule packs were more likely to display technological appeals than non-capsule packs.

CONCLUSIONS

Menthol and flavor capsule cigarettes are packaged differently (most notably, in terms of color and technological appeals) than non-menthol and non-capsule packs. Packaging and labeling policy should take this into consideration.

Maternal Knowledge, Attitudes, and Behavioral Intention after Exposure to Injury Prevention Recommendations in the News Media

INTRODUCTION

Injury prevention recommendations are frequently presented in the media. Parental understanding and response to these recommendations remain uninvestigated.

METHODS

A nationally representative sample of 1,081 mothers completed a cross-sectional survey measuring knowledge, attitudes, and behavioral intention after watching/reading video news stories and print articles on two child safety topics.

RESULTS

Of the 1,081 respondents, 33% reported hearing little about injury prevention in the media in the past 30 days, and 32% reported never hearing about injury prevention. Nearly one-half (46%) reported the injury prevention studies they had previously read or heard about in the media were confusing to them at least some of the time. The proportion of mothers who recalled the correct key statistic presented in the story varied by safety topic and medium in which the story was presented. A greater proportion of mothers correctly recalled information from the story narrative than the statistics. Mothers also rated the most interesting part of the story differently based on safety topic and medium. A small proportion were not planning to follow the safety recommendations after viewing the news story.

CONCLUSIONS

There are gaps in making injury news stories understandable and memorable for mothers in order to encourage behavioral change.

Preparing Older Patients With Serious Illness for Advance Care Planning Discussions in Primary Care

CONTEXT

Little is known about how to prepare older patients for advance care planning (ACP) discussions in primary care.

OBJECTIVES

The objective of the study was to explore older patients' perspectives and experiences on ACP discussions with family members and/or primary care clinicians.

METHODS

We conducted a qualitative interview study with 20 older patients who were involved in the clinic's ACP quality improvement initiative. We used an inductive approach to generate a coding scheme and used thematic analysis alongside a constant comparative methodology to iteratively refine emergent themes after coding the data. We used the transtheoretical behavior change model to conceptualize the process of ACP discussions, focusing on the contemplation, preparation, and action stages.

RESULTS

Four key themes emerged from our analyses: 1) the relevance/importance of ACP as a whole; 2) independently conceptualizing wishes and preferences for the future; 3) the process of engagement in ACP discussions; and 4) different outcomes of ACP discussions. While patients contemplated having an ACP discussion, they needed time to conceptualize their wishes on their own before documenting wishes or engaging with others. Moving to the preparation stage, patients shared their perspectives about how to engage family members and primary care clinicians in ACP discussions and reported different outcomes of these discussions, which varied according to patients' goals for ACP.

CONCLUSION

Understanding how to best prepare patients for ACP discussions from patients enrolled in an ACP primary clinic quality improvement initiative may assist primary care practices in developing interventions to improve the occurrence and effectiveness of such discussions.

Promoting Bike Helmet Safety for Urban Children Through a Culturally Tailored Educational Video Intervention

Bicycle-related falls are a significant cause of mortality and morbidity. Use of bicycle helmets substantially reduces risk of severe traumatic brain injury but compliance with this safety practice is particularly low in urban children. We recruited eleven 8- to 15-year-old youth to participate in focus groups to inform the creation of a video promoting helmet use. Key emerging themes included that youth were responsible for keeping themselves safe and that most youth had cell phones with cases to protect them. A video was created that linked the concept of use of cases to protect phones to use of helmets to protect heads. Soliciting information from urban youth was helpful for developing this educational video.

A randomized pilot trial of a couple-based intervention addressing sexual concerns for breast cancer survivors

The purpose was to test the feasibility, acceptability, and preliminary efficacy of a 4-session couple-based Intimacy Enhancement (IE) intervention addressing breast cancer survivors' sexual concerns delivered via telephone. Twenty-nine post-treatment breast cancer survivors reporting sexual concerns and their intimate partners were randomized (2:1) to the IE intervention or to an educational control condition, both of which were delivered by trained psychosocial providers. Feasibility and acceptability were measured through recruitment, retention, session completion, and post-intervention program evaluations. Couples completed validated sexual, relationship, and psychosocial outcome measures at pre- and post-intervention. Between-group effect sizes and 95% confidence intervals were calculated using the Hedges g. Data supported intervention feasibility and acceptability. For survivors, the IE intervention had medium to large positive effects on all sexual outcomes and most psychosocial outcomes. Effects were less visible for relationship outcomes and were similar but somewhat smaller for partners. The IE intervention demonstrated feasibility, acceptability, and promise in addressing breast cancer survivors' sexual concerns and enhancing their and their partners' intimate relationships and psychosocial well-being. Implications for Psychosocial Oncology Practice The IE intervention demonstrated feasibility and acceptability, suggesting it could be well-received by breast cancer survivors with sexual concerns and their partners. Effects of the IE intervention on breast cancer survivors' sexual concerns and on their and their partners' intimate relationships and psychosocial well-being could not be attributed to therapist time and attention. Interventions that psychosocial providers can use to address breast cancer survivors' sexual concerns are important to the growing number of breast cancer survivors living for many years after their diagnosis.

Cost-effectiveness of health coaching and financial incentives to promote physical activity after total knee replacement

OBJECTIVE

We evaluated the cost-effectiveness of Telephonic Health Coaching and Financial Incentives (THC + FI) to promote physical activity in total knee replacement recipients.

DESIGN

We used the Osteoarthritis Policy Model, a computer simulation of knee osteoarthritis, to evaluate the cost-effectiveness of THC + FI compared to usual care. We derived transition probabilities, utilities, and costs from trial data. We conducted lifetime analyses from the healthcare perspective and discounted all cost-effectiveness outcomes by 3% annually. The primary outcome was the Incremental Cost-Effectiveness Ratio (ICER), defined as the ratio of the differences in costs and Quality-Adjusted Life Years (QALYs) between strategies. We considered ICERs <$100,000/QALY to be cost-effective. We conducted one-way sensitivity analyses that varied parameters across their 95% confidence intervals (CI) and limited the efficacy of THC + FI to 1 year or to 9 months. We also conducted a probabilistic sensitivity analysis (PSA), simultaneously varying cost, utilities, and transition probabilities.

RESULTS

THC + FI had an ICER of $57,200/QALY in the base case and an ICER below $100,000/QALY in most deterministic sensitivity analyses. THC + FI cost-effectiveness depended on assumptions about long-term efficacy; when efficacy was limited to 1 year or to 9 months, the ICER was $93,300/QALY or $121,800/QALY, respectively. In the PSA, THC + FI had an ICER below $100,000/QALY in 70% of iterations.

CONCLUSIONS

Based on currently available information, THC + FI might be a cost-effective alternative to usual care. However, the uncertainty surrounding this choice is considerable, and further research to reduce this uncertainty may be economically justified.

Combining online and in-person methods to evaluate the content validity of PROMIS fatigue short forms in rheumatoid arthritis

PURPOSE

Fatigue is frequent and often severe and disabling in RA, and there is no consensus on how to measure it. We used online surveys and in-person interviews to evaluate PROMIS Fatigue 7a and 8a short forms (SFs) in people with RA.

METHODS

We recruited people with RA from an online patient community (n = 200) and three academic medical centers (n = 84) in the US. Participants completed both SFs then rated the comprehensiveness and comprehensibility of the items to their fatigue experience. Cognitive debriefing of items was conducted in a subset of 32 clinic patients. Descriptive statistics were calculated, and associations were evaluated using Pearson and Spearman correlation coefficients.

RESULTS

Mean SF scores were similar (p ≥ .61) among clinic patients reflecting mild fatigue (i.e., 54.5-55.9), but were significantly higher (p < .001) in online participants. SF Fatigue scores correlated highly (r ≥ 0.82; p < .000) and moderately with patient assessments of disease activity (r ≥ 0.62; p = .000). Most (70-92%) reported that the items "completely" or "mostly" reflected their experience. Almost all (≥ 94%) could distinguish general fatigue from RA fatigue. Most (≥ 85%) rated individual items questions as "somewhat" or "very relevant" to their fatigue experience, averaged their fatigue over the past 7 days (58%), and rated fatigue impact versus severity (72 vs. 19%). 99% rated fatigue as an important symptom they considered when deciding how well their current treatment was controlling their RA.

CONCLUSIONS

Results suggest that items in the single-score PROMIS Fatigue SFs demonstrate content validity and can adequately capture the wide range of fatigue experiences of people with RA.

Family companions' involvement during pre-surgical consent visits for major cancer surgery and its relationship to visit communication and satisfaction

OBJECTIVE

To examine the association between family companion presence during pre-surgical visits to discuss major cancer surgery and patient-provider communication and satisfaction.

METHODS

Secondary analysis of 61 pre-surgical visit recordings with eight surgical oncologists at an academic tertiary care hospital using the Roter Interaction Analysis System (RIAS). Surgeons, patients, and companions completed post-visit satisfaction questionnaires. Poisson and logistic regression models assessed differences in communication and satisfaction when companions were present vs. absent.

RESULTS

There were 46 visits (75%) in which companions were present, and 15 (25%) in which companions were absent. Companion communication was largely emotional and facilitative, as measured by RIAS. Companion presence was associated with more surgeon talk (IRR 1.29, p = 0.006), and medical information-giving (IRR 1.41, p = 0.001). Companion presence was associated with less disclosure of lifestyle/psychosocial topics by patients (IRR 0.55, p = 0.037). In adjusted analyses, companions' presence was associated with lower levels of patient-centeredness (IRR 0.77, p 0.004). There were no differences in patient or surgeon satisfaction based on companion presence.

CONCLUSION

Companions' presence during pre-surgical visits was associated with patient-surgeon communication but was not associated with patient or surgeon satisfaction.

PRACTICE IMPLICATIONS

Future work is needed to develop interventions to enhance patient-companion-provider interactions in this setting.

Compliance with the City of Chicago's partial ban on menthol cigarette sales

INTRODUCTION

In the USA, menthol cigarettes are associated with smoking initiation and decreased likelihood of cessation, particularly for low-income and non-White populations. Local ordinances to restrict menthol cigarette sales are an emergent policy option. In July 2016, Chicago, Illinois became the first major US city to ban menthol cigarette sales within 500 feet of schools. This study assessed ban compliance in June 2017.

METHODS

We randomly selected 100 of 154 stores within 500 feet of a high school. Ninety stores were included in the analysis, excluding permanently closed stores or stores that did not sell tobacco prior to the ban. Compliance was determined by whether a menthol cigarette pack was purchased. We also assessed presence of menthol cigarette replacement packs. Multivariable logistic regression modelled compliance by store type, school (distance to high school, school type) and neighbourhood-level factors (poverty level, proportion of non-White residents).

RESULTS

Compliance rate was 57% (weighted, n=53) and no replacement packs were observed. Non-compliant stores were more likely to advertise menthol cigarettes, but ads were present in eight compliant stores. Gas stations had 81% lower odds (OR=0.19, 95% CI 0.06 to 0.58) of complying with the menthol cigarette ban compared with larger/chain stores. School-level and neighbourhood factors were not associated with compliance.

DISCUSSION

The poor compliance observed with Chicago's partial menthol cigarette ban highlights the need for comprehensive efforts. Optimising local resources to target enforcement efforts in gas stations could improve compliance. Ordinances that also restrict advertising could potentially enhance ban impact by reducing exposure to product and promotions.

Older Patients' Perspectives on Quality of Serious Illness Care in Primary Care

BACKGROUND

Despite increased focus on measuring and improving quality of serious illness care, there has been little emphasis on the primary care context or incorporation of the patient perspective.

OBJECTIVE

To explore older patients' perspectives on the quality of serious illness care in primary care.

DESIGN

Qualitative interview study.

PARTICIPANTS

Twenty patients aged 60 or older who were at risk for or living with serious illness and who had participated in the clinic's quality improvement initiative.

METHODS

We used a semistructured, open-ended guide focusing on how older patients perceived quality of serious illness care, particularly in primary care. We transcribed interviews verbatim and inductively identified codes. We identified emergent themes using a thematic and constant comparative method.

RESULTS

We identified 5 key themes: (1) the importance of patient-centered communication, (2) coordination of care, (3) the shared decision-making process, (4) clinician competence, and (5) access to care. Communication was an overarching theme that facilitated coordination of care between patients and their clinicians, empowered patients for shared decision-making, related to clinicians' perceived competence, and enabled access to primary and specialty care. Although access to care is not traditionally considered an aspect of quality, patients considered this integral to the quality of care they received. Patients perceived serious illness care as a key aspect of quality in primary care.

CONCLUSIONS

Efforts to improve quality measurement and implementation of quality improvement initiatives in serious illness care should consider these aspects of care that patients deem important, particularly communication as an overarching priority.

A review of paper-based advance care planning aids

Background

Advance care planning (ACP) aids can help prepare patients, family members, and physicians for in-the-moment medical decision-making. We wished to describe the content and approach of paper-based ACP aids in order to characterize existing aids and inform the development of a new ACP aid.

Methods

Paper-based ACP aids were identified through an environmental scan and screened for eligibility. ACP conceptual frameworks and data were gathered via stakeholder engagement and used to inform the coding framework that two investigators used to independently code each aid. A directed content analysis was conducted on these eligible aids. Aids were categorized through a deliberative process with an investigator abstracting general information for each aid.

Results

Fifteen aids met the eligibility criteria. They ranged in length from 6 to 78 pages with the average aid written at an eighth-grade reading level. The content analysis revealed that many aids encouraged choosing a surrogate decision maker and informed users about legal medical documents. Fewer than half of the aids facilitated patient clarification of values regarding quality of life issues. The authors identified and termed the following three categories of aids: informative; semi-action oriented; and action-oriented. It was often unclear whether patients contributed to the development or testing of the ACP aids reviewed.

Conclusions

Most existing paper-based ACP aids address legal matters such as completing an advance directive. Only a minority elicited patient values and it was unclear whether any were developed in partnership with patients. Future development of ACP aids should account for patient preferences with a goal of supporting in-the-moment medical decision-making.

Abstract P6-12-21: Breast cancer survivors undergoing survivorship visits at Johns Hopkins are a high-risk population

Background: Survivorship care plans (SCPs) are strongly recommended for all breast cancer survivors to address sequelae of cancer care, plan cancer surveillance and screening, and encourage health promotion and care coordination. Ongoing studies are evaluating the impact of SCPs in cancer survivor populations and the role of survivorship visits (SVs) as an intervention. Here we describe characteristics and outcomes of patients who participated in SVs at Johns Hopkins (JH).

Methods: We retrospectively reviewed the charts of patients who participated in a SV with one of two nurse practitioners ˜1-3 months after completion of locoregional therapy and initial systemic therapy, as referred by their JH breast cancer provider. We collected patient demographics, comorbidity status, tumor characteristics, treatments received, and responses to GAD7 (generalized anxiety disorder 7-item), PHQ9 (patient health questionnaire-9), and a symptom questionnaire. Characteristics of SV participants were compared to analytical breast cancer cases from the JH Cancer Registry (JHCR 2010-2015), matched for stage.

Results: 87 women (stages I-III) who participated in a SV in 2010-2016 were identified. Compared to patients in the JHCR (n=2,942), the SV cohort was younger (age ≤50, 43% v 34%, p=0.14), more likely to be African American (33% v 22%, p=0.04), and more likely to have a higher TNM stage (I, 26% v 49%; II, 48% v 37%; III, 25% v 15%, p&lt;0.001), node-positive status (60% v 33%, p&lt;0.001), hormone receptor-negative disease (44% v 18%, p&lt;0.001), and HER2-positive disease (38% v 14%, p&lt;0.001). The SV cohort was also more likely to receive chemotherapy (94% v 43%, p&lt;0.001) and undergo radiation therapy (78% v 54%, p&lt;0.001). The SV cohort had a higher recurrence event rate than the JHCR cohort (11.5% v 8.0%) and a shorter median follow-up (886 v 1292 days), suggestive of a higher risk profile. In the SV cohort, a comparison of comorbidities at breast cancer diagnosis versus time of SV visit identified a significant increase in the prevalence of peripheral neuropathy (9% v 73%, p&lt;.001), anemia (15% v 50%, p&lt;.001), lymphedema (0% v 28%, p&lt;.001), anxiety (15% v 38%, p&lt;.001), and depression (13% v 29%, p&lt;.001). Patients in the SV cohort were overweight at diagnosis (body mass index, median 29 [IQR 24, 32]). At the time of the SV, patients reported symptoms of sleep difficulty (53%), numbness or tingling (46%), weight changes (45%), muscle aches (44%), and pain (37%).

Conclusions: Patients who participated in SVs had high-risk cancers and, compared to baseline, a higher frequency of comorbidities that are potentially associated with breast cancer and its treatment. These data can inform future breast cancer survivorship care models as they describe a population that may be at greater risk for worse cancer and non-cancer outcomes, and that might benefit more from interventions like SCPs and SVs. Ongoing studies are identifying optimal target populations, appropriate timing of such interventions, and informative measures of patient-centered outcomes.

Funding: Komen Maryland/Komen Scholar SAC110053 (ACW).

Citation Format: Skuli SJ, Bantug ET, Zafman N, Riley C, Ruck JM, Sheng J, Smith KC, Snyder CF, Smith KL, Stearns V, Wolff AC. Breast cancer survivors undergoing survivorship visits at Johns Hopkins are a high-risk population [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-21.

Media Messages and Perception of Risk for Ebola Virus Infection, United States

News media have been blamed for sensationalizing Ebola in the United States, causing unnecessary alarm. To investigate this issue, we analyzed US-focused news stories about Ebola virus disease during July 1–November 30, 2014. We found frequent use of risk-elevating messages, which may have contributed to increased public concern.

A qualitative exploration of companion involvement in the presurgical consent visit for patients undergoing major surgery for advanced cancer

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Background: The decision to undergo non-emergent cancer surgery is complicated by risk of mortality and diminished quality of life weighed against potential benefits of extended life and symptom management. Sometimes, unanticipated clinical information or quality of life considerations (“disruptions”) arise during these pre-surgical visits, which can lead to to the surgery’s reconsideration, postponement, or cancelation. Little is known about disruptions. This paper explores case studies of how patients, companions, and surgeons negotiate surgical plan disruptions. Methods: This study is based on secondary analysis of pre-surgical recordings with 61 patients and nine surgeons. Patients were recruited at nine surgical oncology clinics at an academic tertiary care hospital from July 2015-September 2016. Qualitative analysis incorporated existing theory and inductively developed codes. Results: Four of the 61 pre-surgical visits were identified as having a disruption. Each case study explores the presentation of the disruption, patient reaction to the disruption, companion involvement and role in the encounter, and resolution of the disruption. While each disruption involves a nuanced approach to decision making, there are cross cutting themes across the cases. Specifically, analysis of these visits explored companion roles, including: patient autonomy-enhancing behaviors and patient autonomy-detracting behaviors. This analysis also addressed variation and similarities in surgeons’ behaviors, including examples of collaborative, facilitative, and informative behaviors. Conclusions: As more high risk surgeries are performed on sicker and older patients, decision making regarding whether to pursue surgery may become increasingly complex, and lend itself more frequently to disruptions. Disruption reflects the engagement and mutual influence of multi-party participants in treatment decision making. By enhancing our understanding of disruptions, we hope to assist in the delicate communication and shared decision making needed for a patient and family centered resolution. Clinical trial information: NCT02489799.

Family companions’ involvement during pre-surgical consent visits for major cancer surgery and its relationship to visit communication and satisfaction

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Background: While research has explored the role of companions (accompanying family members) in medical visits, studies have not examined companions’ involvement in pre-surgical visits. This study explored how companions’ presence impacts communication and satisfaction during pre-surgical visits to discuss major cancer surgery. Methods: Secondary analysis of 61 pre-surgical visit recordings with 8 surgical oncologists at an academic tertiary care hospital. Recordings were analyzed using the Roter Interaction Analysis System, and surgeons and patients completed a post-visit satisfaction questionnaire. Poisson and logistic regression models were used to assess differences in communication and satisfaction when companions were present (n = 46, 75%) and not present (n = 16, 25%). Models were fit using generalized estimating equations to account for nesting of patients within surgeons. Results: Companion communication was largely emotional and facilitative. In unadjusted analyses, companion presence was associated with a 29% increase in surgeon talk in the visit overall (IRR 1.29, p = 0.006), and a 41% increase in the amount of medical information provided (IRR 1.41, p = 0.001). Companion presence was associated with 45% less patient disclosure related to lifestyle/psychosocial topics (IRR 0.55, p = 0.037). In adjusted analyses, companions’ presence was associated with 23% lower levels of patient-centeredness (IRR 0.77, p 0.004). No difference between visits with and without companions in patient nor surgeon satisfaction. Conclusions: Companions’ presence increased the medical focus of the discussion; surgeons conveyed more medical information, and patients disclosed less psychosocial information. Companions might perceive patients as anxious prior to major surgery, compelling companions to advocate for the patient. Companion’s presence might be beneficial; however, this benefit might not be captured by the patient-centeredness ratio. As there was no difference in satisfaction, patient and surgeon satisfaction may not be predicated on patient-centeredness, but on the conveyance of timely, surgery-related information. Clinical trial information: NCT02489799.

"We're Just Not Prepared for Eating Over Our Whole Life": A Mixed Methods Approach to Understanding Dietary Behaviors Among Longer Term Cancer Survivors

Background: In many countries, there are growing numbers of persons living with a prior diagnosis of cancer, due to the aging population and more successful strategies for treatment. There is also growing evidence of the importance of healthful diet and weight management for survivorship, yet many long-term cancer survivors are not successfully following recommendations. Methods: We explored this issue in a mixed methods study with 53 adult survivors of 3 cancers (breast, prostate, and non-Hodgkin’s lymphoma), living in Maryland. Participants provided three 24-hour dietary recalls, and results were used to classify respondents on 2 metrics of healthful eating (the Healthy Eating Index 2010, and a 9-item index based on current dietary recommendations). Recalls were also used to guide in-depth qualitative discussions with participants regarding self-assessment of dietary behaviors, healthful eating, and diet’s importance in cancer prevention and survivorship. Results: Survivors following a more healthful diet were more likely to be female, have greater socioeconomic resources, more years since diagnosis, normal weight, and no smoking history. Qualitative discussions revealed a more nuanced understanding of dietary strategies among healthful eaters, as well as the importance of household members in dietary decision making. Discussion: Most survivors had received little nutrition counseling as part of their cancer care, highlighting the importance of holistic, household-oriented nutrition education for maintaining health among long-term cancer survivors.

An analysis of purchase price of legal and illicit cigarettes in urban retail environments in 14 low- and middle-income countries

BACKGROUND/AIMS

To estimate and compare price differences between legal and illicit cigarettes in 14 low- and middle-income countries (LMIC).

DESIGN

A cross-sectional census of all packs available on the market was purchased.

SETTING

Cigarette packs were purchased in formal retail settings in three major cities in each of 14 LMIC: Bangladesh, Brazil, China, Egypt, India, Indonesia, Mexico, Pakistan, the Philippines, Russia, Thailand, Turkey, Ukraine and Vietnam.

PARTICIPANTS

A total of 3240 packs were purchased (range = 58 packs in Egypt to 505 in Russia). Packs were categorized as 'legal' or 'illicit' based on the presence of a health warning label from the country of purchase and existence of a tax stamp; 2468 legal and 772 illicit packs were in the analysis.

MEASUREMENTS

Descriptive statistics stratified by country, city and neighborhood socio-economic status were used to explore the association between price and legal status of cigarettes.

FINDINGS

The number of illicit cigarettes in the sample setting was small (n < 5) in five countries (Brazil, Egypt, Indonesia, Mexico, Russia) and excluded from analysis. In the remaining nine countries, the median purchase price of legal cigarettes ranged from US$0.32 in Pakistan (n = 72) to US$3.24 in Turkey (n = 242); median purchase price of illicit cigarettes ranged from US$0.80 in Ukraine (n = 14) to US$3.08 in India (n = 41). The difference in median price between legal and illicit packs as a percentage of the price of legal packs ranged from 32% in Philippines to 455% in Bangladesh. Median purchase price of illicit cigarette packs was higher than that of legal cigarette packs in six countries (Bangladesh, India, Pakistan, Philippines, Thailand, Vietnam). Median purchase price of illicit packs was lower than that of legal packs in Turkey, Ukraine and China.

CONCLUSIONS

The median purchase price of illicit cigarettes is higher than that of legal cigarette packs in Bangladesh, India, Pakistan, Philippines, Thailand, and Vietnam, Brazil, Egypt, Indonesia, Mexico, Russia appear to have few or no illicit cigarettes for purchase from formal, urban retailers.