Initial leadership concerns and availability of tobacco cessation services moderate changes in employee-reported concerns about tobacco-free workplace policy implementation over time

Tobacco-free workplace policies (TFWPs) are underused evidence-based interventions that reduce the elevated use of tobacco among substance use treatment center (SUTC) employees and patients. SUTC employees' anticipated concerns about stakeholder pushback are barriers to TFWP adoption. Examination of discrepancies between anticipated and actualized employee-reported TFWP concerns arising from coworkers, patients, and community members in the context of leadership concerns and tobacco cessation care availability for employees may inform strategies to increase TFWP uptake. This study analyzed changes in employee-reported TFWP concerns from before to after a comprehensive tobacco-free workplace intervention that included TFWP implementation, using Chi-square/Fisher's exact tests. Preimplementation leadership policy concerns and tobacco cessation care availability were examined as moderators in generalized linear mixed models. Overall, 452 employees and 13 leaders provided data from 13 SUTCs collectively serving >82 000 patients annually. Results revealed significant decreases over time in employee-reported concerns about TFWP resistance from coworkers. Moderation analyses indicated that employee-anticipated concerns from coworkers and patients, respectively, were less likely to be actualized in SUTCs where leadership endorsed preimplementation TFWP concerns, whereas employee-reported patient concerns rose over time in SUTCs where leadership had no initial implementation concerns. Additionally, employee-anticipated concerns from coworkers were overestimated in SUTCs that did not offer tobacco cessation care to employees. Results supporting the nonactualization of anticipated employee concerns following TFWP implementation can be used to engage other SUTCs for TFWP adoption. Furthermore, moderation effects may suggest that center characteristics translate to greater attention to rollout, ultimately enhancing TFWP stakeholder acceptance.

Financial strain among adult African American/Black cannabis users

African American/Black persons belong to the second largest racial/ethnic minority group in the United States. This group evinces significant disparities related to cannabis use problems. Social determinants of health may be potentially relevant to better understand cannabis use problems among African American/Black adults. As such, the current study sought to provide an initial test of the role of financial strain, a prominent social determinant of health, in cannabis use problems and perceived barriers for cannabis cessation among African American/Black adults. Participants were 76 (32.9% female, Mage = 38.64, SD = 10.82) African American/Black adult, current cannabis users. Hierarchical regression results indicated that greater financial strain was associated with more cannabis use problems and greater perceived barriers for cannabis cessation; such effects were evident above and beyond the variance explained by a range of relevant covariates, including age, sex, income, education, and depressive symptoms. These findings suggest addressing financial strain (e.g., financial planning, psychoeducation about the handling financial stress) may be a useful therapeutic tactic in the larger landscape of treatment programming when targeting cannabis use behaviors and beliefs among African American/Black adult cannabis users.

Negotiating cancer alone: A qualitative study exploring care experiences of racially and ethnically diverse women diagnosed with breast cancer during COVID-19

COVID-19 has critically impacted cancer care services including reduced screenings, diagnoses, and surgeries; particularly among Black and Latina/x women who already suffer worse outcomes. This qualitative study explored the care experiences of a diverse sample of breast cancer survivors (N = 21; 7 Black, 4 Hispanic, 10 White) undergoing treatment during the pandemic via online semi-structured interviews. Grounded theory analysis yielded the core category "negotiating cancer alone," that included: (1) psychological distress, negotiating the cancer trajectory in isolation; (2) provider/healthcare system diagnostic and treatment delays; (3) heightened anxiety about treatment delays causing cancer progression; (4) supportive care limitations; and (5) disparate experiences of cancer care disruptions. Black and Latina/x women described greater delays in care, financial challenges, treatment complications, and insurance limitations than White women. The study identifies cancer patients' pandemic-related psychological, healthcare system, and health equity challenges and suggests recommendations to support their increased psychological needs during oncologic care disruptions.

Implementing a tobacco-free workplace program at a substance use treatment center: a case study

BACKGROUND

People with substance use disorders smoke cigarettes at much higher rates than the general population in the United States and are disproportionately affected by tobacco-related diseases. Many substance use treatment centers do not provide evidence-based tobacco cessation treatment or maintain comprehensive tobacco-free workplace policies. The goal of the current work is to identify barriers and facilitators to a successful and sustainable implementation of a tobacco-free workplace program, which includes a comprehensive tobacco-free policy and evidence-based cessation treatment services, in a substance use treatment center.

METHODS

This study is based on an ethnographic approach and uses a qualitative case study design. Data were collected via interviews with staff (n = 6) and clients (n = 16) at the substance use treatment center and site visits (n = 8). Data were analyzed using thematic analysis guided by the extended Normalization Process Theory designed to inform the implementation of innovations in healthcare practice.

RESULTS

Staff at the substance use treatment center supported the implementation of the program and shared a good understanding of the purpose of the intervention and its potential benefits. However, the study identified significant challenges faced by the center during implementation, including widespread tobacco use among clients, contributing to attitudes among staff that tobacco cessation was a low-priority problem due to a perceived lack of interest in quitting and inability to quit among their clients. We identified several factors that contributed to changing this attitude, including provision of tobacco training to staff, active leadership support, low number of staff members who smoked, and access to material resources, including nicotine replacement products. The implementation and active enforcement of a comprehensive tobacco-free workplace program contributed to a gradual change in attitudes and improved the provision of evidence-based tobacco cessation care at the substance use treatment center.

CONCLUSIONS

Substance use treatment centers can integrate tobacco cessation practices in their daily operations, despite multiple challenges they face due to the complex behavioral health and socioeconomic needs of their clients. With proper support, substance use treatment centers can provide much needed tobacco cessation care to their clients who are disproportionately affected by tobacco-related health conditions and systemic health inequities.

Geographic Variation in Late-Stage Cervical Cancer Diagnosis

Importance

There are stark disparities in cervical cancer burden in the United States, notably by race and ethnicity and geography. Late-stage diagnosis is an indicator of inadequate access to and utilization of screening.

Objective

To identify geospatial clusters of late-stage cervical cancer at time of diagnosis in Texas.

Design, Setting, and Participants

This population-based cross-sectional study used incident cervical cancer data from the Texas Cancer Registry from 2014 to 2018 of female patients aged 18 years or older. Late-stage cervical cancer cases were geocoded at the census tract level (n = 5265) using their residential coordinates (latitude and longitude) at the time of diagnosis. Statistical analysis was performed from April to September 2023.

Exposures

Census tract of residence at diagnosis.

Main Outcome and Measures

Late-stage cervical cancer diagnosis (ie, cases classified by the National Cancer Institute Surveillance, Epidemiology and End Results summary stages 2 to 4 [regional spread] or 7 [distant metastasis]). A Poisson probability-based model of the SaTScan purely spatial scan statistics was applied at the census tract-level to identify geographic clusters of higher (hot spots) or lower (cold spots) proportions than expected of late-stage cervical cancer diagnosis and adjusted for age.

Results

Among a total of 6484 female patients with incident cervical cancer cases (mean [SD] age, 48.7 [14.7] years), 2300 (35.5%) were Hispanic, 798 (12.3%) were non-Hispanic Black, 3090 (47.6%) were non-Hispanic White, and 296 (4.6%) were other race or ethnicity. Of the 6484 patients, 2892 with late-stage diagnosis (mean [SD] age, 51.8 [14.4] years were analyzed. Among patients with late-stage diagnosis, 1069 (37.0%) were Hispanic, 417 (14.4%) were non-Hispanic Black, 1307 (45.2%) were non-Hispanic White, and 99 (3.4%) were other race or ethnicity. SaTScan spatial analysis identified 7 statistically significant clusters of late-stage cervical cancer diagnosis in Texas, of which 4 were hot spots and 3 were cold spots. Hot spots included 1128 census tracts, predominantly in the South Texas Plains, Gulf Coast, and Prairies and Lakes (North Texas) regions. Of the 2892 patients with late-stage cervical cancer, 880 (30.4%) were observed within hot spots. Census tract-level comparison of characteristics of clusters suggested that hot spots differed significantly from cold spots and the rest of Texas by proportions of racial and ethnic groups, non-US born persons, and socioeconomic status.

Conclusions and Relevance

In this cross-sectional study examining geospatial clusters of late-stage cervical cancer diagnosis, place-based disparities were found in late-stage cervical cancer diagnosis in Texas. These findings suggest that these communities may benefit from aggressive cervical cancer interventions.

Texas tobacco quitline knowledge, attitudes, and practices within healthcare agencies serving individuals with behavioral health needs: A multimethod study

Patients with behavioral health conditions have disproportionately high tobacco use rates and face significant barriers to accessing evidence-based tobacco cessation services. Tobacco quitlines are an effective and accessible resource, yet they are often underutilized. We identify knowledge, practices, and attitudes towards the Texas Tobacco Quitline (TTQL) within behavioral healthcare settings in Texas. Quantitative and qualitative data were collected in 2021 as part of a statewide needs assessment in behavioral healthcare settings. Survey respondents (n = 125) represented 23 Federally Qualified Health Centers, 29 local mental health authorities (LMHAs), 12 substance use treatment programs in LMHAs, and 61 standalone substance use treatment centers (26 people participated in qualitative interviews). Over half of respondents indicated familiarity with the TTQL and believed that the TTQL was helpful for quitting. Qualitative findings reveal potential concerns about inconsistency of services, long wait time, and the format of the quitline. About half of respondents indicated that their center promoted patient referral to TTQL, and few indicated that their center had an electronic referral system with direct TTQL referral capacity. Interview respondents reported overall lack of systematic follow up with patients regarding their use of the TTQL services. Findings suggest the need for (1) increased TTQL service awareness among healthcare providers; (2) further investigation into any changes needed to better serve patients with behavioral health conditions who use tobacco; and (3) electronic health record integration supporting direct referrals and enhanced protocols to support patient follow up after TTQL referral.

Behavioral health care provider's beliefs, confidence, and knowledge in treating cigarette smoking in relation to their use of the 5A's intervention

Introduction

Evidence-based smoking cessation interventions are underused settings where behavioral health treatment is provided, contributing to smoking-related health disparities in this patient group. This study assessed the relationship of provider's beliefs about patients' smoking, perceptions of treatment capability, and knowledge of referral options and their use of the 5A's (Ask, Advise, Assess, Assist, and Arrange) intervention for smoking cessation.

Methods

Surveys were collected from providers in healthcare settings in Texas where patients receive behavioral health care (N = 86; 9 federally qualified health centers, 16 Local Mental Health Authorities (LMHAs), 6 substance use treatment programs in LMHAs, and 55 stand-alone substance use treatment centers). Logistic regression analyses were used to assess the association between provider's beliefs about patients' concern and desire to quit smoking; perceptions of their confidence, skills, and effectiveness in treating smoking; their knowledge of referral options; and their use of the 5A's with patients who smoked.

Results

Providers who believed that patients were concerned about smoking and wanted to quit; who perceived themselves as confident in providing cessation care, having the required skills, and being effective in providing advice; and/or who had greater referral knowledge were more likely to use the 5A's with patients who smoked than their (respective) provider counterparts (ps < 0.05).

Conclusion

Provider-level constructs affect their 5A's provision for patients with behavioral health needs. Future work should train providers to correct misconceptions about patients' interest in quitting, bolster their confidence, and provide referral options to support tobacco provision efforts.

Learning Through Doing: Comprehensive Programming for a Training Program in Cancer Disparities

In the United States, preparing researchers and practitioners for careers in cancer requires multiple components for success. In this reflection article, we discuss our approach to designing a comprehensive research training program in cancer disparities. We focused on elements that provide students and early career scientists a deep understanding of disparities through first-hand experiences and skills training necessary to build a research career in the area. Our Educational Program sits within the framework of an NCI P20 program, "UHAND (University of Houston/MD Anderson Cancer Center)", jointly established by an NCI-designated comprehensive cancer center and a minority-serving university as a collaborative partnership devoted to the elimination of cancer inequities among disproportionately affected racial and ethnic groups (UHAND Program to Reduce Cancer Disparities; NCI P20CA221696/ P20CA221697). The Education Program was designed to build on and enhance skills that are critical to pursuing a career in cancer disparities research at the undergraduate, doctoral, and post-doctoral levels-such as scientific communication, career planning and development, professional and community-based collaboration, and resilience in addition to solid scientific training. As such, our program integrates (1) opportunities for learning through service to community organizations providing resources to populations with documented cancer disparities, (2) a tailored curriculum of learning activities with program leadership and mentored research with scientists focused on cancer disparities and cancer prevention, (3) professional development training critical to career success in disparities research, and (4) support to address unique challenges faced by trainees from backgrounds that are historically underrepresented in research.

Lung Cancer Screening Eligibility and Referral Practices in Texas Organizations Serving People with Substance Use Disorders

For people at elevated risk for lung cancer, lung cancer screening (LCS) reduces lung cancer mortality. People with non-nicotine substance use disorders (SUDs) have elevated rates of smoking compared with the general population, highlighting them as a priority population for LCS consideration. Although research has shown LCS is underutilized, there is little literature to inform whether organizations that serve individuals with SUDs have existing clinical protocols surrounding LCS. In the current study, we examine the LCS eligibility and referral practices among these organizations. We conducted a statewide needs assessment survey in 2021 to discern how tobacco use was being addressed at Texas organizations that provide treatment or services to individuals with SUDs. Respondents were asked to report on their center’s LCS eligibility and referral practices. The analytic sample consists of 125 respondents who represented 23 federally qualified health centers, 29 global local mental health authorities (LMHAs), 12 substance use treatment programs in LMHAs, and 61 standalone substance use treatment centers. Very few respondents indicated that healthcare providers at their center made referrals to LCS for patients (8.8%); a few respondents indicated that their healthcare providers assessed patients’ eligibility for LCS but did not make referrals (3.2%). Intervention and implementation efforts are needed in these and other SUD healthcare settings to bolster organizational capacity and ensure that patients are being navigated to lung cancer screening at multiple touch points across the care continuum.

Influence of Provider and Leader Perspectives about Concurrent Tobacco-Use Care during Substance-Use Treatment on Their Tobacco Intervention Provision with Clients: A Mixed-Methods Study

People with substance-use disorders have elevated rates of tobacco use compared with the general population, yet rarely receive tobacco-dependence treatment within substance-use treatment settings (SUTS). One barrier to delivering evidence-based interventions in SUTS is providers' misconception that treating tobacco use and non-nicotine substance use concurrently jeopardizes clients' substance-use recovery, although research indicates that it enhances support for recovery and relapse prevention. A total of 86 treatment providers employed in SUTS (i.e., 9 Federally Qualified Health Centers, 16 Local Mental Health Authorities (LMHAs), 6 substance-use treatment programs in LMHAs, and 55 stand-alone substance-use treatment centers) in Texas, USA, answered survey questions about their (1) thoughts about treating tobacco during substance-use treatment, and (2) delivery of the 5A's tobacco-use intervention (Ask, Advise, Assess, Assist, Arrange). Twenty-six providers and leaders were interviewed about attitudes toward tobacco-free workplace policies and tobacco dependence and the relative importance of treating tobacco (vs. other substance-use disorders) at their center. Providers who did not believe tobacco use should be addressed as soon as clients begin treatment (i.e., endorsed responses of after 1 year, it depends on the client, or never) had lower odds of Asking clients about their tobacco use (OR = 0.195), Advising clients to quit smoking (OR = 0.176), and Assessing interest in quitting smoking (OR = 0.322). Qualitative results revealed barriers including beliefs that clients need to smoke to relieve the stress of substance-use recovery, are disinterested in quitting, fears that concurrent treatment would jeopardize substance use, and limited resources; additional training and education resources was the key facilitator theme. The results demonstrate a critical need to eliminate barriers to tobacco-treatment provision for clients in SUTS through education to correct misperceptions, specialized training to equip providers with knowledge and skills, and resources to build center capacity. Integrating evidence-based smoking interventions into routine care is key to support the recovery efforts of clients in SUTS.

Abstract P4-05-03: Investigating Financial Toxicity among Breast Cancer Patients Diagnosed during the Pandemic: The Role of Cancer Care Disruptions and Social Isolation

Background: Financial toxicity (FT) is a multi-faceted construct, encompassing material hardship, psychological responses, and coping behaviors. FT adversely impacts patient-reported outcomes by decreasing mental health, affecting health-related quality of life (HRQOL), and deteriorating healthcare adherence. Few studies have assessed the relationship between financial toxicity, distress, coping, self-efficacy, and HRQOL within the context of cancer care disruptions resulting from the pandemic. Methods: In the COVID-19 Breast Cancer Care Survey, 46 women with primary breast cancer were cross-sectionally evaluated for financial hardship (FACIT-COST), distress (Perceived Stress Scale), coping behaviors (Brief COPE), self-efficacy (Cancer Behavior Inventory–Brief) and HRQOL using the Functional Assessment of Cancer Therapy General (FACT-G) measure. Cancer care disruptions were measured with a series of questions investigating the impact of COVID-19 guidelines on access to healthcare services, treatment, and transition to telemedicine. Given the role of informal caregivers for patients’ outcomes, social isolation was additionally included (PROMIS Social Isolation Scale). Descriptive statistics were computed, and bivariate correlations examined. Then, a subsequent regression model investigated predictors of FT in the present sample. Statistical analyses were performed using SAS 9.4 and significance level was set at p&lt; 0.05. Results: Overall, participants were adult (Mage= 46.3±10.9) women diagnosed with early-stage breast cancer (75.61% Stage I/II). Approximately half of the participants were in active treatment (51.2%) and received multiple types of treatment (85.4% surgery; 61% chemotherapy, and 36.5% radiation). Although all participants were insured at time of the study, the mean score of FT was 22.75 (SD=4.10, range: 0-44). Correlation analyses indicated that cancer care disruptions (r= -0.57, p&lt;.001), health-related quality of life (r=-0.51, p=0.0007), coping behaviors (r=-0.33, p=0.037), well-being (r=0.56, p=0.0001), social isolation (r=-0.40, p=0.0096), and psychological distress (r=-0.42, p=0.0064) were significantly correlated with FT. That is, women who reported greater disrupted cancer care delivery, greater difficulties managing the illness, reduced physical and mental health, and those experiencing more social isolation reported worse financial toxicity. Results of the final regression model showed that women who experienced greater COVID19-related cancer care disruptions (β=-2.82, p=0.0013) and isolation (β=-0.44, p=0.0196) from supportive networks were more likely to indicate elevated FT scores. Conclusions: A multidisciplinary and patient-centered FT management approach can be implemented to extend current financial navigation models to address psychosocial and behavioral factors exacerbated by altered care delivery protocols.

Citation Format: Chiara Acquati, Tzuan Chen, Isabel Martinez Leal, Shahnjayla Connors, Anastasia Rogova, Mathew Banegas, Grace Smith, Lorraine R. Reitzel, Lorna McNeill. Investigating Financial Toxicity among Breast Cancer Patients Diagnosed during the Pandemic: The Role of Cancer Care Disruptions and Social Isolation [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-05-03.

Educating Substance Use Treatment Center Providers on Tobacco Use Treatments Is Associated with Increased Provision of Counseling and Medication to Patients Who Use Tobacco

Tobacco use is the leading preventable cause of death in America and is elevated among patients with non-tobacco substance use disorders. Substance use treatment centers (SUTCs) do not commonly address their patients' tobacco use. Lack of knowledge on treating tobacco use with counseling and medication may be a barrier that underlies this inaction. A multi-component tobacco-free workplace program implemented in Texas SUTCs educated providers on treating tobacco use with evidence-based medication (or referral) and counseling. This study examined how center-level changes in knowledge from pre- to post-implementation (i.e., over time) affected center-level behavioral changes in providers' provision of tobacco use treatment over time. Providers from 15 SUTCs completed pre- and post-implementation surveys (pre N = 259; post N = 194) assessing (1) perceived barriers to treating tobacco use, specifically, a lack of knowledge on treating tobacco use with counseling or medication; (2) receipt of past-year education on treating tobacco use with counseling or medication; and (3) their intervention practices, specifically, the self-reported regular use of (a) counseling or (b) medication intervention or referral with patients who use tobacco. Generalized linear mixed models explored associations between provider-reported knowledge barriers, education receipt, and intervention practices over time. Overall, recent counseling education receipt was endorsed by 32.00% versus 70.21% of providers from pre- to post-implementation; the regular use of counseling to treat tobacco use was endorsed by 19.31% versus 28.87% from pre- to post-implementation. Recent medication education receipt was endorsed by 20.46% versus 71.88% of providers from pre- to post-implementation; the regular use of medication to treat tobacco use was endorsed by 31.66% versus 55.15% from pre- to post-implementation. All changes were statistically significant (ps < 0.05). High versus low reductions in the provider-reported barrier of "lack of knowledge on pharmacotherapy treatment" over time were a significant moderator of effects, such that SUTCs with high reductions in this barrier were more likely to report greater increases in both medication education receipt and medication treatment/referral for patients who use tobacco over time. In conclusion, a tobacco-free workplace program implementation strategy that included SUTC provider education improved knowledge and resulted in increased delivery of evidence-based treatment of tobacco use at SUTCs; however, treatment provision rates-in particular, offering tobacco cessation counseling-remained less than desirable, suggesting that barriers beyond lack of knowledge may be important to address to improve tobacco use care in SUTCs. Moderation results suggest (1) differences in the mechanisms underlying uptake of counseling education versus medication education and (2) that the relative difficulty of providing counseling versus providing medication persists regardless of knowledge gains.

The Indirect Effect of Smoking Level in the Association Between Urban Stress and Readiness to Quit Smoking among Adults Experiencing Homelessness

Over 70% of adults experiencing homelessness are cigarette smokers, a fivefold greater rate than in the general U.S. population. Consequently, tobacco-related conditions are the leading causes of disease and death for this group. Adults experiencing homelessness tend to seek shelter in urban areas. Thus, they not only experience the daily stressors of being homeless, they may additionally experience unique or additive urban stressors (e.g., stress related to using public services, crime and violence, and/or cultural conflicts with others). For some smokers, stress is known to increase smoking rates and decrease readiness to quit smoking. Likewise, increased smoking rates alone may lead to a lower likelihood of making a quit attempt. The current study examined the potential mediating role of smoking level in the association of urban stress and quit readiness among adults experiencing homelessness (N=411). Two multinomial logistic regression analyses revealed that urban stress was positively associated with smoking level (p = 0.02). The odds ratio for one-unit increase in stress was 1.047 (CI_.95:1.014, 1.082) for being a heavy vs. non-daily smoker. Furthermore, analyses revealed smoking level mediated the effect of stress on quit readiness (ab= -0.005, CI_.95:-0.010, -0.002]). Homeless smokers who report high levels of stress might smoke at higher levels, which could attenuate quit readiness.

Exploring COVID-19 Vaccine Attitudes among Racially and Ethnically Minoritized Communities: Community Partners' and Residents' Perspectives

COVID-19 has disproportionately affected Black, Indigenous, and People of Color (BIPOC) communities, yet rates of COVID-19 vaccination remain low among these groups. A qualitative study was undertaken to better understand the factors contributing to low vaccine acceptance among these communities. Seventeen focus groups were conducted in English and Spanish from 8/21 to 9/22, with representatives from five critical community sectors: (1) public health departments (n = 1); (2) Federally Qualified Health Centers (n = 2); (3) community-based organizations (n = 1); (4) faith-based organizations (n = 2); and (5) BIPOC residents in six high-risk, underserved communities in metropolitan Houston (n = 11), for a total of 79 participants, comprising 22 community partners and 57 community residents. A social-ecological model and anti-racism framework were adopted to guide data analysis using thematic analysis and constant comparison, which yielded five key themes: (1) legacy of structural racism: distrust and threat; (2) media misinformation: mass and social; (3) listening and adapting to community needs; (4) evolving attitudes towards vaccination; and (5) understanding alternative health belief systems. Although structural racism was a key driver of vaccine uptake, a notable finding indicated community residents' vaccine attitudes can be changed once they are confident of the protective benefits of vaccination. Study recommendations include adopting an explicitly anti-racist lens to: (1) listen to community members' needs and concerns, acknowledge their justified institutional distrust concerning vaccines, and learn community members' healthcare priorities to inform initiatives built on local data; (2) address misinformation via culturally informed, consistent messaging tailored to communal concerns and delivered by trusted local leaders through multimodal community forums; (3) take vaccines to where people live through pop-up clinics, churches, and community centers for distribution via trusted community members, with educational campaigns tailored to the needs of distinct communities; (4) establish vaccine equity task forces to continue developing sustainable policies, structures, programs and practices to address the structural issues driving vaccine and health inequities within BIPOC communities; and (5) continue investing in an effective infrastructure for healthcare education and delivery, essential for competently responding to the ongoing healthcare and other emergency crises that impact BIPOC communities to achieve racial justice and health equity in the US. Findings underscore the crucial need to provide culturally tailored health education and vaccination initiatives, focused on cultural humility, bidirectionality, and mutual respect to support vaccine re-evaluation.

Changes in Substance Use Treatment Providers' Delivery of the 5A's for Non-Cigarette Tobacco Use in the Context of a Comprehensive Tobacco-Free Workplace Program Implementation

Tobacco use treatment is not prioritized in substance use treatment centers (SUTCs), leading to tobacco-related health inequities for patients with substance use disorders (SUDs) and necessitating efforts to enhance providers' care provision. Training providers on how to treat tobacco use increases their intervention on patients' smoking, but limited work addresses its effects on their non-cigarette tobacco use intervention provision. This study redressed this gap using data from 15 unaffiliated SUTCs in Texas (serving 82,927 patients/year) participating in a tobacco-free workplace program (TFWP) that included provider education on treating tobacco use, including non-cigarette tobacco use. SUTC providers completed surveys before (n = 259) and after (n = 194) TFWP implementation. Past-month screening/intervention provision for non-cigarette tobacco use (the 5A's; ask, advise, assess, assist, arrange) and provider factors theoretically and practically presumed to underlie change [i.e., beliefs about concurrently treating tobacco use disorder (TUD) and other SUDs, self-efficacy for tobacco use assessment (TUA) delivery, barriers to treating tobacco dependence, receipt of tobacco intervention training] were assessed. Generalized linear or linear mixed models assessed changes over time from before to after TFWP implementation; low vs. high SUTC-level changes in provider factors were examined as moderators of changes in 5A's delivery. Results indicated significant improvement in each provider factor and increases in providers' asking, assisting, and arranging for non-cigarette tobacco use over time (ps < 0.04). Relative to their counterparts, SUTCs with high changes in providers' beliefs in favor of treating patients' tobacco use had greater odds of advising, assessing, assisting, and arranging patients, and SUTCs with greater barrier reductions had greater odds of advising and assisting patients. Results suggest that TFWPs can address training deficits and alter providers' beliefs about treating non-tobacco TUD during SUD care, improve their TUA delivery self-efficacy, and reduce intervention barriers, ultimately increasing intervention provision for patients' non-cigarette tobacco use. SUTCs with the greatest room for improvement in provider beliefs and barriers to care provision seem excellent candidates for TFWP implementation aimed at increasing non-cigarette tobacco use care delivery.

Abstract P025: Tobacco screening practices and perceived barriers in offering tobacco cessation services in the primary prevention of lung cancer among Texas healthcare centers providing behavioral health treatment

Cigarette smoking is the leading cause of preventable death and illness globally and accounts for over 80% of all lung cancer diagnoses in the U.S. Patients with behavioral health (e.g., mental health and/or substance use) needs have elevated levels of smoking relative to the general population and are thus disparately impacted by tobacco-related cancers. Tobacco screenings, a precursor to providing evidence-based interventions for smoking cessation, play a critical role in the primary prevention of lung cancer. However, their use in behavioral health treatment centers has historically been inconsistent. The aim of this study was to analyze barriers and facilitators to tobacco screening in settings where Texans receive behavioral health care to contextualize current screening trends and, in turn, provide recommendations for improvement. This study assessed the prevalence of mandated tobacco screenings in 80 centers providing healthcare to Texans with behavioral health needs. We examined key factors that could enhance screening conduct (i.e., provision of a tobacco use assessment template, hard stop in the electronic health record [EHR] for patient tobacco use status, and the availability of tobacco screening training), assessed associations between center practices and mandated tobacco screenings, and delineated providers’ perceived barriers to tobacco use intervention provision. Results indicated that 80% of surveyed centers mandated tobacco use screenings; those that did were significantly more likely than those that did not to have a hard stop for tobacco use status in the EHR (p&lt;0.008) and to make training on tobacco screening available to providers (p=0.016). The most widespread barriers to tobacco use disorder care provision, endorsed by at least 50% of all respondents at &gt;1 type of healthcare center (e.g. federally qualified health centers, global local mental health authorities, substance use treatment centers in local mental health authorities, and stand-alone substance use treatment centers), were relative perceived importance of competing diagnoses, lack of community resources for referral, perceived lack of time, lack of provider knowledge or confidence, and belief that patients do not comply with cessation treatment. Overall, there are opportunities for centers providing care to Texans with behavioral health needs to bolster their tobacco screening and intervention capacity to prevent cancer-related disparities in this group. Healthcare centers can support their providers to intervene upon tobacco use by mandating screenings, streamlining clinical workflow with hard stops in patient records, and by educating providers about patient’s interest in quitting along with the importance of treating tobacco with brief evidence-based intervention strategies. Future work should focus on how these healthcare centers can facilitate providers’ ability to link tobacco screenings with smoking cessation services and lung cancer eligibility screening to increase the early detection of lung cancers and prevent tobacco-related cancer disparities.

Citation Format: Ammar D. Siddiqi, Maggie Britton, Tzuan A. Chen, Brian J. Carter, Carol Wang, Isabel Martinez Leal, Anastasia Rogova, Bryce Kyburz, Teresa Williams, Mayuri Patel, Lorraine R. Reitzel. Tobacco screening practices and perceived barriers in offering tobacco cessation services in the primary prevention of lung cancer among Texas healthcare centers providing behavioral health treatment. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P025.

A Text-Based Smoking Cessation Intervention for Sexual and Gender Minority Groups: Protocol for a Feasibility Trial

BACKGROUND

Smoking among sexual and gender minority (SGM) groups, which include lesbian, gay, bisexual, transgender, and queer individuals, has been reported to be highly prevalent. This is attributed to several factors, including minority-specific stress and targeted tobacco marketing. Therefore, this population is at an increased risk for tobacco-related diseases. SMS text messaging programs have been found to be effective for smoking cessation and appeal to traditionally hard-to-reach populations over other interventions. It has also been suggested that targeted and tailored interventions could be more effective among SGM smokers because they can be designed to assure a safe, validating health care environment that enhances receptivity to cessation.

OBJECTIVE

The aim of this study is to develop SmokefreeSGM, a text-based smoking cessation program tailored to and tested among SGM smokers.

METHODS

The study consists of three phases, culminating in a feasibility trial. In Phase 1, our research team will collaborate with a Community Advisory Board to develop and pretest the design of SmokefreeSGM. In Phase 2, the tailored text messaging program will be beta tested among 16 SGM smokers. Our research team will use a mixed-methods approach to collect and analyze data from participants who will inform the refinement of SmokefreeSGM. In Phase 3, a feasibility trial will be conducted among 80 SGM smokers either enrolled in SmokefreeSGM or SmokefreeTXT, the original text-based program developed by the National Cancer Institute for the general population. Our research team will examine recruitment, retention, and smoking abstinence rates at 1-, 3-, and 6-month follow-up. Additionally, a qualitative interview will be conducted among 32 participants to evaluate the feasibility and acceptability of the programs (SmokefreeSGM and SmokefreeTXT).

RESULTS

This study received approval from The University of Texas Health Science Center at Houston Committee for the Protection of Human Subjects to begin research on August 21, 2020. Recruitment for the beta testing of SmokefreeSGM (Phase 2) began in January 2022. We estimate that the feasibility trial (Phase 3) will begin in September 2022 and that results will be available in December 2023.

CONCLUSIONS

Findings from this research effort will help reduce tobacco-related health disparities among SGM smokers by determining the feasibility and acceptability of SmokefreeSGM, an SGM-tailored smoking cessation intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05029362; https://clinicaltrials.gov/ct2/show/NCT05029362.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42553.

Exploring the provider and organization level barriers to medication for opioid use disorder treatment for Black Americans: A study protocol

Objectives

This study seeks to examine the provider and organizational factors that could be limiting the treatment of Opioid Use Disorder (OUD) for Black Americans in Texas. Formative research at the provider and organizational level will assist in understanding the current facilitators, potential barriers, and capacity for OUD treatment for Black Americans.

Study design

Using the exploration phase of the Explore, Preparation, Implementation, Sustainment (EPIS) framework, the project will be a formative assessment of local factors that influence Medication for OUD (MOUD) treatment availability for Black Americans to guide the design of a culturally and locally relevant multi-level intervention strategy.

Methods

and analysis: This project will utilize emergent mixed methods to identify and clarify the problems that are obstructing treatment for Black patients with OUD. First, the perspectives of individual providers in their openness and willingness to provide MOUD treatment to Black Americans diagnosed with OUD will be explored through in-depth interviews. The organizational capacity factors associated with increased availability to treatment for Black American OUD patients will be examined with the organizational leaders using an exploratory sequential mixed-methods design. Leader and program managers of organizations that provide MOUD will be invited to participate in an online survey, with the option to participate in a follow-up in-depth interview. All qualitative data from the provider and organization staff interviews will be analyzed with a thematic analysis approach. The analysis of the two different types of qualitative data will be analyzed together, as a form of triangulation.

Conclusions

This project will assess the understandings of individual providers as well as the organizational-level awareness of the cultural contexts of MOUD intervention for Black Americans. This formative research seeks to highlight the current status of the opioid crisis in the Black community, and what additional supports are needed.

Providers' Non-Cigarette Tobacco Use Intervention Practices in Relation to Beliefs about Patients, Prioritization of and Skills for Intervention, and Referral Knowledge in Texas Healthcare Centers Providing Care to Persons with Behavioral Health Needs

Rates of non-cigarette (colloquially, other) tobacco use is elevated among adults with behavioral health conditions. Little is known about whether behavioral health providers are using brief interventions, including the evidence-based 5As (Ask, Advise, Assess, Assist, and Arrange) for other tobacco use, or what provider factors may be associated with use of these interventions. The current study redressed this gap. Overall, 86 providers in Texas (9 Federally Qualified Health Centers, 16 Local Mental Health Authorities (LMHAs) that provide a broad range of mental and behavioral health services, 6 substance use treatment programs in LMHAs, and 55 stand-alone substance use treatment programs) took a survey assessing their beliefs regarding (1) patients' concerns about other tobacco use; (2) their desire to quit; (3) importance of intervening on other tobacco use with cessation counseling; (4) perceived skills to intervene; (5) knowledge of referral options for treatment. Logistic regression analyses were conducted to determine the association between each factor and use of the 5As. Results showed that 70.9% of providers asked patients about other tobacco use status, 65.1% advised them to quit, 59.3% assessed quit interest, 54.7% assisted with a quit attempt, and 31.4% arranged a follow-up. Providers who believed patients were concerned about other tobacco use, recognized the importance of offering other tobacco use cessation counseling, believed they had the necessary skills to treat other tobacco use, and possessed knowledge of referral options, respectively, were more likely to deliver the 5As (ps < 0.05). Results add to a limited literature on provider intervention practices for other tobacco use in settings where behavioral health care is provided, highlighting the significance of provider beliefs, perceived skills, and referral knowledge to care delivery. Findings reveal opportunities to increase delivery of the 5As for other tobacco use to behavioral health patients and suggest provider factors that could be targeted to build this capacity.

Smoking Intervention Practices in Texas Healthcare Centers with Sexual and Gender Minority Patients

Objectives

This study evaluated the use of evidence-based practices (EBPs) for smoking cessation in centers providing behavioral healthcare for patient populations that included some proportion of sexual and gender minorities (SGMs).

Methods

Healthcare providers from 75 healthcare centers across Texas serving SGMs with behavioral health needs participated in a survey assessing their center's tobacco control policies and practices.

Results

Nearly half (N = 36) of participating centers had a comprehensive tobacco-free workplace policy, 30.67% employed ≥1 tobacco treatment specialist, 73.91% employed ≥1 prescriber, 80.82% mandated screening for patient tobacco use at intake, and 57.53% provided a template for tobacco use assessments. Overall, 70.67% of providers asked patients about smoking status, 69.33% advised patients to quit, 64.00% assessed patients' interest in quitting, 58.67% assisted patients with quit attempts, and 36.00% arranged follow-up. Providers' ability to tailor interventions for special populations like SGMs ranged from very low/0 to very high/10 (M = 4.63 ± 2.59).

Conclusions

There are opportunities to improve policy implementation, standardization and usage of evidence-based interventions, and intervention tailoring within settings providing care to SGM patients in Texas to better address their tobacco use inequities.

Examining Associations between Source of Cancer Information and Mammography Behavior among Black Church-Going Women

Black women have a slightly lower breast cancer incidence rate than White women, but breast cancer mortality is approximately 40% higher among Black women than among White women. Early detection by mammography may improve survival outcomes. Outlets providing information on cancer and cancer screening often present data, including mammography recommendations, that are unreliable, accessible, and/or inconsistent. We examined associations between sources of cancer information and mammography behavior among Black church-going women. A logistic regression model was used to examine associations between self-reported preferred source of cancer information (provider, cancer organization, social network, internet, or other media (e.g., books, magazines)) and self-reported most recent source of cancer information (same categories as preferred sources), respectively, and having received a mammogram within the prior 12 months. Participants were 832 Black women over 40 years old, recruited from three churches in Houston, Texas. Data were collected in 2012. Overall, 55.41% of participants indicated their preferred source of cancer information was a provider, 21.88% the internet, 11.54% other media, 10.22% a cancer organization, and 0.96% their social network. In contrast, 17.88% of participants indicated their most recent source of cancer information was a provider, 63.02% the internet, 12.04% other media, 4.50% a cancer organization, and 2.55% their social network. About 70% of participants indicated receiving a mammogram in the prior 12 months. Results indicated that women who most recently sought information from the internet had lower odds of having a mammogram than those who most recently sought information from a provider (aOR: 0.546, CI_95%: 0.336-0.886, p = 0.014). These results reveal an opportunity to advance health equity by encouraging Black church-going women to obtain cancer information from providers rather than from the internet as a method to enhance mammography use. These results also reveal an opportunity to investigate what modifiable social determinants or other factors prevent Black church-going women from seeking cancer information from their preferred source, which was a provider for the majority of the sample, and designing interventions to better actualize this preference.

Organization-Level Factors Associated with Changes in the Delivery of the Five A's for Smoking Cessation following the Implementation of a Comprehensive Tobacco-Free Workplace Program within Substance Use Treatment Centers

Many adults with a substance use disorder smoke cigarettes. However, tobacco use is not commonly addressed in substance use treatment centers. This study examined how provider beliefs about addressing tobacco use during non-nicotine substance use treatment, provider self-efficacy in delivering tobacco use assessments, and perceived barriers to the routine provision of tobacco care were associated with changes in the delivery of the evidence-based five A's for smoking intervention (asking, advising, assessing, assisting, and arranging) at the organizational level. The data were from 15 substance use treatment centers that implemented a tobacco-free workplace program; data were collected before and after the program's implementation. Linear regression examined how center-level averages of provider factors (1) at pre-implementation and (2) post- minus pre-implementation were associated with changes in the use of the five A's for smoking in substance use treatment patients. The results indicated that centers with providers endorsing less agreement that tobacco use should be addressed in non-nicotine substance use treatment and reporting lower self-efficacy for providing tobacco use assessments at pre-implementation were associated with significant increases in asking patients about smoking, assessing interest in quitting and assisting with a quit attempt by post-implementation. Centers reporting more barriers at pre-implementation and centers that had greater reductions in reported barriers to treatment over time had greater increases in assessing patients' interest in quitting smoking and assisting with a quit attempt by post-implementation. Overall, the centers that had the most to learn regarding addressing patients' tobacco use had greater changes in their use of the five A's compared to centers whose personnel were already better informed and trained. Findings from this study advance implementation science and contribute information relevant to reducing the research-to-practice translational gap in tobacco control for a patient group that suffers tobacco-related health disparities.

Tobacco Screening Practices and Perceived Barriers to Offering Tobacco Cessation Services among Texas Health Care Centers Providing Behavioral Health Treatment

Tobacco use, and thus tobacco-related morbidity, is elevated amongst patients with behavioral health treatment needs. Consequently, it is important that centers providing health care to this group mandate providers' use of tobacco screenings to inform the need for tobacco use disorder intervention. This study examined the prevalence of mandated tobacco screenings in 80 centers providing health care to Texans with behavioral health needs, examined key factors that could enhance screening conduct, and delineated providers' perceived barriers to tobacco use intervention provision. The results indicated that 80% of surveyed centers mandated tobacco use screenings; those that did were significantly more likely than those that did not to have a hard stop for tobacco use status in health records and were marginally more likely to make training on tobacco screening available to providers. The most widespread barriers to tobacco use disorder care provision were relative perceived importance of competing diagnoses, lack of community resources to refer patients, perceived lack of time, lack of provider knowledge or confidence, and belief that patients do not comply with cessation treatment. Overall, the results suggest that there are opportunities for centers providing care to Texans with behavioral health needs to bolster their tobacco screening and intervention capacity to better address tobacco-related health disparities in this group. Health care centers can support their providers to intervene in tobacco use by mandating screenings, streamlining clinical workflows with hard stops in patient records, and educating providers about the importance of treating tobacco with brief evidence-based intervention strategies while providing accurate information about patients' interest in quitting and providers' potential impacts on a successful quit attempt.

Collaborative Learning: A Qualitative Study Exploring Factors Contributing to a Successful Tobacco Cessation Train-the-Trainer Program as a Community of Practice

Individuals with behavioral health conditions account for 50% of annual smoking-related deaths, yet rarely receive tobacco dependence treatment within local mental health authorities (LMHAs). As lack of training and knowledge are key barriers to providing tobacco dependence treatment, Taking Texas Tobacco-Free (TTTF) developed an iterative, 4–6-months train-the-trainer program to embed expertise and delivery of sustained education on tobacco-free workplace policies and practices in participating centers. We explore the employee “champions’” train-the-trainer program experiences using a community of practice (CoP) model to identify key contributors to successful program implementation. Across 3 different LMHAs, we conducted semi-structured individual and group interviews online at 2 time points. We interviewed each champion twice (except for 1 champion who dropped out between measurements); pre-implementation (3 group interviews; N = 4 + 4 + 3 = 11 champions); post-implementation (7 individual interviews and 1 group interview; 7 + 3 = 10 champions). Therefore, 11 champions participated in pre- and post-implementation interviews from July 2020–May 2021. Guided by an iterative, thematic analysis and constant comparison process, we inductively coded and summarized data into themes. Five factors contributed to successful program implementation: value of peer support/feedback; building knowledge, champion confidence, and program ownership; informative curriculum, adaptable to targeted populations; staying abreast of current tobacco/nicotine research and products; and TTTF team responsiveness and practical coaching/assistance. Champions reported the TTTF train-the-trainer program was successful and identified attitudes and CoP processes that effectively built organizational capacity and expertise to sustainably address tobacco dependence. Study findings can guide other agencies in implementing sustainable tobacco-free training programs.

Perceived Disease Risk of Smoking, Barriers to Quitting, and Cessation Intervention Preferences by Sex Amongst Homeless Adult Concurrent Tobacco Product Users and Conventional Cigarette-Only Users

Adults experiencing homelessness smoke conventional cigarettes and engage in concurrent tobacco product use at very high rates; however, little is known about how use patterns, perceived disease risk, barriers to quitting smoking, and smoking cessation intervention preferences differ by sex in this group. Participants comprised a convenience sample of 626 adult conventional cigarette smokers experiencing homelessness. Participants self-reported their sex, smoking history, mental health and substance use diagnosis history, other concurrent tobacco product use (CU), disease risk perceptions, perceived barriers to quitting smoking, and preferences regarding tobacco cessation interventions via a computer-administered survey. CU rates were 58.1% amongst men and 45.3% amongst women smokers. In both sexes, CUs started smoking earlier (p-values < 0.001) and were more likely to have been diagnosed with a non-nicotine substance use disorder (p-values < 0.014) relative to cigarette-only users. Among men only, CUs were younger, smoked more cigarettes per day and were more likely to identify as non-Hispanic White (p-values < 0.003) than cigarette-only users. Additionally, male CUs reported a greater risk of developing ≥1 smoking-related disease if they did not quit for good; were more likely to endorse craving cigarettes, being around other smokers, habit, stress/mood swings, and coping with life stress as barriers for quitting smoking; and were less likely to prefer medications to quit smoking relative to male cigarette-only users (p-values < 0.04). On the other hand, female CUs reported a greater risk of developing ≥1 smoking-related disease even if they quit for good; were more likely to endorse stress/mood swings and coping with life stress as barriers for quitting smoking relative to female cigarette-only users (p-values < 0.05); and did not differentially prefer one cessation medication over another. Overall, findings confirm high rates of CU among both sexes, characterize those who may be more likely to be CUs, and reveal opportunities to educate men and women experiencing homeless on the benefits of evidence-based interventions for smoking cessation.

An epidemic and a pandemic collide: Assessing the feasibility of tobacco treatment among vulnerable groups at COVID-19 protective lodging

INTRODUCTION

Individuals experiencing homelessness have elevated smoking rates in addition to chronic and acute physical and mental health conditions, which may increase chances for complications associated with COVID-19 recovery. Unfortunately, there is underuse of tobacco cessation services in many agencies (e.g., substance use treatment centers, mental health treatment centers) providing care to these individuals. The purpose of the current study was to evaluate the feasibility of providing tobacco cessation treatment alongside local COVID-19 emergency response efforts.

METHOD

Taking Texas Tobacco Free (TTTF) partnered with relevant emergency response teams at 5 isolation centers (repurposed hotels) in Austin, Texas, to address tobacco use among presumed or confirmed COVID-19 positive individuals who had nowhere else to seek care and shelter. TTTF trained staff on tobacco cessation treatment; specifically, the 5A's and use of nicotine replacement therapy.

RESULTS

Over 5 months in 2020; 170 of 379 (44.9%) isolation center residents were reached and assessed for cigarette or vape use. Smoking/vaping prevalence was 70.6%, and 41.7% of tobacco users accepted cessation treatment.

DISCUSSION

Results suggest the feasibility and potential acceptability of providing tobacco treatment services in similar care settings during local emergency response efforts, including but potentially not limited to the COVID-19 pandemic. Further, this initiates a call to action for health care providers to deliver tobacco use cessation services for typically hard-to-reach groups (e.g., individuals/families experiencing homelessness) who may have increased contact with service agencies and health providers during times of crisis. Limitations and suggestions for future implementation are also provided. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Implementation and Outcomes of a Comprehensive Tobacco Free Workplace Program in Opioid Treatment Centers

Tobacco use is exceedingly high among individuals receiving care for opioid addiction, but not commonly addressed by clinicians in treatment settings. Taking Texas Tobacco Free (TTTF) is a comprehensive tobacco-free workplace (TFW) program that builds treatment centers' capacity to address tobacco use with evidence-based tobacco cessation policies and practices. Here, we examine the process and outcomes of TTTF's implementation within 7 opioid addiction centers. Program goals were structured according to the RE-AIM framework. Pre- and post-implementation data were collected from client facing and non-client facing employees to assess changes in education, training receipt, knowledge, and intervention behaviors, relative to program goals. Centers reported tobacco screenings conducted and nicotine replacement therapy (NRT) delivered through 6 months post-implementation. Overall, 64.56% of employees participated in TTTF-delivered tobacco education, with a 54.9% gain in tobacco control and treatment knowledge (p < 0.0001), and significant increases in exposure to education about tobacco use and harms among individuals with opioid use disorder (p = 0.0401). There were significant gains in clinicians' receipt of training in 9/9 tobacco education areas (ps ≤ 0.0118). From pre- to post-implementation, there were mean increases in the use of the 5A's (ask, advise, assess, assist, and arrange) and other evidence-based interventions for tobacco cessation, with statistically significant gains seen in NRT provision/referral (p < 0.0001). Several program goals were achieved or exceeded; however, 100% center participation in specialized clinical trainings was among notable exceptions. One program withdrew due to competing pandemic concerns; all others implemented comprehensive TFW policies. Overall, TTTF may have improved participating opioid treatment centers' capacity to address tobacco use, although study limitations, including lower post-implementation evaluation response rates, suggest that results require replication in other opioid addiction treatment settings.

The Impact of the COVID-19 Pandemic on Cancer Care and Health-Related Quality of Life of Non-Hispanic Black/African American, Hispanic/Latina and Non-Hispanic White Women Diagnosed with Breast Cancer in the U.S.: A Mixed-Methods Study Protocol

The COVID-19 pandemic has had critical consequences for cancer care delivery, including altered treatment protocols and delayed services that may affect patients’ quality of life and long-term survival. Breast cancer patients from minoritized racial and ethnic groups already experience worse outcomes, which may have been exacerbated by treatment delays and social determinants of health (SDoH). This protocol details a mixed-methods study aimed at comparing cancer care disruption among a diverse sample of women (non-Hispanic White, non-Hispanic Black/African American, and Hispanic/Latina) and assessing how proximal, intermediate, and distal SDoH differentially contribute to care continuity and health-related quality of life. An embedded mixed-methods design will be implemented. Eligible participants will complete an online survey, followed by a semi-structured interview (with a subset of participants) to further understand factors that influence continuity of care, treatment decision-making, and self-reported engagement. The study will identify potentially modifiable factors to inform future models of care delivery and improve care transitions. These data will provide the necessary evidence to inform whether a subsequent, multilevel intervention is warranted to improve quality of care delivery in the COVID-19 aftermath. Additionally, results can be used to identify ways to leverage existing social resources to help manage and support patients’ outcomes.

Implementation and Outcomes of a Train-the-Trainer Program at Behavioral Health Treatment Centers as a Mechanism to Maintain Organizational Capacity to Address Tobacco Use Disorder

Despite prior successful implementation of Taking Texas Tobacco Free (TTTF), an evidence-based tobacco-free workplace program, in local mental health authorities (LMHAs), post-implementation employee attrition necessitated continuing education on tobacco-free policies and tobacco treatment practices. Here, we report on the outcomes of a train-the-trainer program which trained "champions" to deliver tobacco cessation education at their LMHAs. Three LMHAs participated in program implementation via 10 champions, iteratively trained and coached by TTTF. Measures administered evaluated four goals: (1) increase champions' self-efficacy in delivering trainings, (2) achieve program fidelity via TTTF staff evaluation of trainer effectiveness and knowledge increases among attending employees, (3) achieve stakeholder program acceptability, and (4) achieve program adoption via an increase in follow-up trainings. Champions' self-efficacy increased throughout TTTF training. TTTF staff ratings of champion-led trainings met the targeted range for trainer effectiveness; employees had a 28.71% knowledge increase over baseline post-training (p < 0.001). Employees rated champions' training delivery "very good" to "excellent", on average; both champions and employees were, on average, "satisfied" to "extremely satisfied" with the curriculum and training received. There was an increase over baseline in trainings delivered during follow-up, and trainings increased in length and topic coverage. Ultimately, the train-the-trainer program achieved the intended goals, although not all changes were statistically significant, likely at least partially attributable to small sample sizes. Overall, these results suggest that TTTF's train-the-trainer program was successful in its delivery and intention to build capacity for the provision of in-house tobacco education trainings to behavioral health employees/providers. However, further evaluation in additional settings, with more champions, et cetera, is necessary to validate these findings, ensure their replicability, link program implementation with reduced patient tobacco use rates, and assess long-term sustainability.

Perceived Social Support Attenuates the Association between Stress and Health-Related Quality of Life among Adults Experiencing Homelessness

Health-related quality of life (HRQoL) is defined as a multidimensional subjective assessment of one’s physical and mental health. Homelessness is associated with numerous stressors that can reduce HRQoL. Social support is defined as the availability of individuals, or resources provided by individuals, to cope with stress. Interpersonal social support may be important in buffering HRQoL from the negative implications of stress. Here, we examine this association in a marginalized group known for high rates of physical and mental health comorbidities: adults experiencing homelessness. Participants (N = 581; 63.7% men; M_age = 43.6 ± 12.2) were recruited from homeless-serving agencies in Oklahoma City. Social support was measured with the 12-item Interpersonal Support Evaluation List (ISEL). HRQoL was measured by the Behavioral Risk Factor Surveillance System (BRFSS) survey using self-rated health, the number of poor mental and poor physical health days over the preceding 30 days, as well as the number of limited activity days as the result of poor mental and/or physical health. Perceived stress was assessed using the 4-item Perceived Stress Scale (PSS). The potential moderation effect of social support was examined by assessing the interaction term of social support and stress in a series of linear regression analyses, controlling for sex, age, months homeless, race, education, health insurance status, serious mental illness diagnosis, and recruitment agency/site. There was a significant interaction effect of social support and stress on the prediction of days of poor physical health, days of poor mental health, and days of limited activity (p in all cases ≤ 0.05). Results add to a growing literature on the potentially protective benefits of social support for HRQoL, extend them to a large sample of adults experiencing homelessness in the South, and demonstrate the significance of this moderating effect of social support over and above the influence of several prominent sociodemographic and diagnostic variables. Future work should determine if interventions designed to enhance social support can buffer HRQoL from the deleterious effects of stress among this vulnerable population.

Did School Meal Programs and SNAP Participation Improve Diet Quality of US Children from Low-Income Households: Evidence from NHANES 2013-2014?

Nutrition assistance programs such as school meals and the Supplemental Nutrition Assistance Program (SNAP) are designed to provide a safety net for the dietary intake of children from low-income families. However, compared with eligible non-participants, the relationship of diet quality with school meals only and school meals + SNAP is not well understood. The objectives of the study include: (1) To explore whether and to what extent nutrition assistance program participation (school meals only and school meals + SNAP) is related to diet quality; and (2) to examine the differences of diet quality between participating in school meals only, school meals + SNAP, or non-participation among American children. Children aged 5 to 18 years old from income eligible households who participated in the 2013-2014 National Health and Nutrition Examination Survey (NHANES) were included in this cross-sectional study (n = 1425). Diet quality was measured using the Healthy Eating Index (HEI)-2015 and its 13 subcomponents. A Rao-Scott Chi-square test, propensity scores approach, and Analysis of Covariance were performed. Covariates included age, sex, race/ethnicity, weight status, and family monthly poverty index. SAS survey procedures were used to incorporate the appropriate sample design weights. Participation in school meals + SNAP was not associated with higher diet quality compared to eligible non-participants or school meals-only participants. Participation in school meals + SNAP improved the intake of total dairy, but not added sugars or total vegetables compared to school meals only. Overall, school meal + SNAP participation did not significantly improve the overall diet quality of children in low-income households relative to comparable non-participants.

Organizational Factors Moderating Changes in Tobacco Use Dependence Care Delivery Following a Comprehensive Tobacco-Free Workplace Intervention in Non-Profit Substance Use Treatment Centers

Although tobacco use is the leading preventable cause of death and is elevated among patients with substance use disorders, many substance use treatment centers (SUTCs) do not offer tobacco use interventions (i.e., screening and treatment). This study examined a key outcome of the implementation of a tobacco-free workplace program that provided education and specialized training to employees; namely, changes in clinician provision of the five As (Asking about tobacco use; Advising to quit; Assessing willingness to quit; Assisting with quitting; Arranging follow-up) from before to after the larger program implementation. The five As are a brief tobacco screening and treatment protocol that was taught as part of the program and that formed the basis for further intervention (e.g., provision of nicotine replacement therapies, Motivational Interviewing to enhance desire and willingness to make a quit attempt). Moreover, we also examined organizational moderators that may have impacted changes in the delivery of the five As over time among clinicians from 15 participating SUTCs. The number of the centers' total and unique annual patient visits; full-time employees; and organizational readiness for implementing change were assessed as potential moderators of change in clinicians' behaviors over time. Clinicians completed pre- and post-program implementation surveys assessing their provision of the five As. Results demonstrated significant increases in Asking (p = 0.0036), Advising (p = 0.0176), Assisting (p < 0.0001), and Arranging (p < 0.0001). SUTCs with higher Change Efficacy (p = 0.025) and lower Resource Availability (p = 0.019) had greater increases in Asking. SUTCs with lower Resource Availability had greater increases in Assessing (p = 0.010). These results help guide tobacco control program implementation to increase the provision of tobacco use interventions (i.e., the five As) to SUTC patients and elucidate Change Efficacy and Resource Availability as organizational factors promoting this clinician behavior change.

Anxiety Sensitivity and Fast-Food Ordering Habits Among Black Adults

Background

Black adults experience high rates of overweight/obesity, which is linked to chronic diseases and is exacerbated by fast-food consumption. Anxiety sensitivity, a relative stable fear of anxiety-related sensations, has been linked to high caloric intake. Here, we examine whether anxiety sensitivity is associated with fast-food ordering habits within a convenience sample of Black adults.

Methods

Of 124 adults (79.4% women; M_age=49.3±11.6; 84.8% overweight/obese), 107 (86.3%) reported eating from a fast-food restaurant in the last month. Participants completed the Anxiety Sensitivity-Index 3, which has a total score and physical, cognitive, and social concerns subscales. Investigator-generated items queried frequency of ordering "supersized" quantities of fast-food (e.g., cheeseburgers, fries), and healthy items (e.g., salads, oatmeal, yogurt), respectively, from "never" to "always." Covariate-adjusted ordinal logistic regression models were used to assess relations between measures of interest.

Results

Anxiety sensitivity (total and physical concerns) was associated with greater odds of more frequently ordering supersized unhealthy fast-food; and anxiety sensitivity (total and cognitive concerns) was associated with lower odds of more frequently ordering healthy items from fast-food restaurants.

Conclusions

Results suggest that adults with greater anxiety sensitivity may engage in fast-food ordering habits that can contribute to the overweight/obesity epidemic. Future studies should replicate results and determine the potential for anxiety sensitivity-reduction interventions to affect dietary choices that contribute to overweight/obesity.

Factors Associated with Breast Cancer Screening Adherence among Church-Going African American Women

Relative to White women, African American/Black women are at an increased risk of breast cancer mortality. Early detection of breast cancer through mammography screening can mitigate mortality risks; however, screening rates are not ideal. Consequently, there is a need to better understand factors associated with adherence to breast cancer screening guidelines to inform interventions to increase mammography use, particularly for groups at elevated mortality risk. This study used the Andersen Behavioral Model of Health Services Use to examine factors associated with adherence to National Comprehensive Cancer Network breast cancer screening guidelines amongst 919 African American, church-going women from Houston, Texas. Logistic regression analyses measured associations between breast cancer screening adherence over the preceding 12 months (adherent or non-adherent) and predisposing (i.e., age, education, and partner status), enabling (i.e., health insurance status, annual household income, employment status, patient-provider communication, and social support), and need (i.e., personal diagnosis of cancer, family history of cancer, and risk perception) factors, separately and conjointly. Older age (predisposing: OR = 1.015 (1.007-1.023)), having health insurance and ideal patient-provider communication (enabling: OR = 2.388 (1.597-3.570) and OR = 1.485 (1.080-2.041)), and having a personal diagnosis of cancer (need: OR = 2.244 (1.058-4.758)) were each associated with greater odds of screening adherence. Only having health insurance and ideal patient-provider communication remained significantly associated with screening adherence in a conjoint model; cancer survivorship did not moderate associations between predisposing/enabling factors and screening adherence. Overall, results suggest that interventions which are designed to improve mammography screening rates amongst African American women might focus on broadening health insurance coverage and working to improve patient-provider communication. Implications for multi-level intervention approaches, including the role of churches in their dissemination, are proposed.

Sociodemographic Determinants of Nonadherence to Depression and Anxiety Medication among Individuals Experiencing Homelessness

Psychiatric medication nonadherence continues to be a leading cause of poor health outcomes for individuals experiencing homelessness. Identifying the sociodemographic factors that contribute to medication nonadherence may help guide strategies to care for and support this group. This study examined 200 adults with depression diagnoses and active anti-depressant prescriptions (Mage = 43.98 ± 12.08, 59.4% Caucasian, 58.5% male, 70% uninsured, 89.5% unemployed) and 181 adults with anxiety diagnoses and active anti-anxiety prescriptions (Mage = 43.45 ± 11.02, 54.4% Caucasian, 57.5% male, 66.3% uninsured, 88.9% unemployed) recruited from six homeless-serving agencies in Oklahoma City. Self-reported sociodemographic variables included: age, sex, race/ethnicity, education, monthly income, employment status, and health insurance status. Adjusted logistic regression analyses revealed that employed (OR = 4.022, CI_0.95: 1.244–13.004) and insured (OR = 2.923, CI_0.95: 1.225–6.973) participants had greater odds of depression medication nonadherence. For anxiety, being employed (OR = 3.573, CI_0.95: 1.160–11.010) was associated with greater odds of anxiety medication nonadherence, whereas having depression and anxiety diagnostic comorbidity (OR = 0.333, CI_0.95: 0.137–0.810) was associated with lower odds of anxiety medication nonadherence. Interventions aimed at facilitating accessible prescription acquisition or otherwise reducing barriers to prescription medications for employed adults, including those with health insurance, may benefit adherence, but more research is needed. Future studies would benefit from using a qualitative approach to better delineate nuanced barriers to psychiatric medication adherence.

Organizational-Level Moderators Impacting Tobacco-Related Knowledge Change after Tobacco Education Training in Substance Use Treatment Centers

Tobacco use is disproportionately elevated among patients with substance use disorders relative to the general U.S. population. Tobacco interventions are lacking within substance use treatment centers (SUTCs) due to lack of knowledge and training. This study examined knowledge gain and the organizational factors that might moderate knowledge gains following tobacco education training provided to employees (N = 580) within 15 SUTCs that were participating in a tobacco-free workplace program. The number of total annual patient visits, unique annual patient visits, number of full-time employees, and organizational readiness for implementing change (ORIC) as assessed prior to implementation were examined as potential moderators. Results demonstrated significant knowledge gain (p < 0.001) after training overall; individually, 13 SUTCs had significant knowledge gain (p's < 0.014). SUTCs with fewer total annual patient visits and fewer full-time employees showed greater knowledge gains. The ORIC total score and all but one of its subscales (Resource Availability) moderated knowledge gain. SUTCs with greater initial Change Efficacy (p = 0.029), Valence (p = 0.027), and Commitment (p < 0.001) had greater knowledge gain than SUTCs with lower scores on these constructs; SUTCs with greater Task Knowledge (p < 0.001) regarding requirements for change exhibited less knowledge gain. Understanding the organizational-level factors impacting training effectiveness can inform efforts in organizational change and tobacco control program implementation.

"UHAND"-A National Cancer Institute Funded Partnership to Advance Cancer Health Equity through Scholar Training

Black and Hispanic adults are disproportionately affected by cancer incidence and mortality, and experience disparities in cancer relative to their White counterparts in the US. These groups, including women, are underrepresented among scientists in the fields of cancer, cancer disparities, and cancer care. The "UHAND" Program is a partnership between institutions (University of Houston and The University of Texas MD Anderson Cancer Center) aiming to build the capacity of underrepresented and racial/ethnic minority student "scholars" to conduct research on eliminating cancer inequities by reducing social and physical risk factors among at-risk groups. Here, we examine the outcomes of the UHAND Program's first scholar cohort (n = 1 postdoctoral fellow, n = 3 doctoral scholars, n = 6 undergraduate scholars). Data collection included baseline, mid-program, and exit surveys; program records; and monthly scholar achievement queries. From baseline to exit, scholars significantly increased their research self-efficacy (p = 0.0293). Scholars largely met goals for academic products, achieving a combined total of 65 peer-reviewed presentations and nine empirical publications. Eight scholars completed the 2-year program; one undergraduate scholar received her degree early and the postdoctoral fellow accepted a tenure-track position at another university following one year of training. Scholars highly rated UHAND's programming and their mentors' competencies in training scholars for research careers. Additionally, we discuss lessons learned that may inform future training programs.

Combining Global Positioning System (GPS) with saliva collection among sexual minority adults: A feasibility study

BACKGROUND

This is the first study, of which we are aware, to evaluate the feasibility and accessibility of simultaneous use of Global Positioning System (GPS) and saliva collection for biomarker assessment as an objective measure of stress physiology among sexual minority (lesbian, gay, bisexual, queer, and other non-heterosexual identities) individuals. The principal motivation for pairing GPS and saliva collection was to investigate how characteristics of the built and social environments along with participants' daily activity paths affect stress. This can contribute to a better understanding of health and health behaviors in the sexual minority community.

METHODS

A convenience sample of enrolled participants (N = 124) from Houston, Texas was asked to complete questionnaires, carry with them a GPS unit daily, and collect and store 6 samples of saliva at specific times across the span of a day prior to a second visit around one week later.

RESULTS

Of 124 participants, 16 participants (12.90%) provided no useable GPS data and 98 (79.03%) provided at least 4 days of data. More than three-fourths (n = 98, 79.03%) also provided complete saliva samples.

CONCLUSIONS

Our results show that the simultaneous use of GPS and saliva collection to assess sexual minority individuals' activity paths and stress level is feasible.

Organizational Characteristics and Readiness for Tobacco-Free Workplace Program Implementation Moderates Changes in Clinician's Delivery of Smoking Interventions within Behavioral Health Treatment Clinics

BACKGROUND

Smoking is elevated amongst individuals with behavioral health disorders, but not commonly addressed. Taking Texas Tobacco Free is an evidence-based, tobacco-free workplace program that addresses this, in-part, by providing clinician training to treat tobacco use in local mental health authorities (LMHAs). This study examined organizational moderators of change in intervention delivery from pre- to post-program implementation.

METHODS

LMHA leaders completed the Organizational Readiness for Implementing Change (ORIC) and provided organization demographics pre-implementation. Clinicians (N = 1237) were anonymously surveyed about their consistent use of the 5As (Asking about smoking; Advising clientele to quit; Assessing willingness to quit; Assisting them to quit; Arranging follow-up) pre- and post-program implementation. Adjusted generalized linear mixed models were used for analyses (responses nested within LMHAs), with interaction terms used to assess moderation effects.

RESULTS

Clinician delivery of 5As increased pre- to post-implementation (p < .001). LMHAs with fewer employees (ref = ≤300) demonstrated greater increases in Asking, Assessing, and Assisting over time. LMHAs with fewer patients (ref = ≤10 000) evinced greater changes in Asking over time. Less initial ORIC Change Efficacy, Change Commitment, and Task Knowledge were each associated with greater pre- to post-implementation changes in Asking. Less initial Task Knowledge was associated with greater increases in Advising, Assessing, and Assisting. Finally, less initial Resource Availability was associated with greater increases in Assisting (all moderation term ps < .025).

CONCLUSION

The smallest and least ready LMHAs showed the largest gains in tobacco cessation intervention delivery; thus, low initial readiness was not a barrier for program implementation, particularly when efficacy-building training and resources are provided.

IMPLICATIONS

This study examined organizational moderators of increases in tobacco cessation treatment delivery over time following the implementation of a comprehensive tobacco-free workplace program within 20 of 39 LMHAs across Texas (hundreds of clinics; servicing >50% of the state) from 2013 to 2018. Overall, LMHAs with fewer employees and patients, and that demonstrated the least initial readiness for change, evinced greater gains in intervention delivery. Findings add to dissemination and implementation science by supporting that low initial readiness was not a barrier for this aspect of tobacco-free workplace program implementation when resources and clinician training sessions were provided.

Examining moment to moment affective determinants of smoking rate following a quit attempt among homeless daily smokers

BACKGROUND

Cigarette smoking disproportionately affects homeless individuals, who have a higher smoking prevalence, fewer resources, and increased stressors compared to domiciled smokers. Little is known about how to facilitate smoking cessation among this population although some findings support focusing efforts on affective variables as well as alternate outcomes in order to optimize interventions for this group.

METHODS

Participants were homeless adults recruited from a Dallas, TX, shelter (N = 57, 61.4% male, M_age = 48.8 ± 9.0) to participate in tobacco cessation classes using an American Cancer Society-based therapy and support group with nicotine replacement therapy. Moment-to-moment changes in affect [e.g., negative affect (NA), positive affect (PA), and stress] were recorded via Ecological Momentary Assessments to assess whether they were associated with concurrent changes in cigarettes smoked per day (CPD) following a specific quit attempt. Separate generalized linear models (GLM) were evaluated for each predictor to examine the associations between affective variables and CPD in covariate-adjusted analyses.

RESULTS

Significant interaction effects of time and affect were found for all variables (NA: p = 0.0011, PA: p = 0.0006, stress: p = 0.0259), whereby the association of affect and CPD were significant in the early part of the week but the effects faded as time progressed. With regard to main effects, only increases in PA during the post-quit week significantly predicted fewer CPD (adjusted incidence rate ratio = 0.924, SE = 0.027, p = 0.0032).

CONCLUSIONS

Homeless smokers may be more likely to decrease their cigarette consumption during periods of greater PA throughout the post-quit week. Relationship between positive affect and reduction in CPD suggest focus on affective variables with homeless smokers may be an effective avenue for change in smoking behaviors, particularly in the days immediately following a quit attempt. Time effects should be further investigated to determine when these interventions might best be implemented.

Empowered Choices: African-American Women's Breast Reconstruction Decisions

Objectives: Breast reconstruction (BR) potentially can improve quality of life in postmastectomy breast cancer survivors (BCS); however, African-American women are less likely to undergo BR than Caucasian women. This qualitative study was undertaken to explore individual, sociocultural, and contextual factors influencing African-American women's BR decision-making processes and preferences. Methods: Postmastectomy African-American BCS with and without BR participated in semi-structured interviews. We adopted a grounded theory approach using the constant comparison method to understand the contexts and processes informing participants' BR decision-making. Results: Twenty-three women participated, of whom 17 elected BR and 6 did not. Whereas women's primary reasons for deciding for or against BR differed, our core category, "empowered choices ," describes both groups' decision-making as a process focused on empowering themselves physically and/or psychologically, through self-advocacy, informed and shared decision-making, and giving back/receiving communal and spiritual support from church and African-American survivor groups. Socioeconomic factors influenced women's access to BR. Women preferred autologous BR and expressed the need for greater culturally-matched resources and support to inform treatment and shared BR decision-making. Conclusions: Understanding and supporting African-American women's BR preferences and empowerment is essential to ensuring equal access, and culturally-relevant, high-quality, and informed patient-centered care.

Examining the moderating effect of anxiety sensitivity on past-month pain severity and heaviness of smoking among adult smokers experiencing homelessness

BACKGROUND

Pain and cigarette smoking are reciprocally related. Domiciled smokers with higher anxiety sensitivity (AS) - the fear of behaviors/sensations associated with the experience of anxiety - consume more cigarettes and report greater tobacco dependence than smokers with lower AS. AS treatment can reduce chronic pain and facilitate smoking cessation. Here, we examine the potentially moderating role of AS in the association between past-month pain (PMP) and heaviness of smoking (HS) among smokers experiencing homelessness.

METHODS

Participants (N = 461; 64.9% men, M_age = 43.1 ± 11.8) were smokers recruited from 6 homeless serving agencies in Oklahoma City, OK. Participants self-reported the presence and severity of PMP ("How much bodily pain have you had during the past four weeks?"), HS was measured via the heaviness of smoking index (HSI), and AS was measured via the Anxiety Sensitivity Index-III (ASI-III) and its 3 subscales: physical, cognitive, and social concerns. Linear regressions were used to examine potential ASI moderation controlling for age, sex, race, education, health insurance, perceived stress, and major depression.

RESULTS

ASI-III total, cognitive, and physical concerns each significantly moderated associations of PMP and HSI (ps < 0.05), whereas social concerns did not. Individuals with high AS had greater cigarette dependence as PMP values increased.

CONCLUSION

Similar to research with domiciled smokers, current results suggest that smokers experiencing homelessness who have high AS may benefit from AS-based interventions to reduce the association between PMP and HS, which may facilitate smoking cessation among this vulnerable group.

Abstract PO-198: Understanding the associations between smoking-related risk perception, interest in quitting smoking, and interest in lung cancer screening among homeless adult smokers

Introduction: The current study was meant to disentangle the associations between smoking-related risk perception, interest in quitting smoking, and interest in lung cancer screening (LCS) in a sample of adult smokers experiencing homelessness.

Smoking-related risk perception and interest in quitting smoking have each been linked with interest in LCS among domiciled samples. However, little is known about this association among homeless smokers, a population with comparatively and significantly higher rates of smoking/smoking-related cancers. Risk perception and interest in quitting smoking may each directly relate to LCS interest, or they may interact with one another to predict interest in LCS. Methods: A convenience sample of 470 adult participants was recruited from a large shelter in Dallas, TX. The analytic sample included those who were self-reported and carbon monoxide verified current smokers (N=310; 72.6% men, Mage=43+11.6). Participants self-reported risk perception (“What are the chances of developing at least one smoking related disease if you do not quit smoking?” measured 0-100%, anchored/coded 0-10), interest in quitting smoking (“I would like to stop smoking” measured yes/no), and interest in LCS (“I would be interested in taking a test that can screen for lung cancer” measured with a 5-point Likert, strongly disagree to strongly agree). Ordinal logistic regression models were used to estimate associations of smoking-related risk perception, interest in quitting smoking, and interest in LCS, controlling for wave of data collection, smoking rate, age, sex, race, and education. The interaction of risk perception and interest in quitting smoking on LCS interest was examined via an interaction term after mean-centering variables of interest. Results: The average risk perception was 6.7+3.2 (range 0-10), 74.8% (n=232) agreed or strongly agreed with interest in LCS, and 65.8% (n=204) were interested in quitting smoking. Greater interest in quitting smoking was associated with greater interest in LCS (adjusted OR: 1.968, (95% CI: 1.213, 3.191), p=0.006). Risk perception and interest in quitting smoking did not interact in their association with interest in LCS. Conclusion: Findings confirm a link between interest in quitting smoking and interest in LCS among homeless smokers. Providing education about LCS eligibility, the benefits of quitting smoking to reducing risk of lung cancer prior to LCS screening eligibility, and increasing access to LCS among eligible homeless smokers may increase intention to quit and engender quit attempts.

Citation Format: Pooja Agrawal, Tzu-An Chen, Matthew Taing, Sean M. Reuven, Michael S. Businelle, Darla E. Kendzor, Lorraine R. Reitzel. Understanding the associations between smoking-related risk perception, interest in quitting smoking, and interest in lung cancer screening among homeless adult smokers [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-198.

Mental Illness and Youth-Onset Homelessness: A Retrospective Study among Adults Experiencing Homelessness

Financial challenges, social and material instability, familial problems, living conditions, structural issues, and mental health problems have been shown to contribute to youth homelessness. Based on the paucity of literature on mental illness as a reason for youth homelessness, the current study retrospectively evaluated the association between the timing of homelessness onset (youth versus adult) and mental illness as a reason for homelessness among homeless adults living in homeless shelters and/or receiving services from homeless-serving agencies. Homeless participants (N = 919; 67.3% men) were recruited within two independent studies from Dallas and Oklahoma. Covariate-adjusted logistic regressions were used to measure associations between homelessness onset and mental illness as a reason for current homelessness, history of specific mental illnesses, the historical presence of severe mental illness, and severe mental illness comorbidity. Overall, 29.5% of the sample reported youth-onset homelessness and 24.4% reported mental illness as the reason for current homelessness. Results indicated that mental illness as a reason for current homelessness (AOR = 1.62, 95% CI = 1.12–2.34), history of specific mental illnesses (Bipolar disorder–AOR = 1.75, 95% CI = 1.24–2.45, and Schizophrenia/schizoaffective disorder–AOR = 1.83, 95% CI = 1.22–2.74), history of severe mental illness (AOR = 1.48, 95% CI = 1.04–2.10), and severe mental illness comorbidities (AOR = 1.30, 95% CI: 1.11–1.52) were each associated with increased odds of youth-onset homelessness. A better understanding of these relationships could inform needs for early interventions and/or better prepare agencies that serve at-risk youth to address precursors to youth homelessness.

Adapting and Evaluating Implementation of a Tobacco-Free Workplace Program in Behavioral Health Centers

Objectives: State-administered community behavioral health centers (CBHCs) rarely treat tobacco dependence, despite high client tobacco use. Using a mixed-methods approach we examine the adaptation and implementation of an evidence-based tobacco-free workplace (TFW) program in 2 CBHCs (17 individual clinics). Methods: Varied data collection included pre- and post-implementation leader, clinician, and staff surveys; pre-, mid-, and post-implementation staff and client focus groups; and monthly implementation logs. The RE-AIM framework guided translation of behavioral interventions into sustainable practice. Results: Pre- to post-implementation increases were seen in training receipt among clinicians and employees. Both CBHCs adopted a 100% TFW policy, integrated tobacco screenings into routine practice, and delivered evidence-based practices (EBPs). Qualitative methods enlisted key stakeholders contributing towards adapting program strategies to local contexts, addressing barriers, adjusting tobacco screening administration, and understanding reasons for success or failure to implement specific components. Conclusions: Program implementation at both CBHCs increased organizational capacity in the provision of EBPs to treat tobacco dependence through successfully meeting the majority of our RE-AIM targets. Findings contribute to the development of flexible strategies and interventions responsive to variable implementation contexts and barriers; enhancing the effectiveness and sustainability of a TFW program.

Tobacco-free Workplace Program at a Substance Use Treatment Center

Objectives: About 65%-87% of substance use disorder patients smoke cigarettes, compared to 14% of the general adult population. Few substance use treatment centers (SUTCs) have comprehensive tobacco-free workplace (TFW) policies or offer tobacco interventions. Taking Texas Tobacco Free (TTTF) implements an evidence-based TFW program in SUTCs, including at the Billy T. Cattan Recovery Outreach Center (BTC). We present a mixed methods case study of BTC's TTTF implementation, success factors, and challenges. Methods: TTTF provided policy development assistance, training, treatment resources, and technical assistance over ∼9 months. Implementation was tailored using mixed methods. Quantitative data included surveys to stakeholders (N_max = 7), a pre- and post-training questionnaire assessing knowledge gain, and reported quantities of tobacco use assessments (TUAs) administered and nicotine replacement therapy (NRT) provided. Qualitative data included stakeholder focus groups and interviews (18 participants). Results: All employees reported TFW policy compliance. Employees exhibited a 20% knowledge gain. Clinicians increased self-report of NRT provision and tobacco cessation counseling. During implementation, BTC administered TUAs to 171 patients and dispensed NRT to 70 of 110 tobacco-using patients. Conclusion: Qualitative findings contextualized quantitative outcomes. TTTF implementation changed clinician attitudes, knowledge, and practices regarding tobacco treatment, facilitating patient quit attempts.

Health Risk Factors in American Indian and Non-Hispanic White Homeless Adults

Objectives: American Indians (AIs) are over-represented among homeless populations, but are understudied regarding their unique risk and resilience factors relative to non-Hispanic white (NHW) adults experiencing homelessness. In the current study, we aimed to address this gap. Methods: We recruited participants (108 AIs and 307 NHWs) from 6 homeless serving agencies in Oklahoma City, OK. Participants completed standard assessments of health, health behaviors, including alcohol and drug use, readiness to change endorsed health behaviors (eg, unsafe sex, fruit and vegetable intake, happiness with weight, physical activity), sleep location and quality, personal victimization, and discrimination. Results: Compared to NHWs, AIs endorsed greater alcohol use problems and were more likely to report having been arrested/booked for disorderly conduct or public drunkenness; however, AIs were less likely to report smoking cigarettes and reported greater readiness to change unsafe/unprotected sexual behaviors. Furthermore, compared to NHWs, AIs reported experiencing greater discrimination and were more likely to report sleeping outside or on the streets, versus in shelters; however, AIs reported fewer days of inadequate sleep. Conclusions: Findings suggest AI-specific risk and resilience factors for homelessness. This information can aid in treatment, service, and housing planning for this under-studied group who experiences some of the greatest health disparities.

Clinician Training in the Adaptation of a Comprehensive Tobacco-Free Workplace Program in Agencies Serving the Homeless and Vulnerably Housed

Tobacco use is exceedingly high among those who are homeless or at risk of homelessness but not commonly addressed by clinicians. Taking Texas Tobacco Free (TTTF) is a tobacco control program that addresses known clinician barriers to intervention (e.g., low training receipt, limited resources). Here, we examine the process and outcomes of TTTF's adaptation within four agencies that provide housing or other services to individuals who are homeless or vulnerably housed. Pre- and post-implementation data were collected from clinicians (N = 68) to assess changes in training receipt, knowledge, and intervention behaviors, relative to program goals. Results indicated significant gains in clinicians' receipt of training in 9 (of 9) target areas (p's ≤ 0.0042) and a 53% knowledge gain (p < 0.0001). From pre- to post-implementation, there were mean increases in the use of the 5As (ask, advise, assess, assist, and arrange) and other evidence-based interventions for tobacco cessation, with significant gains seen in assisting residents/clients to quit, arranging follow-ups, and providing or referring for non-nicotine medications (p's ≤ 0.0491). All program goals, except gains related to advising smokers to quit and the use of specific interventions (behavioral counseling), were met. Overall, TTTF improved clinicians' capacity to address tobacco use among homeless and vulnerably housed individuals and can serve as a model for tobacco control efforts in similar agencies.