Using pod based e-cigarettes and nicotine pouches to reduce harm for adults with low socioeconomic status who smoke: A pilot randomized controlled trial

INTRODUCTION

Alternative Nicotine Delivery Systems (ANDS) such as e-cigarettes (EC) and oral nicotine pouches (ONP) may facilitate the substitution of smoking for those unwilling to quit. This pilot study assesses the harm reduction potential of EC and ONP among smokers with low socioeconomic status (SES).

METHODS

Adults who smoked daily in the past 6 months, had a household income < 250% federal poverty level and had no intention of quitting smoking in the next 30 days were randomized 2:2:1 to 8 Weeks of 5% nicotine EC; 4mg ONP or assessment-only control (CC). The primary outcome was a within-group change in cigarettes per day (CPD) from Baseline to Week 8.

RESULTS

45 individuals were randomized (EC: N=18; ONP: N=18; CC: N=9). Analyses included 33 participants who completed the Week 8 visit. Mean age was 50.2 years (SD:10.7) and average CPD at baseline was 13.9 (SD: 10.1). For those randomized to EC, average CPD decreased from 14.7 (95%CI: 10.3; 19.1) at Baseline to 2.9 (95%CI: 0.09; 5.79) at Week 8 (p-value <0.001). For those randomized to ONP, average CPD decreased from 15.0 (95%CI: 5.02; 24.93) to 8.3 (95%CI: 1.34; 15.18) by Week 8 (p-value =0.01). In the EC and ONP groups, respectively, 4 (28.6%) and 1 (8.3%) participant fully switched from smoking to the ANDS product by Week 8.

CONCLUSIONS

Individuals with low SES who smoke had lower CPD after switching to EC or ONP. These findings show the potential of ANDS in helping smokers switch to less harmful devices.

IMPLICATIONS

This study provides novel evidence that e-cigarettes and nicotine pouches can be a harm reduction tool for individuals with lower SES who smoke and are not willing to quit smoking, contributing to reducing tobacco-related disparities in this population.

Career disruption and limitation of financial earnings due to cancer

PURPOSE

This study investigated how cancer diagnosis and treatment lead to career disruption and, consequently, loss of income and depletion of savings.

DESIGN

This study followed a qualitative descriptive design that allowed us to understand the characteristics and trends of the participants.

METHOD

Patients recruited (n = 20) for this study were part of the University of Kansas Cancer Center patient advocacy research group (Patient and Investigator Voices Organizing Together). The inclusion criteria were that participants must be cancer survivors or co-survivors, be aged 18 years or older, be either employed or a student at the time of cancer diagnosis, have completed their cancer treatment, and be in remission. The responses were transcribed and coded inductively to identify themes. A thematic network was constructed based on those themes, allowing us to explore and describe the intricacies of the various themes and their impacts.

RESULTS

Most patients had to quit their jobs or take extended absences from work to handle treatment challenges. Patients employed by the same employer for longer durations had the most flexibility to balance their time between cancer treatment and work. Essential, actionable items suggested by the cancer survivors included disseminating information about coping with financial burdens and ensuring that a nurse and financial navigator were assigned to every cancer patient.

CONCLUSIONS

Career disruption is common among cancer patients, and the financial burden due to their career trajectory is irreparable. The financial burden is more prominent in younger cancer patients and creates a cascading effect that financially affects close family members.

Evaluating Work Impairment as a Source of Financial Toxicity in Cancer Healthcare and Negative Impacts on Health Status

How the socioeconomic factors intersect for a particular patient can determine their susceptibility to financial toxicity, what costs they will encounter during treatment, the type and quality of their care, and the potential work impairments they face. The primary goal of this study was to evaluate financial factors leading to worsening health outcomes by the cancer subtype. A logistic model predicting worsening health outcomes while assessing the most influential economic factors was constructed by the University of Michigan Health and Retirement Study. A forward stepwise regression procedure was implemented to identify the social risk factors that impact health status. Stepwise regression was done on data subsets based on the cancer types of lung, breast, prostate, and colon cancer to determine whether significant predictors of worsening health status were different or the same across cancer types. Independent covariate analysis was also conducted to cross-validate our model. On the basis of the model fit statistics, the two-factor model has the best fit, that is, the lowest AIC among potential models of 3270.56, percent concordance of 64.7, and a C-statistics of 0.65. The two-factor model used work impairment and out-of-pocket costs, significantly contributing to worsening health outcomes. Covariate analysis demonstrated that younger patients with cancer experienced more financial burdens leading to worsening health outcomes than elderly patients aged 65 years and above. Work impairment and high out-of-pocket costs were significantly associated with worsening health outcomes among cancer patients. Matching the participants who need the most financial help with appropriate resources is essential to mitigate the financial burden.

Significance

Among patients with cancer, work impairment and out-of-pocket are the two primary factors contributing to adverse health outcomes. Women, African American or other races, the Hispanic population, and younger individuals have encountered higher work impairment and out-of-pocket costs due to cancer than their counterparts.

eDECIDE a web-based problem-solving interventions for diabetes self-management: Protocol for a pilot clinical trial

Background

In the US, diabetes affects 13.2% of African Americans, compared to 7.6% of Caucasians. Behavioral factors, such as poor diet, low physical activity, and general lack of good self-management skills and self-care knowledge are associated with poor glucose control among African Americans. African Americans are 77% more likely to develop diabetes and its associated health complications compared to non-Hispanic whites. A higher disease burden and lower adherence to self-management among this populations calls for innovative approaches to self-management training. Problem solving is a reliable tool for the behavior change necessary to improve self-management. The American Association of Diabetes Educators identifies problem-solving as one of seven core diabetes self-management behaviors.

Methods

We are using a randomized control trial design. Participants are randomized to either traditional DECIDE or eDECIDE intervention. Both interventions run bi-weekly over 18 weeks. Participant recruitment will take place through community health clinics, University health system registry, and through private clinics. The eDECIDE is an 18-week intervention designed to deliver problem-solving skills, goal setting, and education on the link between diabetes and cardiovascular disease.

Conclusion

This study will provide feasibility and acceptability of the eDECIDE intervention in community populations. This pilot trial will help inform a powered full-scale study using the eDECIDE design.

Changes in dependence, withdrawal, and craving among adult smokers who switch to nicotine salt pod-based e-cigarettes

BACKGROUND AND AIMS

For electronic cigarettes (e-cigarettes) to be a viable substitute for combustible cigarettes, it is likely that they must be rewarding enough for regular use, indicated by factors such as craving and dependence, important aspects of reinforcement. This study aimed to understand short-term changes in measures of nicotine dependence between groups differing by use trajectory in a switching trial, and within group changes of these measures.

DESIGN

Secondary data analysis of one arm of an e-cigarette randomized clinical trial.

SETTING

San Diego, California and Kansas City, Missouri, United States.

PARTICIPANTS

114 African American (n = 60) and Latinx (n = 54) smokers (58.8% male) attempting to switch to nicotine salt pod system (NSPS) e-cigarettes in a 6-week trial.

MEASUREMENTS

At week 6, participants were classified by use trajectory: exclusive smokers (n = 16), exclusive e-cigarette (n = 32), or dual users (n = 66). E-cigarette, cigarette, and total nicotine dependence (cigarette + e-cigarette), use patterns, cigarette craving and nicotine withdrawal, and cotinine were assessed at baseline and week 6 using standard measures.

FINDINGS

In between group comparisons, exclusive e-cigarette and dual users showed greater reductions in cigarette dependence (e-cigarette: -32.38, 95% CI = -37.7,-27.1; dual: -18.48, 95% CI = -22.2,-14.7), withdrawal (e-cigarette: -6.25, 95% CI = -8.52,-3.98; dual: -3.18, 95% CI = -5.02,-1.34), craving (e-cigarette: -11.44, 95% CI = -14.2,8.7; dual: -9.59, 95% CI = -11.6,-7.59), and cigarettes per day (CPD; e-cigarette: -11.19, 95% CI = -13.1,-9.27; dual: -9.39, 95% CI = -11.3, -7.52) compared with exclusive smokers. In within group analyses, e-cigarette and dual users showed reductions in craving and withdrawal from baseline to week 6. Exclusive e-cigarette and dual users, maintained cotinine levels (all Ps > 0.05) and showed reductions in CPD and cigarette dependence (all Ps < 0.01). Findings were inconclusive regarding changes in total nicotine dependence from baseline to week 6 among exclusive e-cigarette users (P = 0.123). Dual users showed increased total nicotine dependence (P < 0.001) and smokers showed decreased total dependence (P = 0.004).

CONCLUSIONS

Smokers who switch to nicotine salt pod system e-cigarettes maintain their nicotine levels and transfer their dependence, suggesting that nicotine salt pod system e-cigarettes have a similar reinforcement potential to cigarettes and facilitate switching.

"Cold turkey" or pharmacotherapy: Examination of tobacco cessation methods tried among smokers prior to developing head and neck cancer

BACKGROUND

Tobacco cessation methods employed by patients with head and neck cancer (HNSCC) are previously unstudied and have the potential to inform choice of cessation method and necessary abstinence support.

METHODS

A total of 130 current smokers with HNSCC were queried regarding prior unsuccessful tobacco cessation techniques, product used (cold turkey, varenicline, and nicotine patch/gum), and maximum time abstained from smoking.

RESULTS

One hundred six smokers retrospectively reported using one of the four main quit methods. Unassisted cessation ("cold turkey") was the most commonly used method (P < .001). A multiple ordinal logistic general estimating equation analysis revealed that cold turkey had increased odds [5.2 (95% confidence interval [CI]: 2.2, 11.8) and 4.3 (95% CI: 1.5, 12.9)] of achieving a longer quit duration than the nicotine patch or varenicline, respectively.

CONCLUSIONS

Among smokers developing HNSCC, previous cessation attempts were most commonly unassisted. This method was associated with longest abstinence periods. These data suggest insufficient support and education regarding behavioral and pharmacologic cessation therapies.

Effect of Long-term Nicotine Replacement Therapy vs Standard Smoking Cessation for Smokers With Chronic Lung Disease: A Randomized Clinical Trial

IMPORTANCE

Smokers with chronic obstructive pulmonary disease (COPD) have particular difficulty quitting. Long-term nicotine replacement therapy (LT-NRT) might offer a strategy for reducing harm from cigarettes and provide a pathway for later cessation.

OBJECTIVE

To compare the effect of LT-NRT vs standard smoking cessation (SSC) on exposure to cigarette smoke, harm related to smoking, and cessation among smokers with COPD.

DESIGN, SETTING, AND PARTICIPANTS

This unblinded, randomized clinical trial recruited smokers who self-reported a diagnosis of COPD at any level of readiness to quit from May 23, 2014, through November 30, 2015. The 12-month follow-up was completed December 6, 2016. Patients were recruited at a clinical research unit of an academic medical center. Analysis was based on intention to treat and performed from March 8 through November 30, 2017.

INTERVENTIONS

Standard smoking cessation treatment included 10 weeks of NRT and 4 follow-up counseling sessions for those willing to make a quit attempt. Long-term NRT included 12 months of NRT and 6 follow-up counseling sessions regardless of initial willingness to quit. Overall, 198 patients were randomized to SSC, and 197 were included in the primary analysis; 200 patients were randomized to LT-NRT, and 197 were included in the primary analysis.

MAIN OUTCOMES AND MEASURES

The primary outcome was 7-day abstinence verified by carbon monoxide (CO) levels at 12 months. Secondary outcomes included cigarettes smoked per day (CPD), exposure to CO, urinary excretion of 4-methylnitrosamino-1-3-pyridyl-1-butanol (NNAL) (a smoking-related carcinogen), and adverse events.

RESULTS

Among 398 patients who were randomized (59.8% female; mean [SD] age, 56.0 [9.3] years), the mean (SD) CPD was 23.1 (12.3). Twelve-month follow-up was completed by 373 participants (93.7%), and 394 (99.0%) were included in the primary analysis. At 12 months, CO-verified abstinence occurred in 23 of 197 participants (11.7%) in the SSC arm and 24 of 197 (12.2%) in the LT-NRT arm (risk difference, 0.5%; 95% CI, -5.9% to 6.9%). Continuing smokers in the SSC and LT-NRT arms had similar, significantly reduced harms caused by smoking, including cigarette consumption by 12.4 and 14.5 CPD, respectively, exhaled CO level by 5.5 and 7.8 ppm, respectively, and mean urinary NNAL excretion by 21.7% and 23.0%, respectively. In multivariate analyses, continuing smokers with greater adherence to NRT experienced less reduction in NNAL exposure. The frequency of major adverse cardiac events was similar in both groups.

CONCLUSIONS AND RELEVANCE

Similar rates of cessation and similar reductions in exposure to tobacco smoke resulted with LT-NRT and SSC. Among continuing smokers, ongoing use of NRT was not associated with reductions in smoke exposure.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02148445.

Gender Differences in Smoking Behavior and Dependence Motives Among Daily and Nondaily Smokers

INTRODUCTION

While the overall prevalence of smoking has declined, nondaily smoking is on the rise. Among daily smokers (DS) men tend to smoke more cigarettes per day and have higher dependence. Unfortunately little is known about gender differences in nondaily smokers (NDS).

METHODS

This secondary-data analysis utilized data from a cross-sectional online survey. Participants reported on smoking behavior (eg, cigarettes per day, history of quit attempts) and nicotine dependence motives as assessed by the Brief Wisconsin Inventory of Dependence Motives via the primary and secondary subscales (ie, core features of tobacco dependence such as craving and accessory motives such as weight control, respectively).

RESULTS

Participants were 1175 DS (60% women) and 1201 NDS (56% women). Two interactions between group and gender were noted suggesting that the NDS had greater gender differences in past quit attempts (P < .01) and reported change in smoking behavior over the past year (P < .01). Further, among the NDS group, men scored significantly higher than women on both the primary and secondary dependence motives subscales (3.6±0.1 vs. 2.9±0.1, P < .0001; 3.8±0.1 vs. 3.3±0.1, P < .0001; respectively). There were no significant differences in dependence motives in the DS group (P > .05).

CONCLUSIONS

Gender differences in smoking behavior and dependence motives varied between NDS and DS. Specifically, gender differences in smoking behavior and smoking dependence motives may be larger among NDS compared to DS. Additional research is needed to explore how these relationships may relate to smoking cessation in NDS.

BMI-based norms for a culturally relevant body image scale among African Americans

The present study provides body mass index (BMI) standards for interpreting culturally relevant body image figure scores among African American men and women. Concordance between participants' and independent raters' figure selection is evaluated and the sensitivity and specificity of the figures for predicting overweight status are reported. African American adults (n = 498, 71% female) selected the figure most closely resembling them currently, and had their height and weight measured to calculate BMI. Three independent raters selected the figure that most closely resembled a subset of the participants (n = 277, 75% female). Probability that overweight status was correctly identified was 85% for participants and 98% for raters. ROC analysis showed that figures selected by raters (86%) and participants (83%) were equally sensitive in predicting overweight status using the gold standard, BMI. Figures selected by raters (98%) were more specific in predicting overweight status than when selected by participants (75%). Considerations in using participant- or rater-based norms for interpreting figure scores are discussed.

CYP2B6 and bupropion's smoking-cessation pharmacology: the role of hydroxybupropion

Bupropion is indicated to promote smoking cessation. Animal studies suggest that the pharmacologic activity of bupropion can be mediated by its major metabolite, hydroxybupropion. We measured plasma bupropion and its metabolite levels in a double-blind, placebo controlled, randomized smoking-cessation trial. Among the treatment-adherent individuals, higher hydroxybupropion concentrations (per μg/ml) resulted in better smoking-cessation outcomes (week 3, 7, and 26 odds ratio (OR) = 2.82, 2.96, and 2.37, respectively, P = 0.005-0.040); this was not observed with bupropion levels (OR = 1.00-1.03, P = 0.59-0.90). Genetic variation in CYP2B6, the enzyme that metabolizes bupropion to hydroxybupropion, was identified as a significant source of variability in hydroxybupropion formation. Our data indicate that hydroxybupropion contributes to the pharmacologic effects of bupropion for smoking cessation, and that variability in response to bupropion treatment is related to variability in CYP2B6-mediated hydroxybupropion formation. These findings suggest that dosing of bupropion to achieve a hydroxybupropion level of 0.7 μg/ml or increasing bupropion dose for CYP2B6 slow metabolizers could improve bupropion's cessation outcomes.

The roles of parenting, church attendance, and depression in adolescent smoking

The aim of the present study was to identify contextual factors related to smoking among urban African-American and White adolescents. We administered a survey assessing demographic and psychosocial variables to 299 adolescents in an urban pediatric clinic in the Midwest. Results indicated that being female, older age, lower academic performance, depressive symptoms, less frequent church attendance, parental smoking, and parental attitudes toward smoking were related to adolescent smoking. After controlling for demographics, the multivariate model predicting adolescent smoking included depressive symptoms, less frequent church attendance, and parental disapproval of smoking. Given these findings, efforts to decrease adolescent smoking may be enhanced by attending to depressive symptoms demonstrated by adolescents as well as contextual factors including parental attitudes and church attendance.

Demographic and psychosocial factors associated with increased fruit and vegetable consumption among smokers in public housing enrolled in a randomized trial

OBJECTIVES

To examine the demographic and psychosocial factors associated with increased fruit and vegetable (FV) consumption among smokers residing in public housing.

DESIGN

Cluster randomized trial of 20 public housing developments (HDs). Ten housing developments were randomly assigned to a FV intervention and 10 to a smoking cessation intervention.

PRIMARY OUTCOME

Change in daily FV intake over the past 7 days at 8 weeks postbaseline.

RESULTS

Above the effect of treatment, baseline confidence for vegetable consumption (model coefficient = 0.19, SE = 0.07, p = .01), decreased barriers (model coefficient = -0.12, SE = 0.04, p = .002) and increased agency (model coefficient = 0.08, SE = 0.04, p = .03) were significantly associated with week 8 FV consumption.

CONCLUSIONS

Although the intervention produced significant change in FV consumption, the majority of individual psychosocial factors were not associated with this change. Future studies examining the dynamic interaction between interventions and individual, social, and environmental factors are needed to more fully explain dietary change among public housing residents.

Perceived barriers and benefits to research participation among school administrators

BACKGROUND

Gaining access to conduct research in schools can be challenging, but little has been done to directly assess school administrators' perceptions of research. The purpose of this qualitative study was to increase understanding of barriers and benefits of research participation as perceived by superintendents and principals in elementary, middle, and high school settings.

METHODS

Administrators (14 elementary, 14 middle, and 15 high school principals and 14 superintendents; total n = 57) were randomly selected from across a Midwestern state and were interviewed by phone following a semistructured guide of questions.

RESULTS

Six major themes were consistent across principals and superintendents and reached saturation. Themes indicated that administrators were interested in research projects that (1) provide tangible benefits to their school, (2) are consistent with their academic mission, (3) are not burdensome, (4) do not take place during state assessment time or other busy times, and (5) are credible and noncontroversial. Previous research experiences leave a lasting impression on administrators and influenced their future decisions.

CONCLUSIONS

Findings indicate that researchers should carefully frame their research in terms of how it will directly benefit the school, keeping in mind that academic performance is the top priority for school administrators. Researchers should be very clear and realistic about the time commitments, how the research results will be provided, and how the study may be used to improve the school's academic mission.

Concordance of patient-physician obesity diagnosis and treatment beliefs in rural practice settings

CONTEXT

Although clinical guidelines recommend routine screening and treatment for obesity in primary care, lack of agreement between physicians and patients about the need for obesity treatment in the primary care setting may be an unexplored factor contributing to the obesity epidemic.

PURPOSE AND METHODS

To better understand this dynamic, we surveyed 439 obese patients (body mass index >or=30) at the time of clinic visits in 2003 at diverse primary care settings in rural Kansas and conducted same-day interviews with their physicians (N = 28). We used Spearman's correlation to describe and compare patient and physician responses.

FINDINGS

Most patients were women (66%). Their mean age was 55.8 years, and mean body mass index was 37.7. Half (51%) reported discussing their weight on that visit date. Overall, 51% of patients wanted to discuss weight more often with their physician and 54% wanted to discuss weight sooner. Patients and physicians gave similar assessments of the patient's preference for discussing weight loss, how often weight was discussed at visits, and the patient's motivation for weight loss. Spearman's correlations on these variables were .33, .54, and .25, respectively (all P < .001).

CONCLUSIONS

These patients and their physicians demonstrated a weak to moderate agreement on several variables crucial to initiating and continuing obesity care. Understanding patient and provider beliefs and preferences regarding obesity diagnosis and treatment is essential in designing obesity interventions for primary care.

A randomized trial of targeted educational materials for smoking cessation in African Americans using transdermal nicotine

This study examines the efficacy of targeted versus standard care smoking cessation materials among urban African American smokers. Five hundred smokers (250 to each group) are randomized to receive a culturally targeted or standard care videotape and print guide. Both groups receive 8 weeks of nicotine patches and reminder telephone calls at Weeks 1 and 3. Process outcomes include material use and salience at 1 and 4 weeks postbaseline. Smoking outcomes include 7-day abstinence, smoking reduction, and readiness to quit at 4 weeks and 6 months postbaseline. Despite greater use of the targeted guide (68.8% vs. 59.6%, p < .05), intervention participants do not perceive the targeted materials as more salient, and no significant differences are found between groups on the smoking outcomes. Findings point to the importance of greater audience segmentation and individual tailoring to better match intervention materials to the needs of the priority population.

Pathway to health: cluster-randomized trial to increase fruit and vegetable consumption among smokers in public housing

OBJECTIVES

Examine the effectiveness of an intervention to increase fruits and vegetables (FV) consumption among smokers.

DESIGN

Cluster-randomized trial of 20 public housing developments; 10 randomly assigned to an FV intervention and 10 to a smoking cessation intervention.

MAIN OUTCOME MEASURES

Usual (past 7 days) and past 30 days change in daily FV intake at 8 weeks and 6 months postbaseline.

RESULTS

Greater increases were seen in the FV group. At Week 8 and Month 6, the FV group had consumed 1.58 (p = .001) and 0.78 (p = .04), respectively, more daily FV servings in the past 7 days than the cessation group. At the same time points, the FV group had consumed 3.61 (p = .01) and 3.93 (p = .01), respectively, more FV servings in the past 30 days than the cessation group. Completing more motivational interviewing sessions (p = .02) and trying more recipes (p = .02) led to significantly greater increases at Month 6 among FV participants.

CONCLUSIONS

Motivational interviewing counseling and lifestyle modification through trying out healthy recipes may be effective in helping a high-risk population increase their FV intake.

Developmental trajectories of overweight during childhood: role of early life factors

OBJECTIVE

Our goal was to identify developmental trajectories of overweight in children and to assess early life influences on these trajectories.

RESEARCH METHODS AND PROCEDURES

Participants consisted of 1739 white, black, and Hispanic children who were younger than 2 years at the first survey and were followed up to 12 years of age. Repeated measures of overweight, defined as BMI > or = 95th percentile, were used to identify overweight trajectories with a latent growth mixture modeling approach.

RESULTS

Three distinct overweight trajectories were identified: 1) early onset overweight (10.9%), 2) late onset overweight (5.2%), and 3) never overweight (83.9%). After adjustment for multiple potential risk factors, male gender [odds ratio (OR), 1.5; 95% confidence interval (CI), 1.0 to 2.2], black ethnicity (OR, 1.7; 95% CI, 1.1 to 2.6), maternal 25 < or = BMI < 30 kg/m2 (OR, 2.2; 95% CI, 1.3 to 3.7) or > or = 30 kg/m2 (OR, 5.1; 95% CI, 2.9 to 9.1), maternal weight gain during pregnancy > or = 20.43 kg (OR, 1.7; 95% CI, 1.0 to 2.9), and birth weight > or = 4000 g (OR, 2.0; 95% CI, 1.2 to 3.4) were associated with an increased risk of early onset overweight. These risk factors, except maternal weight gain, exerted similar effects on late onset overweight. In addition, maternal smoking (OR, 1.6; 95% CI, 0.8 to 3.1) and birth order > or = 3 (OR, 2.3; 95% CI, 1.0 to 5.2) were associated with an increased risk of late onset overweight only. Breastfeeding > or = 4 months was associated with a decreased risk of both early (OR, 0.7; 95% CI, 0.3 to 1.3) and late onset overweight (OR, 0.7; 95% CI, 0.3 to 1.7).

DISCUSSION

Two trajectories of overweight and one never overweight group were identified. Early life predictors may have a significant influence on the developmental trajectories of overweight in children.

Homelessness and smoking cessation: insights from focus groups

Smoking prevalence among homeless persons is approximately 70%, yet little is known about tobacco use patterns or smoking cessation practices in this population. We assessed smoking attitudes and behaviors, psychosocial and environmental influences on smoking, barriers to and interest in quitting, and preferred methods for cessation among some homeless smokers. Six 90-min focus groups of current smokers (N = 62) were conducted at homeless service facilities. Participants had a mean age of 41.5 years (SD = 9.3), were predominantly male (69.4%) and African American (59%), and smoked an average of 18.3 cigarettes/day. Although most reported that they were motivated to quit, a number of barriers to quitting were identified. Participants reported that the pervasiveness and social acceptance of tobacco use in homeless settings contributed to smoking more cigarettes per day, adopting alternative smoking behaviors such as smoking cigarette butts and making their own cigarettes, and experiencing difficulty in quitting. High levels of boredom and stress also were cited as reasons for continued smoking. Smoking frequently occurred in combination with alcohol or illicit drug use or to achieve a substitute "high." Most participants (76%) reported that they planned to quit smoking in the next 6 months. Many were interested in using pharmacotherapy in combination with behavioral treatments. Results suggest that, although motivated to quit smoking, homeless smokers are faced with unique social and environmental barriers that make quitting more difficult. Interventions must be flexible and innovative to address the unique needs of homeless smokers. Smoking restrictions at homeless service facilities and funding for smoking cessation assistance in this underserved population may help to reduce prevalence.

Pathways to health: a cluster randomized trial of nicotine gum and motivational interviewing for smoking cessation in low-income housing

Despite high smoking rates among those living in poverty, few cessation studies are conducted in these populations. This cluster-randomized trial tested nicotine gum plus motivational interviewing (MI) for smoking cessation in 20 low-income housing developments (HDs). Intervention participants (10 HDs, n = 66) received educational materials, 8 weeks of 4 mg nicotine gum, and 5 MI sessions on quitting smoking. Comparison participants (10 HDs, n = 107) received 5 MI sessions and educational materials addressing fruit and vegetable consumption. Participants had a mean age of 46.3 years and were predominantly female (70%) and African American (83%). Biochemically-verified 7-day abstinence rates at 8 weeks were 6.1% and 5.6% in the intervention and comparison arms, respectively (p = ns); and at 26 weeks were 7.6% and 9.3%, respectively (p = ns). Results suggest that nicotine gum plus MI were not effective for smoking cessation in low-income housing. Programs are needed to enhance the effectiveness of pharmacotherapy and counseling in underserved populations.

The effects of nicotine gum and counseling among African American light smokers: a 2 x 2 factorial design

AIM

Approximately 50% of African American smokers are light smokers (smoke < or = 10 cigarettes a day). The prevalence of light smoking in the United States is increasing, yet there has not been a single smoking cessation clinical trial targeting light smokers. The purpose of this 2 x 2 factorial, randomized clinical trial was to evaluate the efficacy of nicotine gum (2 mg versus placebo) and counseling (motivational interviewing versus health education) for African American light smokers.

DESIGN

Participants were assigned randomly to one of four study arms: 2 mg nicotine gum plus health education (HE); 2 mg nicotine gum plus motivational interviewing (MI); placebo gum plus HE; and placebo gum plus MI.

PARTICIPANTS AND SETTING

A total of 755 African American light smokers (66% female, mean age = 45) were enrolled at a community health center over a 16-month period.

INTERVENTION AND MEASUREMENTS

Participants received an 8-week supply of nicotine gum and six counseling sessions during the course of the 26-week study. Biochemical measures included expired carbon monoxide (CO) and serum and salivary cotinine.

FINDINGS

Seven-day quit rates for nicotine gum were no better than for the placebo group (14.2% versus 11.1%, P = 0.232) at 6 months. However, a counseling effect emerged, with HE performing significantly better than MI (16.7% versus 8.5%, P < 0.001). These results were consistent across outcome time-points (weeks 1, 8, and 26).

CONCLUSIONS

Results highlight the potential positive impact of directive information and advice-oriented counseling on smoking cessation. Studies are needed to assess other interventions that may further improve quit rates among African American light smokers who are motivated to quit.

Fruit, Vegetable, and Fat Intake among Non-Hispanic Black and Non-Hispanic White Adolescents: Associations with Home Availability and Food Consumption Settings

OBJECTIVE

This study sought to explore home food availability and common settings of food consumption as correlates of fruit, vegetable, and fat intake among a sample of non-Hispanic black and non-Hispanic white adolescents.

PARTICIPANTS AND DESIGN

Adolescents (n=144 black, 84 white) and their parents completed a cross-sectional survey in an urban adolescent health clinic. The adolescent survey included screening measures for fruit, vegetable, and fat intake and items on frequency of eating meals with family, while watching television, and at three types of restaurants. Parents provided information on home availability of foods.

MAIN OUTCOMES

Correlates of fruit, vegetable, and fat consumption.

STATISTICAL ANALYSIS

Spearman correlations for associations among variables, t tests for mean comparisons, and multiple stepwise regression conducted separately for black and white adolescents.

RESULTS

In multiple regression, home availability was not significantly associated with fruit, vegetable, or fat intake except for fruit intake among white adolescents only. Use of non-fast-food restaurants was the strongest positive predictor of vegetable intake. For both black and white adolescents, fast-food and buffet restaurant use and eating while watching television were the strongest predictors of fat intake.

CONCLUSIONS

Compared with restaurant use and eating while watching television, home availability had a relatively small impact on fruit, vegetable, and fat consumption for both black and white adolescents. Intervention programs on adolescent nutrition should target not just availability of healthful foods, but also ease of access, such as the preparation of fruits and vegetables so that they are flavorful and ready to eat.

Enhanced cue-elicited brain activation in African American compared with Caucasian smokers: an fMRI study

Current evidence indicates that, although African Americans (AA) are more likely to attempt to quit smoking than Caucasians (CC) in any given year, success rates are lower for AA. However, factors contributing to these differences are not well known. In order to explore potential factors, this study assessed differences in attention to smoking cues between ethnic groups. Participants underwent morning functional magnetic resonance imaging scanning while viewing images of AA models and CC models who were either smoking (smoking cues) or engaging in everyday activities (neutral cues), interspersed with a fixation baseline period. The study was conducted at the Hoglund Brain Imaging Center of the University of Kansas Medical Center in Kansas City, KS. We studied 17 smokers (eight AA, nine CC) after 12-hour abstinence and 17 non-smokers (eight AA, nine CC) matched by age, gender, years of education, and handedness. The AA and CC smoking groups were also matched for number of cigarettes smoked per day. All results are P < 0.01, corrected for whole brain. There was a strong ethnicity by condition interaction among smokers in several a priori regions of interest. AA smokers showed a greater increase in response to smoking (versus neutral cues) than CC smokers in the medial prefrontal cortex, right lateral orbitofrontal cortex, and bilateral ventrolateral prefrontal cortex. In smoking versus baseline contrasts, additional areas of greater activation were found in AA, including the right amygdala and left caudate nucleus. No significant differences in cue-elicited brain activation were found between AA and CC non-smokers. These preliminary findings demonstrate variation in brain activation in response to smoking cues between AA and CC smokers in structures known to be associated with nicotine addiction. Differences in neural response may reflect fundamental differences in attention to smoking cues, which may in turn contribute to differences in effectiveness of nicotine dependence treatments among ethnic populations.

Knowledge and perceptions of colorectal cancer screening among urban African Americans

OBJECTIVE

To explore colorectal cancer (CRC) screening knowledge, attitudes, barriers, and preferences among urban African Americans as a prelude to the development of culturally appropriate interventions to improve screening for this group.

DESIGN

Qualitative focus group study with assessment of CRC screening preferences.

SETTING

Community health center serving low-income African Americans.

PARTICIPANTS

Fifty-five self-identified African Americans over 40 years of age.

MEASUREMENTS AND MAIN RESULTS

Transcripts were analyzed using an iterative coding process with consensus and triangulation on final thematic findings. Six major themes were identified: (1) Hope--a positive attitude toward screening, (2) Mistrust--distrust that the system or providers put patients first, (3) Fear--fear of cancer, the system, and of CRC screening procedures, (4) Fatalism--the belief that screening and treatment may be futile and surgery causes spread of cancer, (5) Accuracy--a preference for the most thorough and accurate test for CRC, and (6) Knowledge--lack of CRC knowledge and a desire for more information. The Fear and Knowledge themes were most frequently noted in transcript theme counts. The Hope and Accuracy themes were crucial moderators of the influence of all barriers. The largest number of participants preferred either colonoscopy (33%) or home fecal occult blood testing (26%).

CONCLUSIONS

Low-income African Americans are optimistic and hopeful about early CRC detection and believe that thorough and accurate CRC screening is valuable. Lack of CRC knowledge and fear are major barriers to screening for this population along with mistrust, and fatalism.