A randomized controlled trial to reduce post-cessation weight gain.

BACKGROUND/OBJECTIVES: Weight gain is a barrier to smoking cessation. Previous interventions targeting weight gain while quitting smoking have largely been unsuccessful. The current study aimed to assess the efficacy of weight stability and weight loss interventions compared to a low-intensity, self-guided bibliotherapy weight management group. SUBJECTS/METHODS: A randomized controlled trial with 12-month follow-up from 2018 to 2022 was conducted with participants (N = 305) who reported smoking at least five cigarettes per day for the last year and interest in quitting initially recruited from the Memphis, TN, USA area. Recruitment was expanded nationally with the onset of the COVID-19 pandemic. Subsequently, 276 completed 12-month follow-up. INTERVENTIONS/METHODS: The Bibliotherapy group was provided a weight management book. Both the Stability and Loss groups met via telephone for eight weeks to learn strategies for maintaining/losing weight, respectively. All three groups then received the same six-week smoking cessation intervention, with six months of varenicline provided. RESULTS: Individuals in the Loss group lost more weight (-2.01 kg, SE = 1.58) than individuals in the Bibliotherapy group (+1.08 kg, SE = 1.49, p = 0.0004), while the Stability group (-0.30 kg, SE = 1.56) was not significantly different from the Bibliotherapy group (p = 0.17). Those in the Stability group did not gain a significant amount of weight. Participants in the Loss group did not gain back all weight lost after smoking cessation and ended the study approximately 2.01 kg lower than baseline. The Bibliotherapy group did not gain the amount of weight expected after cessation. There were no significant differences between groups related to self-reported smoking cessation at each time point except at eight-month follow-up (p = 0.005). CONCLUSIONS AND RELEVANCE: Results indicated the Stability and the Loss interventions were effective for preventing post-smoking cessation weight gain, with the Loss group having the benefit of sustained weight loss. These interventions may be helpful to implement to combat weight gain and potentially facilitate smoking cessation. TRIAL REGISTRATION: The trial is registered on clinicaltrials.gov (NCT03156660).

Reengagement for Long-Term Smoking-Cessation In Military Personnel, Retirees, Family Members (TRICARE): A Randomized Trial.

INTRODUCTION: We sought to determine what type of treatment reengagement after smoking relapse would increase long-term cessation. AIMS AND METHODS: Participants were military personnel, retirees, and family members (TRICARE beneficiaries) recruited across the United States from August 2015 through June 2020. At baseline, consented participants (n = 614) received a validated, four-session, telephonic tobacco-cessation intervention with free nicotine replacement therapy. At the 3-month follow-up, 264 participants who failed to quit or relapsed were offered the opportunity to reengage in cessation. Of these, 134 were randomized into three reengagement conditions: (1) repeat initial intervention ("recycle"), (2) Smoking reduction with eventual cessation goal ("rate reduction"), or (3) Choose #1 or #2 ("choice"). Prolonged abstinence and 7-day point prevalence abstinence were measured at 12 months. RESULTS: Despite being in a clinical trial advertised as having the opportunity for reengagement, only 51% (134 of the 264) of participants who still smoked at 3-month follow-up were willing to reengage. Overall, participants randomized to recycle had higher prolonged cessation rates at 12 months than rate reduction conditions (OR = 16.43, 95% CI: 2.52 to 107.09, Bonferroni adjusted p = .011). When participants who randomly received recycle or rate reduction were pooled, respectively, with participants who chose recycle or rate reduction in the Choice group, recycle had higher prolonged cessation rates at 12 months than rate reduction (OR = 6.50, 95% CI: 1.49 to 28.42, p = .013). CONCLUSIONS: Our findings suggest service members and their family members who fail to quit smoking but are willing to reengage in a cessation program are more likely to benefit from repeating the same treatment. IMPLICATIONS: Finding methods that are both successful and acceptable to reengage people who smoke who want to quit can have a significant impact on improving the health of the public by reducing the portion of the population who smoke. This study suggests that repeating established cessation programs will result in more people ready to quit successfully achieving their goal.

Effect of Integrated Gastroenterology Specialists in a Primary Care Setting: a Retrospective Cohort Study.

BACKGROUND: Gastrointestinal (GI) complaints are common in primary care practices. The patient-centered medical home (PCMH) may improve coordination and collaboration by facilitating coordination across healthcare settings and within the community, enhancing communication between providers, and focusing on quality of care delivery. OBJECTIVE: To investigate the effect of integrated community gastroenterology specialists (ICS-GI) model within a large primary care practice. DESIGN: Retrospective cohort with propensity-matched historic controls. PATIENTS: We identified 265 patients who had a visit with one of our ICS-GI specialists and matched them (1:2) to 530 similar patients seen prior to the implementation of the ICS-GI model. MAIN MEASURES: Frequency of diagnostic testing for GI indications, visits to our outpatient GI referral practice, emergency department and hospital utilization, and time to access of specialty care for the whole population and by GI condition group. KEY RESULTS: Patients seen in our ICS-GI model had similar outpatient care utilization (OR = 1.0, 95% CI 0.7-1.4, p = 0.90), were more likely to have visits in primary care (OR OR=1.5, 95% CI 1.1-2.2, p = 0.02), and were less likely to have visits to our GI outpatient referral practice (OR = 0.3, 95% CI 0.2-0.7, p < 0.0001). Condition-specific analyses show that all GI conditions experienced decreased visits to the outpatient GI referral practice outside of patients with GI neoplasm. Populations did not differ in emergency department, hospital, or diagnostic utilization. CONCLUSIONS: We observed that an embedded specialist in primary care model is associated with improved care coordination without compromising patient safety. The PCMH could be extended to include subspecialty care.

Electronic Vaping Product Use among Young Adults Who Receive Care at a Major Medical Institution.

Background: National estimates of electronic vaping product (EVP) use exist, but little is known about young adult EVP users who interact with the healthcare setting. Methods: Cross-sectional survey of 18-25 year olds receiving care in our ambulatory medical practice. Population differences were evaluated with the chi square test reporting unadjusted odds ratios (ORs). Results: Response rate was 16.6% (n = 1,017/6,119). The prevalence of ever EVP use was 46.0% of whom 13.9% used every day. Each additional day of alcohol use (past 30 days) was associated with increased odds of being an EVP user (OR = 1.06, 95% CI 1.02-1.09), and cannabis use (past 30 days) was associated with a higher odds of being an EVP user compared to non-cannabis users (OR = 40.0, 95% CI 17.4 - 111.8). Observing a biological parent (OR = 2.89, 95% CI 1.98-4.24), step parent (OR = 2.03, 95% CI 1.02-4.19) and full sibling (OR = 2.31, 95% CI 1.78-3.00) using inhaled substances (past 30 days) was associated with increased odds of being an ever EVP user. Ever EVP users had lower odds than never users to report that EVPs with nicotine are "a little" or "a lot" more harmful than smoking "regular" tobacco cigarettes (OR = 0.53, 95% CI 0.37 - 0.76). Conclusion: Our survey is limited by a low response rate but confirms observed associations between EVP use and substance use and social influences. Our data also suggest that professionals should regularly screen for EVP use among young people, especially those with exposure to family members who used inhaled substances.

Low-level laser therapy for weight reduction: a randomized pilot study.

Obesity and overweight is a global health crisis and novel methods of treatment are needed to address it. Low-level laser therapy (LLLT) is a currently available non-invasive procedure for lysing excess fat, but there is a lack of consensus exists on LLLT frequency and limited research from studies of LLLT. The purpose of this pilot study is to compare the effect of three of the most common LLLT frequencies on weight, waist circumference, body fat percentage, and quality of life. Sixty overweight (body mass index (BMI) 25-29.9 kg/m2) adult participants were randomized to 12 LLLT treatments: (1) three times weekly for 4 weeks, (2) twice weekly for 6 weeks, or (3) once weekly for 12 weeks. All participants attended an in-person visit at baseline and at weeks 4, 6, 12, and 26. Participants were recruited September 30, 2016 through to August 27, 2017. The majority of the 60 participants were female (90%) with an average age of 43.7 years (± 9.2 years). Most participants (98%) completed 10 or more of the 12 LLLT treatments. When comparing across treatment groups, the greatest reductions from baseline were observed in those assigned to twice weekly for 6 weeks in weight (1 ± 1.7 (±SD) kg by week 6), waist circumference (- 2.0 ± 3.2 in. by week 6 and - 1.5 ± 3.2 in. by week 26), body mass index (- 0.4 ± 0.6 kg/m2), and body fat mass (- 1.1 ± 1.6 kg). This group also had the most significant improvement from baseline in quality of life (+ 0.5 ± 0.8 by week 6), body satisfaction (+ 0.2 ± 0.4 by week 6 and week 26), and body appreciation (+ 0.2 ± 0.3 by week 6 and + 0.3 ± 0.3 by week 26). LLLT twice weekly for 6 weeks could be proposed as the optimal frequency and duration for the management of body weight. Trial registration: https://clinicaltrials.gov/ct2/show/NCT02877004. Registered August 24, 2016.

Prevalence and correlates of dual tobacco use in cancer survivors.

PURPOSE: Tobacco use in cancer survivors remains a significant problem, however, the use of non-cigarette tobacco products (NCTPs) in this population is less understood. This study examined prevalence and correlates of tobacco use among cancer survivors who were never, current, and former cigarette users. Tobacco-related behaviors and quitting attitudes were compared between survivors dually using cigarettes and electronic cigarettes (ECs) and cigarette-only users. METHODS: In this cross-sectional study, patients at Mid-South cancer centers (n = 629; 50.4% never, 17.8% current, and 31.8% former cigarette users) responded to an anonymous questionnaire about tobacco-related behaviors and quitting attitudes. RESULTS: Among current cigarette users, 27.7% reported using two or more tobacco products. Most commonly, 15.2% of cigarettes users were using ECs. Compared to cigarette only use, dual use of tobacco products was associated with male gender (p < 0.0001), being single (p = 0.009), and a lung cancer diagnosis (p < 0.0001). Dual users of cigarettes and ECs were more likely to report a readiness to quit cigarettes within 6 months (p = 0.0317) and that a physician recommended ECs as a quit resource (p = 0.0361) compared to cigarette-only users. CONCLUSIONS: Results suggest that using more than one tobacco product is common among cancer survivor cigarette users. Dual use of cigarettes and ECs was associated with an increased readiness for cigarette cessation and a physician recommendation of ECs. Targeting potential dual use of tobacco products, particularly cigarettes and ECs, might be beneficial for cigarette cessation among cancer survivors.

Variation in Patient Experience Across the Clinic Day: a Multilevel Assessment of Four Primary Care Practices.

BACKGROUND: Patient satisfaction with healthcare is associated with clinical outcomes, provider satisfaction, and success of healthcare organizations. As the clinic day progresses, provider fatigue, deterioration with communication within the care team, and appointment spillover may decrease patient experience. OBJECTIVE: To understand the relationship between likelihood to recommend a primary care practice and scheduled appointment time across multiple practice settings. DESIGN: Retrospective cohort. PARTICIPANTS: A retrospective cohort was created of all patients seen within four primary care practices between July 1, 2016, and September 30, 2017. MAIN MEASURES: We looked at scheduled appointment time against patient likelihood to recommend a practice as a measure of overall patient experience collected routinely for clinical practice improvement by the Press Ganey Medical Practice Survey®. Adjusted mixed effects logistic regression models were created to understand the relationship between progressing appointment time on patient likelihood to recommend a practice. We constructed locally weighted smoothing (LOESS) curves to understand how reported patient experience varied over the clinic day. RESULTS: We had a response rate of 14.0% (n = 3172), 80.2% of whom indicated they would recommend our practice to others. Appointment time scheduling during the last hour (4:00-4:59 PM) had a 45% lower odds of recommending our practice when compared to the first clinic hour (adjusted OR = 0.55, 95% CI 0.35-0.86) which is similar when controlling for patient-reported wait time (aOR = 0.59, 95% CI 0.37-0.95). LOESS plots demonstrated declining satisfaction with subsequent appointment times compared with the first session hour, with no effect just after the lunch hour break. CONCLUSIONS: In primary care, appointment time of day is associated with patient-reported experience.

Episodic and Chronic Migraine in Primary Care.

OBJECTIVE: To inform migraine care model development by assessing differences between patients with chronic migraine (CM) and episodic migraine (EM) in the current state of treatment, disability, patient satisfaction, and quality improvement opportunities. BACKGROUND: Efficient and focused use of scarce resources will be needed to address challenges within large populations of migraine patients. METHODS: We deployed a cross-sectional survey study of randomly selected migraine patients within a community primary care practice. RESULTS: There were 516 survey respondents (516/1804 [30%] response rate). CM patients were more likely than EM patients to report care from a neurologist (76/110 [69%] vs 229/406 [56%]; P = .0026), and higher disability according to the Migraine Disability Assessment and Headache Impact Test - 6 questionnaires (P < .0001). CM patients were less likely than EM patients to report overall satisfaction with care (16/110 [38%] vs 156/406 [66%], P = .0002), satisfaction with access to care (17/110 [33%] vs 176/406 [68%], P < .0001), and advice they needed (16/110 [31%] vs 160/406 [62%], P < .0001). Most patients with migraine had been offered triptan medications 377/516 (78%). Overall, 156/516 (31%) of individuals were currently taking any medication for migraine prevention, and 208/516 (40%) including botulinum toxin injections. CM patients were more likely to be taking preventive medication (39/110 [36%] vs 117/406 [29%], P = .0191) and report familiarity with the diagnosis of medication-overuse headache than patients with EM (80/110 [81%] vs 256/406 [69%], P = .0178). CONCLUSIONS: We observed differences between patients with chronic and EM and expected care delivery improvement opportunities for migraine patients in primary care. CM patients report higher levels of disability and less satisfaction with access to perceived needed medical advice and care. These findings support the need to further develop and study novel care models to efficiently and effectively deliver high-quality care and expertise in limited supply to a diverse migraine population.

Attributes, Attitudes, and Practices of Clinicians Concerned with Opioid Prescribing.

BACKGROUND: Many clinicians who prescribe opioids for chronic noncancer pain (CNCP) express concerns about opioid misuse, addiction, and physiological dependence. We evaluated the association between the degree of clinician concerns (highly vs less concerned), clinician attributes, other attitudes and beliefs, and opioid prescribing practices. METHODS: A web-based survey of clinicians at a multispecialty medical practice. RESULTS: Compared with less concerned clinicians, clinicians highly concerned with opioid misuse, addiction, and physiological dependence were more confident prescribing opioids (risk ratio [RR] = 1.34, 95% confidence interval [CI] = 1.08-1.67) but were more reluctant to do so (RR = 1.13, 95% CI = 1.03-1.25). They were more likely to report screening patients for substance use disorder (RR = 1.18, 95% CI = 1.01-1.37) and to discontinue prescribing opioids to a patient due to aberrant opioid use behaviors (RR = 1.30, 95% CI = 1.13-1.50). They were also less likely to prescribe benzodiazepines and opioids concurrently (RR = 0.40, 95% CI = 0.25-0.65). Highly concerned clinicians were more likely to work in clinics which engage in "best practices" for opioid prescribing requiring urine drug screening (RR = 4.65, 95% CI = 2.51-8.61), prescription monitoring program review (RR = 2.90, 95% CI = 1.84-4.56), controlled substance agreements (RR = 4.88, 95% CI = 2.64-9.03), and other practices. Controlling for clinician concern, prescribing practices were also associated with clinician confidence, reluctance, and satisfaction. CONCLUSIONS: Highly concerned clinicians are more confident but more reluctant to prescribe opioids. Controlling for clinician concern, confidence in care and reluctance to prescribe opioids were associated with more conservative prescribing practices.

A survey of the attitudes, beliefs and knowledge about medical cannabis among primary care providers.

BACKGROUND: Healthcare providers play a critical role in facilitating patient access to medical cannabis. However, previous surveys suggest only a minority of providers believe that medical cannabis confers benefits to patients. Significant new knowledge about the potential benefits and harms of medical cannabis has recently emerged. Understanding current attitudes and beliefs of providers may provide insight into the ongoing challenges they face as states expand access to medical cannabis. METHODS: We conducted an electronic survey of primary care providers in a large Minnesota-based healthcare system between January 23 and February 5, 2018. We obtained information about provider characteristics, attitudes and beliefs about medical cannabis, provider comfort level in answering patient questions about medical cannabis, and whether providers were interested in receiving additional education. RESULTS: Sixty-two providers completed the survey (response rate 31%; 62/199). Seventy-six percent of respondents were physicians and the average age was 46.3 years. A majority of providers believed ("strongly agree" or "somewhat agree") that medical cannabis was a legitimate medical therapy (58.1%) and 38.7% believed that providers should be offering to patients for managing medical conditions. A majority (> 50%) of providers believed that medical cannabis was helpful for treating the qualifying medical conditions of cancer, terminal illness, and intractable pain. A majority of providers did not know if medical cannabis was effective for managing nearly one-half of the other state designated qualifying medical conditions. Few believed that medical cannabis improved quality of life domains. Over one-third of providers believed that medical cannabis interacted with medical therapies. One-half of providers were not ready to or did not want to answer patient questions about medical cannabis, and the majority of providers wanted to learn more about it. CONCLUSIONS: Healthcare providers generally believe that medical cannabis is a legitimate medical therapy. Provider knowledge gaps about the effectiveness of medical cannabis for state designated qualifying conditions need to be addressed, and accurate information about the potential for drug interactions needs to be disseminated to address provider concerns. Clinical trial data about how medical cannabis improves patient quality of life domains is desperately needed as this information can impact clinical decision-making.

Predicting cigarette initiation and reinitiation among active duty United States Air Force recruits.

Background: The first year of military service in the United States Air Force (USAF) is a high-risk time for tobacco use. Previous studies have demonstrated the effectiveness of a tobacco ban during Basic Military Training (BMT). However, no studies have examined the effect of increasing the protracted ban for an additional 4 weeks. Understanding the patterns of initiation and reinitiation following the protracted ban will inform future intervention and policy efforts. Methods: The current study examines patterns of cigarette smoking among a sample of 2188 USAF personnel at baseline and after their first year of service. Results: One year after BMT, we observed that 65.0% of USAF enlistees remained never smokers, 9.6% remained abstinence from cigarettes, 9.3% initiated cigarette smoking, and 16.1% reinitiated cigarette smoking. Despite the extended tobacco ban in BMT and Technical Training, 12.6% of individual who never smoked initiated cigarette smoking and 62.6% of individuals who formerly smoked reinitiated. Over half (54.2%) of Airmen who reported smoking cigarettes at follow-up reported initiating or reinitiating during Technical Training. Conclusions: Our findings indicate that although the increased ban prevents additional individuals who smoked cigarettes prior to joining the Air Force from reinitiating, it has no effect on initiation among individuals who report never using prior to military service. Additional research is needed to understand what may be leading to these high rates of initiation and reinitiation in Technical Training following the ban.

Use of echocardiography in outpatients with chest pain and normal resting electrocardiograms referred to Mayo Clinic Rochester.

OBJECTIVES: To determine how often unnecessary resting echocardiograms that are "not recommended" by clinical practice guidelines are performed in patients with stable chest pain and normal resting electrocardiograms (ECGs). BACKGROUND: There are scant data to indicate how often Class III recommendations are ignored in clinical practice. PATIENTS AND METHODS: We searched electronically all medical records of referral outpatients seen at Mayo Clinic Rochester from January 1, 2010, through December 31, 2013, to identify patients with stable chest pain and known or suspected coronary artery disease who underwent resting echocardiography and had normal resting ECGs and no other indication for echocardiography. RESULTS: Of the 15,529 referral outpatients who were evaluated at Mayo Clinic Rochester with chest pain, 3976 (25.6%) had resting echocardiograms. Eight hundred seventy of these 3976 patients (21.9%) had normal resting ECGs. Six hundred nineteen of these 870 patients (71.1%) had other indications for echocardiography. The remaining 251 patients (6.3% of all echocardiograms and 1.6% of all patients) had normal resting ECGs and no other indication for echocardiography. Two hundred thirty-nine of these 251 patients (95.2%) had normal echocardiograms. Of the 12 abnormal echocardiograms, only 4 led to any change in clinical management. Sixty-one of these 251 echocardiograms (24.3%) were "preordered" before the provider (physicians, nurses, physician assistants) visit. CONCLUSION: Echocardiograms were performed in 1 in 4 referral outpatients with chest pain seen at Mayo Clinic Rochester. However, only 1 in 16 of these echocardiograms was performed in violation of the class III recommendation in the American College of Cardiology Foundation/American Heart Association guidelines for the management of stable angina. These unnecessary echocardiograms were almost always normal, and had little impact on clinical management. The rate of unnecessary echocardiograms could be decreased by eliminating preordering.

Neuroimaging utilization and findings in headache outpatients: Significance of red and yellow flags.

Background Neuroimaging for headache commonly exceeds published guideline recommendations and may be overutilized. Methods We conducted a retrospective cross-sectional study of all outpatient community patients at Mayo Clinic Rochester who underwent a neuroimaging study for a headache indication in 2015. We assessed the neuroimaging utilization pattern, clinical application of red flags, and concordance with neuroimaging guidelines. Results We identified 190 outpatients who underwent 304 neuroimaging studies for headache. The median age was 46.5 years (range 18-91 years), 65% were female, and most reported no prior history of headache (n = 97, 51%). A minority of patients had prior brain imaging studies (n = 44, 23%) and neurological consultations for headache (n = 29, 15%). Few studies were ordered after consultation with a neurologist (n = 14, 7%). Seventy-seven percent of patients were documented to have a "red flag" justifying the imaging study. Abnormal neuroimaging findings were found in 3.1% of patients with warning flags (5/161); carotid dissection (n = 3) and reversible cerebral vasoconstrictive syndrome (n = 2). An estimated 35% of patients were imaged against guidelines. Conclusions The prevalence of serious causes of headache in a community practice was low despite the presence of a documented red flag symptom. Inadequate understanding or application of red flags may be contributing to recommendations to image patients against current guidelines. Interventions to reduce unnecessary neuroimaging of patients with headache need to be designed and implemented.

Attitudes, Beliefs, Practices, and Concerns Among Clinicians Prescribing Opioids in a Large Academic Institution.

Objectives: Opioid treatment of chronic noncancer pain (CNCP) adds complexity and uncertainty to patient interactions. We sought to assess clinician attitudes, beliefs, practice styles, and concerns around opioid prescribing following the release of the US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain. Methods: E-mailed electronic survey to clinicians at a large academic medical institution. Results: A total of 961 clinicians responded to the survey (response rate = 40%), 720 of whom prescribed opioids and were not in training. Sixty-five percent were physicians, and 35% were nurse practitioners or physician assistants, with a mean age of 47 years (SD ± 11.4 years). Eighty-two percent were reluctant to prescribe opioids for CNCP, and only 47% expressed confidence in their care for CNCP patients. Sixty-seven percent were aware of the CDC guideline, 55% were enrolled in the state Prescription Drug Monitoring Program (PDMP), and 2% always or frequently prescribed naloxone to patients on opioids. Guideline awareness was associated with increased confidence in caring for CNCP patients. Clinicians having knowledge of a patient overdose were 31% more likely to be enrolled in the PDMP (relative rate= 1.31, 95% confidence interval = 1.14-1.52, chi-square = 11.00, P <0.01). Clinicians who knew of a patient overdose event were also more likely to express concern about patient opioid dependence and addiction. Conclusions: Opportunities exist to increase awareness of the CDC guideline and to increase clinician confidence in opioid prescribing. Knowledge of an overdose event may influence clinician behavior and concerns about dependence and addiction.

Combination Varenicline and Lorcaserin for Tobacco Dependence Treatment and Weight Gain Prevention in Overweight and Obese Smokers: A Pilot Study.

INTRODUCTION: Post-cessation weight gain (PCWG) is a major barrier to maintaining abstinence, especially in weight-concerned smokers. Varenicline is the most effective medication for smoking cessation but has minimal impact on PCWG. Lorcaserin is an FDA-approved medication for weight management in overweight or obese patients which also provides a noticeable benefit in treating drug dependence. We hypothesized that combining varenicline with lorcaserin may help prevent PCWG. We conducted an open-label, single arm, Phase II clinical pilot study to obtain preliminary data on the safety and effectiveness of combination varenicline and lorcaserin in preventing PCWG in overweight and obese smokers. METHODS: Twenty overweight or obese (body mass index 27-40 kg/m2) cigarette smokers were enrolled. The primary outcomes were weight and waist circumference (WC) changes at 12 and 26 weeks in smokers meeting criteria for prolonged smoking abstinence. All participants received open-label varenicline (1 mg twice a day) and lorcaserin (10 mg twice a day) for 12 weeks with follow-up at 26 weeks. RESULTS: Ten subjects met criteria for prolonged smoking abstinence at 12 weeks (50%) and 6 at 26 weeks (30%). Among those achieving prolonged smoking abstinence at 12 weeks, WC was +0.2 ± 6.0 cm (90% CI; -2.9, +3.4) and weight gain was +1.1 ± 3.9 kg (90% CI; -0.9, +3.1). CONCLUSIONS: Weight gain and WC increases following prolonged smoking abstinence may be reduced among overweight and obese smokers using combination varenicline and lorcaserin. This combinatory treatment warrants further research in the obese and weight-concerned smoking population. IMPLICATIONS: This is the first published prospective pilot study to evaluate lorcaserin for use in reducing PCWG in overweight and obese smokers. When combined with varenicline, lorcaserin minimized PCWG and increases in WC. In addition to the benefit on PCWG reduction, lorcaserin may be a potential new pharmacological treatment for smoking cessation and warrants further larger studies.

Step Care treatment for smoking cessation.

We compared the effectiveness of a 'stepped care' approach with increasing treatment intensity ('Step Care') to one with repeated treatments ('Recycle') among cigarette smokers interested in quitting smoking. Step 1 of the Step Care intervention consisted of a single counseling session, nicotine patch for six weeks and telephonic contact. For smokers not achieving tobacco abstinence 6 months after randomization with Step 1, the intensity of the intervention increased to four counseling sessions, bupropion sustained-release, nine telephone calls and three mailings (Step 2). For those not achieving tobacco abstinence 12 months after randomization, smokers received six behavioral counseling sessions, nicotine patch and nicotine gum, nine telephone calls and three mailings (Step 3). The Recycle participants received one session of health behavior counseling, six weeks of the nicotine patch and a telephone call at each step. 270 cigarette smokers were randomized. At 24 months after randomization using an intention to treat analysis, no statistically significant difference was observed in prolonged smoking abstinence between the Step Care and Recycle condition (16.9% versus 9.4%; adjusted OR = 1.88; 95% CI 0.88­4.01; P =0.10). Additional research is needed to explore whether a stepped care intervention increases long-term smoking abstinence rates compared with repeating the same intervention.

Smokeless tobacco use among United States Air Force trainees.

BACKGROUND: The prevalence of smokeless tobacco use in the United States Air Force (USAF) exceeds civilian use rates. The prevalence and correlates of smokeless tobacco use were assessed and evaluated in a sample of USAF trainees. METHODS: We conducted a cross-sectional survey of USAF technical training school personnel at Joint Base San Antonio-Lackland and Fort Sam Houston (N = 14,810). Survey completion rate was 78%. Logistic regression was used to analyze the associations between demographic variables, tobacco use, and social factors for both regular and infrequent smokeless tobacco (e.g., chewing tobacco, snuff) users. RESULTS: Overall, 16% of Airmen had ever used smokeless tobacco and 10% regularly used smokeless tobacco. In multivariate analyses, men had greater odds than women of regular smokeless tobacco use (adjusted odds ratio [OR] = 15.2; 95% confidence interval [CI]: 10.8-21.5) and infrequent smokeless tobacco use (adjusted OR = 4.2; 95% CI: 3.1-5.7). Smokeless tobacco use was associated with participation in high school sports (adjusted OR = 1.9; 95% CI: 1.6-2.3 for regular users; adjusted OR = 1.4; 95% CI: 1.1-1.7 for infrequent users), smoking cigarettes (adjusted OR = 4.3; 95% CI: 3.6-5.1 for regular users; adjusted OR = 4.0; 95% CI: 3.2-5.0 for infrequent users), or living with someone who used smokeless tobacco (adjusted OR = 2.2; 95% CI: 1.9-2.6 for regular users; adjusted OR = 1.4; 95% CI: 1.1-1.7 for infrequent users). Black or African Americans were less likely than whites to be regular (adjusted OR = 0.3; 95% CI: 0.1-0.4) or infrequent (adjusted OR = 0.3; 95% CI: 0.2-0.4) users of smokeless tobacco. CONCLUSIONS: Smokeless tobacco use among incoming Air Force recruits is common and negatively impacts the Air Force's goal to be tobacco-free. Understanding sociodemographic characteristics perpetuating smokeless tobacco use in the Air Force population can inform the development of health promotion interventions.

Types of Dual and Poly-Tobacco Users in the US Military.

The present investigation was designed to determine the prevalence and types of dual and poly-use of tobacco products in the US Air Force, as well as characteristics and factors associated with these types. We conducted a cross-sectional assessment of tobacco-product use among 13,873 Air Force trainees from 2013 to 2014. The assessment included prevalence of the use of 10 different tobacco products and demographic and environmental factors, such as risk perceptions of tobacco use, peer use, and tobacco-company influences. Latent class analysis was carried out to determine types of poly-tobacco users. Tobacco-product use was reported by 27.1% of participants, and of those, over half reported using more than 1 tobacco product. Latent class analysis indicated 5 classes of poly-tobacco use. Factors associated with poly-tobacco (vs. mono-tobacco) use included lower confidence to remain tobacco-free, low harm perceptions, and receiving tobacco products free at bars or social events. Rates of dual and poly-tobacco use are high among trainees, and while these groups are similar to mono users in some ways, there are a number of differences that need to be considered when developing targeted interventions to address use of multiple tobacco products.

Treating tobacco dependence in a medical setting.

The US Public Health Service Guideline for Treating Tobacco Use and Dependence 2008 Update emphasizes tobacco use as a chronic medical disorder; highlights both behavioral counseling and the use of 1 or more of the 7 approved medications; and points out the utility, efficacy, and reach of telephone quitlines. The treatment of users of smokeless tobacco continues to be less than optimal. Although providing evidence-based treatment for tobacco- dependent patients is a challenge for busy physicians, a team approach including trained and certified tobacco treatment specialists (TTS) provides an efficient treatment model. TTS represent a new and growing part of the health care team and hold great potential for expanding the collective tobacco treatment expertise in the medical setting. The effective treatment of tobacco dependence frequently requires tailoring, and often intensifying, interventions (both counseling and pharmacotherapy) to meet the needs of the individual patient.

Younger age at initiation of the human papillomavirus (HPV) vaccination series is associated with higher rates of on-time completion.

Vaccination rates for human papillomavirus (HPV) have remained disappointingly low. It is critical to identify methods to increase on-time vaccine series completion rates (before 13 or 15years). To determine whether younger age (9 to 10years of age) at HPV vaccine series initiation was associated with improved on-time completion rates compared to initiation at 11 to 12years, we examined the prevalence of on-time HPV vaccine series completion rates from August 2006 through December 2012 in a large, population-based cohort of children and adolescents (aged 9.5 to 27years) residing in Olmsted County, MN on December 31, 2012 (n=36,223). We compared age at vaccine initiation between individuals who successfully completed both 2 and 3 doses of the vaccination series on-time (before age 13.5 or 15.0years) using multivariate logistic regression. On-time completion of both 2 and 3 doses of the vaccine series by age 13.5 or 15.0years was significantly associated with initiation at 9 to 10years as compared to 11 to 12years after adjusting for sex, race, insurance status, frequent health care visits, and year of first vaccination (all p<.01). Interventions focused on beginning the vaccination series at 9 to 10years of age may result in higher rates of timely series completion.