Effectiveness of a culturally tailored text messaging program for promoting cervical cancer screening in accra, Ghana: a quasi-experimental trial.

INTRODUCTION: Despite breakthroughs in cervical cancer detection, resource-constrained countries continue to have a disproportionately high incidence and death rate. Mhealth has been identified as an important tool for increasing cervical cancer screening rates in Sub-Saharan Africa. We determined whether sending Ghanaian women culturally tailored one-way mobile phone SMS text messages about cervical cancer would encourage the uptake of the human papillomavirus (HPV) test. METHODS: From August to November 2016, 88 women aged 18 to 39 living or working in an urban community (Accra, Ghana) participated in a quasi-experimental study. For 8 weeks, 32 SMS messages regarding cervical cancer were developed and sent to the personal phones of intervention arm participants (n = 42). Women in the control group (n = 46) received SMS texts with general health and lifestyle advice. Fischer's exact tests were performed to assess cervical cancer screening uptake and associated reasons for non-uptake between the intervention and control groups (p < 0.05). RESULTS: At the baseline, women differed in terms of ethnicity and wealth. After the intervention, participants' self-reported risk factors for cervical cancer, such as early menarche, usual source of medical treatment, family history of cancer, smoking, and alcohol history, changed. None of the women in the intervention group sought cervical cancer screening after the intervention, but only one (2.2%) of the control arm participants did. Almost all the women (> 95%) agreed that an HPV test was essential and that regular healthcare check-ups could help prevent cervical cancer. Some women believed that avoiding particular foods could help prevent cervical cancer (23.8% intervention vs. 58.7% control, p < 0.001). Time constraints and out-of-pocket expenses were significant barriers to cervical cancer screening. CONCLUSION: A one-way SMS delivered to urban women did not increase cervical cancer screening attendance. The time spent in screening facilities and the lack of coverage by the National Health Insurance Scheme limited screening uptake. We urge for the establishment of screening centers in all healthcare facilities, as well as the inclusion of cervical cancer screening in healthcare programs through cost-sharing.

Research interests of family physicians applying for research training.

BACKGROUND: There is an ongoing need for research to support the practice of high quality family medicine. The Family Medicine Discovers Rapid Cycle Scientific Discovery and Innovation (FMD RapSDI) program is designed to build capacity for family medicine scientific discovery and innovation in the United States. Our objective was to describe the applicants and research questions submitted to the RapSDI program in 2019 and 2020. METHODS: Descriptive analysis for applicant characteristics and rapid qualitative analysis using principles of grounded theory and content analysis to examine the research questions and associated themes. We examined differences by year of application submission and the applicant's career stage. RESULTS: Sixty-five family physicians submitted 70 applications to the RapSDI program; 45 in 2019 and 25 in 2020. 41% of applicants were in practice for five years or less (n = 27), 18% (n = 12) were in in practice 6-10 years, and 40% (n = 26) were ≥ 11 years in practice. With significant diversity in questions, the most common themes were studies of new innovations (n = 20, 28%), interventions to reduce cost (n = 20, 28%), improving screening or diagnosis (n = 19, 27%), ways to address mental or behavioral health (n = 18, 26%), and improving care for vulnerable populations (n = 18, 26%). CONCLUSION: Applicants proposed a range of research questions and described why family medicine is optimally suited to address the questions. Applicants had a desire to develop knowledge to help other family physicians, their patients, and their communities. Findings from this study can help inform other family medicine research capacity building initiatives.

A Randomized Trial of Nicotine versus No-nicotine E-cigarettes Among African American Smokers: Changes in Smoking and Tobacco Biomarkers.

INTRODUCTION: The objective of this clinical trial was to compare the effects of e-cigarettes with and without nicotine on patterns of combustible cigarette use and biomarkers of exposure to tobacco toxicants among African American smokers. METHODS: African American smokers (n = 234) were enrolled in a 12-week, single blind, randomized controlled trial and assigned to ad lib use of nicotine e-cigarettes with or without menthol (2.4% nicotine [equivalent to combustible cigarettes], n = 118), or no-nicotine e-cigarettes (n = 116) for 6 weeks. Surveys were administered at baseline, 2, 6, and 12 weeks, and urinary biomarkers 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and total nicotine equivalents (TNE) were assessed at baseline and 6 weeks. RESULTS: Participants smoked an average of 11.4 cigarettes per day (CPD) and 88% used menthol cigarettes at baseline. At Week 6, the nicotine group reported using e-cigarettes 9.1 times per day compared to 11.4 times in the no-nicotine group (p = 0.42). Combustible cigarette smoking decreased 3.0 CPD in the nicotine group compared to 2.7 CPD in the no-nicotine group (p = 0.74). Neither TNE nor NNAL changed significantly between baseline and Week 6. There were no differences in nicotine withdrawal symptoms between treatment groups. Smoking reduction persisted in both groups at Week 12. CONCLUSIONS: Contrary to our hypotheses, nicotine e-cigarettes did not significantly reduce the use of combustible cigarettes compared to no-nicotine e-cigarettes in this cohort of African American smokers. Findings suggest e-cigarettes are modestly associated with the decreased use of combustible cigarettes among non-treatment seeking smokers, regardless of nicotine content, but without a reduction in tobacco toxicants. IMPLICATIONS: Although e-cigarettes have the potential to reduce harm if substituted for combusted cigarettes (or if they promoted cessation) because of lower levels of tobacco toxicants, this study suggests ad lib use of e-cigarettes among African American smokers, with or without nicotine, results in modest smoking reduction but does not change toxicant exposure in a cohort where smoking cessation or reduction is not the goal. These data suggest that testing future harm reduction interventions using e-cigarettes should include more specific behavioral change coaching, including substituting for or completely stopping combusted cigarettes. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov - NCT03084315.

Developing a culturally tailored short message service (SMS) intervention for improving the uptake of cervical cancer screening among Ghanaian women in urban communities.

BACKGROUND: There has been extensive research across the globe to understand the barriers and facilitators of cervical cancer (CC) screening. However, few studies have focused on how such information has been used to develop text messages for mHealth screening programs, especially in resource-poor countries. This study elicited information on barriers and facilitators, the preferences of women regarding the modalities for delivery of health SMS messages on screening for cervical cancer, and demonstrates how this information was used to create a health screening program among women in the Greater Accra Region of Ghana. METHODS: Four main activities were carried out, including (1) a total of five focus group discussions, (2) a baseline survey involving 62 female bankers and 68 women from the communities, (3) a stakeholder meeting involving experts in cervical cancer research and clinical care, and (4) pilot testing of the text messages. Focus group discussions and the baseline survey data were collected concurrently between February and May 2017 and the results were used to develop 5 specific communication objectives during the stakeholder engagements held in June 2017. RESULTS: In all, 32 text messages were developed and pretested in July 2017(13 addressed knowledge on CC; 6 highlighted the importance of early detection; 5 allayed fear as a barrier to CC screening; 5 encouraged women to have time for their health, and 3 messages contained information on where to go for screening and the cost involved). Although awareness about the disease was high, knowledge of CC screening was low. For two-thirds of respondents (22/33), perceived lack of time, high cost, and fear (of cc, screening procedure, and potential for negative outcome) accounted for the reasons why respondents will not go for screening, while education on CC, especially from health workers and the mass media enabled uptake of CC screening. CONCLUSION: Several factors prevent women from accessing screening services for CC, however, barriers such as low levels of education on CC, lack of time, and fear can be targeted in SMS messaging programs.

Variations of a group coaching intervention to support early-career biomedical researchers in Grant proposal development: a pragmatic, four-arm, group-randomized trial.

BACKGROUND: Funded grant proposals provide biomedical researchers with the resources needed to build their research programs, support trainees, and advance public health. Studies using National Institutes of Health (NIH) data have found that investigators from underrepresented groups in the biomedical workforce are awarded NIH research grants at disproportionately lower rates. Grant writing training initiatives are available, but there is a dearth of rigorous research to determine the effectiveness of such interventions and to discern their essential features. METHODS: This 2 × 2, unblinded, group-randomized study compares the effectiveness of variations of an NIH-focused, grant writing, group coaching intervention for biomedical postdoctoral fellows and early-career faculty. The key study outcomes are proposal submission rates and funding rates. Participants, drawn from across the United States, are enrolled as dyads with a self-selected scientific advisor in their content area, then placed into coaching groups led by senior NIH-funded investigators who are trained in the intervention's coaching practices. Target enrollment is 72 coaching groups of 4-5 dyads each. Groups are randomized to one of four intervention arms that differ on two factors: [1] duration of coaching support (regular dose = 5 months of group coaching, versus extended dose = regular dose plus an additional 18 months of one-on-one coaching); and [2] mode of engaging scientific advisors with the regular dose group coaching process (unstructured versus structured engagement). Intervention variations were informed by programs previously offered by the NIH National Research Mentoring Network. Participant data are collected via written surveys (baseline and 6, 12, 18, and 24 months after start of the regular dose) and semi-structured interviews (end of regular dose and 24 months). Quantitative analyses will be intention-to-treat, using a 2-sided test of equality of the effects of each factor. An inductive, constant comparison analysis of interview transcripts will be used to identify contextual factors -- associated with individual participants, their engagement with the coaching intervention, and their institutional setting - that influence intervention effectiveness. DISCUSSION: Results of this study will provide an empirical basis for a readily translatable coaching approach to supporting the essential grant writing activities of faculty, fellows, and other research trainees, including those from underrepresented groups.

Effects on Smoking Behavior of Switching Menthol Smokers to Non-menthol Cigarettes.

INTRODUCTION: Bans of menthol characterizing flavor in cigarettes have been implemented in some localities and have been proposed more broadly. One proposed benefit of such a ban is to increase cessation rates among current menthol smokers. There is currently relatively limited data regarding how smoking behavior changes if menthol smokers switch to non-menthol cigarettes. AIMS AND METHODS: African American menthol smokers interested in quitting smoking were randomized to either continue smoking menthol (n = 60) or switch to non-menthol cigarettes (n = 62) for 1 month prior to a cessation attempt. Cessation results were reported previously; this analysis reports the results from the pre-cessation visits at which amount smoked, exhaled carbon monoxide (CO) concentration, urinary cotinine concentrations, and subjective measures were assessed. RESULTS: Over the 4-week study period, those switching to non-menthol (vs. continuing to smoke menthol) cigarettes smoked fewer cigarettes per day (mean ratio: 0.86; 95% confidence interval [CI]: 0.76, 0.98; p = .02), reported lower withdrawal symptom severity (mean difference -1.29; 95% CI: -2.6 to -0.01; p = .05) and higher perceived effectiveness of their skills for quitting smoking (mean difference 0.56; 95% CI: 0.02-1.10; p = .05). No significant differences were found between groups in exhaled CO, urinary cotinine concentrations, or most other subjective effects including support for a ban on menthol characterizing flavor in cigarettes. CONCLUSIONS: These results suggest that were menthol cigarettes no longer available, those that switch to non-menthol cigarettes would not change their smoking behavior in a way that is likely to be more hazardous, with some indicators suggesting that there may be some benefit.Clinicaltrials.gov # NCT02342327. IMPLICATIONS: A ban on menthol characterizing flavor in cigarettes has been proposed as a potential means by which to increase smoking cessation rates among current menthol cigarette smokers. This study evaluated how African American menthol cigarette smokers adjusted their smoking behavior after switching to non-menthol cigarettes. Although the overall differences between groups were modest, they were in a direction consistent with decreased smoking suggesting that current smokers would not adjust their behavior in a way that is likely to be more hazardous, with some indicators suggesting that there may be some benefits.

Testing the Feasibility and Acceptability of a Religiously-Tailored Text Messaging Intervention to Reduce Smoking Among Somali Muslim Men During Ramadan.

INTRODUCTION: The prevalence of smoking among Somali Muslim male immigrants residing in Minnesota is estimated at 44%, however smoking reduction is common during the month of Ramadan. This study evaluated the feasibility and impact of a religiously tailored text message intervention delivered during Ramadan to encourage smoking reduction among Somali Muslim men who smoke. METHODS: Fifty Somali men were recruited. Participants received two text messages per day starting 1 week prior to and throughout the month of Ramadan. Approximately half were religiously tailored and half were about the risks of smoking and benefits of quitting. Smoking behavior was assessed at baseline, and at weeks 4 (end of Ramadan), 8, and 16. Outcomes included feasibility, acceptability, and preliminary impact of the text message intervention on smoking reduction and bioverified abstinence. RESULTS: The average age was 41 years. Average time to first cigarette was 1.8 hours at baseline, and 46% of participants smoked menthol cigarettes. Eighteen of 50 participants selected English and 32 selected Somali text messages. Subjects significantly reduced self-reported cigarettes per day (CPD) from 12.4 CPD at baseline to 5.8 CPD at week 16 (p < 0.001). Seven subjects reported quitting at week 16, five completed CO testing, confirming self-reported abstinence. The majority of participants found the cultural and religious references encouraging at the end of the week 16 survey. CONCLUSIONS: Religiously tailored text messages to decrease smoking are feasible and acceptable to Somali Muslim men who smoke during Ramadan. This intervention for addressing smoking disparities is worthy of further study. IMPLICATIONS: Recruitment of Somali Muslim men who smoke is feasible and supports the idea that further studies targeting smoking during Ramadan are practical. Ramadan presents a window of opportunity upon which to build smoking cessation interventions for smokers who identify as Muslim. These preliminary findings suggest that text messaging is a feasible and acceptable intervention strategy, and that religious tailoring was well received. Such an approach may offer potential for addressing smoking disparities among Somali Muslim male smokers. TRIAL REGISTRATION: ClinicalTrial.gov: NCT03379142.

Effects on time to lapse of switching menthol smokers to non-menthol cigarettes prior to a cessation attempt: a pilot study.

INTRODUCTION: Menthol smokers (particularly African-Americans) have lower cessation success rates than non-menthol smokers. With bans being considered on characterising menthol flavour in cigarettes, data are needed regarding how switching to non-menthol cigarettes impacts cessation measures. METHODS: In this randomised pilot study, African-American menthol cigarette smokers interested in quitting smoking either continued smoking menthol cigarettes (n=60) or switched to non-menthol cigarettes (n=62) for a 1-month period prior to a cessation attempt. The primary endpoint was time to smoking lapse (ie, time from quitting until any smoking). Additional endpoints included time to smoking relapse (ie, number of days from quitting until the first of seven consecutive smoking days) and difference between groups in subjective measures. RESULTS: After attempting to quit, the non-menthol cigarette group had indications of delayed time to lapse (HR 0.82; 95% CI 0.55 to 1.22; p=0.33) and time to relapse (HR 0.67; 95% CI 0.42 to 1.06; p=0.09), although these were not statistically significant. Post hoc analyses suggest that observed differences were largely due to a smaller proportion of participants in the non-menthol group relapsing within the first day of quitting (21% vs 40%; p=0.05). Values of other measures assessed postcessation were largely similar between groups. CONCLUSIONS: These data suggest that among African-American smokers, a menthol cigarette ban would not undermine short-term cessation measures and may result in some benefits. Future research is needed to assess longer term cessation rates and to identify interventions to maximise cessation success in the event of a menthol ban. TRIAL REGISTRATION NUMBER: NCT02342327.

Impact of the Society for Research on Nicotine and Tobacco Health Disparities Network's Scholarship on Professional Development of Its Recipients.

INTRODUCTION: Diversifying the workforce is an important strategy to reducing health disparities. Since 2007, the Society for Research on Nicotine and Tobacco (SRNT) Health Disparities Network has funded a travel scholarship to promote inclusion, professional development, and diversity among investigators interested in tobacco-related health disparities research. This study examined indicators of productivity among former scholarship recipients.Methods: Scholarship recipients between 2007 and 2014 were invited to complete a survey online. The survey assessed demographic characteristics, academic productivity, and perceived professional benefit resulting from the scholarship.Results: Of the 117 scholarships recipients, 89 (77%) responded. Respondents were 67% female and had a mean age of 37.8 years. Twenty eight percent were African American, 25% Asian American, and 17% Latino. Most respondents worked in academia (80%) and nearly three-quarters (74%) reported publishing manuscripts on tobacco-related disparities, with a mean of 3.8 (SD 4.4) disparities-related publications since receiving the scholarship. Respondents' work focused on a wide range of health disparities topics and nearly all respondents reported that the scholarship removed barriers to attending the meeting and reported professional benefit from receiving the travel scholarship. Following receipt of the SRNT travel scholarship, a diverse group of scientists demonstrated scholarly productivity, professional development, and advancement of health disparities research. Similar efforts are encouraged in other professional societies. IMPLICATIONS: This study examines the productivity of early career recipients of the SRNT Health Disparities Scholarship. Results suggest that the investment in annual travel scholarships by a professional organization is an important support system for emerging scientists from diverse backgrounds. This investment may help to advance the science of health disparities and engage researchers in an area where there are critical gaps in the research workforce.

Disparities in current cigarette smoking among US adults, 2002-2016.

BACKGROUND: To assess disparities in current (past 30 days) cigarette smoking among US adults aged ≥ 18 years during 2002-2016. METHODS: Nine indicators associated with social disadvantage were analysed from the 2002 to 2016 National Survey on Drug Use and Health: education, annual family income, sex, race/ethnicity, urbanicity, serious psychological distress, health insurance, public assistance, and employment status. Using descriptive and multivariable analyses, we measured trends in smoking overall and within the assessed variables. We also evaluated effect of interactions on disparities and estimated the excess number of smokers attributable to disparities. RESULTS: During 2002-2016, current cigarette smoking prevalence declined overall (27.5%-20.7%; p trend < 0.01), and among all subgroups except Medicare insurees and American Indians/Alaska Natives (AI/ANs). Overall inequalities in cigarette smoking grew even wider or remained unchanged for several indicators during the study period. In 2016, comparing groups with the least versus the most social advantage, the single largest disparity in current smoking prevalence was seen by race/ethnicity (prevalence ratio = 5.1, AI/ANs vs Asians). Education differences alone explained 38.0% of the observed racial/ethnic disparity in smoking prevalence. Interactions were also present; compared with the population-averaged prevalence among all AI/AN individuals (34.0%), prevalence was much higher among AI/ANs with

Harm reduction treatment for smoking (HaRT-S): findings from a single-arm pilot study with smokers experiencing chronic homelessness.

Background: Smoking prevalence and mortality is 5 times higher for the chronically homeless versus general population. Unfortunately, traditional smoking cessation treatment does not optimally engage this population. In a preliminary study, smokers experiencing chronic homelessness suggested providers avoid giving advice to quit and instead use a more compassionate, nonjudgmental style to discuss a broader menu of patient-driven options, including safer nicotine use. Most had negative perceptions of smoking cessation medications; however, 76% expressed interest in a switchover to electronic nicotine delivery systems (ENDS). Methods: Using a community-based participatory research approach, we codeveloped harm-reduction treatment for smoking (HaRT-S) together with people with lived experience of chronic homelessness and smoking and a community-based agency that serves them. In HaRT-S, interventionists embody a compassionate, advocacy-oriented "heart-set" and deliver manualized components: a) participant-led tracking of smoking-related outcomes, b) elicitation of harm-reduction goals and progress made toward them, c) discussion of relative risks of nicotine delivery systems, and d) distribution and instructions on use of safer nicotine products. We then conducted a single-arm, 14-week pilot of HaRT-S (N = 44). Results: Participants rated procedures "totally acceptable/effective," which was reflected in 26% overrecruitment within a 4-month period and 70% retention at the 14-week follow-up. For each week in the study, participants experienced an 18% increase in odds of reporting 7-day, biochemically verified, point-prevalence abstinence. All participants reporting abstinence used ENDS. Participants evinced reductions in cigarette dependence (-45%), frequency (-29%), and intensity (-78%; ps < .05). Participants who used ENDS experienced an additional 44% reduction in smoking intensity and a 1.2-point reduction in dependence compared to participants who did not. Conclusions: Harm-reduction counseling plus ENDS shows promise for smokers experiencing chronic homelessness. Randomized controlled trials are needed to establish the efficacy of this approach in decreasing smoking-related harm and improving health-related quality of life for this marginalized and disproportionately affected population.

What do medical students know about e-cigarettes? A cross-sectional survey from one U.S. medical school.

BACKGROUND: Although electronic cigarette (e-cigarette) use has rapidly increased, there is little data about what United States medical students know or are taught about them. This study examined medical students' experiences, knowledge, and attitudes regarding e-cigarettes, as well as their evaluation of their education on e-cigarettes. METHODS: A cross-sectional online survey of medical students currently enrolled at the University of Minnesota Medical School (n = 984) was conducted over a three-week period in August and September 2015. Primary outcomes included students' personal experiences with e-cigarettes, knowledge and attitudes about e-cigarettes, and students' assessment of their education on e-cigarettes. RESULTS: 66.9% medical students completed the survey. 58% (n = 382) of participants identified as female. 35.8% (n = 235) were "not sure" whether e-cigarettes were approved by the FDA for smoking cessation, while 4.1% (n = 27) falsely believed they were. While 82.9% (n = 543) agreed or strongly agreed that they felt confident in their ability to discuss traditional cigarette use with patients, only 12.4% (n = 81) agreed or strongly agreed that they felt confident in their ability to discuss e-cigarettes with patients. 94.8% (n = 619) of participants believed that they had not received adequate education about e-cigarettes in medical school. A higher proportion of males reported ever using an e-cigarette. CONCLUSIONS: The gaps in medical student knowledge and wide variances in attitudes about e-cigarettes at one medical school together with their report of inadequate education in an environment of increasing use of e-cigarette use in the U.S. speaks to a need for the development of medical school curriculum on e-cigarettes.

Randomized Controlled Trial of Group-Based Culturally Specific Cognitive Behavioral Therapy Among African American Smokers.

INTRODUCTION: This study tested the efficacy of group-based culturally specific cognitive behavioral therapy (CBT) for smoking cessation among low-income African Americans. METHODS: Participants (N = 342; 63.8% male; M = 49.5 years old; M cigarettes per day = 18) were randomly assigned to eight sessions of group-based culturally specific or standard CBT, plus 8 weeks of transdermal nicotine patches. Biochemically verified 7-day point prevalence abstinence (ppa) was assessed at the end-of-therapy (ie, CBT) (EOT), and 3-, 6-, and 12-month follow-ups. Primary outcomes were the longitudinal intervention effect over the 12-month follow-up period, and 7-day ppa at the 6-month follow-up. Secondary outcomes included 7-day ppa at the EOT and 12-month follow-up, and intervention ratings. Generalized linear mixed modeling tested the longitudinal effect and logistic regression tested effects at specific timepoints. RESULTS: Generalized linear mixed modeling demonstrated a longitudinal effect of intervention condition. Specifically, 7-day ppa was two times (P = .02) greater following culturally specific CBT versus standard CBT when tested across all timepoints. Analyses by timepoint found no significant difference at 6 or 12 months, yet culturally specific CBT was efficacious at the EOT (62.5% vs. 51.5% abstinence, P = .05) and the 3-month follow-up (36.4% vs. 22.9% abstinence, P = .007). Finally, intervention ratings in both conditions were high, with no significant differences. CONCLUSIONS: Culturally specific CBT had a positive longitudinal effect on smoking cessation compared to a standard approach; however, the effects were driven by short-term successes. We recommend the use of group-based culturally specific CBT in this population when possible, and future research on methods to prevent long-term relapse. IMPLICATIONS: Culturally specific interventions are one approach to address smoking-related health disparities; however, evidence for their efficacy in African Americans is equivocal. Moreover, the methodological limitations of the existing literature preclude an answer to this fundamental question. We found a positive longitudinal effect of culturally specific CBT versus standard CBT for smoking cessation across the follow-up period. Analyses by assessment point revealed that the overall effect was driven by early successes. Best practices for treating tobacco use in this population should attend to ethnocultural factors, but when this is not possible, standard CBT is an alternative approach for facilitating long-term abstinence.

A Community-Driven Implementation of the Body and Soul Program in Churches in the Twin Cities, Minnesota, 2011-2014.

BACKGROUND: African Americans have high disease and death rates due to cancer and cardiovascular disease. Health promotion efforts to improve diet have the potential to reduce these rates. COMMUNITY CONTEXT: Given their importance in the community and the extent of their reach, churches are effective avenues for health promotion efforts targeting African Americans. The objectives of this project were to promote healthy eating among African American church members, engage African American churches in the implementation of Body and Soul (an evidenced-based program that encourages healthy eating), and implement the program in the community with minimal resources. METHODS: From 2011 through 2014 we conducted a community engagement project to implement the 12-week Body and Soul program, which includes demonstrations of healthy recipes and peer counseling, in 20 churches. Participants (n = 310) completed baseline and follow-up surveys on their eating habits and experience with peer counseling. Church coordinators (n = 11) completed a survey evaluating the program. OUTCOME: Participants' weekly servings of fruit (baseline, 4.3; follow-up, 5.4; P < .001) and vegetables (baseline, 4.5; follow-up, 5.3; P < .001) increased. Church coordinators reported enthusiasm about Body and Soul at their church, and 10 of 11 church coordinators indicated that their pastor encouraged members to attend Body and Soul events. Program success was promoted by engaging the pastor in program activities and by scheduling events soon after church services. Implementation challenges were variation in peer counseling among churches and low turnout at follow-up events. INTERPRETATION: The project was successfully implemented in the 20 churches, and increases in healthy eating were observed. This project demonstrated that Body and Soul can be implemented in communities with little funds or other resources.

Depression Symptoms Among Homeless Smokers: Effect of Motivational Interviewing.

BACKGROUND: Tobacco use is higher among homeless individuals than the general population. Homeless individuals are also more likely to have symptoms of depression. Depression symptoms may add to the burden of homelessness by increasing psychological distress and serve as a barrier to quitting smoking. OBJECTIVES: The primary goal of this study is to assess the impact of depression symptoms on psychological distress in homeless smokers. The effect of depression symptoms on abstinence and the effect of Motivational Interviewing (MI) on cessation among smokers is also explored. METHODS: Homeless smokers (N = 430) enrolled in a smoking cessation study were randomized to Motivational Interviewing (MI) or standard care (SC). Participants received nicotine replacement therapy and were followed for 26 weeks. Participants were categorized into a depression symptoms (DS) group or control group using the Patient Health Questionnaire-9. Between group differences of perceived stress, hopelessness, confidence, craving and abstinence were assessed at weeks 8 and 26. The interaction between depression symptoms (levels: DS and control) and the intervention (levels: MI and SC) was also assessed. RESULTS: Homeless smokers in the DS group reported higher levels of hopelessness, perceived stress, and craving. There was no effect of DS status on abstinence at week 8 or week 26. There was no significant interaction between depression symptoms (DS vs. Control) and the intervention (MI vs. SC). CONCLUSION: Despite reporting greater psychological distress, homeless smokers with depression symptoms in this sample had abstinence levels similar to the control group. Future research should explore protective factors among depressed smokers.

Tobacco counseling experience prior to starting medical school, tobacco treatment self-efficacy and knowledge among first-year medical students in the United States.

OBJECTIVE: To explore students' tobacco dependence counseling experiences prior to medical school and their associations with tobacco counseling self-efficacy, and familiarity with and perceived effectiveness of tobacco dependence treatment among first-year medical students in the United States. METHOD: In 2010, 1266 first-year medical students from 10 US medical schools completed a survey reporting their clinical experiences with specific tobacco counseling skills (e.g., 5As) prior to medical school. The survey also included questions on tobacco counseling self-efficacy, perceived physician impact on smokers, and familiarity and effectiveness of tobacco-related treatments. RESULTS: Half (50.4%) reported some tobacco counseling experiences prior to medical school (i.e. at least one 5A). Students with prior counseling experiences were more likely to have higher tobacco counseling self-efficacy, and greater familiarity with medication treatment, nicotine replacement treatment, and behavioral counseling for smoking cessation, compared to those with no prior experiences. Perceived physician impact on patient smoking outcomes did not differ by prior tobacco counseling experiences. CONCLUSIONS: Many first-year medical students may already be primed to learn tobacco dependence counseling skills. Enhancing early exposure to learning these skills in medical school is likely to be beneficial to the skillset of our future physicians.

Medical school curriculum characteristics associated with intentions and frequency of tobacco dependence treatment among 3rd year U.S. medical students.

OBJECTIVE: Physicians play a critical role in addressing tobacco dependence, yet report limited training. Tobacco dependence treatment curricula for medical students could improve performance in this area. This study identified student and medical school tobacco treatment curricula characteristics associated with intentions and use of the 5As for tobacco treatment among 3rd year U.S. medical students. METHODS: Third year medical students (N=1065, 49.3% male) from 10 U.S. medical schools completed a survey in 2009-2010 assessing student characteristics, including demographics, tobacco treatment knowledge, and self-efficacy. Tobacco curricula characteristics assessed included amount and type of classroom instruction, frequency of tobacco treatment observation, instruction, and perception of preceptors as role models. RESULTS: Greater tobacco treatment knowledge, self-efficacy, and curriculum-specific variables were associated with 5A intentions, while younger age, tobacco treatment self-efficacy, intentions, and each curriculum-specific variable were associated with greater 5A behaviors. When controlling for important student variables, greater frequency of receiving 5A instruction (OR=1.07; 95%CI 1.01-1.12) and perception of preceptors as excellent role models in tobacco treatment (OR=1.35; 95%CI 1.04-1.75) were significant curriculum predictors of 5A intentions. Greater 5A instruction (B=.06 (.03); p<.05) and observation of tobacco treatment (B=.35 (.02); p<.001) were significant curriculum predictors of greater 5A behaviors. CONCLUSIONS: Greater exposure to tobacco treatment teaching during medical school is associated with both greater intentions to use and practice tobacco 5As. Clerkship preceptors, or those physicians who provide training to medical students, may be particularly influential when they personally model and instruct students in tobacco dependence treatment.

Retention of Homeless Smokers in the Power to Quit Study.

INTRODUCTION: Concerns about retention are a major barrier to conducting studies enrolling homeless individuals. Since smoking is a major problem in homeless communities and research on effective methods of promoting smoking cessation is needed, we describe strategies used to increase retention and participant characteristics associated with retention in smoking cessation study enrolling homeless adults. METHODS: The parent study was a 2-group randomized controlled trial with 26-week follow-up enrolling 430 homeless smokers from emergency shelters and transitional housing units in Minneapolis/Saint Paul, MN, USA. Multiple strategies were used to increase retention, including conducting visits at convenient locations for participants, collecting several forms of contact information from participants, using a schedule that was flexible and included frequent low-intensity visits, and providing incentives. Participant demographics as well as characteristics related to tobacco and drug use and health status were analyzed for associations with retention using univariate and multivariate analysis. RESULTS: Overall retention was 75% at 26 weeks. Factors associated with increased retention included greater age; having healthcare coverage; history of multiple homeless episodes, lower stress level; and higher PHQ-9 (Patient Health Questionnaire-9) score. A history of excessive drinking and drug use were associated with decreased retention. CONCLUSIONS: It is possible to successfully retain homeless individuals in a smoking cessation study if the study is designed with participants' needs in mind.

Prevalence of cardiovascular risk factors across six African Immigrant Groups in Minnesota.

BACKGROUND: Although African immigrants represent a large and growing segment of the U.S. population, there are little or no data available on the prevalence of cardiovascular disease (CVD) risk factors among this diverse population. This study compared the prevalence of self-reported CVD risk factors and health behaviors and examined the associations between immigration related characteristics and CVD risk factors and health behaviors across six African immigrants groups. METHODS: Data were from 996 African immigrants in the U.S., (37.9% Somalis; 26.8% Ethiopians; 14% Liberians; 8.5% Sudanese; 5.1% Kenyans and 7.8% others group) from a cross-sectional survey conducted in the Twin cities of Minnesota. Logistic regression models estimated the associations of demographic characteristics, and immigration-related factors (length of stay in the United states, English proficiency, income and health insurance) with prevalence of CVD risk factors (overweight/obese; hypertension and diabetes mellitus) and self-reported health behaviors (cigarette smoking, physical inactivity, conscious effort to exercise and eating a healthy diet). RESULTS: We found a relatively low self-reported prevalence of diabetes, hypertension, and smoking. However, significant differences were noted by country of origin. Using Somalis as our referent country of origin group, we found that Liberians and Kenyans were more likely to report having diabetes or hypertension. On all measures of health behaviors, Liberians were more likely to engage in more health protective behaviors than other individuals. CONCLUSIONS: Although African immigrants have different prevalence rates for CVD risk factors and health behaviors, there is a need to further explore the differences observed by country of emigration.

Smoking cessation in homeless populations: who participates and who does not.

INTRODUCTION: Although homeless individuals smoke at an alarmingly high rate, few smoking cessation clinical trials have focused on this vulnerable population. Little is known about recruitment efforts and suitable eligibility criteria for tobacco control research in homeless populations. METHODS: The aim of this article is to describe the recruitment, eligibility, and enrollment of homeless smokers who participated in the Power to Quit smoking study, a randomized smoking cessation clinical trial funded by the National Institutes of Health. The study compared motivational interviewing and standard counseling while participants received an 8-week treatment of the nicotine patch. RESULTS: Working with local emergency shelters, a total of 839 adult smokers were screened for study eligibility, 580 of whom (69.1%) met eligibility criteria. Of those eligible, 430 (74.1%) returned for randomization. Those who returned for randomization were older and more likely to have a phone number compared with eligible participants not enrolled. The most common reasons for exclusion included exhaled carbon monoxide levels less than or equal to 5 parts per million (indicating nonsmoking status), use of smoking cessation aid during the past 30 days, and not meeting the study definition of homelessness. CONCLUSION: Knowledge of these factors may help researchers tailor criteria that accurately identify and include homeless smokers in future research.