Randomized controlled trial of a text-based smokeless tobacco cessation intervention for rural and medically underserved communities.

INTRODUCTION: Smokeless tobacco use remains prevalent in rural and medically underserved populations, leading to increased rates of tobacco-related cancers and chronic disease. While access to effective cessation programs is limited, text-based interventions may offer a delivery approach with broad reach. This two-armed randomized control trial (RCT) assessed the efficacy of #EnufSnuff.TXT, a text-based smokeless tobacco cessation intervention, in rural and medically underserved communities. METHODS: We conducted a two-arm RCT assessing #EnufSnuff.TXT, a text-based scheduled reduction intervention paired with text-based cessation support messages compared with the modified Enough Snuff intervention comprised of a cessation education booklet and bi-weekly motivational text messages. We recruited participants via social media and surveyed participants at three and six months post-randomization. The primary outcome was self-reported seven-day point prevalence abstinence at six months. RESULTS: We recruited and randomized 532 participants. At three months post randomization, the quit rate was significantly higher in #EnufSnuff.TXT arm compared to the Enough Snuff arm for intent-to-treat (ITT) cases (29.2% vs 19.0%, OR=1.75, p=0.0066). The quit rate at six months post randomization remained higher in #EnufSNuff.TXT compared to Enough Snuff for ITT cases (23.1% vs 20.9%, OR=1.14, p=0.5384), although no longer significantly different. CONCLUSION: This is the first large-scale text-based cessation clinical trial for individuals in underserved areas who use smokeless tobacco. The #EnufSnuff.TXT intervention performed better in the short term, however both interventions yielded similar quit-rates at 6-months post randomization. Future research should focus on improving long-term abstinence in the #EnufSNuff.TXT intervention. IMPLICATIONS: Text-based cessation approaches have the potential to increase access to cessation interventions in rural and medically underserved areas and reduce tobacco-related chronic disease morbidity and mortality. Our study shows short-term efficacy from the first ever randomized controlled trial of a smokeless tobacco cessation intervention, #EnufSnuff.TXT, for rural and medically underserved residents in the United States. Our #EnufSnuff.TXT Intervention offers a scalable solution to reach and provide much needed access to cessation interventions in medically underserved, rural communities in the United States. This work provides the foundation for further inquiry on augmented text-based approaches to increase cessation in this at-risk group.

Experiences and Perceptions of E-Cigarette Cessation for Young Adults in Rural Communities.

BACKGROUND: Electronic nicotine delivery systems (ENDS), also known as e-cigarettes, are the most commonly used tobacco products among young adults in the United States. Young adults in rural areas have a higher prevalence of ENDS use compared to their urban counterparts, yet there is limited evidence regarding the in-depth understanding of experiences and perspectives directly from young adults. OBJECTIVES: The aim of this study was to explore individual experiences and perspectives about use and cessation of ENDS from young adults in rural areas. METHODS: This was a qualitative study using interpretive description for analysis. Young adults (18-24 years) who used ENDS every day but not other tobacco products (cigarettes, smokeless, etc.) in the past month and had an address in a rural county of Wisconsin were eligible; there were nine participants interviewed using Zoom. Interview questions focused on initial use, maintenance of use, experiences of quitting, and social and rural environmental contexts regarding ENDS. RESULTS: Three themes emerged with eight categories: (a) addiction to ENDS and health, (b) cessation and resources, and (c) rural environment and culture in ENDS addiction. DISCUSSION: Findings have implications for ENDS cessation interventions targeting young adults in rural areas.

Smoking Quit Attempts and Associated Factors Among Rural Adults Who Smoke Daily in the US.

INTRODUCTION: Rural American communities are heavily affected by tobacco-related health disparities. This study aims to evaluate the prevalence of quit attempts (QA) and factors that promote or impede QA among rural adults who smoke daily. METHODS: Data from Wave 5 of the Population Assessment of Tobacco and Health study were analyzed. Multivariable logistic regression was used to identify factors associated with quit attempt. Backwards selection was used to identify variables included in the final model with statistical significance set at p <0.05. RESULTS: Among 1,610 rural adults who smoked daily, the prevalence of a quit attempt in the past 12 months was 25.6% (95% CI: 23.2, 28.2). Factors associated with greater QA odds: having greater education (aOR = 1.35, 95% CI: 1.03, 1.77), e-cigarette use (aOR=1.35 95% CI: 1.03, 1.80), disapproval of smoking from friends/family (aOR= 1.46, 95% CI: 1.09-1.94), greater frequency of thinking about the harm of tobacco (aOR = 1.48, 95% CI: 1.28, 1.71), fair/poor physical health (aOR=1.31, 95% CI: 1.00, 1.70), and being advised to quit by a doctor (aOR =1.63 , 95% CI:1.25, 2.13). Smokeless tobacco use (aOR = 0.67, 95% CI: 0.47, 0.96) and greater cigarettes per day (aOR = 0.67, 95% CI: 0.47, 0.96) were associated with QA lower odds. CONCLUSION: Only 1 in 4 rural adults who smoke made a past year quit attempt. Interventions that promote provider advice to quit smoking, tobacco health harms, and normative beliefs may increase quit attempts in rural communities. IMPLICATIONS: Along with higher smoking rates and lower quitting attempts, rural communities face limited access to programs, medication, and health care professionals as tools to help them quit smoking. Public Health initiatives should focus on developing cultural sensitivity training targeting health care professionals to advise patients to quit smoking and the role of multiple tobacco products use. Furthermore, given the low rates of smoking quitting attempts future mixed methods research is needed to inform policies and interventions targeted at eliminating tobacco-related health disparities.

An exploration of language: How nurses describe social factors that contribute to health.

BACKGROUND: Over the last two centuries nurses have been practicing, teaching, and conducting research on social factors that contribute to health and the language has evolved over this time. PURPOSE: To explore how social factors that contribute to health are described by nurse authors and how that use has changed over time. METHODS: A scoping review using the JBI Manual for Evidence Synthesis, Cochrane Handbook, and PRISMA guidelines was completed. FINDINGS: From 1967 to 2021, nurses used the term "social factors" most commonly and there was a shift from demographic to social factors. DISCUSSION: As the language that nurses use has shifted from demographic descriptions to the social factors that may be associated with those descriptions, nurses have an opportunity to promote the use of non-deterministic language for health promotion and research.

Preparing nurse scientists for health services and policy research: Five-year outcomes of interprofessional postdoctoral training in the National Clinician Scholars Program.

BACKGROUND: The National Clinician Scholars Program (NCSP) is an interprofessional postdoctoral fellowship for physicians and nurses with a PhD. or DNP focused on health services research, policy, and leadership. PURPOSE: To evaluate 5-year outcomes of nurse postdoctoral scholars in the NCSP. METHODS: We describe the 5-year outcomes of nurse fellows and graduates from six NCSP sites (positions, number of peer-reviewed publications, citations, and h-index). CONCLUSION: There were 53 nurses in the sample (34 alumni, 19 fellows). Approximately half (47%, n = 16) of alumni had tenure-track faculty positions and had bibliometric performance indicators (such as h-indices) 2 to 4 times greater than those previously reported for assistant professors in nursing schools nationally. NCSP nurse scholars and alumni also had an impact on community partnerships, health equity, and health policy DISCUSSION: This study highlights the potential of interprofessional postdoctoral fellowships such as the NCSP to prepare nurse scientists for health care leadership roles.

Effects of Smoking Reduction and Cessation on Birth Outcomes in a Scheduled Gradual Reduction Cessation Trial.

INTRODUCTION: Smoking during pregnancy can affect infant birthweight. We tested whether an intervention that promoted scheduled gradual reduction improved birth outcomes among pregnant women who smoked. We also examined race differences in birth outcomes. METHODS: We conducted a 2-arm randomized controlled trial where pregnant women who smoked received either SMS text-delivered scheduled gradual smoking reduction (SGR) program plus support texts or support messages only throughout their pregnancy. The outcomes for this paper were birth outcomes including birth weight and gestational age obtained from chart review. Analyses were conducted using chi-square and t-tests in SAS. RESULTS: We approached 2201 pregnant women with smoking history. Of the 314 women recruited into the study, 290 completed a medical release form (92%). We did not find any significant differences in birth outcomes by arm or race. The majority of participants reduced smoking by the 80%. Women who reduced more than 50% of their baseline cigarettes per day had a birth weight increase of 335 g compared to those that did not (p = 0.05). The presence of alcohol/drug use in prenatal visit notes was associated with low infant birth weight (p = 0.05). DISCUSSION: The scheduled gradual reduction intervention did not improve birth outcomes. Additional research is needed to help improve birth outcomes for pregnant women who engage in tobacco and illicit substance use. CLINICAL TRIAL #: NCT01995097.

Trajectories of Situational Temptations in Pregnant Smokers participating in a Scheduled Gradual Reduction Cessation Trial.

OBJECTIVE: The purpose of this paper was to examine changes in situational temptations to smoke among women in early to late pregnancy enrolled in a texting trial to help them quit smoking. We compared changes between (1) intervention arms, (2) those who quit, (3) those who reduced by 50% or more, and (4) those who reduced by less than 50%. We also examined cravings overtime in the intervention arm and the relationship between real-time cravings assessed via text message and situational temptations. METHODS: This was a secondary analysis of the Baby Steps trial, a randomized controlled trial testing the efficacy of a text-based scheduled gradual reduction (SGR) intervention on cessation. We used t-tests to examine changes across intervention arms and repeated measured proc mixed to explore changes in situational temptations and cravings. RESULTS: Among all women, situational temptations decreased from early to late pregnancy for the positive, negative, and habitual subscales, (ps < 0.001). We found no difference in situational temptations across arms. We found a positive relationship between negative situational temptation and average craving during the Weeks 2 and Weeks 3 of the intervention. Negative ST increased by 0.11 for each unit increase of craving at Week 2. CONCLUSIONS: As women progress through pregnancy their temptation to smoke reduces. A different relationship might exist, however with negative affect situations in which women reported higher craving but not in response to other temptations. Future work might have a particular focus on the intersection of negative affect with cravings and temptations to promote cessation during pregnancy. CLINICAL TRIAL: NCT01995097.

The Impact of Smoking and Multiple Health Behaviors on All-Cause Mortality.

Four common health risk behaviors have the greatest impact on all-cause mortality risk, but studies are needed with larger samples and the appropriate age range for cigarette smokers. We examined the impact of smoking in the context of multiple health behaviors on all-cause mortality using a nationally representative sample of adults aged 30 and older in the United States. National Health Interview Survey data from 1997 to 2005 were linked to the National Death Index with a follow-up to December 2015. The primary dependent variable was all-cause mortality, and the primary predictors were smoking, heavy drinking, physical inactivity, and unhealthy weight (underweight or obesity). The sample contained 189,087 individuals (≥ age 30; population estimate = 140.7 million). Our primary statistical analysis tool involved fitting Cox proportional hazards models. Our findings demonstrated that smoking led to the highest mortality risk among the four risk behaviors examined, but more than half of smokers engaged in at least one additional health risk behavior. Smokers who engaged in multiple health behaviors experienced higher increased mortality risks: smoking combined with one other health risk behavior increased mortality risk by 32% and by 82% when combined with two behaviors. Engaging in all four risk behaviors more than doubled the mortality risk of smokers. Smoking cessation interventions that address multiple risk behaviors-physical inactivity, heavy drinking, and unhealthy weight-will likely prevent premature death better than interventions that address only smoking.

Efficacy of a Texting Program to Promote Cessation Among Pregnant Smokers: A Randomized Control Trial.

INTRODUCTION: Smoking during pregnancy poses serious risks to baby and mother. Few disseminable programs exist to help pregnant women quit or reduce their smoking. We hypothesized that an SMS text-delivered scheduled gradual reduction (SGR) program plus support texts would outperform SMS support messages alone. METHODS: We recruited 314 pregnant women from 14 prenatal clinics. Half of the women received theory-based support messages throughout their pregnancy to promote cessation and prevent relapse. The other half received the support messages plus alert texts that gradually reduced their smoking more than 3-5 weeks. We conducted surveys at baseline, end of pregnancy, and 3 months postpartum. Our primary outcome was biochemically validated 7-day point prevalence abstinence at late pregnancy. Our secondary outcome was reduction in cigarettes per day. RESULTS: Adherence to the SGR was adequate with 70% responding to alert texts to smoke within 60 minutes. Women in both arms quit smoking at the same rate (9%-12%). Women also significantly reduced their smoking from baseline to the end of pregnancy from nine cigarettes to four; we found no arm differences in reduction. CONCLUSIONS: Support text messages alone produced significant quit rates above naturally occurring quitting. SGR did not add significantly to helping women quit or reduce. Sending support messages can reach many women and is low-cost. More obstetric providers might consider having patients who smoke sign up for free texting programs to help them quit. IMPLICATIONS: A disseminable texting program helped some pregnant women quit smoking.Clinical Trial Registration number: NCT01995097.

Understanding Social Determinants of Cardiometabolic Disease Risk in Rural Women.

Women living in rural America experience significant disparities in cardiometabolic diseases warranting research to aid in understanding the contextual factors that underlie the rural and urban disparity and in planning effective primary prevention interventions. While research has established a general understanding of cardiometabolic risks individually, the combination or bundling of these risk behaviors is not clearly understood. The purpose of this study is to explore the association of social determinants of health on obesity and adiposity related cardiometabolic disease risk among rural women. Data were from the multi-state Rural Families Speak about Health Study. A total of 399 women were included in the analyses. Data were collected using a self-administered questionnaire on women's demographics, economic stability, education, and health and healthcare. Food insecurity, education, healthcare access and comprehension health literacy were associated with higher obesity and adiposity-related cardiometabolic risk. Health behaviors, tobacco use and physical activity were not associated with higher cardiometabolic risk in this sample of rural women. This is one of the first studies to focus on multiple social determinants of health and cardiometabolic risk in rural American women. Understanding combinations of risk behaviors can assist health care providers and community health professionals in tailoring multiple health behavior change interventions to prevent cardiometabolic disease among rural women. The findings support a focus on community and societal level factors may be more beneficial for improving the cardiometabolic health of rural women.

Pilot Test of Connecting Pregnant Women who Smoke to Short Message Service (SMS) Support Texts for Cessation.

INTRODUCTION: Most pregnant women know that smoking poses serious risks to baby and mother, yet many still smoke. We conducted a large randomized controlled trial and found that an SMS text-delivered program helped about 10% of these women quit smoking. In this paper, we describe the feasibility of disseminating a text-based intervention to pregnant women who smoke. METHODS: We tested dissemination in two ways from prenatal clinics and compared recruitment rates to those found in our large randomized controlled trial. The first method involved "direct texting" where study staff identified women who smoked and sent them a text asking them to text back if they wanted to receive texts to help them quit. The second involved "nurse screening" where clinic staff from county health departments screened women for smoking and asked them to send a text to the system if they wanted to learn more about the program. Our primary outcome was feasibility assessed by the number of women who texted back their baby's due date, which served as "enrolling" in the texting program, which we compared to the recruitment rate we found in our large trial. RESULTS: Over 4 months, we texted 91 women from the academic health system. Of those, 17 texted back and were counted as "enrolled." In the health departments, across the 4 months, 12 women texted the system initially. Of those, 10 were enrolled. This rate was similar to the rate enrolled in the randomized controlled trial. DISCUSSION: Two different methods connected pregnant women who smoke to a texting program. One of these methods can be automated further and have the potential of helping many women quit smoking with minimal effort. Clinical Trial # NCT01995097.

Smoking behavior and social contexts associated with smoking among dual-smoker couples.

OBJECTIVES: To examine smoking behavior and social contexts related to smoking among dual-smoker couples. DESIGN: Cross-sectional online survey study. SAMPLE: A convenience sample of 183 dual-smoker couples. MEASUREMENTS: Investigator-developed survey on smoking and related social contexts. RESULTS: Participants smoked 16.0 cigarettes daily for 14.2 years; 48.4% shared more than half of their smoking time with their spouse. More than half made quit attempts in the past year individually (M = 5.3) and jointly (M = 2.5). Couples sharing more smoking time were more likely to be motivated to quit (p = .002), make quit attempts (p < .0001), and be interested in cessation interventions (p = .002); but less likely to implement home smoking bans (p < .001). Among those who reported quit attempts, 41% quit by themselves and 15.3% sought professional assistance. Most common reasons for relapse were chronic stress and crisis, 63.6%, however, were interested in smoking cessation services, preferably technology-based interventions. CONCLUSIONS: We found smoking interdependence within dual-smoker couples. Despite high levels of motivation to quit, most did not utilize professional help, leading to low successful quit rates. Technology-based smoking cessation interventions incorporating spousal support and addressing stress/crisis may best assist dual-smoker couples.

Psychosocial Correlates of Jordanian Adolescents' Help-Seeking Intentions for Depression: Findings From a Nationally Representative School Survey.

Little is known about help-seeking for depression among Jordanian adolescents who are a vulnerable population with high rates of depressive symptoms and few mental health services. The purpose of this study was to (1) explore Jordanian adolescents' helpseeking intentions for depression and (2) examine whether depression stigma, depression severity, or their interaction are associated with Jordanian adolescents' willingness to seek help for depression and the type of treatment they would seek. In collaboration with the Jordanian Ministry of Education, we conducted a nationally representative, school-based survey of adolescents aged 12-17 years ( N = 2,349). One fourth of the adolescents reported they would not seek professional help for depression, and those respondents had higher average depression scores. Among those adolescents willing to seek help, the most likely sources included family member (57%), school counselor (46%), psychiatrist (43%), religious leader (39%), and general health practitioner (28%). Lower stigma scores were associated with greater likelihood to seek psychotherapy or visit a psychiatrist, while higher stigma scores were associated with increased likelihood to seek help from a school counselor or a family member. Jordanian adolescents experience significant barriers to seeking professional help for depression. However, even among adolescents with greater depression severity and depression stigma, school counselors were identified as a key resource for help. These findings suggest that school-based interventions may fill a critical service need for adolescents with depression and other mental health problems. School nurses should be leveraged along with counselors to address mental health issues in this vulnerable population.

The Effects of a Couples-Based Health Behavior Intervention During Pregnancy on Latino Couples' Dyadic Satisfaction Postpartum.

Many couples tend to report steadily decreasing relationship quality following the birth of a child. However, little is known about the postpartum period for Latino couples, a rapidly growing ethnic group who are notably underserved by mental and physical health caregivers in the United States. Thus, this study investigated whether a brief couples' intervention focused on helping couples support each other while increasing healthy behaviors might improve dyadic functioning postpartum. This study presents secondary analyses of data regarding couple functioning from a larger randomized controlled trial with 348 Latino couples to promote smoking cessation. Portions of the intervention taught the couple communication and problem-solving skills to increase healthy behavior. Couples participated in four face-to-face assessments across 1 year starting at the end of the first trimester. Latent growth curve analyses revealed that the treatment group reported an increase in relationship satisfaction and constructive communication after the intervention, which diminished by 1-year follow-up, returning couples to their baseline levels of satisfaction. Results suggest that incorporating a brief couple intervention as part of a larger health intervention for Latinos may prevent postpartum decreases in relationship satisfaction.

The prevalence of depressive symptoms among Arab adolescents: Findings from Jordan.

BACKGROUND: The lack of research regarding the current profile of adolescent depression in the Arab countries in general, and Jordan in particular, makes it difficult to design, implement, and disseminate effective interventions to improve the prevention, diagnosis, and treatment of adolescent depression in the region. The purpose of this study was to estimate a national prevalence of depressive symptoms among adolescents in Jordan, and to identify characteristics associated with severity of depression. METHODS: A descriptive, cross-sectional, nationally representative school survey was utilized. A total of 2,349 Jordanian adolescents aged 12-17 completed and returned the survey packets, which included the Beck Depression Inventory-II and measures of sociodemographics and health history. Participants represented all three regions in the country, with 34% from the northern (suburban) region, 43% from the central (urban) region, and 23% from the southern (rural) region. RESULTS: The majority of the adolescents were females (59%) and 15-17 years old (67%). Almost 14% reported having at least one chronic health problem, 15% reported having a mental health problem, 25% reported having academic difficulties, 8% reported that they had received a psychiatric diagnosis, and 22% reported that they had sought psychological help at some point in the past. The mean total depression score was 16.3 (SD = 11.2, 95% CI = 15.8-16.7), with 34% of the sample reporting moderate to severe depression. Depression was significantly higher among respondents who were female, ages 14-15 years, and living in families with low monthly incomes; and who reported having a chronic health problem, mental health problem, learning difficulty, a psychiatric diagnosis and/or seeking previous psychological help. CONCLUSIONS: Our findings should serve as an alarm, particularly given that rates of depression in the Arab countries are expected to increase rapidly in the context of the Arab Spring. Healthcare providers, researchers, and educators should focus attention on developing effective and culturally appropriate screening, prevention, and intervention approaches using evidence-based guidelines to promote Jordanian adolescent mental health, particularly for depression.

Adolescent Depression in Jordan: Symptoms Profile, Gender Differences, and the Role of Social Context.

The influence of gender and other individual and context characteristics on the prevalence and severity of depressive symptoms among Jordanian adolescents remains unclear. The aims of the current study were to: (a) characterize depressive symptoms profiles for Jordanian adolescents; and (b) examine gender differences in the type, severity, and correlates of depressive symptoms. Cross-sectional data were collected from 2,349 Jordanian adolescents ages 12 to 17 using a nationally representative school survey. The Beck Depression Inventory-II was used to assess the presence and severity of depressive symptoms. Female adolescents had significantly higher mean depression scores (17.9 [SD = 11.6], 95% confidence interval [CI] [17.3, 18.5]) than their male counterparts (13.8 [SD = 10.2], 95% CI [13.2, 14.5]). Approximately 41% of girls and 26% of boys reported scores indicating moderate to severe depression. Sex differences and socially constructed gender differences need to be adequately considered in the planning and delivery of mental health care for adolescent depression. If the risk for depression is gender-specific, prevention strategies cannot be gender-neutral. [Journal of Psychosocial Nursing and Mental Health Services, 56(2), 44-55.].

Collaborating with Public Housing Residents and Staff to Improve Health: A Mixed-Methods Analysis.

This study described the health behaviors and barriers and facilitators of those behaviors in elderly and/or disabled residents of public housing. A mixed-methods design was used. Residents (N = 88) completed a survey with validated measures of health behaviors. A sub-sample (N = 16) participated in three focus groups. Residents scored worse than population norms on the majority of behaviors measured. Qualitative results framed in an ecological model indicated the majority of facilitators and barriers to health behaviors were perceived as occurring at the intrapersonal and interpersonal levels. Interventions to promote health should consider the unique barriers and facilitators to health behaviors among residents.

Personal and Perceived Depression Stigma among Arab Adolescents: Associations with Depression Severity and Personal Characteristics.

BACKGROUND: In Arab communities, the selection, utilization, and attitudes towards mental health services are substantially affected by existing mental illness stigma. However, little is known about how the stigma of depression manifests among Arab adolescents, which makes it difficult to design, implement, and disseminate effective anti-stigma interventions for this vulnerable population. Therefore, the purpose of this study was to determine levels of depression stigma among Arab adolescents. The specific aims were to (1) describe the severity of personal and perceived depression stigma among Arab adolescents and its relationship to severity of depression, and (2) determine characteristics associated with severity of depression stigma among Arab adolescents. METHODS: This study was conducted in Jordan, a Middle Eastern Arab country. A nationally representative, school-based survey was utilized. A total of 2349 Jordanian adolescents aged 12-17 completed and returned the survey packets, which included measures on individual characteristics, depression severity, and depression stigma. RESULTS: The majority of the adolescents (88%) reported scores indicating moderate to high depression stigma. Adolescents reported higher rates of perceived stigma than personal stigma. Depression stigma was not significantly associated with severity of depression, but with adolescent's sex, age, region of residence, parents' education, and history of mental health problem. CONCLUSIONS: This is the first Arab study to isolate the influence of adolescent depression and personal characteristics on personal and perceived depression stigmas, and highlight the presence of these distinctions early in adolescence. Such distinction can inform the design and implementation of policies and interventions to reduce both personal and perceived stigma. The study provides important recommendations on when, how, and why to utilize school settings for anti-depression stigma interventions.