Leveraging National Data and Regional Innovations to Right-Size Tobacco Treatment Policy for Behavioral Health in a Midwestern State.

BACKGROUND: People with mental health (MH) and substance use disorders (SUD) have high rates of tobacco use and tobacco-related mortality. They want to stop smoking and studies have shown they can quit, but few behavioral health facilities provide tobacco treatment. The purpose of this paper is to describe how a midwestern statewide behavioral health collaboration used regional data to pinpoint strengths and weaknesses in tobacco treatment trends, identified policies in neighboring states that were associated with high rates of tobacco treatment, and worked with state leaders to implement these policies to enhance treatment. METHODS: We used publicly available data from 2 SAMHSA annual national surveys of MH/SUD facilities to describe tobacco treatment services and policies in behavioral health facilities in Kansas and 3 neighboring states (Missouri, Nebraska and Oklahoma). We interviewed neighboring state leaders to identify policies they had implemented to boost tobacco recovery services in behavioral health. We collaborated with our state behavioral health agency to encourage adoption of similar policies. RESULTS: Using 7 years of survey data (2014-2020), rates for screening, counseling, and medications for tobacco dependence were highest in Oklahoma and Missouri facilities. Oklahoma had the highest percentages of facilities reporting smoke-free campuses. In all states, rates of tobacco service provision and smoke-free campuses were lower among SUD facilities than in MH facilities. State leaders associated several policies with high performance, including (a) requiring programs contracting with the state to conduct screening, provide counseling, and adopt smoke-free campuses (Oklahoma and Missouri); (b) state-based collection of tobacco treatment service provision data (Oklahoma); (c) providing facilities with free NRT for clients (Oklahoma); (d) setting benchmarks for service provision (Oklahoma); (e) comprehensive Medicaid coverage of cessation medications (Missouri). Upon review of these findings, Kansas behavioral health officials adopted a 2-year process to implement similar policies and are integrating tobacco treatment requirements into the state Certified Community Behavioral Health Clinic program. CONCLUSIONS: Summarizing and sharing freely-available data across states laid the groundwork for cross-border networking and policy change. State and federal agencies should integrate these policies into contracts and block grants to reduce tobacco-related disparities among individuals with behavioral health conditions.

Maternal COVID vaccination and breastfeeding during a pandemic: Habitus and health behavior decision making.

OBJECTIVE: To examine the influence of habitus on women's health behavior regarding breastfeeding and subsequent COVID-19 vaccination. DESIGN: A qualitative descriptive design, guided by Pierre Bourdieu's concept of habitus. SAMPLE: Eighteen women who were postpartum, breastfeeding, and vaccinated against COVID- 19 either during pregnancy or while breastfeeding postpartum. MEASURES: Individual semi-structured interviews. RESULTS: Two major themes shaped participants' habitus: health-focused knowledge, and attitudes and beliefs. Attitudes and beliefs included five subthemes: (1) exposure/acceptance/expectations from family, (2) community acceptance of breastfeeding and COVID-19 vaccination, (3) socioeconomic status, (4) easily accessed support, and (5) outside experiences and exposure. DISCUSSION: An individual's habitus impacts one's knowledge, attitudes, and beliefs and interacts with past behaviors when discussing options for infant feeding and health promoting behaviors such as vaccinations. A better understanding of how health care providers assess and utilize habitus in clinical management is needed.

Components in tobacco-free school policies-A coding tool for assessment.

OBJECTIVE: To develop an instrument to examine tobacco-free campus policy components. PARTICIPANTS: Missouri two- and four-year, specialized/technical, and religious colleges and universities (N = 76). Methods: The instrument was informed via literature review and expert interviews. Coder agreement was strong (κ = .80). Qualitative policy language examples were identified. RESULTS: Model policy components including consideration for population, prohibited products, location restrictions, enforcement, consequences, promotions, communications, cessation, designated smoking areas and exemptions; comprehensive policies included all populations, for all tobacco products, and at all locations on the campus. Nineteen campuses had comprehensive tobacco-free policies, five had comprehensive smoke-free policies (cigarettes and e-cigarettes), and no policy included all model components. Fifty-two were non-comprehensive. CONCLUSIONS: This instrument can allow campuses to identify components for comprehensive and model tobacco-free campus policies and assist officials in improving policy language. Future research can use this instrument to examine the effectiveness of components and their impact on tobacco use outcomes.

Tobacco Control Policy Adoption Dynamics: A Case Study of Missouri Communities.

Tobacco control policies reduce the health and economic burden caused by tobacco. With over half of the United States communities lacking adequate protective policies, an examination of policy adoption factors can provide insights to facilitate policy adoption. A case study approach examines the rate of adoption, prominent media frames, policy leaders' perceptions and coalition activities for smokefree and Tobacco 21 policies adopted in Missouri. Findings show compared to smokefree policy, Tobacco 21 requires a considerably shorter timeframe and fewer resources for adoption. Tobacco 21 coalitions target a small group of stakeholders compared to smokefree coalitions' emphasis on broad community engagement. Both policies are formally opposed, but elected officials perceive less political risk supporting Tobacco 21. As a new tobacco control policy tool, Tobacco 21 has relative advantage that should be considered by community health advocates.

Can Smoke-Free Policies Reduce Tobacco Use Disparities of Sexual and Gender Minorities in Missouri?

OBJECTIVE: The purpose of this study is to explore the associations between smoke-free policies, current and former smoking status, personal smoking restrictions, and intention to quit among sexual and gender minority (SGM) and non-SGM individuals in Missouri. AIMS AND METHODS: The current analysis derives from the Out, Proud and Healthy project. Chi-squares examined differences between SGM (N = 2210) and non-SGM (N = 586) respondents and former (N = 836) and current (N = 1960) smokers on smoking-related variables. Odds ratios and 95% confidence intervals from logistic regression identified variables associated with former (vs. current) smoking. RESULTS: SGM current smokers (25%) were significantly more likely than SGM former smokers (19%) to live in a community without a smoke-free policy. Among SGM current smokers, significantly greater intention to quit was seen in those living in a smoke-free community with a smoke-free policy of two or more years (94%) compared with those living in a community without a smoke-free policy (76%). CONCLUSIONS: Living in an area with smoke-free policies is related to greater intention to quit among SGM current smokers, greater support for smoke-free policies, and lower smoking prevalence for this community. The SGM community may collectively accrue greater public health benefits from the adoption of smoke-free policies than the non-SGM community. IMPLICATIONS: Prior to this study, no data are available regarding current and former smoking status among SGM individuals following the implementation of a local smoke-free policy. The purpose of this study was to explore the relationship between smoke-free policies, current and former smoking status, and intention to quit among SGM and non-SGM individuals in Missouri. This study finds evidence of lower current smoking prevalence and greater intentions to quit among SGM current smokers who live in communities with smoke-free policies. The SGM community may collectively accrue greater public health benefits from the adoption of smoke-free policies than the non-SGM community.

A Persistent Disparity: Smoking in Rural Sexual and Gender Minorities.

PURPOSE: Sexual and gender minorities (SGM) smoke cigarettes at higher rates than the general population. Historically, research in SGM health issues was conducted in urban populations and recent population-based studies seldom have sufficient SGM participants to distinguish urban from rural. Given that rural populations also tend to have a smoking disparity, and that many SGM live in rural areas, it is vitally important to understand the intersection of rural residence, SGM identity, and smoking. This study analyzes the patterns of smoking in urban and rural SGM in a large sample. METHODS: We conducted an analysis of 4280 adult participants in the Out, Proud, and Healthy project with complete data on SGM status, smoking status, and zip code. Surveys were conducted at 6 Missouri Pride Festivals and online in 2012. Analysis involved descriptive and bivariate methods, and multivariable logistic regression. We used GIS mapping to demonstrate the dispersion of rural SGM participants. RESULTS: SGM had higher smoking proportion than the non-SGM recruited from these settings. In the multivariable model, SGM identity conferred 1.35 times the odds of being a current smoker when controlled for covariates. Rural residence was not independently significant, demonstrating the persistence of the smoking disparity in rural SGM. Mapping revealed widespread distribution of SGM in rural areas. CONCLUSION: The SGM smoking disparity persists among rural SGM. These communities would benefit from continued research into interventions targeting both SGM and rural tobacco control measures. Recruitment at Pride Festivals may provide a venue for reaching rural SGM for intervention.

Smoking and intention to quit among a large sample of black sexual and gender minorities.

The purpose of this study is to more completely quantify smoking and intention to quit from a sample of sexual and gender minority (SGM) Black individuals (N = 639) through analysis of data collected at Pride festivals and online. Frequencies described demographic characteristics; chi-square analyses were used to compare tobacco-related variables. Black SGM smokers were more likely to be trying to quit smoking than White SGM smokers. However, Black SGM individuals were less likely than White SGM individuals to become former smokers. The results of this study indicate that smoking behaviors may be heavily influenced by race after accounting for SGM status.

Smoking initiation, tobacco product use, and secondhand smoke exposure among general population and sexual minority youth, Missouri, 2011-2012.

INTRODUCTION: Research indicates disparities in risky health behaviors between heterosexual and sexual minority (referred to as LGBQ; also known as lesbian, gay, bisexual, queer, and questioning) youth. Limited data are available for tobacco-use-related behaviors beyond smoking status. We compared data on tobacco age of initiation, product use, and secondhand smoke exposure between general population and LGBQ youth. METHODS: Data for general population youth were from the statewide, representative 2011 Missouri Youth Tobacco Survey, and data for LGBQ youth were from the 2012 Out, Proud and Healthy survey (collected at Missouri Pride Festivals). Age-adjusted Cochran-Mantel-Haenszel tests were used to examine differences between general population (N = 1,547) and LGBQ (N = 410) youth, aged 14 to 18 years. Logistic regression models identified variables associated with current smoking. RESULTS: The 2 groups differed significantly on many tobacco-use-related factors. General population youth initiated smoking at a younger age, and LGBQ youth did not catch up in smoking initiation until age 15 or 16. LGBQ youth (41.0%) soon surpassed general population youth (11.2%) in initiation and proportion of current smokers. LGBQ youth were more likely to use cigars/cigarillos, be poly-tobacco users, and be exposed to secondhand smoke (SHS) in a vehicle (for never smokers). Older age (odds ratio [OR] = 1.39, 95% confidence interval [95% CI] = 1.18-1.62), female sex (OR = 1.64, 95% CI = 1.13-2.37), LGBQ identity (OR = 3.86, 95% CI = 2.50-5.94), other tobacco product use (OR = 8.67, 95% CI = 6.01-12.51), and SHS exposure in a vehicle (OR = 5.97, 95% CI = 3.83-9.31) all significantly increased the odds of being a current smoker. CONCLUSION: This study highlights a need for the collection of data on sexual orientation on youth tobacco surveys to address health disparities among LGBQ youth.

Unique perspectives of women and their partners using the Prenatal Psychosocial Profile Scale.

AIM: This paper is a report of a study to examine the underlying factors of the Prenatal Psychosocial Profile as a composite measure of stress, support from partner, support from others and self-esteem; and compares factor structures between pregnant women and men. BACKGROUND: In order to promote positive pregnancy outcomes, addressing unique differences in psychosocial factors between women and men is important. There is very little information or data directly collected from both groups. METHODS: As part of a larger smoking cessation study during pregnancy, a sample of 66 low-income couples (n =132) living in rural Missouri--the Midwestern region of the United States of America--was selected between 2006 and 2008. Principal component analysis was used to evaluate the factor structure of the composite measure. RESULTS: Similarities and unique differences in the Prenatal Psychosocial Profile subscales between the two groups were found. For the stress subscale, 'problems related to family', 'the current pregnancy' and 'feeling generally overloaded' loaded as financial stressors for men but as emotional stressors for women. For the partner support subscale, women perceived they were receiving more tangible support from their partners whereas men perceived receiving more emotional support. The support from others subscale was similar for both partners. The self-worth factor explained more of the variance in self-esteem among pregnant women, while the self-criticism factor explained more of the variance among men. CONCLUSION: Assessment of psychosocial well-being in both women and men during pregnancy, especially careful assessment of stressors of pregnancy should be part of nursing practice.

An examination of smoking behavior and opinions about smoke-free environments in a large sample of sexual and gender minority community members.

INTRODUCTION: The purpose of this study is to more completely quantify smoking rate and support for smoke-free policies in private and public environments from a large sample of self-identified sexual and gender minority (SGM) populations. METHODS: A targeted sampling strategy recruited participants from 4 Missouri Pride Festivals and online surveys targeted to SGM populations during the summer of 2008. A 24-item survey gathered information on gender and sexual orientation, smoking status, and questions assessing behaviors and preferences related to smoke-free policies. RESULTS: The project recruited participants through Pride Festivals (n = 2,676) and Web-based surveys (n = 231) representing numerous sexual and gender orientations and the racial composite of the state of Missouri. Differences were found between the Pride Festivals sample and the Web-based sample, including smoking rates, with current smoking for the Web-based sample (22%) significantly less than the Pride Festivals sample (37%; p < .0001). The SGM group (n = 2,162) was 1.49 times more likely to be current smokers compared with the study's heterosexual group (n = 436; p = .005). Statistically fewer SGM racial minorities (33%) are current smokers compared with SGM Whites (37%; p = .04). Support and preferences for public and private smoke-free environments were generally low in the SGM population. CONCLUSIONS: The strategic targeting method achieved a large and diverse sample. The findings of high rates of smoking coupled with generally low levels of support for smoke-free public policies in the SGM community highlight the need for additional research to inform programmatic attempts to reduce tobacco use and increase support for smoke-free environments.

Baby BEEP: A randomized controlled trial of nurses' individualized social support for poor rural pregnant smokers.

OBJECTIVES: We tested the effect of nurse-delivered telephone individualized social support ("Baby BEEP") and eight mailed prenatal smoking cessation booklets singly and in combination (2 x 2 factorial design) on smoking cessation in low-income rural pregnant women (N = 695; 75% participation). METHODS: Participants randomized to Baby BEEP groups (n = 345) received weekly calls throughout pregnancy plus 24-7 beeper access. Saliva cotinine samples were collected monthly from all groups by other nurses at home visits up to 6 weeks post-delivery. Primary outcomes were point prevalence abstinence (cotinine < 30 ng/ml) in late pregnancy and post-delivery. RESULTS: Only 47 women were lost to follow-up. Intent-to-treat analyses showed no difference across intervention groups (17-22%, late pregnancy; 11-13.5%, postpartum), and no difference from the controls (17%, late pregnancy; 13%, postpartum). Post hoc analyses of study completers suggested a four percentage-point advantage for the intervention groups over controls in producing early and mid-pregnancy continuous abstainers. Partner smoking had no effect on late pregnancy abstinence (OR = 1.7, 95% CI = 0.95, 3.2), but post-delivery, the effect was pronounced (OR = 3.2, 95% CI = 1.8, 5.9). CONCLUSIONS: High abstinence rates in the controls indicate the power of biologic monitoring and home visits to assess stress, support, depression, and intimate partner violence; these elements plus booklets were as effective as more intensive interventions. Targeting partners who smoke is needed.

Rural mothers experiencing the stress of intimate partner violence or not: their newborn health concerns.

Pregnancy and the postpartum period is a time of great physical, psychological, and emotional upheaval. Women who experience intimate partner violence experience more depression and anxiety and a higher risk of adverse pregnancy outcomes (such as those related to the abuse). While the literature supports the presence of increased health care utilization for abused women, there is little information on the way that these mothers seek medical care for their infants. This secondary analysis is part of a larger study on smoking cessation in low-income, rural pregnant women called Baby Behavioral Education Enhancement of Pregnancy (Baby BEEP). Women (N = 616) were classified as abused or not abused based on their answers to the Abuse Assessment Screen. At 6 weeks postdelivery, each woman was asked, "Has your baby had any problems that you talked to the doctor or nurse about?" The abused women (n = 211) sought health care advice significantly more often than the nonabused women (n = 405; Pearson chi(2) = 4.89; P = .027). Stress scores were elevated for all women in the study, but women categorized as abused experienced significantly more stress (P < .001).

A review of research literature addressing male partners and smoking during pregnancy.

OBJECTIVE: To gain a more complete understanding of cigarette smoking and cessation during pregnancy by examining the men's role in supporting smoking cessation of their pregnant partners. DATA SOURCES: A search of online data included CINAHL, Medline, and PsychLit databases. STUDY SELECTION: Studies published in the last 10 years, in English language, included three phenomena: pregnancy, male partners, and cigarette smoking. DATA EXTRACTION: Data were identified and organized according to theoretical, descriptive, and intervention methods of research. DATA SYNTHESIS: A growing body of literature indicates an interaction between pregnancy, male partners, and smoking behaviors. Explicating relationships between these phenomena is necessary for understanding and encouraging behaviors that promote maternal, child, and family health. CONCLUSIONS: Current research that includes the phenomena of pregnancy, male partners, and smoking behaviors highlights a need to further investigate the potential relationships, interactions, and health consequences of smoking behaviors of men and women during pregnancy.

Men's tobacco and alcohol use during and after pregnancy.

Men's health risk behaviors are rarely considered as a component of their partners' prenatal care. Men living with a pregnant partner completed telephone surveys at two time points, during pregnancy and postpartum, answering questions about tobacco and alcohol use behaviors and other sociodemographic variables. Men's smoking did not change significantly from pregnancy (46.9%) to postpartum (45.8%). Hazardous drinking (five or more drinks/day in a month) changed from 27.1% to 22.9%. Nonsmoking status of men was significantly related to a pregnant partner's quitting smoking during pregnancy and remaining quit at postpartum (p = .019). Household prohibitions from indoor smoking increased from 62.5% at pregnancy to 76% postpartum (p = .009). Pregnancy alone does not appear sufficient for men to quit smoking or change hazardous drinking. Continued exclusion of young men during prenatal care is a missed opportunity to address health risk behaviors and improve paternal, maternal, and family health.

Health risk behavior of rural low-income expectant fathers.

OBJECTIVE: To assess expectant fathers' health risk behaviors and attitudes about pregnancy-related health issues. Pregnancy may be viewed as a teachable moment: a time when women are receptive to health advice and take action to improve their health and the health of their babies. Pregnancy may also be a teachable moment for expectant fathers, although men's behaviors are rarely considered as part of prenatal care or in associated research. DESIGN: Cross-sectional prevalence study. SAMPLE: Rural low-income expectant fathers (N=138) whose pregnant partners had enrolled in a Medicaid managed care health plan. MEASUREMENT: A telephone survey measuring five health risk behaviors, sociodemographic variables, and pregnancy- and behavior change-related attitudes. RESULTS: Analyses found the following: 49.3% smoked cigarettes; 30.4% engaged in hazardous drinking in the past month; 27.5% had very low physical activity levels; 94.9% had at-risk fruit/vegetable intake; and 42% had weight-related health risk (25.4% met body mass index [BMI] criteria for obesity). Further, 47.9% of the men engaged in three or more of five assessed health risk behaviors. CONCLUSIONS: This sample of expectant fathers engages in high rates of health risk behaviors. Failure to address the health risk behavior of men during prenatal care represents a missed opportunity to improve paternal, maternal, and family health.

Characteristics of smoking cessation guideline use by primary care physicians.

This study, based on a random sample mail survey of Missouri primary care physicians, identifies: (1) the extent and predictors of these physicians' awareness, agreement, adoption, and adherence to tobacco cessation guidelines; and (2) their knowledge/ beliefs about tobacco interventions. While primary care physicians play a key role in helping patients quit smoking, guidelines are not widely followed. "Reliance on respected colleagues for advice" was the one variable consistently identified as a predictor of guideline compliance.

Addressing the insidious health and financial burden of tobacco use in Missouri: the role of medical and public health professionals.

Despite the widespread knowledge that tobacco use causes death and debilitating disease, tobacco control efforts in Missouri remain inadequate. No other health issue combines the prevalence, lethality, and neglect of tobacco addiction. This paper discusses comprehensive tobacco-use prevention and cessation programs that could, if implemented, effectively reduce tobacco-related health problems. Successful tobacco control efforts change society by creating an environment in which nonsmoking is the norm and quitting smoking is supported. This paper concludes that it is time for medicine and public health professionals to communicate, collaborate, and assume leadership in reducing the health burden of tobacco use in Missouri.

Integrative review of parenting in nursing research.

PURPOSE: To synthesize and critically analyze parenting research in nursing. DESIGN: Qualitative, integrative review of nursing research studies about parenting 1993-2004. METHODS: Studies published by nurse researchers in peer-reviewed journals were systematically searched using CINAHL and Medline databases. Data were organized and analyzed with a sample of 17 nursing research studies from core nursing journals. FINDINGS: The majority of parenting research has been focused on mothers, primarily about parenting children with physical or developmental disabilities. Research about fathers as parents is sparse. Parenting across cultures, parenting in the context of family, and theoretical frameworks for parenting research are not well developed. CONCLUSIONS: The scope of nursing research on parenting is limited. The roles, functions, and contexts of parenting are not well defined. Further research is required to describe parenting and how parenting affects the health of individuals and families.

A pilot study of smoking and associated behaviors of low-income expectant fathers.

Pregnancy is considered a teachable moment for helping women who smoke to quit, yet few studies have examined smoking behavior of expectant fathers. The present study considers the possibility that pregnancy is a teachable moment for expectant fathers as well and describes smoking and associated behaviors of men during their partner's pregnancy. Participants were 138 low-income men living with their pregnant partners. Using telephone interviews, we found 63% of the men had smoked at least 100 cigarettes in their lifetime. Current smoking was reported by 49.3% of expectant fathers (39.1% daily smoking; 10.2% some days). Expectant fathers' current smoking was associated with having a lower level of education (p<.0001), pregnant partner being a current smoker (p=.0002), higher quantity of alcohol consumption per day of drinking (p=.0003), and absence of smoking prohibitions inside the home (p<.0001). In the past year, 70.1% of the current smokers tried to quit. We found high rates of smoking in low-income expectant fathers, and an expectant father's smoking during his partner's pregnancy was associated with his pregnant partner continuing to smoke. A majority of expectant fathers identified as current smokers tried to quit in the past year or indicated an intention to quit in the near future. Intervention during pregnancy that targets pregnant women and expectant fathers who smoke could lead to more households without tobacco use and thus have positive implications for paternal, maternal, and family health. Further clinical and research attention is needed to address the smoking behaviors of both expectant fathers and their pregnant partners.