Teachers' dissatisfaction during the COVID-19 pandemic: Factors contributing to a desire to leave the profession.

Introduction: The COVID-19 pandemic required more responsibilities from teachers, including implementing prevention strategies, changes in school policies, and managing their own mental health, which yielded higher dissatisfaction in the field. Methods: A cross-sectional web survey was conducted among educators to collect information on their experiences teaching during the COVID-19 pandemic throughout the 2020-2021 academic year. Qualtrics, an online survey platform, fielded the survey from May 6 to June 8, 2021 to a national, convenience sample of 1,807 respondents. Results: Findings revealed that overall, 43% of K-12 teachers reported a greater intention to leave the profession than previously recalled prior to the COVID-19 pandemic. Intention to leave was multi-level, and associated with socio-demographic factors (e.g., age: AOR = 1.87, p < 0.05), individual factors (e.g., perceived COVID risks: AOR = 1.44, p < 0.05), and teachers' agency (e.g., dissatisfaction with school/district communications and decisions: AOR = 1.34, p < 0.05). We also found demographic disparities with respect to race and gender (e.g., female teachers: AOR: 1.78, p < 0.05) around teachers' ability to provide feedback to schools on opening/closing and overall dissatisfaction with school/district COVID-19 prevention strategies implementation and policies. Conclusion: These findings are consistent with the Job-Demand and Resources Model (JD-R), which posits that lack of organizational support can exacerbate job stressors, leading to burnout. Specifically, dissatisfaction with the way school policies were implemented took a toll on teachers' mental health, leading to a desire to leave the profession. These findings are also consistent with research conducted once in-person teaching resumed in 2020-2021, specifically that the COVID-19 pandemic exacerbated preexisting teacher shortages that led to self-reported issues of stress, burnout, and retention. Implications: Further research is necessary to understand the resources that may be most useful to reduce the demands of teaching in the context of the COVID-19 pandemic. Some teachers are more likely to leave the field, and educational agencies may wish to target their teacher-retention efforts with emphasis on strong employee wellness programs that help educators to manage and reduce their stress. Education agency staff may wish to review policies and practices to provide meaningful opportunities to give input to school/district decisions and enable proactive communication channels.

Receipt of Cessation Treatments Among Medicaid Enrollees Trying to Quit Smoking.

INTRODUCTION: Cigarette smoking prevalence is higher among adults enrolled in Medicaid than adults with private health insurance. State Medicaid coverage of cessation treatments has been gradually improving in recent years; however, the extent to which this has translated into increased use of these treatments by Medicaid enrollees remains unknown. AIMS AND METHODS: Using Medicaid Analytic eXtract (MAX) files, we estimated state-level receipt of smoking cessation treatments and associated spending among Medicaid fee-for service (FFS) enrollees who try to quit. MAX data are the only national person-level data set available for the Medicaid program. We used the most recent MAX data available for each state and the District of Columbia (ranging from 2010 to 2014) for this analysis. RESULTS: Among the 37 states with data, an average of 9.4% of FFS Medicaid smokers with a past-year quit attempt had claims for cessation medications, ranging from 0.2% (Arkansas) to 32.9% (Minnesota). Among the 20 states with data, an average of 2.7% of FFS Medicaid smokers with a past-year quit attempt received cessation counseling, ranging from 0.1% (Florida) to 5.6% (Missouri). Estimated Medicaid spending for cessation medications and counseling for these states totaled just over $13 million. If all Medicaid smokers who tried to quit were to have claims for cessation medications, projected annual Medicaid expenditures would total $0.8 billion, a small fraction of the amount ($45.9 billion) that Medicaid spends annually on treating smoking-related disease. CONCLUSIONS: The receipt of cessation medications and counseling among FFS Medicaid enrollees was low and varied widely across states. IMPLICATIONS: Few studies have examined use of cessation treatments among Medicaid enrollees. We found that many FFS Medicaid smokers made quit attempts, but few had claims for proven cessation treatments, especially counseling. The receipt of cessation treatments among FFS Medicaid enrollees varied widely across states, suggesting opportunities for additional promotion of the full range of Medicaid cessation benefits. Continued monitoring of Medicaid enrollees' use of cessation treatments could inform state and national efforts to help more Medicaid enrollees quit smoking.

Cigarette and cigar sales in Hawaii before and after implementation of a Tobacco 21 Law.

INTRODUCTION: On 1 January 2016, Hawaii raised the minimum legal age for tobacco access from 18 to 21 years ('Tobacco 21 (T21)') statewide, with no special population exemptions. We assessed the impact of Hawaii's T21 policy on sales of cigarettes and large cigars/cigarillos in civilian food stores, including menthol/flavoured product sales share. METHODS: Cigarette and large cigar/cigarillo sales and menthol/flavoured sales share were assessed in Hawaii, California (implemented T21 in June 2016 with a military exemption), and the US mainland using the only Nielsen data consistently available for each geographical area. Approximate monthly sales data from large-scale food stores with sales greater than US$2 million/year covered June 2012 to February 2017. Segmented regression analyses estimated changes in sales from prepolicy to postpolicy implementation periods. RESULTS: Following T21 in Hawaii, average monthly cigarette unit sales dropped significantly (-4.4%, p<0.01) coupled with a significant decrease in menthol market share (-0.8, p<0.01). This combination of effects was not observed in comparison areas. Unit sales of large cigars/cigarillos decreased significantly in each region following T21 implementation. T21 policies in Hawaii and California showed no association with flavoured/menthol cigar sales share, but there was a significant increase in flavoured/menthol cigar sales share in the USA (7.1%, p<0.01) relative to Hawaii's implementation date, suggesting T21 may have attenuated an otherwise upward trend. CONCLUSIONS: As part of a comprehensive approach to prevent or delay tobacco use initiation, T21 laws may help to reduce sales of cigarette and large cigar products most preferred by US youth and young adults.

E-cigarette susceptibility among U.S. middle and high school students: National Youth Tobacco Survey Data Trend Analysis, 2014-2018.

Youth e-cigarette use has rapidly increased in the last few years. Susceptibility is a validated measure associated with future tobacco use. We examined trends in e-cigarette susceptibility across five years (2014-2018) of the National Youth Tobacco Survey among youth e-cigarette never users. We observed increases in overall e-cigarette susceptibility from 2014 to 2016 and decreases from 2016 to 2018. Generally, sociodemographic variables were not associated with trend effects; however, there was an interaction between linear trends with both race/ethnicity and other tobacco product (OTP) use. The percentage of youth who were susceptible to using e-cigarettes ranged from 32.9% in 2014 to 33.2% in 2018 with a high of 36.7% in 2016. We also examined the prevalence of e-cigarette susceptibility by race/ethnicity, sex, school level, OTP use, and e-cigarette harm perception. E-cigarette susceptibility was associated with race, school level, OTP ever use, and e-cigarette harm perceptions. Hispanic youth, those in high school, and OTP ever users were more likely to be susceptible to e-cigarette use compared to their counterparts across all years. E-cigarette susceptibility was most prevalent among those who perceived e-cigarettes to pose "no harm" in 2014 and "little harm" in 2018 when compared to other item response options in 2014 and 2018, respectively. This study is the first to document trends in e-cigarette susceptibility among youth. Understanding antecedents of e-cigarette use and identifying youth subgroups vulnerable to e-cigarette use is valuable to developing effective prevention efforts. Disclaimer: The findings and conclusions in this publication are those of the authors and do not necessarily represent the official position of the Food and Drug Administration or the Centers for Disease Control and Prevention.

Adults' attitudes toward raising the minimum age of sale for tobacco products to 21 years, United States, 2014-2017.

Raising the minimum age of sale for tobacco products to 21 years (Tobacco 21) could help prevent and delay tobacco product initiation among youth. This study examined changes in U.S. adults' attitudes toward Tobacco 21 policies during 2014-2017. Data came from the 2014-2017 annual Summer Styles surveys, an Internet-based, cross-sectional survey of U.S. adults aged ≥18 years, drawn from GfK's KnowledgePanel®. Sample sizes ranged from 4107 in 2017 to 4269 in 2014. Each year, respondents were asked if they "strongly favor," "somewhat favor," "somewhat oppose," or "strongly oppose" Tobacco 21 policies. Weighted prevalence estimates of favorability (strongly or somewhat favor) were assessed each year; differences in favorability between years were assessed by chi square tests. Adjusted odds ratios (aOR) of favorability with 95% confidence intervals (CI) were calculated using logistic regression for the year 2017. Tobacco 21 policy favorability was reported by 75.0% in 2014; 72.3% in 2015; 78.4% in 2016; and 75.2% in 2017; the difference in favorability between 2014 and 2017 was not statistically significant. In 2017, lower odds of favorability toward Tobacco 21 policies were observed for current (aOR = 0.49, CI = 0.37-0.64) and former (aOR = 0.54, CI = 0.44-0.66) cigarette smokers, and current other tobacco product users (aOR = 0.54, CI = 0.49-0.64) than respective nonusers. Among U.S. adults, Tobacco 21 favorability has remained high since 2014, coinciding with a period of rapid state and local-level policy adoption. These results could be helpful for states and localities as they work to understand the feasibility of Tobacco 21 policies in their jurisdiction.

Associations between public e-cigarette use and tobacco-related social norms among youth.

IMPORTANCE: E-cigarette use in public places may renormalise tobacco use. OBJECTIVE: To measure associations between e-cigarette use in public places and social norms among youth. DESIGN: Cross-sectional survey. SETTING: School-based. PARTICIPANTS: 24 353 never tobacco users in US 6th-12th grades who completed the 2016-2017 National Youth Tobacco Surveys. EXPOSURE: Individuals were classified as exposed in public places within the past 30 days to: (1) neither e-cigarette secondhand aerosol (SHA) nor combustible tobacco secondhand smoke (SHS); (2) SHA only; (3) SHS only; and (4) both SHA and SHS. OUTCOMES: Outcomes were overestimation of peer e-cigarette use (a measure of descriptive norms), harm perception and susceptibility. Data were analysed using descriptive statistics and logistic regression (p<0.05). RESULTS: Overall prevalence of SHS and SHA exposure in public places was 46.6% and 18.3%, respectively. SHA exposure in public places was associated with increased odds of overestimating peer e-cigarette use (adjusted OR (AOR): 1.83; 95% CI 1.29 to 2.58) and decreased odds of perceiving e-cigarettes as harmful (AOR: 0.63; 95% CI 0.51 to 0.79), compared with those exposed to neither emission. SHA exposure in public places was also associated with increased susceptibility to using e-cigarettes (AOR: 2.26; 95% CI 1.82 to 2.81) and cigarettes (AOR: 1.51; 95% CI 1.20 to 1.90). E-cigarette harm perception was lower among students in jurisdictions with no comprehensive clean indoor air laws (AOR: 0.79; 95% CI 0.71 to 0.88) or cigarette-only laws (AOR: 0.88; 95% CI 0.78 to 0.99) than in those prohibiting both cigarette and e-cigarette use in public places. CONCLUSIONS: Prohibiting both e-cigarette and cigarette use in public places could benefit public health.

Assessing the implementation of a patient navigation intervention for colonoscopy screening.

BACKGROUND: A recent study demonstrated the effectiveness of the New Hampshire Colorectal Cancer Screening Program's (NHCRCSP) patient navigation (PN) program. The PN intervention was delivered by telephone with navigators following a rigorous, six-topic protocol to support low-income patients to complete colonoscopy screening. We applied the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework to examine implementation processes and consider potential scalability of this intervention. METHODS: A mixed-methods evaluation study was conducted including 1) a quasi-experimental, retrospective, comparison group study examining program effectiveness, 2) secondary analysis of NHCRCSP program data, and 3) a case study. Data for all navigated patients scheduled and notified of their colonoscopy test date between July 1, 2012 and September 30, 2013 (N = 443) were analyzed. Researchers were provided in-depth call details for 50 patients randomly selected from the group of 443. The case study included review of program documents, observations of navigators, and interviews with 27 individuals including staff, patients, and other stakeholders. RESULTS: Program reach was state-wide, with navigators serving patients from across the state. The program successfully recruited patients from the intended priority population who met the established age, income, and insurance eligibility guidelines. Analysis of the 443 NHCRCSP patients navigated during the study period demonstrated effectiveness with 97.3% completing colonoscopy, zero missed appointments (no-shows), and 0.7% late cancellations. Trained and supervised nurse navigators spent an average of 124.3 min delivering the six-topic PN protocol to patients. Navigators benefited from a real-time data system that allowed for patient tracking, communication across team members, and documentation of service delivery. Evaluators identified several factors supporting program maintenance including consistent funding support from CDC, a strong program infrastructure, and partnerships. CONCLUSIONS: Factors supporting implementation included funding for colonoscopies, use of registered nurses, a clinical champion, strong partnerships with primary care and endoscopy sites, fidelity to the PN protocol, significant intervention dose, and a real-time data system. Further study is needed to assess scalability to other locations.

Association of Peer Influence and Access to Tobacco Products With U.S. Youths' Support of Tobacco 21 Laws, 2015.

PURPOSE: Tobacco 21 (T21) is a population-based strategy to prevent tobacco initiation. A majority of U.S. youths support T21; however, the extent to which individual, interpersonal, and community factors influence T21 support is uncertain. This study explored predictors of T21 support among U.S. youth. METHODS: We analyzed data from the 2015 National Youth Tobacco Survey (n = 17,683) to assess the association of peer influence and access to tobacco products on T21 support. We used multivariable logistic regression to calculate adjusted odds ratios (aORs) with 95% confidence intervals for T21 support. For tobacco nonusers, the model included peer influence along with covariates including sex, age, race/ethnicity, household tobacco use, and perceived harm. For tobacco users, the model included tobacco access sources (direct purchase, social sources, and other means), the aforementioned covariates, and tobacco product type. RESULTS: Among nonusers, students least receptive to peer influence (aOR = 2.5), those youngest in age (11-14 years, aOR = 2.3), and those who believe tobacco is dangerous (aOR = 2.5) had higher odds of T21 support. Among users, lower odds of T21 support were observed among those who purchased tobacco (aOR = .3) and accessed tobacco through social sources (aOR = .7) or other means (aOR = .6) in the past 30 days. Younger tobacco users (11-14 years, aOR = 2.2), black, non-Hispanic users (aOR = 3.8), e-cigarette users (aOR = 2.5), and users who believe that tobacco is dangerous (aOR = 2.8) had higher odds of T21 support. CONCLUSIONS: Low receptivity to peer influence and lack of access to tobacco products are associated with T21 support. Results underscore that T21 implementation may require a social-ecological approach.

Smoking cessation attitudes and practices among cancer survivors - United States, 2015.

PURPOSE: The prevalence of smoking among cancer survivors is similar to the general population. However, there is little evidence on the prevalence of specific smoking cessation behaviors among adult cancer survivors. METHODS: The 2015 National Health Interview Survey (NHIS) data were analyzed to examine the prevalence of smoking cessation behaviors and use of treatments among cancer survivors. Weighted self-reported prevalence estimates and 95% confidence intervals were calculated using a sample of 2527 cancer survivors. RESULTS: Among this sample of US cancer survivors, 12% were current smokers, 37% were former smokers, and 51% were never smokers. Compared with former and never smokers, current smokers were younger (< 65 years), less educated, and less likely to report being insured or Medicaid health insurance (p < 0.01). More males were former smokers than current or never smokers. Current smokers reported wanting to quit (57%), a past year quit attempt (49%), or a health professional advised them to quit (66%). Current smokers reported the use of smoking cessation counseling (8%) or medication (38%). CONCLUSIONS: Even after a cancer diagnosis, about one in eight cancer survivors continued to smoke. All could have received advice to quit smoking by a health professional, but a third did not. IMPLICATIONS FOR CANCER SURVIVORS: Health professionals could consistently advise cancer survivors about the increased risks associated with continued smoking, provide them with cessation counseling and medications, refer them to other free cessation resources, and inform them of cessation treatments covered by their health insurance.

Discordance between perceived and actual tobacco product use prevalence among US youth: a comparative analysis of electronic and regular cigarettes.

IMPORTANCE: Two components of social norms-descriptive (estimated prevalence) and injunctive (perceived acceptability)-can influence youth tobacco use. OBJECTIVE: To investigate electronic cigarettes (e-cigarette) and cigarette descriptive norms and measure the associations between overestimation of e-cigarette and cigarette prevalence and tobacco-related attitudes and behaviours. DESIGN: Cross-sectional. SETTING: School-based, using paper-and-pencil questionnaires. PARTICIPANTS: US 6th-12th graders participating in the 2015 (n=17 711) and 2016 (n=20 675) National Youth Tobacco Survey. EXPOSURE: Students estimated the percent of their grade-mates who they thought used e-cigarettes and cigarettes; the discordance between perceived versus grade-specific actual prevalence was used to categorise students as overestimating (1) neither product, (2) e-cigarettes only, (3) cigarettes only or (4) both products. OUTCOMES: Product-specific outcomes were curiosity and susceptibility (never users), as well as ever and current use (all students). Descriptive and multivariable logistic regression analyses were performed. Statistical significance was at P<0.05. Data were weighted to be nationally representative. RESULTS: More students overestimated cigarette (74.0%) than e-cigarette prevalence (61.0%; P<0.05). However, the associations between e-cigarette-only overestimation and e-cigarette curiosity (adjusted OR (AOR)=3.29), susceptibility (AOR=2.59), ever use (AOR=5.86) and current use (AOR=8.15) were each significantly larger than the corresponding associations between cigarette-only overestimation and cigarette curiosity (AOR=1.50), susceptibility (AOR=1.54), ever use (AOR=2.04) and current use (AOR=2.52). Despite significant declines in actual e-cigarette use prevalence within each high school grade level during 2015-2016, perceived prevalence increased (11th and 12th grades) or remained unchanged (9th and 10th grades). CONCLUSIONS: Four of five US students overestimated peer e-cigarette or cigarette use. Counter-tobacco mass media messages can help denormalise tobacco use.

Social Aspects of Hookah Smoking Among US Youth.

: media-1vid110.1542/5789657771001PEDS-VA_2018-0341Video Abstract BACKGROUND: We investigated 3 social dimensions of youth hookah smoking: frequency, places smoked, and descriptive social norms. METHODS: Data were from the 2016 National Youth Tobacco Survey of US sixth- to 12th-graders (n = 20 675). Hookah smoking frequency was classified as never, former, current occasional, and current frequent. Places where past 30-day hookah smoking occurred and students' perceptions of their classmates' hookah smoking prevalence were assessed. Descriptive and multivariable analyses were performed (P < .05). RESULTS: Overall, 10.5% reported smoking hookah ≥1 time in their lifetime. Of these, 65.8% were former, 26.3% were current occasional, and 7.9% were current frequent smokers. Overall, 59.3% of students overestimated hookah smoking prevalence in their grade. Current occasional smoking was predicted by female sex (adjusted odds ratio [aOR] = 1.54) and peer hookah-smoking overestimation (aOR = 9.30). Current frequent smoking was most strongly predicted by living with a hookah smoker (aOR = 20.56), speaking a second language other than English (aOR = 2.17), and co-use of mentholated cigarettes (aOR = 19.94) or other flavored noncigarette tobacco products (aOR = 17.59). The top 3 places hookah was smoked were a friend's house (47.7%), the respondent's own house (31.8%), and another family member's house (20.8%). CONCLUSIONS: The home environment was the most common place for youth hookah smoking. Home-tailored interventions that encourage voluntary smoke-free rules and warn about the dangers of social smoking could help denormalize hookah smoking.

Association Between Media Doses of the Tips From Former Smokers Campaign and Cessation Behaviors and Intentions to Quit Among Cigarette Smokers, 2012-2015.

BACKGROUND: Since 2012, the Centers for Disease Control and Prevention (CDC) has implemented Tips From Former Smokers ( Tips), the first federally funded tobacco education campaign in the United States. To date, there are no evaluations of its long-term impact. AIMS: To assess the impact of varied doses of the Tips campaign from 2012 through 2015 on cessation-related behaviors and intentions among U.S. smokers. METHOD: We used a national probability-based online survey of cigarette smokers ( n = 22,189) and recent quitters ( n = 776) to examine associations between doses of Tips advertising, measured by gross rating points (GRPs), and intentions to quit smoking in the next 30 days and quit attempts within the past 3 months. A curvilinear (i.e., square root) functional form of GRPs was used to capture patterns of diminishing effects at higher GRP levels. RESULTS: An increase of 1,000 quarterly Tips GRPs at the media market level was associated with increased odds of making a quit attempt in the past 3 months (adjusted odds ratio = 1.23, p < .001) and increased odds of intending to quit in the next 30 days (adjusted odds ratio = 1.17, p = .030). DISCUSSION: Results suggest that CDC-recommended media buys of 800 to 1,000 GRPs per quarter are sufficient to generate statistically significant increases in the likelihood of quit attempts in the past quarter. CONCLUSIONS: The Tips campaign has had a substantial impact on cessation behaviors among U.S. adult smokers over time. These data support the continued use of graphic and/or emotional media campaigns that encourage smokers to quit to further reduce tobacco use in the United States.

Increasing colonoscopy screening in disparate populations: Results from an evaluation of patient navigation in the New Hampshire Colorectal Cancer Screening Program.

BACKGROUND: To investigate uniformly successful results from a statewide program of patient navigation (PN) for colonoscopy, this comparison study evaluated the effectiveness of the PN intervention by comparing outcomes for navigated versus non-navigated patients in one of the community health clinics included in the statewide program. Outcomes measured included screening completion, adequacy of bowel preparation, missed appointments and cancellations, communication of test results, and consistency of follow-up recommendations with clinical guidelines. METHODS: The authors compared a subset of 131 patients who were navigated to a screening or surveillance colonoscopy with a similar subset of 75 non-navigated patients at one endoscopy clinic. The prevalence and prevalence odds ratios were computed to measure the association between PN and each study outcome measure. RESULTS: Patients in the PN intervention group were 11.2 times more likely to complete colonoscopy than control patients (96.2% vs 69.3%; P<.001), and were 5.9 times more likely to have adequate bowel preparation (P =.010). In addition, intervention patients had no missed appointments compared with 15.6% of control patients, and were 24.8 times more likely to not have a cancellation <24 hours before their appointment (P<.001). All navigated patients and their primary care providers received test results, and all follow-up recommendations were consistent with clinical guidelines compared with 82.4% of patients in the control group (P<.001). CONCLUSIONS: PN appears to be effective for improving colonoscopy screening completion and quality in the disparate populations most in need of intervention. To the best of our knowledge, the results of the current study demonstrate some of the strongest evidence for the effectiveness of PN to date, and highlight its value for public health. Cancer 2017;123:3356-66. © 2017 American Cancer Society.

Tobacco Advertising and Promotional Expenditures in Sports and Sporting Events - United States, 1992-2013.

Smokeless tobacco has been actively promoted by tobacco companies using endorsements by major sport figures, and research indicates that tobacco advertising can lead to youth initiation of tobacco use (1,2). Television and radio advertisements for cigarettes and smokeless tobacco have been prohibited since 1969,* and the 1998 Master Settlement Agreement(†) further prohibited tobacco companies from targeting youths with tobacco product advertisements in specified areas. In 2010, the Food and Drug Administration (FDA), under authority of the 2009 Family Smoking Prevention and Tobacco Control Act (FSPTCA), prohibited tobacco-brand sponsorship (i.e., sponsorship of sports and entertainment events or other social or cultural events using the tobacco brand name or anything identifiable with any brand of cigarettes or smokeless tobacco).(§) However, corporate-name tobacco sponsorship (i.e., sponsorship using the name of the corporation that manufactures regulated tobacco products) is still permitted under certain conditions.(¶) To monitor tobacco advertising and promotional activities in sports in the United States, CDC analyzed trends in sports-related marketing expenditures for cigarettes and smokeless tobacco during 1992-2013 using data from the Federal Trade Commission (FTC). During 1992-2013, sports-related marketing expenditures, adjusted by the consumer price index to constant 2013 dollars, decreased significantly for both cigarettes (from $136 million in 1992 to $0 in 2013) and smokeless tobacco (from $34.8 million in 1992 to $2.1 million in 2013). During 2010-2013, after the prohibition of tobacco-brand sponsorship in sports under the FSPTCA, cigarette manufacturers reported no spending (i.e., $0) on sports-related advertising and promotional activities; in contrast, smokeless tobacco manufacturers reported expenditures of $16.3 million on advertising and promoting smokeless tobacco in sports during 2010-2013. These findings indicate that despite prohibitions on brand sponsorship, smokeless tobacco products continue to be marketed in sports in the United States, potentially through other indirect channels such as corporate-name sponsorship. Enhanced measures are warranted to restrict youth-oriented tobacco marketing and promotional activities that could lead to tobacco initiation and use among children and adolescents (2). Reducing tobacco industry promotion through sponsorship of public and private events is an evidence-based strategy for preventing youth initiation of tobacco use (3). In addition, other proven interventions (e.g., tobacco price increases, anti-tobacco mass media campaigns, tobacco-free policies inclusive of smokeless tobacco, and barrier-free access to cessation services), could help reduce smokeless tobacco use in the United States (1).

Identifying promising practices for evaluation: the National Breast and Cervical Cancer Early Detection Program.

PURPOSE: The Centers for Disease Control and Prevention conducted a systematic screening and assessment process to identify promising practices implemented by grantees of the National Breast and Cervical Cancer Early Detection Program and its partners that were appropriate for rigorous evaluation. METHODS: The systematic screening and assessment (SSA) process was conducted from September 2010 through March 2012 and included five steps: (1) nominations of promising practices; (2) a first rating by subject matter experts; (3) field-based evaluability assessments; (4) a second rating by experts; and (5) use of results. Nominations were sought in three program areas including health education and promotion, quality assurance and quality improvement, and case management/patient navigation. RESULTS: A total of 98 practices were nominated of which 54 % were eligible for the first review by the experts. Fifteen practices were selected for evaluability assessment with ten forwarded for the second review by the experts. Three practices were ultimately recommended for rigorous evaluation, and one evaluation was conducted. Most nominated practices were based on evidence-based strategies rather than representing new, innovative activities. Issues were identified through the process including inconsistent implementation and lack of implementation fidelity. CONCLUSION: While the SSA was successful in identifying several programs for evaluation, the process also revealed important shortcomings in program implementation. Training and technical assistance could help address these issues and support improved programming.

Implementing the CDC's Colorectal Cancer Screening Demonstration Program: wisdom from the field.

BACKGROUND: Colorectal cancer, as the second leading cause of cancer-related deaths among men and women in the United States, represents an important area for public health intervention. Although colorectal cancer screening can prevent cancer and detect disease early when treatment is most effective, few organized public health screening programs have been implemented and evaluated. From 2005 to 2009, the Centers for Disease Control and Prevention funded 5 sites to participate in the Colorectal Cancer Screening Demonstration Program (CRCSDP), which was designed to reach medically underserved populations. METHODS: The authors conducted a longitudinal, multiple case study to analyze program implementation processes. Qualitative methods included interviews with 100 stakeholders, 125 observations, and review of 19 documents. Data were analyzed within and across cases. RESULTS: Several themes related to CRCSDP implementation emerged from the cross-case analysis: the complexity of colorectal cancer screening, the need for teamwork and collaboration, integration of the program into existing systems, the ability of programs to use wisdom at the local level, and the influence of social norms. Although these themes were explored independently from 1 another, interaction across themes was evident. CONCLUSIONS: Colorectal cancer screening is clinically complex, and its screening methods are not well accepted by the general public; both of these circumstances have implications for program implementation. Using patient navigation, engaging in transdisciplinary teamwork, assimilating new programs into existing clinical settings, and deferring to local-level wisdom together helped to address complexity and enhance program implementation. In addition, public health efforts must confront negative social norms around colorectal cancer screening.

Recruiting patients into the CDC's Colorectal Cancer Screening Demonstration Program: strategies and challenges across 5 sites.

BACKGROUND: In 2005, the Centers for Disease Control and Prevention (CDC) funded 5 sites as part of the Colorectal Cancer Screening Demonstration Program (CRCSDP) to provide colorectal cancer screening to low-income, uninsured, and underinsured individuals. Funded sites experienced unexpected challenges in recruiting patients for services. METHODS: The authors conducted a longitudinal, qualitative case study of all 5 sites to document program implementation, including recruitment. Data were collected during 3 periods over the 4-year program and included interviews, document review, and observations. After coding and analyzing the data, themes were identified and triangulated across the research team. Patterns were confirmed through member checking, further validating the analytic interpretation. RESULTS: During early implementation, patient enrollment was low at 4 of the 5 CRCSDP sites. Evaluators found 3 primary challenges to patient recruitment: overreliance on in-reach to National Breast and Cervical Cancer Early Detection Program patients, difficulty keeping colorectal cancer screening and the program a priority among staff at partnering primary care clinics responsible for patient recruitment, and a lack of public knowledge about the need for colorectal cancer screening among patients. To address these challenges, site staff expanded partnerships with additional primary care networks for greater reach, enhanced technical support to primary care providers to ensure more consistent patient enrollment, and developed tailored outreach and education. CONCLUSIONS: Removing financial barriers to colorectal cancer screening was necessary but not sufficient to reach the priority population. To optimize colorectal cancer screening, public health practitioners must work closely with the health care sector to implement evidence-based, comprehensive strategies across individual, environmental, and systems levels of society.

Developmental milestones across the programmatic life cycle: implementing the CDC's Colorectal Cancer Screening Demonstration Program.

BACKGROUND: In 2005 through 2009, the Centers for Disease Control and Prevention (CDC) funded 5 sites to implement a colorectal cancer screening program for uninsured, low-income populations. These 5 sites composed a demonstration project intended to explore the feasibility of establishing a national colorectal cancer screening program through various service delivery models. METHODS: A longitudinal, multiple case study was conducted to understand and document program implementation processes. Using metaphor as a qualitative analytic technique, evaluators identified stages of maturation across the programmatic life cycle. RESULTS: Analysis rendered a working theory of program development during screening implementation. In early stages, program staff built relationships with CDC and local partners around screening readiness, faced real-world challenges putting program policies into practice, revised initial program designs, and developed new professional skills. Midterm implementation was defined by establishing program cohesiveness and expanding programmatic reach. In later stages of implementation, staff focused on sustainability and formal program closeout, which prompted reflection about personal and programmatic accomplishments. CONCLUSIONS: Demonstration sites evolved through common developmental stages during screening implementation. Findings elucidate ways to target technical assistance to more efficiently move programs along their maturation trajectory. In practical terms, the time and cost associated with guiding a program to maturity may be potentially shortened to maximize return on investment for both organizations and clients receiving service benefits.