A multilevel intervention in pediatric primary care for youth tobacco control: Outcomes of implementing an Ask, Advise, and Connect model.

Multilevel interventions in healthcare settings (e.g. Ask, Advise, and Connect; AAC) can reduce tobacco product use among adult patients: their effectiveness in pediatric practice is largely unknown. We implemented an AAC model in pediatric primary care to deter children's tobacco use, and evaluated its effectiveness in a single-arm trial. At wellness visits, young patients (ages 12-17) completed a tablet-based assessment (Ask) of lifetime and current tobacco use. These data were made available within the electronic health record to pediatric primary care providers for preventive counseling (Advise). Providers then referred patients to an e-health evidence-based tobacco control intervention (Connect). Tobacco control outcomes were examined in the clinic population (N = 2219) and in a sample of patients (N = 388, 62% female, 39% non-White, M age = 15) over time, along with intervention engagement. Population use of tobacco products decreased following introduction of AAC (more than 2-fold). At the patient level, most children (80.9%) engaged with the intervention: those who were Black or African American, who never used tobacco products/were not susceptible to use, and who used fewer non-cigarette tobacco products were more likely to engage, but only after multiple prompts versus a single prompt. Engagement was positively associated with lowering children's susceptibility to using tobacco at follow-up. A pediatric AAC model holds promise in deterring youth tobacco use, including among historically marginalized populations who may require additional support.

By implementing a multilevel Ask, Advise, and Connect intervention, pediatric tobacco use declined in a clinical population, with high intervention engagement and improved outcomes.

Identifying Novel Motivation Phase-Specific Cessation Targets for Youth Experiencing Homelessness in the United States.

INTRODUCTION: Of youth experiencing homelessness (YEH; 14-24 years old), 70%+ smoke combustible, commercial tobacco. Though many have tried to quit, most use ineffective methods. Drop-in centers for YEH are opportune places to link YEH to evidence-based treatment. Using the Phase-Based Model (PBM) for Cessation Research, the aim of this study was to identify "Motivation" phase-specific challenges impacting YEH's willingness to make a quit attempt-the goal of this cessation phase. AIMS AND METHODS: Surveys were interview administered with 96 past-week combusted tobacco users accessing drop-in services. Regression models were fit to confirm hypothesized challenges impacting YEH's willingness to quit. RESULTS: Moderate nicotine dependence was noted-a key Motivation phase cessation mechanism targeted-and was associated with population challenges including, but not limited to, replacing food with tobacco, accidental oxygen-deprivation events, and smoking to socialize. While 67.1% of participants made a past-year quit attempt, 45.8% expressed 30-day quit interest. Dimensions of coping with housing were associated with quit attempts and quit interest. Quit attempts were also associated with nicotine dependence, working, and smoking to socialize. Whereas, quit interest was associated with less endorsement of smoking to regulate affect and more endorsement to avoid danger. CONCLUSIONS: Though common challenges targeted in Motivation phase cessation exist among YEH, other challenges may also need to be addressed to promote quitting. IMPLICATIONS: Future research in optimizing evidence-based cessation access for YEH through drop-in centers may consider addressing the challenges of housing, food security, social context, violence, and neurotrauma sequela to bolster YEH willingness to make a quit attempt.

Brain Injury Is Prevalent and Precedes Tobacco Use among Youth and Young Adults Experiencing Homelessness.

70%+ of youth and young adults experiencing homelessness (YYEH; 14-24 years old) smoke combustible tobacco. Little is known about the prevalence of acquired brain injury (ABI) among youth and young adult smokers experiencing homelessness (YYSEH) and its impact on tobacco use progression-the aim of our study. Through an interviewer-administered survey, YYSEH were asked about timing of tobacco use; exposure to causes of ABI; including brain oxygen deprivation (BOD; strangulation; accidental; choking games) and blunt force head trauma (BFHT; intentional; shaken violently; accidental); and perpetrators of intentional assault. Participants (n = 96) were on average 22 years old and from populations who experience structural disparities; including those minoritized by race (84.4%) and gender/sexual orientation (26.0%). In total, 87% of participants reported at least one exposure to BFHT and 65% to BOD. Intentional injury was more common than accidental. Furthermore, 60.4% of participants (n = 59) were classified as having ABI using the Brain Injury Severity Assessment. A significant proportion of YYSEH living with ABI were exposed to both BFHT and BOD prior to trying (68.5%, p = 0.002) and to first regular use (82.8%, p < 0.001) of tobacco. Among YYSEH with ABI; injury exposure occurred a median of 1 and 5 years before age of first regular tobacco use, dependent on injury mechanism. ABI from intentional violence is prevalent and precedes tobacco use among YYSEH.

Psychosocial factors influencing smoking relapse among youth experiencing homelessness: A qualitative study.

OBJECTIVES: In the United States, up to 70% of youth experiencing homelessness smoke cigarettes. Many are interested in quitting; however, little is known about psychosocial factors influencing smoking relapse in this population. This study, part of a larger project to develop an optimized smoking cessation intervention for youth experiencing homelessness, aimed to describe how psychosocial factors influence smoking relapse in this group. METHODS: This study describes the smoking relapse experiences of 26 youth tobacco users, aged 14-24 years, who were recruited from a homeless drop-in center in Ohio. We conducted semi-structured interviews to understand how stress, opportunity, and coping contribute to smoking relapse. RESULTS: Five themes emerged from the data: (1) smoking as a lapse in emotional self-regulation in response to stress; (2) smoking as active emotional self-regulation in response to stress; (3) social opportunities facilitate smoking in the context of emotion-focused stress coping; (4) problem-focused stress coping; and (5) opportunity facilitates smoking relapse. CONCLUSIONS: Stress was a primary driver of smoking relapse among youth experiencing homelessness, yet social and environmental opportunities to smoke also precipitated relapse. Interventions to improve abstinence among this population should target foundational stressors, coping skills, social supports, and nicotine dependence.

Characterizing tobacco and marijuana use among youth combustible tobacco users experiencing homelessness - considering product type, brand, flavor, frequency, and higher-risk use patterns and predictors.

BACKGROUND: Cigarette smoking is three times more prevalent among youth experiencing homelessness compared with the general population. Co-use of tobacco and marijuana is also common. The aim of this study is to characterize tobacco and marijuana use among youth experiencing homelessness who use combustible tobacco in a Midwestern city to inform smoking cessation intervention. METHODS: This study included 96 youth (ages 14-24 years; 52% male, 39% female, 5% transgender/non-binary) attending a homeless drop-in center who had used at least one combustible tobacco product in the past week. We assessed past-month use of tobacco products and marijuana, other product use characteristics (e.g., frequency, brand and flavor), and psychosocial predictors of more frequent (i.e., daily) use of combustible tobacco and marijuana. RESULTS: Most youth experiencing homelessness with past-week combustible tobacco use had used cigarettes (n = 85, 88.5%), cigars (n = 89, 92.7%), and marijuana (n = 82, 85.4%) in the past month. One-third (n = 34) used electronic vapor products (EVPs), 19.8% (n = 19) smoked hookah, and 11.5% (n = 11) used smokeless tobacco (ST). Most marijuana users co-administered with tobacco (n = 67, 69.8%). Daily combustible tobacco smoking was associated with having a child and smoking out of boredom/habit. Daily marijuana use was associated with using substances to cope with one's housing situation. Newport (n = 66, 72.5%) and Black & Mild (n = 48, 51.1%) were the most popular brands of cigarettes and cigars among ever users. Most non-combustible tobacco ever users reported not having a usual brand (EVPs: n = 51, 73.9%; ST: n = 16, 57.1%). Cigar smokers reported the most varied selection of flavors. CONCLUSIONS: Young combustible tobacco users experiencing homelessness engage in high-risk use patterns, including poly-tobacco use, co-use of tobacco with marijuana, and frequent combustible product use. Interventions that consider the full context of tobacco and marijuana use are needed to support smoking cessation in this population.

"I Smoked That Cigarette, and It Calmed Me Down": A Qualitative Analysis of Intrapersonal, Social, and Environmental Factors Influencing Decisions to Smoke Among Youth Experiencing Homelessness.

INTRODUCTION: Approximately 70% of youth experiencing homelessness smoke cigarettes; many try to quit and are interested in formal smoking cessation programs. The purpose of this study was to describe the intrapersonal, social, and environmental contexts associated with the most recent smoking experience among youth experiencing homelessness and (2) identify differences in contextual factors by age and willingness to quit. METHODS: Thirty-six youth experiencing homelessness aged 14-24 years and who reported current smoking were recruited from a drop-in center in a Midwestern city. Semi-structured in-person interviews were analyzed to understand smoking behaviors. RESULTS: Two-thirds of participants reported stress and nicotine dependence as primary reasons for smoking, and older youth (aged 18-24 years) reported smoking to de-escalate negative emotions associated with stressful events. For 25% of participants, and especially older youth, smoking was described as part of a routine. Over 80% of participants smoked outside at the homeless drop-in center or the places they lived. Social prompts from drop-in center peers regularly preempted smoking. Younger youth (aged 14-17 years) reported smoking socially while older youth were more likely to smoke alone. CONCLUSIONS: For youth experiencing homelessness, smoking is integrated into daily life and is often used to manage stress associated with homelessness and engage socially with homeless peers. Multicomponent interventions to reduce structural stressors specific to homelessness, change social smoking norms (environmental and social context), and address stress management and nicotine dependence (intrapersonal context) are needed to support smoking cessation among youth experiencing homelessness. IMPLICATIONS: Youth experiencing homelessness overwhelmingly described how daily stressors associated with homelessness and nicotine dependence preceded recent smoking. Older youth (aged 18-24 years) also reported smoking as "routine", which likely underscores nicotine dependence in this group. Younger youth (aged 14-17 years) described social smoking. Researchers must develop optimized multilevel interventions to support youth experiencing homelessness who want to quit smoking. Interventions directly targeting social determinants of stress (e.g., poverty, housing instability, food insecurity) and linkages to supportive services are needed. Complementary strategies to address stress coping and nicotine dependence (intrapersonal context) and social smoking norms (social and environmental context) are also necessitated.

Effectiveness of Cessation Messages Targeting Pregnant and Nonpregnant Female Smokers in the United States: A Cross-Sectional Analysis into the Impact of Pregnancy, Self-Efficacy, and Risk Perception.

OBJECTIVES: Roughly 10% of pregnant women are current smokers. Improving smoking cessation in this population before and during pregnancy is essential to prevent adverse fetal outcomes. This study aimed to examine cessation messages targeting American women. METHODS: An obstetrics-gynecological clinic-based sample of female, current smokers of reproductive age (18-44 years old) was recruited (n = 135) from January to May 2019; half (51.2%) were currently pregnant. Participants completed a within-subjects study with a randomized set of gain- and loss-framed text-only pregnancy-related cessation messages (5 each). Each individual message was rated on a validated, 10-point scale for perceived effectiveness; responses to the seven items were averaged. Regression analyses examined differences in effectiveness ratings by message framing. RESULTS: Study participants (female smokers) rated the gain-framed messages as slightly more effective than loss-framed messages (7.9 versus 7.7, p < 0.01). After adjusting for quit intention and pregnancy, the relationship between gain- and loss-framing and effectiveness ratings was modified by both self-efficacy and risk perceptions. Women who perceived high risks of smoking during pregnancy had higher effectiveness ratings of both gain- and loss-framed cessation messages, compared to women who perceived low risks. Lower cessation self-efficacy was significantly associated with lower effectiveness ratings for gain- and loss-framed messages (1.53 and 1.92, respectively; p < 0.05). CONCLUSIONS FOR PRACTICE: Women with lower self-efficacy and low risk perception of smoking risks had the lowered effectiveness ratings for both frames of cessation messages. Enhancing self-efficacy and risk perceptions through clinical interventions may improve the effectiveness of targeted messages to promote quitting smoking before or during pregnancy.

Framing pregnancy-related smoking cessation messages for women of reproductive age.

INTRODUCTION: Communicating harms of smoking and benefits of quitting to tobacco users to motivate cessation is critical to reduce the burden of tobacco-related disease. Most messaging strategies focus on health risks of smoking using loss-framing; yet, gain-framed messages to increase confidence in quitting have shown promise for smokers with lower self-efficacy. This study examined the impact of message framing on perceived effectiveness of targeted, pregnancy-related smoking cessation messages among pregnant and not-pregnant smoking women of reproductive age. METHODS: An obstetrics-gynecological clinic-based sample of female, current smokers of reproductive age (18-44 years old) was recruited during January to May 2019 (n = 135). Participants self-reported ratings for 10 pregnancy-related cessation messages (half gain-framed) on a validated perceived effectiveness scale. Multivariable regression analyses were conducted using generalized estimating equations to account for clustering by message themes. RESULTS: Gain-framed messages were rated significantly higher (0.20; p < 0.01) compared to loss-framed messages for perceived effectiveness, after accounting for quit intentions, self-efficacy to quit, health literacy, cessation risk perceptions, nicotine dependence, and pregnancy status. CONCLUSIONS: Gain-framed health messages about cessation were deemed to be more effective than loss-framed messages among adult female smokers. Targeted, positively framed messages to highlight the benefits of quitting to women of reproductive age show promise as a strategy to promote smoking cessation.

Smoking cessation methods among homeless youth in a Midwestern city.

INTRODUCTION: Nearly three times as many homeless youth smoke cigarettes in the United States (US) compared to the general population of youth. Few studies have focused on how to help homeless youth quit smoking. As part of a series of studies to develop a smoking cessation intervention for homeless youth, this study aimed to describe methods used in past quit attempts by homeless youth. METHODS:  Recruited from a drop-in center in the Midwestern US, the analytic sample was comprised of 32 unaccompanied homeless youth aged 14-24 who smoked combustible tobacco at some point in the past week. In-person qualitative interviews were conducted to understand prior quit attempt experiences of homeless youth. RESULTS: Twenty-two youth (69%) were willing to quit smoking in the next 30 days. Most previous quit attempts were unassisted (78%). Participants frequently reported engaging in distracting behaviors (e.g., video games) or thoughts (e.g., remaining positive). Nicotine replacement therapy (NRT) was another popular method (38%), but with mostly negative reactions. While less common, vaping and use of cannabis to substitute cigarettes was reported in a notable faction of youth (28%), primarily 18-24 years of age. CONCLUSIONS: Youth are primarily engaging in non-evidence-based strategies to quit smoking. Existing evidence-based treatments are often underutilized or not used according to instructions, and youth who do use evidence-based treatments do not find them useful. Future research should explore effective cessation treatment among homeless youth that can ideally be provided at shelters and drop-in centers. IMPLICATIONS: Existing evidence-based treatments are underutilized by homeless youth in this study. Most homeless youth are willing to quit in the next month and are interested in trying behavioral counseling and monitored use of NRT. Drop-in centers may be an effective location from which to develop and offer targeted smoking cessation interventions for homeless youth.

Effects of Pictorial Warning Labels for Cigarettes and Quit-Efficacy on Emotional Responses, Smoking Satisfaction, and Cigarette Consumption.

Background: Experimental research on pictorial warning labels for cigarettes has primarily examined immediate intentions to quit. Purpose: Here, we present the results of a clinical trial testing the impact on smoking during and after a 28-day period of naturalistic exposure to pictorial versus text-only warnings. Methods: Daily cigarette smokers (N = 244) at two sites in the USA were randomly assigned to receive their regular brand of cigarettes for 4 weeks with one of three warnings: (a) text-only, (b) pictures and text as proposed by FDA, or (c) the warnings proposed by FDA with additional text that elaborated on the risks of smoking. Analyses examined the effects of pictorial versus text-only warnings and self-efficacy for quitting on cigarette consumption during and 1 month after the trial as mediated by emotional and cognitive responses as well as satisfaction with smoking. Results: Stronger emotional responses to pictorial than text-only warnings predicted reduced satisfaction with smoking during the trial and lower cigarette consumption at follow-up among the majority of smokers who continued to smoke. Consistent with the efficacy-desire model, those with moderate efficacy reported the greatest reduction in consumption at follow-up. However, a small proportion of smokers (7%) who reported 7-day abstinence at follow-up did not exhibit a significant relation with self-efficacy. Conclusions: Pictorial warning labels proposed by FDA create unfavorable emotional reactions to smoking that predict reduced cigarette use compared to text alone, with even smokers low in self-efficacy exhibiting some reduction. Predictions that low self-efficacy smokers will respond unfavorably to warnings were not supported.