Smoking Cessation among Female and Male Veterans before and after a Randomized Trial of Proactive Outreach.

INTRODUCTION: Female veterans smoke cigarettes at high rates compared with both male veterans and nonveteran women. Proactive outreach to smokers may reduce gender disparities in cessation care. The objectives of this study were to compare baseline experiences with VA smoking cessation care for men and women and to assess for gender differences in response to a proactive outreach intervention. METHODS: We conducted a post hoc subgroup analysis of a pragmatic, multisite randomized, controlled trial comparing proactive outreach with usual care (UC). Baseline experiences included physician advice to quit, satisfaction with care, and past-year treatment use. At the 1-year follow-up, treatment use, quit attempts, and 6-month prolonged abstinence for women and men randomized to proactive outreach versus UC were compared using logistic regression. RESULTS: Baseline and follow-up surveys were returned by 138 women and 2,516 men. At baseline, women were less likely than men to report being very or somewhat satisfied with the process of obtaining smoking cessation medications in the VA (47% of women vs. 62% of men), but no less likely to report having used cessation medications from the VA in the past year (39% of women vs. 34% of men). After the intervention, phone counseling and combined therapy increased among both women and men in proactive outreach as compared with UC. At the 1-year follow-up, men in proactive outreach were significantly more likely to report prolonged abstinence than those in UC (odds ratio, 1.65; 95% CI, 1.28-2.14); results for women were in the same direction but not statistically significant (odds ratio, 1.39; 95% CI, 0.48-3.99). CONCLUSIONS: Satisfaction with cessation care in VA remains low. Proactive outreach to smokers was associated with an increased use of cessation therapies, and increased odds of achieving prolonged abstinence. A subgroup analysis by gender did not reveal significant differences in the treatment effect.

Population Smoking Characteristics and Cessation Behaviors in a Nationally Representative Cohort of Hispanic Veterans and Hispanic Non-Veterans.

INTRODUCTION: The proportion of Hispanics in the U.S. Veteran population is expected to increase rapidly in the next several decades. Although Veterans have a heightened smoking risk relative to the civilian population, few studies have examined whether this risk extends to Hispanic Veterans. The aims of the present study were to examine differences in the smoking and cessation characteristics of Hispanic Veterans and Hispanic non-Veterans, and to determine whether these differences persist after controlling for demographics and markers of acculturation. MATERIALS AND METHODS: This was a secondary analysis of the 2014-2015 Tobacco Use Supplement of the Current Population Survey administered by the U.S. Census Bureau. The main analysis included Hispanics aged 18 or older (N = 27,341). Additional analyses were restricted to participants who had smoked at least 100 cigarettes in their lifetime (N = 4,951), and current smokers (N = 2,345). Regressions modeled the associations between Veteran status and demographics, markers of acculturation, smoking characteristics, and cessation behaviors. Additional regressions modeled the associations between Veteran status and the smoking and cessation outcomes while adjusting for demographics and the acculturation variables of U.S. nativity, U.S. citizenship, and English interview language. Probability weights produced nationally representative findings. RESULTS: Hispanic Veterans were older, more likely to be male, and more acculturated than Hispanic non-Veterans. Unadjusted analyses revealed that Hispanic Veterans were more likely to be current daily smokers (8.6% vs. 5.7%, p = 0.015) and much less likely to be never smokers (59.3% vs. 81.0%, p < 0.001) compared to Hispanic non-Veterans. These differences were reduced after adjusting for the demographic and acculturation characteristics of the two groups. However, Hispanic Veterans were still less likely to be never smokers compared to non-Veterans after this adjustment (74.3% vs 80.7%, p < 0.001). In unadjusted analyses, Veterans were less likely to have stopped smoking for one day or longer as part of a quit attempt than non-Veterans (33.2% vs 45.4%, p = 0.056), although this was not a significant difference. Use of telephone quit line was very low for both Hispanic Veterans and Hispanic non-Veterans (4.3%). After adjustment, the difference in the likelihood of stopping smoking for one day or longer as part of a quit attempt was increased, becoming statistically significant (31.4% vs 45.8%, p = 0.030). CONCLUSION: Demographic and acculturation differences account for much, but not all, of the differences in the smoking characteristics and cessation behaviors of Hispanic Veterans and Hispanic non-Veterans. These findings suggest that Hispanic Veterans, and Veterans more broadly, should be a focal point for cessation efforts. These efforts should include facilitating access to under-utilized cessation treatments, and providing coordinated cessation care for Veterans being treated for comorbid health conditions.

Patient perspectives on alcohol use disorder pharmacotherapy and integration of treatment into primary care settings.

Background: Evidence-based pharmacotherapies for alcohol use disorders (AUDs) are underutilized. This mixed-methods study reports supplementary findings from the alcohol use disorder pharmacotherapy and treatment in primary care (ADaPT-PC) implementation study at 3 Veterans Health Administration (VHA) hospital sites to understand why prescription rates did not increase following the ADaPT-PC intervention. Methods: Qualitative interviews (N = 30) were conducted in advance of the ADaPT-PC intervention to understand patients' pharmacotherapy attitudes among those in AUD treatment, with previous treatment experience, or who needed assistance with their alcohol use. Following the ADaPT-PC intervention, chart reviews from a random sample of patients with AUD or a most recent Alcohol Use Disorders Identification Test consumption questions (AUDIT-C) score >8, and no active AUD prescription, were conducted to determine the frequency of alcohol-related conversations (N = 455). Results: Most interviewed patients welcomed a discussion about their alcohol use and pharmacotherapy. Of the 15 medication-naïve patients interviewed, 6 stated that they would be willing to try pharmacotherapy, 5 stated that they were unlikely, 2 identified reservations, 1 said no, and 1 was not asked. Fifteen patients were either currently taking medications (n = 10) or had taken medication in the past (n = 7; 2 patients had past and current experience). Chart reviews indicated that although 66% of charts (n = 299) documented a discussion of their alcohol use with the provider, only 7.5% (n = 22) of individuals with an AUD diagnosis had a documented discussion of AUD pharmacotherapy, and only 5 received pharmacotherapy. Conclusion: Most interviewed patients were open to discussing AUD treatment, including discussions of pharmacotherapy, with their provider. From documented conversations about alcohol use to treatment options, medical records suggests a continuous narrowing of the number of patients engaged in alcohol-related consultations. Although some interviewed patients expressed reticence about initiating pharmacotherapy, these findings suggest that the treatment cascade may have a greater influence on the number of pharmacotherapy prescriptions than patients' preferences.

Validating the use of veterans affairs tobacco health factors for assessing change in smoking status: accuracy, availability, and approach.

BACKGROUND: Accurate smoking status is key for research purposes, but can be costly and difficult to measure. Within the Veteran's Health Administration (VA), smoking status is recorded as part of routine care as "health factors" (HF)-fields that researchers can query through the electronic health record (EHR). Many researchers are interested in using these fields to track changes in smoking status over time, however the validity of this measure for assessing change is unknown. The primary goal of this project was to examine whether HFs can be used to accurately measure change in tobacco status over time, with secondary goals of assessing the optimum timeframe for assessment and variation in accuracy by site. METHODS: Secondary analysis of the Veterans VICTORY study, a pragmatic smoking cessation randomized controlled trial conducted from 2009 to 2011. Eligible subjects were identified via the EHR using a past 90-day HF indicating current tobacco use (for example: "CURRENT SMOKER", "CURRENTLY USES TOBACCO"). Participants were surveyed at 1 year to determine prolonged smoking abstinence. We identified HFs for tobacco status within +/- 120 days of the follow-up survey mailing date and recorded the temporally closest HF. Among subjects with both measures, we compared the two for agreement using kappa statistics and concordance. RESULTS: 1713 subjects (33%) had both follow-up survey and HF data, 1594 (31%) had only a survey response, 790 (15%) had only HF and 1026 (20%) had neither. For subjects with both measures, there was 90% concordance and moderate agreement (Kappa 0.48, 95%CI 0.41-0.55, Sensitivity 54.4, 95%CI 41.1-67.7, Specificity 94.3, 95%CI 87.5-100.0). CONCLUSIONS: We found high concordance but only moderate agreement by kappa statistics between HFs and survey data. The difference is likely accounted for by the natural history of quit attempts, in which patients cycle in and out of quit attempts. HFs appear to provide an accurate measure of population level quit behavior utilizing data collected in the course of clinical care.

The Development of Culturally Appropriate Tobacco Prevention Videos Targeted Toward Somali Youth.

BACKGROUND: Approximately 18% of Somali youth in Minnesota intend to use tobacco in the next year and youth perceive that 64% of their peers smoke. High perceived prevalence increases tobacco use intentions and initiation, indicating that Somali youth-targeted tobacco prevention efforts are needed. OBJECTIVES: To develop a Somali youth-targeted tobacco prevention intervention using a community-based participatory research (CBPR) approach. METHODS: Three focus groups were conducted to inform the development of a tobacco prevention intervention. Three tobacco prevention videos were developed. Twenty interviews were conducted to evaluate the videos. LESSONS LEARNED: It was essential to partner with Somali youth to develop the videos. Recruitment and development of the videos were facilitated through collaborating with trusted, existing community programs. CONCLUSIONS: A CBPR approach can be used to develop a culturally tailored intervention. It was important to involve academic and community partners in all stages of the research project.

Characteristics of Employees of Small Manufacturing Businesses by Occupation: Informing Evidence-Based Intervention Planning.

OBJECTIVES: We examined characteristics of employees in six occupational categories in small manufacturing businesses (20-150 employees). METHODS: We analyzed survey data from 47 businesses (n = 2577 employees; 86% response rate) and examined relationships between job type and sociodemographic, health, and organizational support characteristics. Analyses were adjusted for age and sex, and company as a random effect. RESULTS: Smoking rates were highest for production workers (33%), production managers (27%), and support staff (28%) and lowest for managers (11%) (P <0.001). Job stress was higher for production workers and support staff than managers (P < 0.0001). Managers perceived social capital (P<0.001), safety climate (P < 0.0001) and support for smoking cessation (P < 0.001) higher than production managers, production workers, and support staff. CONCLUSIONS: Differences in characteristics by occupation call for integrated interventions that target working class employees, leverage the influence of production managers, and enhance organizational support.

Smoking patterns, quit behaviors, and smoking environment of workers in small manufacturing companies.

BACKGROUND: This study describes smokers employed at 47 small manufacturing companies in Minnesota, USA. METHODS: Smokers (n = 713) participating in a group-randomized trial completed a baseline survey on their smoking patterns, quit behaviors, smoking environment, workplace attitudes about smoking, and correlates of smoking. These characteristics were examined by job type and a latent class analysis (LCA) was performed to group workers with similar characteristics. RESULTS: Production workers had the highest prevalence of daily smoking (88% vs. 68% among managers), and addiction (61% vs. 26% among managers), and the highest mean level of perceived stress (6.4 vs. 4.9 among managers). The LCA identified three subgroups of smokers that differed in levels of barriers to cessation. Production workers were most likely to be in the group with greater barriers (P = 0.01). CONCLUSIONS: These results underscore the importance of targeting interventions to production workers and those who exhibit the greatest barriers to cessation.

Perceptions of addiction, attempts to quit, and successful quitting in nondaily and daily smokers.

We aimed to qualitatively examine differences in perceptions of addiction, attempts to quit, and successful quitting among nondaily versus daily college student smokers. We conducted 16 focus groups with a total of 73 college student smokers from the southeastern U.S. Focus groups were homogenous in terms of gender, smoking status (nondaily, daily), and type of school (2-year college, 4-year university). Questions centered on perceptions of addiction, their own addiction, what constitutes a quit attempt, and successful quitting. Themes that emerged among all smokers regarding conceptualization of general addiction included physiological and psychological dependence and an inability to quit smoking. In terms of their own addiction, nondaily smokers referenced their ability to quit and sense of choice to smoke as factors indicating a lack of addiction, whereas daily smokers reported dependence symptoms and their inability to control their smoking indicating addiction. Nondaily smokers discussed quit attempts in terms of making the decision to quit and avoiding situational triggers, whereas daily smokers reported taking more behavioral steps toward cessation (e.g., not buying cigarettes, reducing cigarette consumption). With regard to successful cessation, both groups identified losing the desire to smoke as a hallmark. However, nondaily smokers reported that the decision to quit might constitute successful cessation; daily smokers had more strict behavioral criteria such as abstinence for an extended period of time. The different perceptions of one's own addiction, attempting to quit smoking, and successful quitting suggest the need to improve assessments of these factors, particularly among nondaily smokers.

Correlates of continued smoking versus cessation among survivors of smoking-related cancers.

OBJECTIVE: We examined correlates of continued smoking versus cessation among a sample of survivors of smoking-related cancers who were actively smoking at the time of cancer diagnosis. METHODS: Participants with a history of smoking and a smoking-related cancer diagnosis (lung, oral, pharynx, larynx, esophagus, bladder, stomach, cervix, kidney, pancreas, acute myeloid leukemia) within the past 4 years were identified in the electronic medical record. We recruited 613 individuals to complete a mail-based survey and received 139 completed surveys (22.7% response rate). We focused on 105 participants who smoked at the time of diagnosis and dichotomized them to having either quit since diagnosis (48.6%; n = 51) or continued smoking (51.4%; n = 54). We assessed sociodemographics, type of cancer and treatment(s), and psychosocial factors (depressive symptoms, social support, hope, quality of life). We then conducted structured interviews with a subset of 21 survey respondents. RESULTS: Binary logistic regression indicated that, controlling for age, gender, ethnicity, marital status, and income, factors associated with continued smoking versus cessation included being diagnosed with other smoking-related cancers versus lung or head and neck cancer (OR = 11.21, CI 2.85, 44.02) and having significant depressive symptoms (OR = 1.25, CI 1.08, 1.45). Qualitative findings highlighted motivators for cessation (impact of being diagnosed with cancer, doctor advice to quit, social influences) and barriers to cessation (hopelessness, stress, addiction). CONCLUSIONS: These findings highlight the need to address depressive symptoms among cancer survivors, particularly those continuing to smoke and the importance of exploring messages cancer survivors are given regarding the need for cessation post cancer diagnosis.

College student reactions to health warning labels: sociodemographic and psychosocial factors related to perceived effectiveness of different approaches.

OBJECTIVE: To examine factors associated with perceiving different types of pictorial cigarette health warning labels as most effective in motivating smokers to quit or preventing smoking initiation among college students. METHOD: We administered an online survey to 24,055 students attending six Southeast colleges in Fall, 2010. We obtained complete data for the current analyses from 2600. RESULTS: Current smoking prevalence was 23.5%. The largest majority (78.6%) consistently rated gruesome images as most effective, 19.5% rated testimonial images as most effective, and only a small proportion rated either standard (1.6%) or human suffering images (0.3%) as most effective. Subsequent analyses focused on differences between those endorsing gruesome images or testimonials as most effective. Factors related to ranking testimonials versus gruesome images as most effective included being female (p<0.01), White (p<0.01), and nonsmokers (p=0.04), lower perceived smoking prevalence (p<0.01), and greater receptivity to laws/restrictions around smoking (p<0.01) and tobacco marketing (p=0.01). Among smokers, factors related to ranking testimonials as most effective versus gruesome images included being female (p=0.03), being White (p=0.03), higher autonomous motivation (p=0.03), and greater extrinsic self-efficacy (p=0.02). CONCLUSIONS: Understanding factors related to perceived effectiveness of different pictorial warnings among subpopulations should inform health warning labels released by the FDA.