Research Priorities for Interventions to Address Health Disparities in Lung Nodule Management: An Official American Thoracic Society Research Statement.

Background: Lung nodules are common incidental findings, and timely evaluation is critical to ensure diagnosis of localized-stage and potentially curable lung cancers. Rates of guideline-concordant lung nodule evaluation are low, and the risk of delayed evaluation is higher for minoritized groups. Objectives: To summarize the existing evidence, identify knowledge gaps, and prioritize research questions related to interventions to reduce disparities in lung nodule evaluation. Methods: A multidisciplinary committee was convened to review the evidence and identify key knowledge gaps in four domains: 1) research methodology, 2) patient-level interventions, 3) clinician-level interventions, and 4) health system-level interventions. A modified Delphi approach was used to identify research priorities. Results: Key knowledge gaps included 1) a lack of standardized approaches to identify factors associated with lung nodule management disparities, 2) limited data evaluating the role of social determinants of health on disparities in lung nodule management, 3) a lack of certainty regarding the optimal strategy to improve patient-clinician communication and information transmission and/or retention, and 4) a paucity of information on the impact of patient navigators and culturally trained multidisciplinary teams. Conclusions: This statement outlines a research agenda intended to stimulate high-impact studies of interventions to mitigate disparities in lung nodule evaluation. Research questions were prioritized around the following domains: 1) need for methodologic guidelines for conducting research related to disparities in nodule management, 2) evaluating how social determinants of health influence lung nodule evaluation, 3) studying approaches to improve patient-clinician communication, and 4) evaluating the utility of patient navigators and culturally enriched multidisciplinary teams to reduce disparities.

Effect of local youth-access regulations on progression to established smoking among youths in Massachusetts.

OBJECTIVE: To test whether community-level restrictions on youth access to tobacco (including both ordinances and enforcement) are associated with less smoking initiation or less progression to established smoking among adolescents. DESIGN: Prospective cohort study of a random sample of adolescents in Massachusetts whose smoking status was assessed by telephone interviews at baseline and 2-year follow-up, and linked to a state-wide database of town-level youth-access ordinances and enforcement practices. PARTICIPANTS: A random sample of 2623 adolescents aged 12-17 years who lived in 295 towns in Massachusetts in 2001-2 and were followed in 2003-4. MAIN OUTCOME MEASURES: The relationship between the strength of local youth access restrictions (including both ordinances and level of enforcement) and (1) never-smokers' smoking initiation rates and (2) experimenters' rate of progression to established smoking was tested in a multilevel analysis that accounted for town-level clustering and adjusted for potential individual, household and town-level confounders. RESULTS: Over 2 years, 21% of 1986 never-smokers initiated smoking and 25% of 518 experimenters became established smokers. The adjusted odds ratio (OR) for smoking initiation was 0.89 (95% CI 0.61 to 1.31) for strong versus weak youth-access policies and 0.93 (95% CI 0.67 to 1.29) for medium versus weak policies. The adjusted OR for progression to established smoking among adolescents who had experimented with smoking was 0.79 (95% CI 0.45 to 1.39) for strong versus weak local smoking restrictions and 0.85 (95% CI 0.50 to 1.45) for medium versus weak restrictions. CONCLUSIONS: This prospective cohort study found no association between community-level youth-access restrictions and adolescents' rate of smoking initiation or progression to established smoking over 2 years.

Statewide evaluation of youth access ordinances in practice: effects of the implementation of community-level regulations in Massachusetts.

The objectives of the study described in this article were to test whether community-level youth access ordinances reduce adolescents' perceived access to tobacco, purchase attempts, and tobacco use. A telephone survey was performed of a random sample of 3,831 Massachusetts adolescents linked to a database of all town-level youth access ordinances in the state. Respondents' perceived ease of access to tobacco, attempts to purchase tobacco, and tobacco use (ever smoking and current [past 30-day] smoking) were assessed. The association of these outcomes with the characteristics of youth access ordinances in the respondents' town of residence (n = 314) was tested in multilevel analyses that included town-level clustering, controlled for multiple individual and environmental characteristics, including a measure of community-level anti-smoking sentiment. Community-level youth access ordinances were not associated with adolescents' perceived access to tobacco, purchase attempts, or tobacco use, with two exceptions: (1) banning free-standing displays was associated with a 40% reduction in perceived access to tobacco (OR = 0.6; 95% CI, 0.4-0.9) and (2) a vending machine ban was associated a 30% higher report of perceived access to tobacco (OR = 1.3; 95% CI, 1.1-1.5). This study found no consistent associations between community-level youth access ordinances and adolescents' perceived access to tobacco, purchase attempts, or smoking prevalence.

State tobacco excise taxes and adolescent smoking behaviors in the United States.

The objective of the study described in this article was to examine the association between state cigarette excise taxes and smoking behaviors among youth in the United States. A survey was nationally mailed to adolescents in the Growing Up Today Study, an ongoing cohort of offspring of participants in the Nurses' Health Study II. A volunteer sample of 10,981 adolescent boy and girl participated in the Growing Up Today Study, who were 12 to 18 years old in 1999. Logistic regression was used to examine the relationship between state cigarette excise taxes (in quartiles) and experimentation (ever smoked) and established smoking (smoked at least 100 cigarettes in a lifetime). State tax levels in 1999 ranged from 2.5 to 100 cents. In a model that adjusted for age, gender, peer smoking, parental smoking, state clustering, state poverty level, and possession of tobacco promotional items, higher tax rates were associated with decreased odds of experimentation (test for trend p < 0.01). The highest quartile of tax (60-100 cents) was significantly associated with lower odds of experimentation (OR = 0.79; 95% CI, 0.64-0.98) and appeared protective against established smoking (OR = 0.80; 95% CI, 0.49-1.29). This study provides recent evidence that higher state cigarette excise taxes are associated with decreased experimental smoking among adolescent boys and girls. Higher state cigarette taxes may also be associated with lower odds of established smoking in this age group, although the association appears to be attenuated by peer and parental smoking. These results support the inclusion of tobacco taxes in state tobacco control programs.

Body mass index and asthma severity among adults presenting to the emergency department.

STUDY OBJECTIVES: Among adults presenting to the emergency department (ED) with acute asthma, we sought to determine the prevalence of obesity, and the relation of body mass index (BMI) to asthma severity in this high-risk population. DESIGN: Multicenter, prospective cohort study. SETTING: Twenty-six North American EDs. PARTICIPANTS: Five hundred seventy-two patients aged 18 to 54 years presenting with acute asthma. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: A standardized interview assessed demographic characteristics, asthma history, and details of the current asthma exacerbation. Data on ED medical management and disposition were obtained by chart review. Three of four asthmatic patients were either overweight (BMI, 25 to 29.9; 30%) or obese (BMI, > or =30; 44%). Normal weight/underweight, overweight, and obese patients did not differ on several markers of chronic asthma severity; obese subjects tended to rate symptoms more severely and to use more inhaled beta-agonists in the 6 h hours prior to ED presentation despite a significantly higher initial percentage of predicted peak expiratory flow (PEF) [44%, 45%, and 51%, respectively; p < 0.05]. The three BMI groups responded similarly to acute therapy in the ED, with all groups demonstrating reversible airway obstruction. The sex distribution by BMI group differed markedly (p < 0.001), with women less often overweight (40% vs 24%) and more often obese (30% vs 52%). Since women were more likely have a higher initial PEF (45% vs 53%, p < 0.001), we stratified by sex to further examine the relation of BMI to asthma severity. The observed BMI-asthma associations were due largely, but not entirely, to confounding by sex. CONCLUSIONS: Despite lingering concerns about the veracity of "asthma" among obese individuals, asthma exacerbations among obese and nonobese adults were remarkably similar. Potential differences (eg, in symptom perception, use of inhaled beta-agonists before ED presentation, initial PEF rate) were due, in large part, to confounding by sex.

Hospital- and clinic-based smoking cessation interventions for smokers with cardiovascular disease.

Cigarette smoking is the leading preventable cause of death in the United States and a major risk factor for cardiovascular disease (CVD). Large observational epidemiologic studies conducted in diverse populations have demonstrated a strong association between smoking and CVD morbidity and mortality. Observational epidemiologic studies have also demonstrated a substantial benefit of smoking cessation on cardiovascular morbidity and mortality. Smoking cessation after myocardial infarction reduces subsequent cardiovascular mortality by nearly 50%. Therefore, the use of effective strategies to reduce the prevalence of tobacco use is a high priority for both the primary and secondary prevention of CVD. Effective smoking cessation interventions have been identified in randomized controlled trials in the general population of smokers. These methods, which include behavioral counseling and pharmacotherapy, are incorporated into clinical practice guidelines for physicians in the United States and Great Britain. A smaller but still substantial body of evidence demonstrates the efficacy of these interventions in hospital- and clinic-based settings for smokers with CVD. This evidence is sufficient to support the routine implementation of these smoking cessation methods in inpatient and outpatient settings for smokers with CVD.

Caretaker-child concordance for child's exposure to violence in a preadolescent inner-city population.

BACKGROUND: Effective screening for exposure to violence (ETV) in the pediatric setting depends on informant reliability and recognition of patients at increased risk. Pediatricians screening for children's ETV often rely on parent reporting. HYPOTHESIS: That there would be poor caretaker-child concordance given that children would report events occurring outside the home not witnessed by the caretaker and that ETV would be higher among immigrant families. OBJECTIVES: To examine concordance between caretaker and child self-report of the child's ETV in a preadolescent population and to explore factors related to increased risk. DESIGN: Community-based survey. SETTING: Urban community health center. PARTICIPANTS: One hundred sixty-five caretaker-child pairs. METHODS: The ETV was assessed by means of a standardized interview questionnaire on location and frequency of ETV. A Rasch model was used to develop summary scores of ETV (frequency and severity). RESULTS: Caretaker-child concordance on reports of child's ETV was poor. The kappa statistics ranged from -0.04 for seeing someone knifed to 0.39 for witnessing a shooting. Children reported ETV more often in their neighborhood or at school, whereas caretakers reported more events near or at home. Univariate predictors of child's self-reported ETV were female sex (beta +/- SE, -10.1 +/- 4.6; P =.03) and caretaker being divorced (beta +/- SE, 12.6 +/- 6.0; P =.04). In multivariate analyses, country of origin predicted child's ETV, adjusting for child's age and sex, and caretaker educational status and marital status. CONCLUSIONS: Caretakers and their children have poor agreement on reports of the child's ETV. Intervention strategies around ETV should include assessment of the child independent of caretaker report for preadolescents. Screening may be more effective if pediatricians are aware of factors related to increased risk, including immigration status and caretaker marital status.