Co-Use of Tobacco Products and Cannabis Is Associated with Absenteeism and Lower Grades in California High School Students.

OBJECTIVE: To examine the association between co-use of commercial tobacco product (hereafter referred to as tobacco) and cannabis with educational outcomes among high school students. STUDY DESIGN: We analyzed high school student data from the 2021-2022 California Healthy Kids Survey (n = 287 653). Current (past-month) or ever tobacco and cannabis use was categorized as co-use, only tobacco or cannabis, or neither. Two self-reported educational outcomes were examined: absenteeism and grades. Adjusted logistic and linear regression models were used to examine the association between tobacco/cannabis use and absenteeism or grades, respectively. Estimates were adjusted for individual, peer, and school covariates, and clustering within schools. RESULTS: Current co-use of tobacco and cannabis was more than double the use of only tobacco (3.7% vs 1.7%) and similar to only cannabis (3.7%). Almost 18% of students reported absenteeism. Compared with students who used neither substance, students with current co-use had greater odds of absenteeism (aOR 1.41, 95% CI 1.33-1.49) and lower grades (ß = -0.87, 95% CI -0.92 to -0.82). Compared with students using tobacco alone, students with co-use also had a significant elevated odds of absenteeism (aOR 1.19, 95% CI 1.10-1.29) and lower grades (ß = -0.39, 95% CI -0.46 to -0.32). Similar results were found for students who ever used tobacco and cannabis. CONCLUSIONS: California youth who co-use tobacco and cannabis were most likely to have absenteeism and lower grades. Comprehensive efforts to prevent or reduce youth substance use may improve educational outcomes.

Serious psychological distress and higher associations with tobacco and cannabis use among college students in the United States.

OBJECTIVE: To examine associations between serious psychological distress (SPD) and tobacco and cannabis use among college students in the United States. METHODS: This cross-sectional study included 257,626 college students from the 2019-2022 National College Health Assessment survey. SPD was defined as having symptoms in the past month. Current tobacco (i.e., cigarettes, e-cigarettes) and cannabis use was defined as past month use. Multiple product use was categorized for single, dual, or triple products. Adjusted logistic regression models were used to examine associations between SPD, tobacco, cannabis, and multiple product use. RESULTS: SPD increased over time (18.4% to 23.8%) among students and nearly 30% of tobacco or cannabis users reported SPD. Cigarette, e-cigarette, or cannabis use was associated with about a 50-60% increased likelihood of reporting SPD than non-current use of each product, with the highest associations in Fall 2020. Triple product users had double the likelihood of reporting SPD, followed by dual users at 70% and single users at 47%, relative to non-current users. Daily users also had nearly twice the likelihood of reporting SPD, followed by non-daily users at 13-35%, relative to non-current users. CONCLUSIONS: College students have an increasing burden of SPD which is significantly associated with tobacco and cannabis use. There is a dose-response relationship between the number of tobacco and cannabis products used, as well as the frequency of use, and SPD among U.S. college students. Colleges addressing student mental health should prioritize the implementation of screening and treatment support for tobacco, cannabis, and multiple product use.

Flavored Tobacco Sales Restrictions and Youth E-cigarette Behavior: Impact by Tobacco Retailer Density in Diverse Communities in California.

INTRODUCTION: Factors that impact flavored tobacco sales restriction (flavor restrictions) effectiveness on youth e-cigarette behavior are unclear. Tobacco retailer density (retailer density) is a health equity issue with greater retailer density in high-minority, low-income areas. We examined the association between flavor restrictions and youth e-cigarette behavior by retailer density across diverse communities in the California Bay Area. AIMS AND METHODS: We analyzed data from the California Healthy Kids Survey using a difference-in-differences (DID) strategy. We compared pre- and post-policy changes in e-cigarette access and use one-year post-implementation among high school students in the Bay Area with a flavor restriction (n = 20 832) versus without (n = 66 126). Separate analyses were conducted for students in cities with low and high retailer density, with a median cutoff of 3.3 tobacco retailers/square mile. RESULTS: Students with high retailer density were more likely to identify as a minority and have parents with lower education. Among students with low retailer density, flavor restrictions were associated with 24% lower odds in the pre- to post-policy increase in ease of access relative to unexposed students (DID = 0.76, 95% CI: 0.58, 0.99). Among students with high retailer density, flavor restrictions were associated with 26% higher odds in ease of access (DID: 1.26, 95% CI: 1.02, 1.56) and 57% higher odds of current use (DID = 1.57, 95% CI: 1.31, 1.87). CONCLUSIONS: Flavor restrictions had positive impacts on youth e-cigarette access in low, but not high retailer density cities. From a health equity perspective, our results underscore how flavor restrictions may have uneven effects among vulnerable groups. IMPLICATIONS: In diverse communities in the California Bay Area, our results suggest a protective association between flavored tobacco sales restrictions and youth access to e-cigarettes in low, but not high tobacco retailer density cities one-year post-implementation. These results underscore how flavor restrictions may have uneven effects, and when implemented in high retailer density areas, may disproportionately place already vulnerable groups at heightened exposure to e-cigarette use and access. In high retailer density areas, additional tobacco control efforts may need to be included with flavor restriction implementation, such as increased education, youth prevention and cessation programs, policies to reduce tobacco retailer density, or stronger tobacco retailer enforcement or compliance monitoring.

Navigating Threats of Wildfires and Individual Rights to Adopt 100% Tobacco-Free Policy in Rural California Community Colleges.

BACKGROUND: In California, all four-year public colleges have adopted 100% smoke-/tobacco-free policies (TFP) whereas community colleges (CCs), particularly rural CCs, are less likely to have tobacco-free environments. This raises concerns about health equity, particularly because smoking prevalence is higher in rural areas compared to urban. We examined policy adoption barriers and facilitators for rural California CCs with the aim of providing lessons learned to support TFP adoption by rural CCs and improve conditions for student health and well-being. METHODS: A multiple case study of four CCs in California with (n = 2) and without (n = 2) TFPs was conducted. Semi-structured interviews with 12 campus and community stakeholders, school administrative data, and policy-relevant documents were analyzed at the case level with comparison across cases to identify key barriers, facilitators and campus-specific experiences. RESULTS: All four CCs shared similar barriers to policy adoption including concerns about wildfires, individual rights, and fear of marginalizing people who smoke on campus. These CCs have experienced serious wildfires in the last ten years, have high community smoking prevalence, and fewer school resources for student health. For the two tobacco-free CCs, long-term wildfire mitigation efforts along with leadership support, campus/community partnerships and a collective approach involving diverse campus sectors were essential facilitators in successful TFP adoption. CONCLUSION: Study results underscore contextual pressures and campus dynamics that impact tobacco control efforts at colleges in rural communities. Strategies to advance college TFP adoption and implementation should recognize rural cultural and community priorities.

Flavored Tobacco Sales Restrictions and Teen E-cigarette Use: Quasi-experimental Evidence From California.

INTRODUCTION: Flavored tobacco sales restrictions (FTSRs) are implemented to reduce access to flavored tobacco products. We examined the association between seven cities with local FTSRs implemented in 2018/2019 and e-cigarette use among high school students in the California Bay Area. AIMS AND METHODS: We analyzed data from the California Healthy Kids Survey using a difference-in-differences (D-I-D) strategy. We compared pre- and post-policy changes one year after implementation in current and ever e-cigarette use among students attending school in a city with a FTSR (exposed) (n = 20 832) versus without (unexposed) (n = 66 126). Other outcomes included ever marijuana use in an e-cigarette and ease of access to e-cigarettes. RESULTS: Pre- to post-policy, the adjusted odds of current and ever e-cigarette use did not significantly change among students exposed and unexposed to a FTSR. In the adjusted D-I-D analysis, the odds of current (aOR: 1.25, 95% CI: 0.95, 1.65) and ever e-cigarette use (aOR: 1.06, 95% CI: 0.89, 1.26) did not significantly change by exposure group. However, one year post-implementation, the odds of ease of access to e-cigarettes significantly increased among exposed (aOR: 1.57, 95% CI: 1.27, 1.95) and unexposed students (aOR: 1.54, 95% CI: 1.39, 1.70). Similarly, the odds of ever using marijuana in an e-cigarette significantly increased among exposed (aOR: 1.35, 95% CI: 1.19, 1.53) and unexposed students (aOR: 1.29, 95% CI: 1.20, 1.39). CONCLUSIONS: Local FTSRs in the California Bay Area were not associated with a change in e-cigarette use one year post-implementation. Increased ease of access and marijuana use may be explanatory factors. IMPLICATIONS: FTSRs were not associated with a decrease in current or ever e-cigarette use among high school students in the California Bay Area one-year post-implementation. Potential explanatory factors are that ease of access to e-cigarettes and using marijuana in an e-cigarette increased. More research is needed to understand the influence of these factors on youth access and behaviors. To address the youth e-cigarette epidemic, a comprehensive approach is needed, including policies, media campaigns, education programs, and cessation tools targeted to youth.

Current Smoking and Risk of Coronavirus Infection and Illness in a Highly Controlled Challenge Study: A Re-analysis of the British Cold Study.

INTRODUCTION: Meta-analyses have shown an association between smoking and the risk of Coronavirus Disease 2019 (COVID-19) disease severity, but the risk of smoking and coronavirus infection is less clear. AIMS AND METHODS: We re-analyzed data from the British Cold Study, a 1986-1989 challenge study that exposed 399 healthy adults to 1 of 5 "common cold" viruses (including n = 55 for coronavirus 229E). Participants with cotinine levels below 15 ng/mL (noncurrent smokers) were compared with participants with higher cotinine levels or self-reported smoking (current smokers). We calculated overall and coronavirus-specific unadjusted and adjusted relative risks (RRs) for current smoking and each outcome (infection and illness), and tested whether each association was modified by the type of respiratory virus. RESULTS: Current smokers had a higher adjusted risk than noncurrent smokers for infection (adjusted RR [aRR] = 1.12, 95% CI: 1.01, 1.25) and illness (aRR = 1.48, 95% CI: 1.11, 1.96). Neither association was modified by an interaction term for smoking and type of virus (infection: p = .44, illness: p = .70). The adjusted RR estimates specific to coronavirus 229E for infection (aRR = 1.22, 95% CI: .91, 1.63) and illness (RR = 1.14, 95% CI: .62, 2.08) were not statistically significant. CONCLUSIONS: These RRs provide estimates of the strength of associations between current smoking and infection and illness that can be used to guide tobacco control decisions. IMPLICATIONS: Systematic reviews and meta-analyses have found an association between smoking and COVID-19 disease severity, but fewer studies have examined infection and illness. The British Cold Study, a high-quality challenge study that exposed healthy volunteers to respiratory viruses including a coronavirus, provides an opportunity to estimate the RR for current smoking and infection and illness from coronaviruses and other viruses to guide tobacco control decisions. Compared with noncurrent smokers, current smokers had a 12% increased risk of having a laboratory-confirmed infection and a 48% increased risk of a diagnosed illness, which was not modified by the type of respiratory virus including a coronavirus.

A Proactive Outreach Strategy Using a Local Area Code to Refer Unassisted Smokers in a Safety Net Health System to a Quitline: A Pragmatic Randomized Trial.

INTRODUCTION: Proactive outreach offering tobacco treatment is a promising strategy outside of clinical settings, but little is known about factors for engagement. The study objective is to examine the impact of caller area code in a proactive, phone-based outreach strategy on consenting low-income smokers to a quitline e-referral. AIMS AND METHODS: This pragmatic randomized trial included unassisted adult smokers (n = 685), whose preferred language was English or Spanish, in a Los Angeles safety-net health system. Patients were randomized to receive a call from a local or generic toll-free area code. Log-binomial regression was used to examine the association between area code and consent to a quitline e-referral, adjusted for age, gender, language, and year. RESULTS: Overall, 52.1% of the patients were contacted and, among those contacted, 30% consented to a referral. The contact rate was higher for the local versus generic area code, although not statistically significant (55.6% vs. 48.7%, p = .07). The consent rate was higher in the local versus generic area code group (adjusted prevalence ratio 1.29, 95% CI 1.01-1.65) and also higher for patients under 61 years old than over (adjusted prevalence ratio 1.47, 95% CI 1.07-2.01), and Spanish-speaking than English-speaking patients (adjusted prevalence ratio 1.40, 95% CI 1.05-1.86). CONCLUSIONS: Proactive phone-based outreach to unassisted smokers in a safety net health system increased consent to a quitline referral when local (vs. generic) area codes were used to contact patients. While contact rate did not differ by area code, proactive phone-based outreach was effective for engaging younger and Spanish-speaking smokers. IMPLICATIONS: Population-based proactive phone-based outreach from a caller with a local area code to unassisted smokers in a safety net health system increases consent to an e-referral for quitline services. Findings suggest that a proactive phone-based outreach, a population-based strategy, is an effective strategy to build on the visit-based model and offer services to tobacco users, regardless of the motivational levels to quit.

Implementation, Maintenance, and Outcomes of an Electronic Referral to a Tobacco Quitline Across Five Health Systems.

INTRODUCTION: Electronic referral (e-referral) to quitlines helps connect tobacco-using patients to free, evidence-based cessation counseling. Little has been published about the real-world implementation of e-referrals across U.S. health systems, their maintenance over time, and the outcomes of e-referred patients. AIMS AND METHODS: Beginning in 2014, the University of California (UC)-wide project called UC Quits scaled up quitline e-referrals and related modifications to clinical workflows from one to five UC health systems. Implementation strategies were used to increase site readiness. Maintenance was supported through ongoing monitoring and quality improvement programs. Data on e-referred patients (n = 20 709) and quitline callers (n = 197 377) were collected from April 2014 to March 2021. Analyses of referral trends and cessation outcomes were conducted in 2021-2022. RESULTS: Of 20 709 patients referred, the quitline contacted 47.1%, 20.6% completed intake, 15.2% requested counseling, and 10.9% received it. In the 1.5-year implementation phase, 1813 patients were referred. In the 5.5-year maintenance phase, volume was sustained, with 3436 referrals annually on average. Among referred patients completing intake (n = 4264), 46.2% were nonwhite, 58.8% had Medicaid, 58.7% had a chronic disease, and 48.8% had a behavioral health condition. In a sample randomly selected for follow-up, e-referred patients were as likely as general quitline callers to attempt quitting (68.5% vs. 71.4%; p = .23), quit for 30 days (28.3% vs. 26.9%; p = .52), and quit for 6 months (13.6% vs. 13.9%; p = .88). CONCLUSIONS: With a whole-systems approach, quitline e-referrals can be established and sustained across inpatient and outpatient settings with diverse patient populations. Cessation outcomes were similar to those of general quitline callers. IMPLICATIONS: This study supports the broad implementation of tobacco quitline e-referrals in health care. To the best of our knowledge, no other paper has described the implementation of e-referrals across multiple U.S. health systems or how they were sustained over time. Modifying electronic health records systems and clinical workflows to enable and encourage e-referrals, if implemented and maintained appropriately, can be expected to improve patient care, make it easier for clinicians to support patients in quitting, increase the proportion of patients using evidence-based treatment, provide data to assess progress on quality goals, and help meet reporting requirements for tobacco screening and prevention.

Tobacco and Cannabis Use During and After Pregnancy in California.

OBJECTIVES: As the social and legal acceptance of cannabis use grows, health professionals must understand and mitigate the impact of cannabis use in the perinatal period. Here we compare the prevalence of tobacco and cannabis use during and after pregnancy in California, a state that recently legalized cannabis use. METHODS: Measures of tobacco and cannabis use during and after pregnancy were obtained from California's Maternal and Infant Health Assessment, an annual population-based survey of California resident women with a live birth. To allow analysis of county-level variation, we pooled data from the 35 counties with the largest numbers of births from 2017 to 2019. RESULTS: Cannabis use was more than twice as common as cigarette smoking among pregnant women (4.9% vs. 2.1%) in California. This difference was even more pronounced in some counties; for example, in Los Angeles, cannabis use was four times more prevalent than cigarette use. Either during or soon after birth, 7.3% of women in California reported cannabis use. Of those who smoked tobacco cigarettes prior to pregnancy, 73% quit before their third trimester of pregnancy, though 33.0% of these women reported a post-partum relapse in cigarette use. CONCLUSIONS: States that have legalized cannabis must attend to the increasing prevalence of perinatal cannabis use, as well as concurrent use with tobacco and other substances. Efforts to support cannabis cessation should draw from successful public health approaches in tobacco control.

Assessment and Counseling Gaps Among Former Smokers Eligible for Lung Cancer Screening in US Adults : A Cross-Sectional Analysis of National Health and Nutrition Examination Surveys (NHANES), 2013-2018.

BACKGROUND: Lung cancer screening (LCS) for former and current smokers requires that current smokers are counseled on tobacco treatment. In the USA, over 4 million former smokers are estimated to be eligible for LCS based on self-report for "not smoking now." Tobacco use and exposure can be measured with the biomarker cotinine, a nicotine metabolite reflecting recent exposure. OBJECTIVE: To examine predictors of tobacco use and exposure among self-reported former smokers eligible for LCS. DESIGN: Cross-sectional study using the 2013-2018 National Health and Nutrition Examination Survey. PARTICIPANTS: Former smokers eligible for LCS (n = 472). MAIN MEASURES: Recent tobacco use was defined as reported tobacco use in the past 5 days or a cotinine level above the race/ethnic cut points for tobacco use. Recent tobacco exposure was measured among former smokers without recent tobacco use and defined as having a cotinine level above 0.05 ng/mL. KEY RESULTS: One in five former smokers eligible for LCS, totaling 1,416,485 adults, had recent tobacco use (21.4%, 95% confidence interval (CI) 15.8%, 27.0%), with about a third each using cigarettes, e-cigarettes, or other tobacco products. Among former smokers without recent tobacco use, over half (53.0%, 95% CI: 44.6%, 61.4%) had cotinine levels indicating recent tobacco exposure. Certain subgroups had higher percentages for tobacco use or exposure, especially those having quit within the past 3 years or living with a household smoker. CONCLUSIONS: Former smokers eligible for LCS should be asked about recent tobacco use and exposure and considered for cotinine testing. Nearly 1.5 million "former smokers" eligible for LCS may be current tobacco users who have been missed for counseling. The high percentage of "passive smokers" is at least double that of the general nonsmoking population. Counseling about the harms of tobacco use and exposure and resources is needed.

Smoking behavior in 18-20 year-olds after tobacco 21 policy implementation in California: A difference-in-differences analysis with other states.

In June 2016, California implemented a Tobacco 21 (T21) policy that increased the minimum sale age of tobacco products from 18 to 21. This study examined the association between California's T21 policy and smoking behavior (ever, current, daily, and nondaily) in 18-20 year-olds using data from the 2012-2019 Behavioral Risk Factor Surveillance System (n = 15,863). The annual change in odds of smoking among 18-20 year-olds post-policy (July 2016-December 2019) was compared with the pre-policy period (January 2012 - June 2016) 1) within California and 2) compared with states without a T21 policy. As a sensitivity analysis, 21-23 year-olds in California were used as the referent. Difference-in-difference estimates (D-I-D) were calculated using adjusted logistic regression and compared the post to pre-policy change in trends in California to the referent groups. Before California's T21 policy, there was an 11% annual decrease in the odds of ever smoking among 18-20 year-olds in California and a 6% decrease in the referent states. After the policy, these trends did not change significantly. Results for current smoking were similar. For daily smoking, there was an 8% annual decrease before the policy and a 26% annual decrease after the policy among 18-20 year-olds in California; D-I-D estimates were 0.80 (95% CI: 0.57, 1.14) using referent states as the comparison and 0.62 (95% CI: 0.41, 0.95) using 21-23 year-olds in California as the comparison. There was an association between California's T21 policy and a decrease in daily smoking among 18-20 year-olds, compared with 21-23 year-olds, more than three years post-implementation.

The Development of a Web-Based Tobacco Tracker Tool to Crowdsource Campus Environmental Reports for Smoke and Tobacco-Free College Policies: Mixed Methods Study.

BACKGROUND: College campuses in the United States have begun implementing smoke and tobacco-free policies to discourage the use of tobacco. Smoke and tobacco-free policies, however, are contingent upon effective policy enforcement. OBJECTIVE: This study aimed to develop an empirically derived web-based tracking tool (Tracker) for crowdsourcing campus environmental reports of tobacco use and waste to support smoke and tobacco-free college policies. METHODS: An exploratory sequential mixed methods approach was utilized to inform the development and evaluation of Tracker. In October 2018, three focus groups across 2 California universities were conducted and themes were analyzed, guiding Tracker development. After 1 year of implementation, users were asked in April 2020 to complete a survey about their experience. RESULTS: In the focus groups, two major themes emerged: barriers and facilitators to tool utilization. Further Tracker development was guided by focus group input to address these barriers (eg, information, policing, and logistical concerns) and facilitators (eg, environmental motivators and positive reinforcement). Amongst 1163 Tracker reports, those who completed the user survey (n=316) reported that the top motivations for using the tool had been having a cleaner environment (212/316, 79%) and health concerns (185/316, 69%). CONCLUSIONS: Environmental concerns, a motivator that emerged in focus groups, shaped Tracker's development and was cited by the majority of users surveyed as a top motivator for utilization.

Moving toward a true depiction of tobacco behavior among Asian Indians in California: Prevalence and factors associated with cultural smokeless tobacco product use.

BACKGROUND: Asian Indians (AIs) in the United States exhibit disproportionate burdens of oral cancer and cardiovascular disease, which are potentially linked to smokeless tobacco. However, little is known about the use of cultural smokeless tobacco (CST) products in this population. METHODS: California Asian Indian Tobacco Use Survey data from 2004 (n = 1618) were used to investigate CST prevalence among California's AIs. CST products included paan, paan masala, and gutka. A multivariable logistic regression was conducted to examine factors (socioeconomic status, acculturation measures, and religious affiliation) associated with current CST use versus never use. RESULTS: The current CST prevalence was 13.0% (14.0% for men and 11.8% for women). In contrast, the prevalence of current cigarette use was 5.5% (8.7% for men and 1.9% for women), and the prevalence was lower for cultural smoked tobacco (0.1% for bidis and 0.5% for hookahs). Factors associated with CST use included the following: being male, being 50 years old or older, being an immigrant, speaking an AI language at home, having a higher level of education (adjusted odds ratio [AOR] for high school/some college, 2.6; 95% confidence interval [CI], 1.1-6.5; AOR for college degree or higher, 4.0; 95% CI, 1.7-9.5), having a higher income (AOR for $75,000-$100,000, 2.5; 95% CI, 1.3-4.7; AOR for ≥$100,000, 2.6; 95% CI, 1.4-5.0), identifying as non-Sikh (AOR for Hinduism, 10.0; 95% CI, 6.0-16.5; AOR for other faiths, 10.2; 95% CI, 5.9-17.7), and disagreeing that spiritual beliefs are the foundation of life (AOR, 2.1; 95% CI, 1.2-3.5). CONCLUSIONS: The current CST prevalence is relatively high among California's AIs in comparison with the prevalence of smoking, with narrower differences between sexes. The association with a higher socioeconomic status is contrary to typical cigarette smoking patterns. Acculturation and religious affiliation are important factors associated with current use. Health care providers and policymakers should consider such determinants for targeted interventions. Cancer 2018;124:1607-13. © 2018 American Cancer Society.

Impact of a cancer education seminar on knowledge and screening intent among Chinese Americans: Results from a randomized, controlled, community-based trial.

BACKGROUND: Cancer is the leading cause of death for Asian Americans. The authors evaluated the status of cancer prevention for Chinese Americans in San Francisco, which has had years of cancer prevention efforts. METHODS: Through a community-based clinic serving Chinese Americans, a randomized, controlled trial (n = 395) was conducted among participants who attended either a cancer prevention seminar or biospecimen education seminar. Changes in knowledge, attitudes, and screening completion/intent were measured across and between seminar groups. RESULTS: Participants were mostly women who had low acculturation and education levels. Over two-thirds to almost all participants knew about modifiable risk factors for cancer and that screening tests were available, including for lung cancer. The majority of women had already completed mammography and Papanicolaou (Pap) tests. Approximately one-half reported having completed colorectal cancer screening, prostate screening, or hepatitis B screening. Most were nonsmokers, but about one-half "strongly agreed" that they would want a test for tobacco smoke exposure. After the cancer prevention seminar, significant increases within group were noted for knowledge (eating healthy foods, from 93.1% to 97.7% [P = .0002]; secondhand smoke causes cancer, from 66.3% to 74.8% [P = .04]) and for screening completion/intent (colorectal cancer, from 58.1% to 64.5% [P = .002] cervical cancer, from 72.9% to 75.5% [P = .04]) and there was a trend toward an increase for prostate cancer (from 50.0% to 61.1%; P = .10). There was a significant change between groups for eating healthy foods (P = .004). CONCLUSIONS: The current reports documents the gains in cancer prevention among Cantonese-speaking Chinese Americans, fostered by academic, community, and public health efforts. A community-based seminar demonstrated improvement in some cancer knowledge or screening intent and opportunities for continued efforts. Cancer 2018;124:1622-30. © 2018 American Cancer Society.

Perspectives of Chinese American smoker and nonsmoker household pairs about the creating smokefree living together program.

BACKGROUND: Chinese men smoke at high rates, and this puts household members at risk for tobacco-related diseases. Culturally responsive interventions that provide education and support are needed to promote smokefree living and reduce smoke exposure, particularly for US immigrants who experience changes in smokefree social norms. This qualitative study examines perspectives of Chinese American smoker and nonsmoker household pairs in the Creating Smokefree Living Together program. METHODS: Four focus groups were conducted with 30 Chinese American participants (15 smokers and 15 nonsmokers) who, in household pairs, completed smokefree education interventions of either brief or moderate intensity. Nearly three-quarters of the smokers continued to smoke after the intervention at the time of focus group participation. All smokers were male, and most household nonsmokers were female spouses. All participants had limited English proficiency. Focus group meetings were recorded, and the recordings were translated and transcribed. Transcripts and field notes were thematically analyzed. RESULTS: The following themes, shared by smokers and nonsmokers across interventions, were identified: 1) there was a preference for dyadic and group interventions because of the support offered, 2) increased knowledge of the health harms of smoke exposure within a pair improved the nonsmoker's support for smokefree living, 3) learning communication strategies improved household relationships and assertiveness for smokefree environments, 4) biochemical feedback was useful but had short-term effects, and 5) project magnets provided cues to action. CONCLUSIONS: Involving household partners is critical to smokefree interventions. Simple reminders at home appear to be more powerful than personal biochemical feedback of smoke exposure for sustaining motivation and engagement in ongoing behavioral changes within the household. Cancer 2018;124:1599-606. © 2018 American Cancer Society.

A physician-initiated intervention to increase colorectal cancer screening in Chinese patients.

BACKGROUND: Among Chinese American individuals, only approximately 42% of cases of colorectal cancer (CRC) are diagnosed at an early stage, possibly because these patients are less likely than non-Hispanic white individuals to undergo CRC screening. METHODS: Primary care physicians (PCPs) were recruited from a local independent practice association serving Chinese Americans and randomized into early-intervention and delayed-intervention groups. PCPs in the early-intervention group received continuing medical education (CME), and their patients received an intervention mailer, consisting of a letter with the PCP's recommendation, a bilingual educational booklet, and a fecal occult blood test (FOBT) kit in year 1. PCPs in the delayed-intervention group received no CME, and their patients received the mailers in year 2. RESULTS: A total of 20 PCPs were assigned to the early-intervention and 22 PCPs to the delayed-intervention group. A total of 3120 patients of these participating PCPs who had undergone CRC screening that was due during the study period were included. A total of 915 mailers were sent in year 1 and 830 mailers were sent in year 2. FOBT screening rates increased from 26.7% at baseline to 58.5% in year 1 in the early-intervention group versus 19.6% at baseline to 22.2% in year 1 in the delayed-intervention group (P<.0001). The overall effect size of the mailer intervention with or without CME was estimated as a difference of 26.6 percentage points (95% confidence interval, 22.0-31.2 percentage points) from baseline compared with usual care. The intervention was found to have no impact on rates of colonoscopy or sigmoidoscopy. CONCLUSIONS: The results of the current pilot study demonstrated that a mailer including educational materials and FOBT kits can increase CRC screening rates with or without CME for the PCPs. Cancer 2018;124:1568-75. © 2018 American Cancer Society.

Impact of a smoke-free-living educational intervention for smokers and household nonsmokers: A randomized trial of Chinese American pairs.

BACKGROUND: Chinese American men smoke at a high rate, which puts household nonsmokers at risk. The objective of this study was to evaluate the effectiveness of a brief-intensity versus moderate-intensity smoke-free-living educational intervention for household pairs. METHODS: The authors conducted a randomized controlled trial of Cantonese-speaking Chinese American smoker and household nonsmoker pairs in San Francisco, California. Pairs were randomized to moderate-intensity or brief-intensity group sessions with their household partner. The moderate-intensity group received 2 group sessions, a laboratory report of their baseline smoke exposure, as measured by 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and 3 follow-up calls over 6 months. The brief-intensity group received 1 group session on tobacco-cessation resources. Primary outcomes were biochemically validated, past-month smoking abstinence and elimination of nonsmoker household exposure at 12 months. RESULTS: Participant pairs (n = 203) were male smokers, one-half of whom did not intend to quit within 6 months, with mostly female spouses as household nonsmokers. Approximately three-quarters of nonsmokers in both groups already had smoke-free home rules. At 12 months, smokers in both groups had similar biochemically validated 30-day abstinence rates (moderate-intensity group, 0%-20.7%; brief-intensity group, 0%-20.0%; P = .002 over time). More smokers in the moderate-intensity group used subsequent cessation group classes (moderate-intensity group, 50%; brief-intensity group, 24%; P = .004). Household nonsmokers in both groups had similar biochemically validated rates of no home exposure (moderate-intensity group, 24.5%-42.2%; brief-intensity group, 24.8%-33.3%; P = .0001 over time). CONCLUSIONS: A moderate-intensity smoke-free-living educational intervention for Chinese-speaking household pairs was not more effective than a brief-intensity intervention for smoking abstinence and elimination of household nonsmoker exposure. Abstinence rates were similar to those achieved with standard group counseling. Cancer 2018;124:1590-8. © 2018 American Cancer Society.

Knowledge of colorectal cancer screening guidelines and intention to obtain screening among nonadherent Filipino, Hmong, and Korean Americans.

BACKGROUND: Nonadherence to colorectal cancer (CRC) screening among Asian Americans is high but not well understood. This study examined correlates of screening intention among Filipino, Hmong, and Korean Americans who were nonadherent to CRC screening. METHODS: Using cross-sectional, preintervention survey data from 504 Asian Americans (115 Filipinos, 185 Hmong, and 204 Koreans) aged 50-75 years who were enrolled in a multisite cluster randomized controlled trial of lay health educator intervention, we analyzed correlates of self-reported CRC screening nonadherence, which was defined as not being up-to-date for fecal occult blood test, sigmoidoscopy, or colonoscopy. RESULTS: Only 26.8% of participants indicated intention to obtain screening within 6 months (Hmong: 12.4%; Korean: 30.8%; and Filipino: 42.6%; P < .001). Only one third of participants had undergone a prior screening, and a majority did not know that screening is a method of CRC prevention method (61.3%) or had any knowledge of CRC screening guidelines (53.4%). Multivariable analyses revealed that patient-provider ethnicity concordance, provider's recommendation of screening, participants' prior CRC screening, perceived severity and susceptibility of CRC, and knowledge of guidelines were positively associated with screening intention. Specifically, knowing one or more screening guidelines doubled the odds of screening intention (adjusted odds ratio, 2.38; 95% confidence interval, 1.32-4.28). Hmong were less likely to have screening intention than Filipinos, which was unexplained by socio-demographics, health care factors, perceived needs for CRC screening, or knowledge of screening guidelines. CONCLUSION: CRC screening intention among nonadherent Filipino, Hmong, and Korean Americans was low. Targeting knowledge of CRC screening guidelines may be effective strategies for increasing CRC screening intention among nonadherent Asian Americans. Cancer 2018;124:1560-7. © 2018 American Cancer Society.

Colorectal cancer beliefs, knowledge, and screening among Filipino, Hmong, and Korean Americans.

BACKGROUND: To the authors' knowledge, there are few studies to date regarding colorectal cancer (CRC) beliefs, knowledge, and screening among multiple Asian American populations, who are reported to have lower CRC screening rates compared with white individuals. The current study was performed to assess knowledge and beliefs regarding the causes of CRC, its prevention, and factors associated with CRC screening among 3 Asian American groups. METHODS: The authors conducted an in-language survey with Filipino (Honolulu, Hawaii), Hmong (Sacramento, California), and Korean (Los Angeles, California) Americans aged 50 to 75 years who were sampled through social networks. Bivariate and multivariable analyses were conducted to assess factors associated with CRC screening. RESULTS: The sample of 981 participants was 78.3% female and 73.8% reported limited proficiency in English. Few of the participants were aware that age (17.7%) or family history (36.3%) were risk factors for CRC; 6.2% believed fate caused CRC. Only 46.4% of participants knew that screening prevented CRC (74.3% of Filipino, 10.6% of Hmong, and 55.8% of Korean participants; P<.001). Approximately two-thirds of participants reported ever having undergone CRC screening (76.0% of Filipino, 72.0% of Hmong, and 51.4% of Korean participants; P<.001) and 48.6% were up to date for screening (62.2% of Filipino, 43.8% of Hmong, and 41.4% of Korean participants; P<.001). Factors found to be significantly associated with ever screening were being Korean (compared with Filipino), having a family history of CRC, having health insurance or a regular source of health care, and knowing that a fatty diet caused CRC. Believing that fate caused CRC and that praying prevented it were found to be negatively associated with ever screening. Factors associated with being up to date for CRC screening included being born in the United States, having a family history of CRC, and having access to health care. CONCLUSIONS: Knowledge regarding the causes of CRC and its prevention among Filipino, Hmong, and Korean individuals is low. However, health care access, not knowledge or beliefs, was found to be a key determinant of CRC screening. Cancer 2018;124:1552-9. © 2018 American Cancer Society.

Results of a lay health education intervention to increase colorectal cancer screening among Filipino Americans: A cluster randomized controlled trial.

BACKGROUND: Filipino colorectal cancer (CRC) screening rates fall below Healthy People 2020 goals. In this study, the authors explore whether a lay health educator (LHE) approach can increase CRC screening among Filipino Americans ages 50 to 75 years in Hawai'i. METHODS: A cluster randomized controlled trial from 2012 through 2015 compared an intervention, which consisted of LHEs delivering 2 education sessions and 2 telephone follow-up calls on CRC screening plus a CRC brochure versus an attention control, in which 2 lectures and 2 follow-up calls on nutrition and physical activity plus a CRC brochure were provided. The primary outcome was change in self-reported ever receipt of CRC screening at 6 months. RESULTS: Among 304 participants (77% women, 86% had > 10 years of residence in the United States), the proportion of participants who reported ever having received CRC screening increased significantly in the intervention group (from 80% to 89%; P = .0003), but not in the control group (from 73% to 74%; P = .60). After covariate adjustment, there was a significant intervention effect (odds ratio, 1.9; 95% confidence interval, 1.0-3.5). There was no intervention effect on up-to-date screening. CONCLUSIONS: This first randomized controlled trial for CRC screening among Hawai'i's Filipinos used an LHE intervention with mixed, but promising, results. Cancer 2018;124:1535-42. © 2018 American Cancer Society.