A comparison of methods to measure daily cigarillo consumption among adolescents and young adults.

OBJECTIVE: Cigarillo use is widespread among young people. Accurate assessment of cigarillo consumption is necessary to inform and evaluate tobacco research, but is complicated by product sharing and irregular use. This study compares a conventional approach with a detailed approach for measuring cigarillo consumption. METHODS: Data are drawn from a cross-sectional, web-based survey of 1089 young (aged 15-28 years) cigarillo smokers. The conventional measure of cigarillo consumption employs two common tobacco use items-the number of days a product was smoked in the past month and the average number of products smoked per day. The detailed measure uses a time line follow-back procedure to assess product use on each of the past 7 days, both in a group and alone. Paired t-tests compare daily cigarillo use estimates from the two methods overall, and are stratified by sample characteristics and behaviours; associations with multiple factors are examined simultaneously using linear regression. RESULTS: Compared with the conventional measure, the detailed measure yields significantly higher daily consumption estimates for moderate and high-level users and for non-daily tobacco users, and significantly lower estimates for those who always share products and daily tobacco users. Differences remain after controlling for demographics and product use behaviours. There are no differences by gender, age, race or multiple product use. CONCLUSIONS: The two measurement methods yield significantly different consumption estimates based on sharing behaviour, regularity of use and use level. Improving accuracy in the measurement of tobacco product consumption is important and timely for tobacco control research and policy.

Electronic medical record documentation of tobacco cessation support at eight community safety-net clinics with a high prevalence of tobacco use.

OBJECTIVES: The high prevalence of tobacco use at primary care safety-net clinics represents an opportunity to offer assistance with cessation. Documentation of smoking status, offering advice and medications, and referral to cessation services are important steps in supporting cessation attempts and are required elements by payors and accrediting agencies to demonstrate care quality. This study examines tobacco cessation support rates and patient characteristics using electronic medical record (EMR) data. METHODS: This cross-sectional study engaged eight community health centers affiliated with a county hospital system in NE Ohio where adult tobacco use rates exceed 30%. EMR data from June 2014 through May 2016 were analysed to assess rates of tobacco cessation counselling, order of cessation medications, or both. The association of tobacco cessation support with patient characteristics and quit attempts was assessed using multivariable logistic regression models. RESULTS: Among 21 702 current tobacco users, 74% had no intervention documented; 15.4% had counselling documented, 6.4% were prescribed tobacco cessation medication, and 4.2% had both documented. Males, those aged 18 to 34, and African Americans were more likely to have no documented intervention. Of current tobacco users with at least two visits, 5.6% had a quit attempt. Medication alone was associated with a greater likelihood of a quit attempt (AOR: 1.72 [95% CI: 1.36-2.17]) as well as counselling and medication combined (AOR: 1.95 [95% CI: 1.48-2.56]). CONCLUSIONS: Tobacco cessation support was lacking for 74% of current smokers and was less likely in subgroups including males, younger adults, and African Americans. Ordering tobacco cessation medication combined with counselling nearly doubled the likelihood of a quit attempt.

Cigarettes, Little Cigars, and Cigarillos: Initiation, Motivation, and Decision-Making.

Introduction: Cigarettes and little cigars and cigarillos (LCCs) are the most prevalent dual-use tobacco combination; one-third of cigarette smokers use LCCs. Risk factors for multiple tobacco product use have been reported; however, there is little understanding of why some individuals transition to and maintain multiple product use. In this study, we examine narratives of tobacco product initiation and decision-making among LCC-only and LCC-cigarette smokers. Methods: We audio-recorded in-depth interviews with 60 individuals, aged 14-28, who reported smoking more than or equal to 1 cigarillo per week; half also smoked cigarettes. Transcribed interviews were coded using a phenomenological approach to examine themes about smoking initiation, motivation, and product decision-making. Results: Among dual users, 60% began smoking LCCs before or at the same time as cigarettes, and 40% began smoking cigarettes first. Reasons for smoking cigarettes in addition to LCCs included easier access when experiencing craving and less time to smoke the product. Cigarette smokers reported first smoking LCCs in social contexts when sharing LCCs with other smokers, or when they could afford a single LCC but not a pack of cigarettes. LCC-only smokers reported not smoking cigarettes because of their expense, unpleasant taste and/or smell, and fear of becoming addicted. Conclusions: In this sample of current LCC users, half also used cigarettes. Product initiation order was almost evenly split, but reasons for initiating the second product differed, with immediacy of reducing cravings as a key reason for LCC users to smoke a cigarette and social and financial reasons for cigarette users to smoke an LCC. Implications: Understanding how and why dual use is initiated and sustained can inform policies to help prevent increased nicotine dependence and initiation of additional tobacco products. This study demonstrates that the beliefs, perceptions, and practices of LCC-only and dual users inform their product selection. Our findings point to the need to apply the strategies that have been effective at decreasing cigarette consumption to LCCs.

Perspective of older African-American and Non-Hispanic white breast cancer survivors from diverse socioeconomic backgrounds toward physical activity: A qualitative study.

BACKGROUND: We sought to explore the perspective of older breast cancer survivors (BCS) from diverse racial and socioeconomic backgrounds toward physical activity (PA) to inform the design of a PA program that fosters acceptability. METHODS: Participants included sixty women, ≥65years, within two years of treatment completion for stage I-III breast cancer. We purposely sampled ≥ten patients in each race [African-American (AA) and Non-Hispanic White (NHW)] and socioeconomic status (SES) [SES disadvantaged and SES non-disadvantaged] group. Participants completed in-person interviews (n=60) and follow-up focus groups (n=45). Thematic analyses were employed. RESULTS: The median age was 71.0years (range: 65-87years). Five themes emerged: 1) importance of PA; 2) current PA participants engaged in; 3) influence of race and culture on PA attitudes and beliefs; 4) barriers to PA and facilitators to PA; and 5) PA preferences. Barriers included health issues (43%), particularly cancer treatment side effects such as fatigue. Facilitators included religious faith (38%) and family (50%). Preferences included group exercise (97%) and strength training (80%) due to concerns participants had with diminished upper body strength after cancer treatment. Although AA (59%) and SES non-disadvantaged (78%) participants reported that race and culture influenced their attitudes toward PA, it did not translate to racial and SES differences in preferences. CONCLUSION: Among older BCS, physical activity preferences were shaped by cancer experience, rather than by race and SES. Physical activity programs for older BCS should focus on addressing cancer treatment-related concerns and should include strength training to ensure PA programs are more acceptable to older BCS.

The Social Context of Adolescent Co-Use of Cigarillos and Marijuana Blunts.

BACKGROUND: The use of cigarillos for smoking as a tobacco product and for making marijuana blunts is increasing among adolescents. Previous research has documented the co-use of these products, however little is known about the contextual features that generate and sustain this practice. OBJECTIVE: This study aims for a deeper understanding of why and how co-use of cigarillos and marijuana blunts occurs. METHODS: Between December 2015 and April 2016, we conducted in-depth interviews with 30 adolescents aged 14-18 who reported smoking ≥1 cigarillo per week. Semi-structured interviews were designed to capture participants' smoking products, practices, and preferences, as well as their beliefs and experiences about smoking. Interviews were audio-recorded and transcribed. Analysis was guided by a phenomenological approach designed to identify emergent themes. RESULTS: All participants reported smoking cigarillos for use as a tobacco product, averaging 13 per week. Twenty-five (83%) also reported using cigarillos to smoke marijuana blunts. A preference for group smoking and product sharing, and the belief that cigarillos extend the high of marijuana were found to promote the co-use of these products. Cigarillos were also found to be used as a substitute for blunts when marijuana was unavailable or when its use was being restricted or monitored. Conclusions/Importance: This analysis of adolescent cigarillo and marijuana co-use demonstrates how marijuana use can initiate, increase, and reinforce tobacco use. These findings can be used to inform public health education campaigns and other programs and policies aimed at reducing cigarillo and marijuana use by youth.

Understanding Nicotine Dependence and Addiction Among Young Adults Who Smoke Cigarillos: A Qualitative Study.

Introduction: Cigarillo use is increasing, particularly among young adults. Nicotine dependence (ND) is important for understanding smoking behavior and cessation, but the development of measures of ND has focused almost exclusively on cigarette smokers. We examined smoking patterns, preferences, and beliefs of cigarillo users to better understand their experience of addiction and expression of ND symptoms. Methods: Using purposive sampling, we conducted in-depth interviews between June 2015 and January 2016 with 30 young adults aged 18-28 who reported smoking ≥1 cigarillo per week. Interviews were based on a semi-structured guide designed to capture participants' smoking levels and patterns as well as their experiences of smoking and addiction. Interviews were audio-recorded and transcribed. Analysis was guided by a phenomenological approach designed to identify emergent themes. Results: Participants had a mean age of 23, with a majority being female (56%) and African American (80%). The median number of cigarillos smoked per week was 20; 70% also smoked cigarettes, and 43% also smoked marijuana blunts. Our analysis highlighted the complexity of measuring cigarillo use due to product manipulation, sharing, and multiple product use. Participants expressed a preference for smoking in a social group where cigarillos were shared, and not smoking an entire cigarillo at once when alone. Most cigarillo users did not consider themselves to be addicted. Conclusions: Cigarillo users express unique smoking practices and beliefs that signify the need for a more product-inclusive measure of ND, and can inform the development of tobacco cessation interventions tailored to cigarillo users. Implications: The increasing use of cigarillos among young adults has significant public health consequences. Addressing this issue requires accurate measurement and effective treatment of dependence on cigarillo products. The results of this study directly inform the development of a revised measure of ND, and can contribute to the efficacy of cessation interventions for cigarillo users.

The Role of Oncology Nurses in Discussing Clinical Trials.

PURPOSE/OBJECTIVES: To describe oncology nurses' experiences discussing clinical trials with their patients, and to assess barriers to these discussions.
. RESEARCH APPROACH: A qualitative study designed to elicit narratives from oncology nurses. 
. SETTING: Community- and academic-based oncology clinics throughout the United States.
. PARTICIPANTS: 33 oncology nurses involved in direct patient care in community-based and large hospital-based settings. The sample was drawn from members of the Oncology Nursing Society. 
. METHODOLOGIC APPROACH: In-depth interviews were conducted and analyzed using a immersion/crystallization approach to identify themes and patterns. The analyses highlight specific issues, examples, and contexts that present challenges to clinical trial discussions with patients.
. FINDINGS: Oncology nurses view their roles as patient educators and advocates to be inclusive of discussion of clinical trials. Barriers to such discussions include lack of knowledge and strategies for addressing patients' common misconceptions and uncertainty about the timing of discussions.
. INTERPRETATION: These data indicate that enabling nurses to actively engage patients in discussions of clinical trials requires educational interventions to build self-efficacy and close knowledge gaps. 
. IMPLICATIONS FOR NURSING: Oncology nurses can play a critical role in advancing cancer care by supporting patients in decision making about clinical trial participation. This will require training and education to build their knowledge, reduce barriers, and increase their self-efficacy to fulfill this responsibility in various clinical settings.

Primary Care Resident Training for Obesity, Nutrition, and Physical Activity Counseling: A Mixed-Methods Study.

National guidelines have been established to support the role of primary care physicians in addressing obesity. Preparing primary care residents to recognize and treat overweight/obesity has been identified as an essential component of postgraduate medical training that is currently lacking. This study aims to identify how primary care residency programs are preparing physicians to counsel about obesity, nutrition, and physical activity (ONPA) and to examine program members' perspectives regarding the place of ONPA counseling in the curriculum, and its relevance in primary care training. Using mixed methods, we collected and analyzed data on 25 family medicine, internal medicine, and obstetrics/gynecology residency programs across Ohio. Programs averaged 2.8 hours of ONPA-related didactics per year. Ten programs (42%) taught techniques for health behavior counseling. Having any ONPA-related didactics was associated with greater counseling knowledge (p = .01) among residents but poorer attitudes (p < .001) and poorer perceived professional norms (p = .004) toward ONPA counseling. Findings from interview data highlighted similar perceived barriers to ONPA counseling across all three specialties but variation in perception of responsibility to provide ONPA counseling. While widespread expectations that primary care physicians counsel their overweight and obese patients prevail, few residency programs provide training to support such counseling.

Primary Care Residents' Knowledge, Attitudes, Self-Efficacy, and Perceived Professional Norms Regarding Obesity, Nutrition, and Physical Activity Counseling.

BACKGROUND: Obesity and being overweight are both significant risk factors for multiple chronic conditions. Primary care physicians are in a position to provide health behavior counseling to the majority of US adults, yet most report insufficient training to deliver effective counseling for obesity. OBJECTIVE: To assess the degree to which residents training in adult primary care programs are prepared to provide obesity, nutrition, and physical activity (ONPA) counseling. METHODS: Senior residents (postgraduate year [PGY]-3 and PGY-4) from 25 Ohio family medicine, internal medicine, and obstetrics and gynecology programs were surveyed regarding their knowledge about obesity risks and effective counseling, as well as their attitudes, self-efficacy, and perceived professional norms toward ONPA counseling. We examined summary scores, and used regression analyses to assess associations with resident demographics and training program characteristics. RESULTS: A total of 219 residents participated (62% response rate). Mean ONPA counseling knowledge score was 50.8 (± 15.6) on a 0 to 100 scale. Specialty was associated with counseling self-efficacy (P < .001) and perceived norms (P = .002). Residents who reported having engaged in an elective rotation emphasizing ONPA counseling had significantly higher self-efficacy and more positive attitudes and professional norms scores. CONCLUSIONS: Our findings suggest that primary care residents' knowledge of ONPA assessment and management strategies has room for improvement. Attitudes, self-efficacy, and perceived norms also are low and vary by training program characteristics. A deeper understanding of curricula associated with improved performance in these domains could inform interventions to enhance residents' ONPA counseling skills and prevent chronic disease.

A randomized trial to evaluate primary care clinician training to use the Teachable Moment Communication Process for smoking cessation counseling.

OBJECTIVE: To implement and evaluate the impact of a Teachable Moment Communication Process (TMCP) training intervention on clinicians' smoking cessation counseling behaviors in practice. METHOD: Using a group randomized trial, 31 community-based, primary care clinicians in Northeast Ohio received either TMCP training or an attention control (2010-2012). TMCP training consisted of two, three-hour sessions involving didactic instruction, skill practice with standardized patients, and coaching. Clinician performance of TMCP elements was assessed by coding audio-recordings of routine visits with smokers at baseline and post-intervention (n=806). RESULTS: Baseline performance of all TMCP elements was similar in the two groups. After the intervention, TMCP-trained clinicians were more often observed advising patients to quit while linking smoking to the patient's concern (58% vs. 44%, p=0.01), expressing optimism (36% vs. 3%, p<0.001), expressing partnership (40% vs. 12%, p=0.003) and eliciting the patient's readiness to quit (84% vs. 65%, p=0.006) than clinicians in the comparison group. TMCP-trained clinician responses were also better aligned with patients' expressed readiness to quit smoking than comparison group clinicians (p<0.001). CONCLUSION: The intervention significantly changed the content of clinicians' smoking cessation communication in ways consistent with the TMCP model for health behavior change.

Teachable moments for health behavior change and intermediate patient outcomes.

OBJECTIVE: Teachable moments (TM) are opportunities created through physician-patient interaction and used to encourage patients to change unhealthy behaviors. We examine the effectiveness of TMs to increase patients' recall of advice, motivation to modify behavior, and behavior change. METHODS: A mixed-method observational study of 811 patient visits to 28 primary care clinicians used audio-recordings of visits to identify TMs and other types of advice in health behavior change talk. Patient surveys assessed smoking, exercise, fruit/vegetable consumption, height, weight, and readiness for change prior to the observed visit and 6-weeks post-visit. RESULTS: Compared to other identified categories of advice (i.e. missed opportunities or teachable moment attempts), recall was greatest after TMs occurred (83% vs. 49-74%). TMs had the greatest proportion of patients change in importance and confidence and increase readiness to change; however differences were small. TMs had greater positive behavior change scores than other categories of advice; however, this pattern was statistically non-significant and was not observed for BMI change. CONCLUSION: TMs have a greater positive influence on several intermediate markers of patient behavior change compared to other categories of advice. PRACTICE IMPLICATIONS: TMs show promise as an approach for clinicians to discuss behavior change with patients efficiently and effectively.

A Teachable Moment Communication Process for smoking cessation talk: description of a group randomized clinician-focused intervention.

BACKGROUND: Effective clinician-patient communication about health behavior change is one of the most important and most overlooked strategies to promote health and prevent disease. Existing guidelines for specific health behavior counseling have been created and promulgated, but not successfully adopted in primary care practice. Building on work focused on creating effective clinician strategies for prompting health behavior change in the primary care setting, we developed an intervention intended to enhance clinician communication skills to create and act on teachable moments for smoking cessation. In this manuscript, we describe the development and implementation of the Teachable Moment Communication Process (TMCP) intervention and the baseline characteristics of a group randomized trial designed to evaluate its effectiveness. METHODS/DESIGN: This group randomized trial includes thirty-one community-based primary care clinicians practicing in Northeast Ohio and 840 of their adult patients. Clinicians were randomly assigned to receive either the Teachable Moments Communication Process (TMCP) intervention for smoking cessation, or the delayed intervention. The TMCP intervention consisted of two, 3-hour educational training sessions including didactic presentation, skill demonstration through video examples, skills practices with standardized patients, and feedback from peers and the trainers. For each clinician enrolled, 12 patients were recruited for two time points. Pre- and post-intervention data from the clinicians, patients and audio-recorded clinician‒patient interactions were collected. At baseline, the two groups of clinicians and their patients were similar with regard to all demographic and practice characteristics examined. Both physician and patient recruitment goals were met, and retention was 96% and 94% respectively. DISCUSSION: Findings support the feasibility of training clinicians to use the Teachable Moments Communication Process. The next steps are to assess how well clinicians employ these skills within their practices and to assess the effect on patient outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01575886.