Data envelopment analysis to evaluate the efficiency of tobacco treatment programs in the NCI Moonshot Cancer Center Cessation Initiative.

BACKGROUND: The Cancer Center Cessation Initiative (C3I) is a National Cancer Institute (NCI) Cancer Moonshot Program that supports NCI-designated cancer centers developing tobacco treatment programs for oncology patients who smoke. C3I-funded centers implement evidence-based programs that offer various smoking cessation treatment components (e.g., counseling, Quitline referrals, access to medications). While evaluation of implementation outcomes in C3I is guided by evaluation of reach and effectiveness (via RE-AIM), little is known about technical efficiency-i.e., how inputs (e.g., program costs, staff time) influence implementation outcomes (e.g., reach, effectiveness). This study demonstrates the application of data envelopment analysis (DEA) as an implementation science tool to evaluate technical efficiency of C3I programs and advance prioritization of implementation resources. METHODS: DEA is a linear programming technique widely used in economics and engineering for assessing relative performance of production units. Using data from 16 C3I-funded centers reported in 2020, we applied input-oriented DEA to model technical efficiency (i.e., proportion of observed outcomes to benchmarked outcomes for given input levels). The primary models used the constant returns-to-scale specification and featured cost-per-participant, total full-time equivalent (FTE) effort, and tobacco treatment specialist effort as model inputs and reach and effectiveness (quit rates) as outcomes. RESULTS: In the DEA model featuring cost-per-participant (input) and reach/effectiveness (outcomes), average constant returns-to-scale technical efficiency was 25.66 (SD = 24.56). When stratified by program characteristics, technical efficiency was higher among programs in cohort 1 (M = 29.15, SD = 28.65, n = 11) vs. cohort 2 (M = 17.99, SD = 10.16, n = 5), with point-of-care (M = 33.90, SD = 28.63, n = 9) vs. no point-of-care services (M = 15.59, SD = 14.31, n = 7), larger (M = 33.63, SD = 30.38, n = 8) vs. smaller center size (M = 17.70, SD = 15.00, n = 8), and higher (M = 29.65, SD = 30.99, n = 8) vs. lower smoking prevalence (M = 21.67, SD = 17.21, n = 8). CONCLUSION: Most C3I programs assessed were technically inefficient relative to the most efficient center benchmark and may be improved by optimizing the use of inputs (e.g., cost-per-participant) relative to program outcomes (e.g., reach, effectiveness). This study demonstrates the appropriateness and feasibility of using DEA to evaluate the relative performance of evidence-based programs.

Developing a Collaborative, Team-Based Smoking Cessation Treatment Program in an Outpatient Oncology Setting.

PURPOSE: Because clinical specialists often lack time and training to address secondary health issues such as smoking cessation, the National Cancer Institute Cancer Center Cessation Initiative (C3I) has mobilized cancer centers to develop systems for treating patients' tobacco dependence. METHODS: One university-based cancer center was able to develop a program that formalized smoking treatment using a collaborative, multidisciplinary care team with overlapping expertise in cancer care, medication management, and tobacco cessation. Program planners delivered tobacco cessation services in the outpatient setting by automating identification of eligible patients using a tobacco registry in the electronic health records, directly involving oncology pharmacists in medication oversight, using dedicated tobacco treatment specialists to provide cessation services, and engaging oncologists through active communications protocols. Evaluators used Practical Robust Implementation and Sustainability Model as the guiding framework for a qualitative assessment of program development and implementation. Evaluators also measured provider satisfaction and utilization of services, program reach, and smoking cessation outcomes 6 months post enrollment. RESULTS: During the evaluation period (July 1, 2018-September 30, 2019), the smoking cessation program engaged 96% of eligible patients (n = 214 of 223 eligible); 82% of those enrolled in the program (n = 183). At 6-month follow-up, 29.1% of enrolled patients self-reported 30-day point prevalence abstinence (n = 53) and 34.9% (n = 64) reported 7-day point prevalence abstinence (intent-to-treat rates). CONCLUSION: Using a team-based approach that leverages individual expertise and interprofessional collaboration to provide patient-centered treatment, a smoking cessation program can identify and treat eligible patients in specialty clinics.

A cross-sectional national survey to explore the relationship between smoking and political abstention: Evidence of social mistrust as a mediator.

RATIONALE: Smoking prevalence is well known to vary socioeconomically but has been less studied in relation to political participation. Growing evidence suggests that health disparities and political nonparticipation are intertwined, but the underlying mechanism is unclear. OBJECTIVE: We investigated the relationship between smoking and voter registration, testing various forms of trust as possible mediators, in U.S. national survey data collected around the 2012 presidential election. METHODS: A random half (n = 9757) of adults who completed The Attitudes and Behaviors Survey on Health (TABS) in 2012 (response rate was 58.4% for landline and 24.3% for cell phone) also answered a section on voter registration, voting behavior, and trust in people and selected institutions. Multivariable logistic regression was used to examine the association between smoking and registering to vote and potential mediation by trust in people and various institutions, adjusted for covariates known to be associated with both. Analyses used design-based methods with weights to account for sampling probabilities, nonresponse, and calibration to the U.S. adult population in 2012. RESULTS: Compared with nonsmokers, daily smokers had significantly lower adjusted odds of being registered to vote (aOR: 0.33, 95% CI: 0.21-0.52) and higher adjusted odds of having low trust in people (aOR: 2.50, 95% CI: 1.29-4.83). Low trust in people predicted lower odds of registering to vote (aOR: 0.55, 95% CI: 0.36 to 0.84) and partially mediated the smoking-registration relationship. CONCLUSION: Lower electoral participation among daily smokers is partly attributable to lower trust in people, a factor that could also affect willingness to use cessation support resources such as quitlines. Low trust and low political participation among daily smokers may have important political and public health consequences.

Mixed-methods economic evaluation of the implementation of tobacco treatment programs in National Cancer Institute-designated cancer centers.

BACKGROUND: The Cancer Center Cessation Initiative (C3I) was launched in 2017 as a part of the NCI Cancer Moonshot program to assist NCI-designated cancer centers in developing tobacco treatment programs for oncology patients. Participating centers have implemented varied evidence-based programs that fit their institutional resources and needs, offering a wide range of services including in-person and telephone-based counseling, point of care, interactive voice response systems, referral to the quitline, text- and web-based services, and medications. METHODS: We used a mixed methods comparative case study design to evaluate system-level implementation costs across 15 C3I-funded cancer centers that reported for at least one 6-month period between July 2018 and June 2020. We analyzed operating costs by resource category (e.g., personnel, medications) concurrently with transcripts from semi-structured key-informant interviews conducted during site visits. Personnel salary costs were estimated using Bureau of Labor Statistics wage data adjusted for area and occupation, and non-wage benefits. Qualitative findings provided additional information on intangible resources and contextual factors related to implementation costs. RESULTS: Median total monthly operating costs across funded centers were $11,045 (range: $5129-$20,751). The largest median operating cost category was personnel ($10,307; range: $4122-$19,794), with the highest personnel costs attributable to the provision of in-person program services. Monthly (non-zero) cost ranges for other categories were medications ($17-$573), materials ($6-$435), training ($96-$516), technology ($171-$2759), and equipment ($10-$620). Median cost-per-participant was $466 (range: $70-$2093) and cost-per-quit was $2688 (range: $330-$9628), with sites offering different combinations of program components, ranging from individually-delivered in-person counseling only to one program that offered all components. Site interviews provided context for understanding variations in program components and their cost implications. CONCLUSIONS: Among most centers that have progressed in tobacco treatment program implementation, cost-per-quit was modest relative to other prevention interventions. Although select centers have achieved similar average costs by offering program components of various levels of intensity, they have varied widely in program reach and effectiveness. Evaluating implementation costs of such programs alongside reach and effectiveness is necessary to provide decision makers in oncology settings with the important additional information needed to optimize resource allocation when establishing tobacco treatment programs.

A Pilot Study and Ecological Model of Smoking Cues to Inform Mobile Health Strategies for Quitting Among Low-Income Smokers.

One crucial factor that leads to disparities in smoking cessation between groups with higher and lower socioeconomic status is more prevalent socioenvironmental smoking cues in low-income communities. Little is known about how these cues influence socioeconomically disadvantaged smokers in real-world scenarios and how to design interventions, especially mobile phone-based interventions, to counteract the impacts of various types of smoking cues. We interviewed 15 current smokers living in low-income communities and scanned their neighborhoods to explore smoking-related experiences and identify multilevel cues that may trigger them to smoke. Findings suggest four major types of smoking cues influence low-income smokers-internal, habitual, social, and environmental. We propose an ecological model of smoking cues to inform the design of mobile health (mHealth) interventions for smoking cessation. We suggest that user-triggered strategies will be most useful to address internal cues; server-triggered strategies will be most suitable in changing perceived social norms of smoking and routine smoking activities to address social and habitual cues; and context-triggered strategies will be most effective for counteracting environmental cues. The pros and cons of each approach are discussed regarding their cost-effectiveness, the potential to provide personalized assistance, and scale.

Asking for Identification and Retail Tobacco Sales to Minors.

BACKGROUND AND OBJECTIVES: A previous single-county study found that retail stores usually asked young-looking tobacco customers to show proof-of-age identification, but a large proportion of illegal tobacco sales to minors occurred after the customers had shown identification proving they were too young to purchase tobacco. We sought to investigate these findings on a larger scale. METHODS: We obtained state reports for federal fiscal years 2017 and 2018 from a federal agency that tracks tobacco sales to supervised minors conducting compliance checks in retail stores. We used descriptive and multivariable logistic regression methods to determine (1) how often stores in 17 states requested identifications, (2) what proportion of violations occurred after identification requests, and (3) if violation rates differed when minors were required versus forbidden to carry identification. RESULTS: Stores asked minors for identification in 79.6% (95% confidence interval: 79.3%-80.8%) of compliance checks (N = 17 276). Violations after identification requests constituted 22.8% (95% confidence interval: 20.0%-25.6%; interstate range, 1.7%-66.2%) of all violations and were nearly 3 times as likely when minors were required to carry identification in compliance checks. Violations were 42% more likely when minors asked for a vaping product versus cigarettes. CONCLUSIONS: Stores that sell tobacco to underage customers are more likely to be detected and penalized when youth inspectors carry identification during undercover tobacco sales compliance checks. The new age-21 tobacco sales requirement presents an opportunity to require identifications be carried and address other long-standing weaknesses in compliance-check protocols to help combat the current adolescent vaping epidemic.

Impact of an incentive-based prenatal smoking cessation program for low-income women in Colorado.

OBJECTIVE: To assess birth outcomes and cost-savings of an incentive-based prenatal smoking cessation program targeting low-income women in Colorado. DESIGN: Prospective observational cohort with nonequivalent population control groups. SAMPLE: Program participants (n = 2,231) linked to the birth certificate to ascertain birth outcomes compared to two reference populations from Pregnancy Risk Assessment Monitoring System (PRAMS) and Colorado live births based on the birth certificate. MEASUREMENTS: Tobacco cessation metrics in the third trimester of pregnancy, neonatal low birth weight (<2,500 g), preterm birth (birth at <37 weeks gestation), neonatal intensive care unit (NICU) admission and maternal gestational hypertension. Cost-savings and return on investment (ROI) were projected using average Medicaid reimbursement. RESULTS: Infants of mothers enrolled in the program had a lower risk of low birthweight (RR = 0.86; 95% CI = 0.75, 0.97), preterm birth (PTB) (RR = 0.76; 95% CI = 0.65, 0.88) and neonatal intensive care unit (NICU) admission (RR = 0.76; 95% CI = 0.66, 0.88) compared to the birth certificate population, corresponding to a ROI of $7.73 and an individual cost savings of $6,040. Compared to PRAMS, infants of enrolled mothers had a lower risk of PTB (RR = 0.72; 95% CI = 0.53, 0.99) and NICU admission (RR = 0.45; 95% CI = 0.32, 0.62), corresponding to an ROI of $2.79 and an individual cost savings of $2,182. CONCLUSIONS: We found a reduction of adverse birth outcomes, and cost savings.

Association of Marijuana, Mental Health, and Tobacco in Colorado.

OBJECTIVES: Marijuana's evolving legality may change marijuana use patterns in adults. Co-use of marijuana and tobacco are strongly associated, and populations with mental health disorders are disproportionately likely to use either substance, but neither association has been assessed in the context of legal recreational marijuana. We assessed the associations of tobacco smoking with marijuana use and with mental health disorders in Colorado in 2015. METHODS: Data came from a population-based survey of adults (n = 8023). Multiple logistic regressions were used with current tobacco smoking as the primary outcome. Past 30-day marijuana use and mental health status were the independent variables of interest. Covariates included age, sex, ethnicity, poverty level, and education. RESULTS: Adults who used marijuana in the past 30 days had 3.4 (95% confidence interval [CI] 2.7, 4.2) greater odds of currently smoking tobacco compared to adults who had not recently used marijuana, after adjusting for sociodemographic and economic factors. A mental health disorder was independently associated with tobacco smoking (adjusted odds ratio [OR] 1.7, 95% CI 1.4, 2.1). Prevalence of co-use among adults self-reporting a mental health disorder was significantly higher compared those without a mental health disorder (11.1% vs 4.3%; P < 0.0001). CONCLUSIONS: This study examined the associations between mental health, marijuana use, and tobacco smoking after the legalization of recreational marijuana in Colorado. Adults using marijuana and/or self-reporting a mental health disorder were more likely to smoke tobacco and should be targeted for cessation interventions.

Modes of Marijuana Consumption Among Colorado High School Students Before and After the Initiation of Retail Marijuana Sales for Adults.

OBJECTIVE: This study aimed to estimate the prevalence of different modes of marijuana consumption (e.g., smoking, ingesting) overall and by sociodemographic factors, marijuana-related perceptions, and other substance use among adolescents, as well as to characterize differences in the usual mode of consumption before and after the initiation of retail marijuana sales in 2014. METHOD: Data are from the 2013 and 2015 administrations of the Healthy Kids Colorado Survey, a cross-sectional, school-based survey. We included 9th-12th grade students who reported past-30-day marijuana use in 2013 (n = 2,792; 44.8% female) or 2015 (n = 1,664; 48.9% female). We estimated the prevalence of any past-month use of each mode in 2015 and usual mode of consumption the past month in both years. We tested differences by year, sociodemographics, marijuana-related perceptions, and other substance use using Rao-Scott chi-square tests and multivariable logistic regression. RESULTS: The prevalence of past-month marijuana use was 20.7% in both years. In 2015, 39.8% of students reported using multiple modes in the past month. Use of any mode other than smoking and use of multiple modes differed by sociodemographics, marijuana-related perceptions, and other substance use. Smoking remained the most common usual mode in 2015. The prevalence of usually ingesting significantly decreased from 4.7% to 2.1% between years, whereas "other mode(s)" significantly increased from 4.0% to 6.0%. CONCLUSIONS: The use of multiple modes of marijuana consumption was prevalent among adolescents in Colorado. The usual mode of consumption changed in years before and after the implementation of retail marijuana sales, suggesting the need for continued surveillance.

Adolescent Marijuana Use, Marijuana-Related Perceptions, and Use of Other Substances Before and After Initiation of Retail Marijuana Sales in Colorado (2013-2015).

Due to the recentness of changes to marijuana policies in a number of states, the effect on adolescent use and perceptions is not yet well understood. This study examines change in adolescent marijuana use and related perceptions in Colorado, before and after the implementation of legal commercial sale of recreational marijuana for adults starting on January 1, 2014. The data are from a repeated cross-sectional survey of a representative sample of Colorado high school students, with separately drawn samples surveyed in fall 2013 (prior to implementation) and fall 2015 (18 months after implementation). We examined change in the prevalence of adolescent marijuana use, measured by lifetime use, past 30-day use, frequent use, and use on school property. To consider the possibility of heterogeneity in the change in marijuana use, we examined change in past 30-day marijuana use by demographic characteristics (sex, grade, race/ethnicity), school characteristics (poverty, percent minority), urbanicity of the school district, and whether the city or county permitted retail marijuana stores. There was an absence of significant effects for change in lifetime or past 30-day marijuana use. Among those reporting past 30-day use, frequent use and use on school property declined. There was a significant decline in the perceived harm associated with marijuana use, but we did not find a significant effect for perceived wrongfulness, perceived ease of access, or perceived parental disapproval. We did not find significant variability in past 30-day use by demographic characteristics or by school and community factors from 2013 to 2015. We did not find a significant effect associated with the introduction of legal sales of recreational marijuana to adults in Colorado on adolescent (illegal) use, but ongoing monitoring is warranted, including consideration of heterogeneity in the effects of marijuana policies.

Assessment of the US Federal Retailer Violation Rate as an Estimate of the Proportion of Retailers That Illegally Sell Tobacco to Adolescents.

Importance: Despite progress against tobacco sales to minors, retailers continue to violate state and federal laws and supply adolescent smokers with tobacco products. Government-sanctioned surveys underestimate the extent of the problem, and retailer associations use these data to block stricter enforcement policies. Objectives: To assess the validity of the US federal retailer violation rate (RVR) as an estimate of the proportion of retailers that sell tobacco to minors and to investigate what proportion always or almost always sells vs refuses to sell cigarettes to minors. Design, Setting, and Participants: This survey study was conducted October 6, 2012, to September 8, 2013; data were analyzed between September 28, 2017, and March 21, 2018. The setting was a suburban county adjacent to Denver, Colorado. Participants were a systematically selected, population-based cluster sample of retailers that stock cigarettes for sale. Retailers were masked to the survey. Main Outcomes and Measures: Each retailer was visited 6 times by supervised minors who attempted to purchase cigarettes at each visit. The main outcome was whether cigarettes were sold. Other measures included whether government-issued photo identification (ID) was requested as required by law, how ID was examined, and what the demographic characteristics of study minors and clerks were. Results: The sample of 201 retailers (44.8% of the 449 listed population) included convenience stores (n = 77), liquor stores (n = 63), grocery stores/supermarkets (n = 33), pharmacies (n = 17), tobacco stores (n = 7), and stand-alone gas stations (n = 4). Bars, clubs, and adult establishments were excluded. A total of 1181 purchase attempts were analyzed; 25 (2.1%) were excluded for missing data. The mean RVR across 6 rounds of checks was 18.0% (95% CI, 14.7%-21.2%) and ranged from 13.7% to 28.0% per round. Most retailers (54.7% [110 of 201]) violated at least once in 6 visits, 26.4% (53 of 201) violated at least twice, and 11.9% (24 of 201) violated half or more times. How retailers examined proof of age largely determined whether violations occurred. Conclusions and Relevance: The proportion of retailers that sold cigarettes to a minor at least once in 6 attempts was 3 times higher than the mean RVR based on a single inspection per retailer. Larger replication studies are needed. Enforcement protocols should reflect the fact that each retailer does not respond consistently when adolescents try to buy tobacco products, and many retailers are not properly validating ID that shows proof of age.

Nicotine Sales to Minors: Store-Level Comparison of E-Cigarette Versus Cigarette Violation Rates.

Introduction: In recent years, e-cigarettes overtook cigarettes as the leading tobacco product used by US adolescents. Most states, as well as federal regulations, have added e-cigarettes to laws prohibiting tobacco products sales to minors. We tested compliance with the newer regulation among Colorado urban retail businesses, speculating that violations might be more common for e-cigarettes than smokable cigarettes. Methods: Supervised minors visited a random sample of urban businesses and sequentially attempted to purchase an e-cigarette product and cigarettes. The protocol prescribed that the same minor make both attempts in each business, separated by at least a day to minimize influence of the first result on the second result. Data were collected during May 2014-January 2015. Results: Among 238 businesses, more than one-fourth (26.1%; 95% confidence interval (CI), 18.9%-33.2%) sold at least one type of product, and 6.3% (CI, 1.8%-10.8%) sold both types. Violation rates were similar for e-cigarette products and cigarettes (17.6% vs. 14.7%, p = n.s.). Conclusion: Enforcement to prevent retail tobacco sales to adolescents should include e-cigarette products. Dual testing of stores indicates that single visits underestimate the problem of underage tobacco sales. Implications: Adolescents can buy e-cigarettes from retail stores as easily as they buy cigarettes. Enforcement of tobacco sales laws should include e-cigarettes, and test-retest protocols are needed to estimate the true extent of the problem.

Where the U.S. tobacco epidemic still rages: Most remaining smokers have lower socioeconomic status.

OBJECTIVE: We estimated the proportion of U.S. smokers who have low socioeconomic status (SES). METHODS: We used 2012 data from a national supplement to The Attitudes and Behaviors Survey on Health (TABS), a periodic population survey of Colorado adults. We estimated smoking prevalence and total smokers by education, poverty level, occupation, health insurance status, and combinations of these factors. RESULTS: Smoking prevalence across low-SES categories ranged from 24.3% to 42.6%. Combining low-SES categories with the highest smoking prevalence accounted for 31.1% of U.S. adults but half (50.1%) of smokers. Combining all low-SES categories regardless of smoking prevalence accounted for roughly half (53.3%) of adults but nearly three-fourths (72.2%) of smokers. CONCLUSIONS: A majority of continuing U.S. smokers have low SES. Further progress against the U.S. cigarette epidemic depends on focusing tobacco research and program initiatives on reaching and engaging these smokers in cessation strategies that work for them.

Usual Modes of Marijuana Consumption Among High School Students in Colorado.

OBJECTIVE: The purpose of this study was to assess the prevalence of modes of marijuana consumption among Colorado youth and explore variation by demographics, access, substance use, and risk perceptions. METHOD: Data are from a 2013 survey of Colorado high school students (N = 25,197; 50.5% female). The outcome variable was usual mode of marijuana consumption (i.e., smoking, vaporizing, ingesting edibles, or other) among those reporting past 30-day marijuana use. Classification variables included sex, grade level, race/ethnicity, sexual orientation, current alcohol and cigarette use, frequent marijuana use, early marijuana use (<13 years), perceived harmfulness, and perceived wrongfulness. We calculated prevalence estimates overall and by the variables listed above, and also conducted multinomial logistic regression models. RESULTS: Findings indicate that 15% of Colorado high school students who use marijuana report that they usually use a mode of consumption other than smoking. Among students reporting past 30-day marijuana use, 85% said smoking was their usual mode of consumption. The remainder reported that their usual mode of consumption was vaporizing (6%), ingesting edibles (5%), or another method (4%). Boys, Whites, Asians, and 12th graders were the most likely to report vaporizing. High perceived harmfulness was associated with vaporizing or ingesting edibles. CONCLUSIONS: The majority of Colorado youth who use marijuana usually smoke it. Youth may be using vaporizers and ingesting edibles as a way to reduce the harm associated with inhaling combusted smoke.

Smoking-Cessation Treatment: Use Trends Among Non-Hispanic White and English-Speaking Hispanic/Latino Smokers, Colorado 2001-2012.

INTRODUCTION: Most smokers who try to quit do not use an evidence-based treatment (EBT), and in 2001, Hispanic/Latino quit-attempters were about half as likely as non-Hispanic white (NHW) quit-attempters to use one. This study analyzed the patterns of EBT use in Colorado across a recent decade, 2001-2012. METHODS: Data were from The Attitudes and Behaviors Survey, a random cross-sectional population-level telephone survey. Data included NHW and English-speaking Hispanic/Latino respondents from 2001 (n=11,872), 2005 (n=10,952), 2008 (n=12,323), and 2012 (n=13,265). Statistical analyses were conducted in 2014-2015. EBT measures included nicotine-replacement therapy, prescription cessation medication, telephone quit-line coaching, and other counseling. Bivariate and multiple logistic regression analyses evaluated associations across years between EBT use and ethnicity, adjusting for covariates. RESULTS: Any EBT use increased with each successive survey year, and the relative increase from 2001 to 2012 was greater among Hispanic/Latino than NHW quit-attempters (75.7% vs 38.7%). However, adjusted for covariates, Hispanic/Latino quit-attempters in 2012 were still 54% less likely to use any EBT (AOR=0.46, 95% CI=0.34, 0.63), 45% less likely to use nicotine-replacement therapy (AOR=0.55, 95% CI=0.39, 0.77), and 50% less likely to use a prescription cessation medication (AOR=0.50, 95% CI=0.30, 0.85). Ethnicity was unrelated to use of a quit-line or other counseling service. CONCLUSIONS: EBT use for smoking cessation has increased over the past decade, with more rapid increase among English-speaking Hispanics/Latinos compared with NHWs, but a large use gap remains. Healthcare and public health efforts are needed to clarify and overcome factors contributing to this ongoing disparity.

Randomised trial of two nicotine patch protocols distributed through a state quitline.

BACKGROUND: Most telephone quitlines provide free nicotine replacement therapy (NRT). An 8-week course is recommended, but few users complete it. Information is needed to help quitlines distribute NRT cost-effectively. DESIGN: Randomised two-group trial. SETTING/PARTICIPANTS: Colorado QuitLine callers who smoked 16-20 cigarettes per day at enrolment and who were eligible for and agreed to receive free NRT. INTERVENTION: Provision of 4-week versus 8-week NRT supply; the 8-week supply was shipped in halves and required participants to request the second half (split-shipment protocol). Enrolment occurred during March 2010-February 2011, follow-up concluded in November 2011, and analysis was performed in 2012. MAIN OUTCOME MEASURES: Point abstinence (7 and 30 day) and prolonged abstinence (6 month) from tobacco use. RESULTS: Overall, 1495 study participants were enrolled and 57.7% completed follow-up. Abstinence rates did not differ significantly between study conditions: 13.8% versus 12.4% in 4-week versus 8-week arms, respectively, (30-day point abstinence, non-respondents treated as smokers). NRT duration was similar in both groups, due in part to purchase of additional patches in the 4-week group. About one-third of the 8-week group requested the full 8-week supply and had higher abstinence rates. Cost per quit was lower in the 4-week (compared to 8-week) group. CONCLUSIONS: A randomised trial did not find worse cessation outcomes among quitline users who received half the minimum recommended course of NRT, but offering the full recommended course using a split-shipment protocol may be reasonably cost-effective and supportive of NRT adherers. TRIAL REGISTRATION NUMBER: NCT01889771.

Smoking and (Not) Voting: The Negative Relationship Between a Health-Risk Behavior and Political Participation in Colorado.

INTRODUCTION: Considerable evidence suggests that cigarette smokers are an increasingly marginalized population, involved in fewer organizations and activities and with less interpersonal trust than their nonsmoking counterparts. However, only two previous studies, both among Swedish populations, have investigated smokers' attitudes toward political systems and institutions. The current, cross-sectional study examines smoking in relation to voting, a direct behavioral measure of civic and political engagement that at least partly reflects trust in formal political institutions. METHODS: Secondary analyses were conducted of interview data from 11 626 respondents in the Colorado Tobacco Attitudes and Behaviors Survey. Data were collected via telephone between October 2005 and mid-April 2006 and included respondents' reported voting behavior in the 2004 national election; the participation rate was 89.7%. Balanced multiple logistic regression was used to examine associations between smoking and voting while controlling for other covariates known to be associated with both variables. RESULTS: In the final model, daily smokers were less than half as likely as nonsmokers to report having voted in the election. CONCLUSIONS: The results suggest possible consonance with previous work linking smoking with political mistrust. Possible causal mechanisms are discussed. This study is the first to link a health-risk behavior with electoral participation, and provides initial evidence that smoking is negatively associated with political participation. Future research should investigate how public health might enhance tobacco control efforts by taking nonvoting behavior into consideration, or creatively combining smoking cessation interventions with voter registration and other civic engagement work, particularly among socioeconomically disadvantaged populations.

Community-based navigators for tobacco cessation treatment: a proof-of-concept pilot study among low-income smokers.

BACKGROUND: A majority of continuing smokers in the United States are socioeconomically disadvantaged (SED) adults, who are less likely than others to achieve and maintain abstinence despite comparable quit-attempt rates. A national research initiative seeks effective new strategies for increasing successful smoking cessation outcomes among SED populations. There is evidence that chronic and acute stressors may interfere with SED smokers who try to quit on their own. Patient navigators have been effectively used to improve adherence to chronic disease treatment. We designed and have pilot-tested an innovative, non-clinical community-based intervention--smoking cessation treatment navigators--to determine feasibility (acceptance, adherence, and uncontrolled results) for evaluation by randomized controlled trial (RCT). METHODS: The intervention was developed for smokers among parents and other household members of inner city pre-school for low-income children. Smoking cessation treatment navigators were trained and deployed to help participants choose and adhere to evidence-based cessation treatment (EBCT). Navigators provided empathy, resource-linking, problem-solving, and motivational reinforcement. Measures included rates of study follow-up completion, EBCT utilization, navigation participation, perceived intervention quality, 7-day point abstinence and longest abstinence at three months. Both complete-case and intent-to-treat analyses were performed. RESULTS: Eighty-five percent of study participants (n = 40) completed final data collection. More than half (53%) enrolled in a telephone quitline and nearly three-fourths (71%) initiated nicotine replacement therapy. Participants completed a mean 3.4 navigation sessions (mean 30 min duration) and gave the intervention very high quality and satisfaction ratings. Self-reported abstinence was comparable to rates for evidence-based cessation strategies (21% among study completers, 18% using intent-to-treat analysis; median 21 days abstinent among relapsers). CONCLUSIONS: The pilot results suggest that smoking cessation treatment navigators are feasible to study in community settings and are well-accepted for increasing use of EBCT among low-income smokers. Randomized controlled trial for efficacy is warranted.

Smoking cessation behaviors among persons with psychiatric diagnoses: results from a population-level state survey.

BACKGROUND: Persons with psychiatric illnesses are disproportionally affected by tobacco use, smoking at rates at least twice that of other adults. Intentions to quit are known to be high in this population, but population-level cessation behaviors and attitudes by mental health (MH) diagnosis are not well known. METHODS: A population-level survey was conducted in 2008 to examine state-level tobacco attitudes and behaviors in Colorado. Respondents were eligible for the study if they had non-missing values for smoking status (n=14,118). Weighted descriptive and multivariate analyses were conducted of smoking prevalence, cessation behaviors, and attitudes toward cessation by MH status and specific diagnosis. RESULTS: Among respondents with MH diagnoses, smoking was twice as prevalent as among respondents without an MH diagnosis, adjusted for demographic characteristics (adjusted odds ratio 2.2, 95% confidence interval 1.6-3.1). Compared to smokers without an MH diagnosis, those with MH diagnoses were more likely to attempt quitting (58.7% vs. 44.4%, p<0.05), use nicotine replacement therapy more often, and succeed in quitting at similar rates. Smokers with anxiety/PTSD were less likely to quit successfully compared those with other MH diagnoses (0.7% vs. 11.9%, p=0.03). CONCLUSIONS: This population-level analysis found that smokers with mental illness are more likely than those without mental illness to attempt quitting and to use cessation treatment at similar rates, but those with anxiety are less likely to achieve short-term abstinence. Additional approaches are needed for smokers with mental illness in order to reach and sustain long-term abstinence from smoking.

A practical way to estimate retail tobacco sales violation rates more accurately.

PURPOSE: U.S. states annually estimate retailer propensity to sell adolescents cigarettes, which is a violation of law, by staging a single purchase attempt among a random sample of tobacco businesses. The accuracy of single-visit estimates is unknown. We examined this question using a novel test-retest protocol. METHOD: Supervised minors attempted to purchase cigarettes at all retail tobacco businesses located in 3 Colorado counties. The attempts observed federal standards: Minors were aged 15-16 years, were nonsmokers, and were free of visible tattoos and piercings, and were allowed to enter stores alone or in pairs to purchase a small item while asking for cigarettes and to show or not show genuine identification (ID, e.g., driver's license). Unlike federal standards, stores received a second purchase attempt within a few days unless minors were firmly told not to return. Separate violation rates were calculated for first visits, second visits, and either visit. RESULTS: Eleven minors attempted to purchase cigarettes 1,079 times from 671 retail businesses. One sixth of first visits (16.8%) resulted in a violation; the rate was similar for second visits (15.7%). Considering either visit, 25.3% of businesses failed the test. Factors predictive of violation were whether clerks asked for ID, whether the clerks closely examined IDs, and whether minors included snacks or soft drinks in cigarette purchase attempts. CONCLUSION: A test-retest protocol for estimating underage cigarette sales detected half again as many businesses in violation as the federally approved one-test protocol. Federal policy makers should consider using the test-retest protocol to increase accuracy and awareness of widespread adolescent access to cigarettes through retail businesses.