The TELEhealth Shared decision-making Coaching and Navigation in Primary carE (TELESCOPE) intervention: a study protocol for delivering shared decision-making for lung cancer screening by patient navigators.

Background: Lung cancer screening (LCS) can reduce lung cancer mortality but has potential harms for patients. A shared decision-making (SDM) conversation about LCS is required by the Centers for Medicare & Medicaid Services (CMS) for LCS reimbursement. To overcome barriers to SDM in primary care, this protocol describes a telehealth decision coaching intervention for LCS in primary care clinics delivered by patient navigators. The objective of the study is to evaluate the effectiveness of the intervention and its implementation potential, compared with an enhanced usual care (EUC) arm. Methods: Patients (n = 420) of primary care clinicians (n = 120) are being recruited to a cluster randomized controlled trial. Clinicians are randomly assigned to 1) TELESCOPE intervention: prior to an upcoming non-acute clinic visit, patients participate in a telehealth decision coaching session about LCS delivered by trained patient navigators and nurse navigators place a low-dose CT scan (LDCT) order for each TELESCOPE patient wanting LCS, or 2) EUC: patients receive enhanced usual care from a clinician. Usual care is enhanced by providing clinicians in both arms with access to a Continuing Medical Education (CME) webinar about LCS and an LCS discussion guide. Patients complete surveys at baseline and 1-week after the scheduled clinic visit to assess quality of the SDM process. Re-navigation is attempted with TELESCOPE patients who have not completed the LDCT within 3 months. One month before being due for an annual screening, TELESCOPE patients whose initial LCS showed low-risk findings are randomly assigned to receive a telehealth decision coaching booster session with a navigator or no booster. Electronic health records are abstracted at 6, 12 and 18 months after the initial decision coaching session (TELESCOPE) or clinic visit (EUC) to assess initial and annual LCS uptake, imaging results, follow-up testing for abnormal findings, cancer diagnoses, treatment, and tobacco treatment referrals. This study will evaluate factors that facilitate or interfere with program implementation using mixed methods. Discussion: We will assess whether a decision coaching and patient navigation intervention can feasibly support high-quality SDM for LCS and guideline-concordant LCS uptake for patients in busy primary care practices serving diverse patient populations. Trial Registration: This study was registered at ClinicalTrials.gov (NCT05491213) on August 4, 2022.

Measurement of cigarette relighting: A common but understudied behavior.

OBJECTIVE: Relighting, i.e., extinguishing, saving, and later relighting and smoking unfinished cigarettes, appears prevalent, may be associated with nicotine dependence and negative health outcomes, yet is poorly understood. We estimate the prevalence, frequency, correlates of, and reasons for, cigarette relighting. METHODS: Survey respondents (n=676) were 18-45-year-old US-based Amazon Mechanical Turk (MTurk) participants who smoked cigarettes every/some days. Items assessed frequency of and reasons for relighting. Reported smoking sessions per day were compared to calculations based on reported cigarettes per day (CPD) and relighting frequency. RESULTS: Seventy-two percent of those who smoked reported relighting cigarettes. Reasons included not having time to finish (77%), not feeling like finishing (75%), saving money or avoiding wasting (70%), and making cigarettes last longer (59%). Nearly half (44%) relight to cut down and 34% to reduce harm. Hispanic (OR=1.73, CI:1.03-2.91) and non-Hispanic Black respondents (OR= 2.23, CI:1.20-4.10) had higher odds of relighting than others, as did those who smoke within 30minutes of waking (OR=2.45, CI:1.33-4.52) or wake up at night to smoke (OR=2.40, CI:1.68-3.44) (all ps <0.05). Respondents demonstrated low consistency in reporting the number of times they smoke (first-lit and relit) compared to calculations based on CPD and relighting frequency. CONCLUSIONS: Relighting is associated with race, ethnicity, nicotine dependence, and is often done to save money, cut down smoking, and reduce harm. Among those who relight, "smoking session" frequency seemed to be underestimated. Single item smoking frequency measures may not be ideal for individuals who smoke and relight.

Prevalence and predictors of colon and prostate cancer screening among volunteer firefighters: The United States Firefighter Cancer Assessment and Prevention Study.

BACKGROUND: Although firefighters have increased risk for colon and prostate cancer, limited information exists on screening practices for these cancers in volunteer firefighters who compose two-thirds of the US fire service. We estimated the prevalence of colon and prostate cancer screening among volunteer firefighters using eligibility criteria from 4 evidence-based screening recommendations and evaluated factors influencing screening. METHODS: We evaluated colon (n = 569) and prostate (n = 498) cancer screening prevalence in a sample of US volunteer firefighters using eligibility criteria from the US Preventive Services Taskforce (USPSTF), National Fire Protection Association, American Cancer Society, and National Comprehensive Cancer Network. We assessed associations with fire service experience, demographics, and cancer risk perception based on USPSTF guidelines. RESULTS: For those eligible based on USPSTF guidelines, colon and prostate cancer screening prevalence was 51.7% (95% CI: 45.7, 57.8) and 48.8% (95% CI: 40.0, 57.6), respectively. Higher odds of colon and prostate cancer screening were observed with older age and with some college education compared to those with less education. Fire service experience and cancer risk perception were not associated with screening practices. CONCLUSION: This is the first large study to assess colon and prostate cancer screening among US volunteer firefighters based on different screening guidelines. Our findings suggest gaps in cancer prevention efforts in the US volunteer fire service. Promoting cancer screening education and opportunities for volunteer firefighters by their fire departments, healthcare professionals, and public health practitioners, may help to address the gaps.

Prevalence and predictors of skin cancer screening among a sample of US volunteer firefighters.

BACKGROUND: Firefighters have a higher risk of melanoma incidence and mortality compared to the general population. In the United States (US), the National Fire Protection Association recommends all firefighters receive annual skin cancer screening through visual skin examination by a clinician. However, there is limited information on skin cancer screening practices among volunteer firefighters who comprise two-thirds of the US fire service. METHODS: This cross-sectional study of 552 US volunteer firefighters estimated the prevalence of skin cancer screening and evaluated associations with their fire service experience, demographics, sun protection practices, and cancer risk perception. RESULTS: The prevalence of receiving skin cancer screening among volunteer firefighters was 26.1% (95% confidence interval [CI]: 22.4, 29.8). The odds of being screened for skin cancer, compared to not being screened, were twice as high for firefighters who used sunscreen (odds ratio [OR]: 2.35, 95% CI: 1.48, 3.73) and who perceived their skin likely to burn with prolonged sun exposure (OR: 1.81, 95% CI: 1.10, 3.00). Older age, some college education, and family history of skin cancer were also positively associated with skin cancer screening. A positive exposure-response relationship was observed between more monthly firefighting calls and receiving screening. Cancer risk perception was not associated with screening. CONCLUSION: To our knowledge, this is the first large study to assess skin cancer screening among US volunteer firefighters. Our findings suggest gaps in skin cancer prevention efforts in the volunteer fire service. Additional assessment of skin cancer prevention practices within volunteer fire departments could help address these gaps.

Electronic Health Record Prompt to Improve Lung Cancer Screening in Primary Care.

INTRODUCTION: Lung cancer is the leading cause of cancer death in the U.S. Combusted tobacco use, the primary risk factor, accounts for 90% of all lung cancers. Early detection of lung cancer improves survival, yet lung cancer screening rates are much lower than those of other cancer screening tests. Electronic health record (EHR) systems are an underutilized tool that could improve screening rates. METHODS: This study was conducted in the Rutgers Robert Wood Johnson Medical Group, a university-affiliated network in New Brunswick, NJ. Two novel EHR workflow prompts were implemented on July 1, 2018. These prompts included fields to determine tobacco use and lung cancer screening eligibility and facilitated low-dose computed tomography ordering for eligible patients. The prompts were designed to improve tobacco use data entry, allowing for better lung cancer screening eligibility identification. Data were analyzed in 2022 retrospectively for the period July 1, 2017 to June 30, 2019. The analyses represented 48,704 total patient visits. RESULTS: The adjusted odds of patient record completeness to determine eligibility for low-dose computed tomography (AOR=1.19, 95% CI=1.15, 1.23), eligibility for low-dose computed tomography (AOR=1.59, 95% CI=1.38, 1.82), and whether low-dose computed tomography was ordered (AOR=1.04, 95% CI=1.01, 1.07) all significantly increased after the electronic medical record prompts were implemented. CONCLUSIONS: These findings show the utility and benefit of EHR prompts in primary care settings to increase identification for lung cancer screening eligibility as well as increased low-dose computed tomography ordering.

US Physicians' Self-reported Discussions About Tobacco-Free Nicotine Pouches During Clinical Encounters With Patients in 2021.

This survey study assesses the extent to which physicians discussed tobacco-free nicotine pouches during clinical encounters with patients.

Tobacco Treatment Knowledge and Practices Among US Psychiatrists.

This study explores the extent to which psychiatrists are familiar with, and utilize, the USPHS guidelines for treating tobacco use and dependence (i.e., the 5A's), deliver cessation treatment, and the barriers they perceive to doing so. An original, national survey of 141 psychiatrists revealed that most Ask patients if they smoke (81.6%). Fewer Advise them to stop (78.7%) and Assess their willingness to quit (73.6%). A minority Assist with a quit plan (15.9%) and Arrange for follow-up (26.4%). Just 11.9% have used the USPHS guidelines in clinical practice; 37% have never heard of them. Even among those who say they have used the USPHS guidelines, implementation of the 5A's is quite low. Time-related factors were the most common barriers to cessation delivery (51.4%). Patient factors (30%) and financial/resource factors (25%) were less common. There is a strong need for increased implementation of clinical guidelines for evidence-based tobacco treatments among psychiatrists.

The Impact of the COVID-19 Pandemic on Tobacco Treatment Program Implementation at National Cancer Institute-Designated Cancer Centers.

INTRODUCTION: The COVID-19 pandemic disrupted cancer screening and treatment delivery, but COVID-19's impact on tobacco cessation treatment for cancer patients who smoke has not been widely explored. AIMS AND METHODS: We conducted a sequential cross-sectional analysis of data collected from 34 National Cancer Institute (NCI)-designated cancer centers participating in NCI's Cancer Center Cessation Initiative (C3I), across three reporting periods: one prior to COVID-19 (January-June 2019) and two during the pandemic (January-June 2020, January-June 2021). Using McNemar's Test of Homogeneity, we assessed changes in services offered and implementation activities over time. RESULTS: The proportion of centers offering remote treatment services increased each year for Quitline referrals (56%, 68%, and 91%; p = .000), telephone counseling (59%, 79%, and 94%; p = .002), and referrals to Smokefree TXT (27%, 47%, and 56%; p = .006). Centers offering video-based counseling increased from 2020 to 2021 (18% to 59%; p = .006), Fewer than 10% of centers reported laying off tobacco treatment staff. Compared to early 2020, in 2021 C3I centers reported improvements in their ability to maintain staff and clinician morale, refer to external treatment services, train providers to deliver tobacco treatment, and modify clinical workflows. CONCLUSIONS: The COVID-19 pandemic necessitated a rapid transition to new telehealth program delivery of tobacco treatment for patients with cancer. C3I cancer centers adjusted rapidly to challenges presented by the pandemic, with improvements reported in staff morale and ability to train providers, refer patients to tobacco treatment, and modify clinical workflows. These factors enabled C3I centers to sustain evidence-based tobacco treatment implementation during and beyond the COVID-19 pandemic. IMPLICATIONS: This work describes how NCI-designated cancer centers participating in the Cancer Center Cessation Initiative (C3I) adapted to challenges to sustain evidence-based tobacco use treatment programs during the COVID-19 pandemic. This work offers a model for resilience and rapid transition to remote tobacco treatment services delivery and proposes a policy and research agenda for telehealth services as an approach to sustaining evidence-based tobacco treatment programs.

Over 1 year later: smokers' EVALI awareness, knowledge and perceived impact on e-cigarette interest.

OBJECTIVES: The e-cigarette or vaping product use-associated lung injury (EVALI) outbreak caused serious lung injuries in over 2800 people in the USA in 2019. By February 2020, most cases were determined as linked with vaping tetrahydrocannabinol (THC), including black market products using vitamin E acetate. This study examined smokers' EVALI awareness, knowledge and perceived impact on their e-cigarette interest approximately 16 months after its peak. DESIGN: Between January and February 2021, we surveyed 1018 adult current smokers from a nationally representative US research panel. Participants were asked if they had heard about EVALI prior to COVID-19, knew its main cause, and if EVALI had impacted their interest in future e-cigarette use. RESULTS: Approximately 54% of smokers had heard of EVALI. Among those who had heard of EVALI (n=542), 37.3% believed its main cause was e-cigarettes used to vape nicotine, like JUUL. Fewer (16.6%) thought the main cause was products for vaping marijuana/THC, and 20.2% did not know. About 29% had heard vitamin E acetate was associated with EVALI, and 50.9% indicated EVALI made them less interested in using e-cigarettes in the future. EVALI awareness was significantly associated with e-cigarette risk perceptions (ie, that e-cigarettes are as harmful as smoking). CONCLUSIONS: Despite the passage of time, considerable lack of knowledge and misperceptions about EVALI remain among those who smoke. Our findings suggest the need for continued efforts to promote better understanding of EVALI and appropriate behavioural and policy responses.

Disease and debt: Findings from the 2019 Panel Study of Income Dynamics in the United States.

Medical debt has grown dramatically over the past few decades. While cancer and diabetes are known to be associated with medical debt, little is known about the impact of other medical conditions and health behaviors on medical debt. We analyzed cross-sectional data on 9174 households - spanning lower-income, middle-income, and higher-income based on the Census poverty threshold - participating in the 2019 wave of the nationally representative United States Panel Study of Income Dynamics (PSID). The outcomes were presence of any medical debt and presence of medical debt≥ $2000. Respondents reported on medical conditions (diabetes, cancer, heart disease, chronic lung disease, asthma, arthritis, anxiety disorders, mood disorders) and on health behaviors (smoking, heavy drinking). Medical debt was observed in lower-income households with heart disease (OR = 2.64, p-value = 0.006) and anxiety disorders (OR = 2.16, p-value = 0.02); middle-income households with chronic lung disease (OR = 1.73, p-value = 0.03) and mood disorders (OR = 1.53, p-value = 0.04); and higher-income households with a current smoker (OR = 2.99, p-value<0.001). Additionally, medical debt ≥$2000 was observed in lower-income households with asthma (OR = 2.16, p-value = 0.009) and a current smoker (OR = 1.62, p-value = 0.04); middle income households with hypertension (OR = 1.65, p-value = 0.05). These novel findings suggest that the harms of medical debt extend beyond cancer, diabetes and beyond lower-income households. There is an urgent need for policy and health services interventions to address medical debt in a wider range of disease contexts than heretofore envisioned. Intervention development would benefit from novel conceptual frameworks on the causal relationships between health behaviors, health conditions, and medical debt that center social-ecological influences on all three of these domains.

Lung Cancer Screening Knowledge and Perceived Barriers Among Physicians in the United States.

Introduction: Lung cancer remains the leading cause of cancer death in the United States and has historically been detected late in its course. Low-dose computed tomography scan (LDCT) reduces lung cancer mortality by 20% and is currently recommended by clinical practice guidelines. However, compared with other cancer screening modalities, LDCT utilization remains low. This study surveyed office-based primary care physicians across the United States to better understand LDCT utilization. Methods: A total of 1500 family and internal medicine physicians selected from the American Medical Association's physician master file were surveyed between April and July 2019 regarding LDCT practices, eligibility, clinical scenarios, and perceived barriers. Results: The American Association for Public Opinion Research response rate 3 was 59% (652 respondents); 599 completed supplemental questions regarding lung cancer screening. A total of 88% of respondents discussed LDCT in the previous year, and 78% had ordered at least one LDCT. Most (59%) knew the tobacco exposure criteria for LDCT and correctly identified appropriate clinical scenarios (49%-86% responded correctly). Less than half of respondents correctly identified the age eligibility criteria (44%-45% responded correctly). In general, male physicians, those who graduated after 1990, and family medicine physicians were more likely to report accurate knowledge regarding LDCT eligibility. The top perceived barriers to LDCT were cost to the patient (48% identified as a major barrier), insurance not covering screening (46% major), and patients being unaware of lung cancer screening (40% major). Conclusion: Knowledge and practices about lung cancer screening are improving, though remain suboptimal. The most common barriers remain cost or insurance-based and suggest the need for a systems-based response to increase awareness and reduce the underutilization of LDCT.

Perceived effectiveness of cancer screening among family medicine and internal medicine physicians in the United States.

Family and internal medicine physicians play an important role in cancer screening, yet there are limited data on their beliefs regarding effectiveness of screening tests, which may affect physicians' likelihood to recommend such tests. The study purpose was to assess current beliefs among family medicine and internal medicine physicians regarding effectiveness of various types of cancer screening. A national sample of 582 physicians from the American Medical Association's Physician Masterfile were surveyed. Participants were asked about their perceived effectiveness of screening for colon, lung, breast, prostate, and cervical cancer among average, healthy individuals. Chi-square tests were conducted to assess relationships between perceiving screening tests to be 'very effective in reducing cancer-related mortality' and demographic characteristics. A substantial majority of physicians perceived colonoscopy (83.8%) and Pap smear (82.9%) to be very effective. Perceiving low-dose computed tomography (LDCT), Pap smear, and prostate-specific antigen (PSA) as 'very effective' differed by gender, with females less likely to endorse LDCT and Pap smear but more likely to endorse PSA. Perceiving PSA as 'very effective' differed by age and graduation year, with younger or more recently graduated physicians being less likely to perceive PSA as 'very effective'. Non-Hispanic Black/African-American physicians were more likely to perceive mammography as 'very effective' than other groups. Physicians' perceived effectiveness about cancer screening tests varies widely and may influence their recommendations or usage of these tests. Understanding physicians' beliefs can help in improving uptake of evidence-based screening tests by providers and patients to promote early detection and successful treatment.

Communication Between US Physicians and Patients Regarding Electronic Cigarette Use.

Importance: Physicians play a primary role in patient smoking cessation, yet their communication regarding e-cigarettes is not well understood. Objective: To assess physician-patient communication regarding e-cigarettes. Design, Setting, and Participants: A national cross-sectional survey in 2018 and 2019 was conducted. Participants were invited by mail; surveys were completed online. Respondents were 2058 board-certified physicians from family medicine, internal medicine, obstetrics and gynecology, cardiology, pulmonary, and oncology. Data were analyzed from August to September 2021. Exposures: Physician demographic characteristics, tobacco use, medical specialty, and harm-reduction beliefs (ie, not all tobacco products are equally harmful) applied within 2 hypothetical clinical scenarios. Main Outcomes and Measures: Physicians' self-reported e-cigarette communication (being asked about e-cigarettes by patients and recommending e-cigarettes to patients) and hypothetical e-cigarette communication in 2 clinical scenarios. Results: Among 2058 physicians, the mean (SD) age was 51.6 (10.5) years, and 1173 (58.5%) were male. More than 60% of physicians believed all tobacco products to be equally harmful. Overall, 69.8% of physicians reported ever being asked about e-cigarettes by their patients (35.9% in the past 30 days), and 21.7% reported ever recommending e-cigarettes to a patient (9.8% in the past 30 days). Pulmonologists (adjusted odds ratio [aOR], 2.14, 95% CI, 1.10-4.16) and cardiologists (aOR, 2.04; 95% CI, 1.03-4.05), as well as physicians who implemented the US Public Health Service Clinical Practice Guidelines (aOR, 1.77; 95% CI, 1.12-2.80), had greater odds of recommending e-cigarettes to patients. Physicians who endorsed a harm-reduction perspective (aOR, 3.04, 95% CI, 2.15-4.31) and had ever smoked cigarettes (aOR, 1.98; 95% CI, 1.27-3.08) were significantly more likely to recommend e-cigarettes. Physicians who reported being asked about e-cigarettes had greater odds of recommending e-cigarettes (aOR, 16.60; 95% CI, 10.33-26.68). In clinical scenarios, physicians were overall more likely to recommend e-cigarettes for cessation to an older heavy smoker with multiple unsuccessful quit attempts (49.3%; 95% CI, 47.1%-51.4%) than a younger light smoker with no prior cessation treatments (15.2%; 95% CI, 13.6%-16.7%) (P < .001). Conclusions and Relevance: In this survey study of physicians, findings suggest that physicians may recommend switching to e-cigarettes for some patients who smoke cigarettes under certain circumstances, presumably for cessation. The belief that all tobacco products are equally harmful was associated with lower rates of recommending e-cigarettes. As the evidence base grows for e-cigarette efficacy for smoking cessation, there is need for physician education regarding e-cigarette efficacy.

Content Analysis of E-cigarette News Articles Amidst the 2019 Vaping-Associated Lung Injury (EVALI) Outbreak in the United States.

INTRODUCTION: News media can shape public perceptions about e-cigarettes, particularly in the context of ongoing uncertainty from the recent outbreak of e-cigarette or vaping product use-associated lung injury (EVALI). This study aimed to characterize news articles published about e-cigarettes in 2019, including before and during the EVALI outbreak. AIMS AND METHODS: Using 24 e-cigarette-related search terms, we gathered all articles published in leading print and online U.S. news sources in 2019 from databases (i.e., Factiva, Access World News) and archival web sites (i.e., www.newspapers.com). We conducted a content analysis of e-cigarette themes and statements, identifying differences in themes between articles that did and did not mention EVALI. RESULTS: Of the 1643 e-cigarette news articles published in 2019, 62% mentioned EVALI. Frequency of e-cigarette articles peaked in September (n = 532) at the height of the EVALI outbreak. Among all articles discussing e-cigarettes, the most prevalent main topics were policy/regulation (45%) and health effects (35%). Articles that mentioned EVALI frequently discussed youth e-cigarette use (40%) and JUUL (33%). Compared to non-EVALI articles, EVALI articles were more likely to discuss health effects (p < .001) but less likely to discuss policies/regulations, except for flavor bans (47% of EVALI articles vs. 39% of non-EVALI articles, p = .002). EVALI articles were also less likely to discuss e-cigarettes being less risky than cigarettes (p = .005). CONCLUSIONS: E-cigarette news coverage was prevalent in 2019, and patterns in frequency and content reflected major events (i.e., EVALI). In turn, news media can shape public perceptions, and even policy, about e-cigarettes and must continue to be monitored. IMPLICATIONS: E-cigarette news coverage in 2019 was high, driven in large part by news coverage of the EVALI outbreak. Indeed, the peak in e-cigarette news articles in September directly coincided with the peak in EVALI cases in the United States. Of note, articles that mentioned EVALI frequently discussed youth e-cigarette use, JUUL, and flavor bans, which may have triggered national and state-level policy responses, and likely influenced public perceptions (including misperceptions) regarding the harms of e-cigarettes.

Smoking Cessation.

Tobacco smoking is the leading cause of preventable death in the United States, and its harms are well established. Physicians have more evidence-based resources than ever before to effectively treat smoking, including new uses and combinations of U.S. Food and Drug Administration-approved pharmacotherapies and expanded community programs. In addition, electronic nicotine delivery systems are potential treatment tools, but their safety and efficacy need to be established. Finally, high-priority groups, such as persons with cancer diagnoses or hospitalized patients, may benefit from particular attention to their tobacco use.

Tobacco Treatment Guideline Use and Predictors Among U.S. Physicians by Specialty.

INTRODUCTION: Physicians play a critical role in tobacco treatment, being a frequent link to smokers and a trusted source of information. Unfortunately, barriers exist that limit physicians' implementation of evidence-based interventions. This study examines the implementation and predictors of the Ask, Advise, Assess, Assist, Arrange model of tobacco treatment clinical guidelines among U.S. physicians. METHODS: A national sample of 1,058 U.S. physicians from 6 specialties (family medicine, internal medicine, obstetrics and gynecology, cardiology, pulmonology, and oncology) were surveyed in 2018 (51.8% response rate). Survey domains included demographics, awareness of the guidelines, tobacco treatment practices (i.e., Ask, Advise, Assess, Assist, Arrange model), perceived barriers to treatment, and perceived efficacy of various treatments. Multiple logistic regression analyzed the predictors of implementing guideline activities. RESULTS: Mean age was 51.3 years, with the majority male (64.4%) and non-Hispanic White (63.9%). Nearly all physicians reported asking patients whether they smoke (95.6%) and advising them to stop (94.8%), slightly fewer assessed the readiness to quit (86.5%), and only a minority assisted with a quit plan (27.4%) or arranged a follow-up (18.6%). Only 18% reported using the U.S. Public Health Service Guidelines in clinical practice. Time-related factors were the most common barriers (53.4%), with patient factors (36.9%) and financial/resource factors (35.1%) cited less frequently. The predictors of implementing aspects of the Ask, Advise, Assess, Assist, Arrange model included physician awareness and utilization of the U.S. Public Health Service Guidelines, specialty, and to a smaller degree, graduating before 1990, not reporting time as a barrier, patient barriers, sex, and higher perceived effectiveness of pharmacotherapy. CONCLUSIONS: This national survey highlights the need for increased implementation of all aspects of the latest guidelines for evidence-based tobacco treatments, including community-based resources.

Cigarette Relighting: A Series of Pilot Studies Investigating a Common Yet Understudied Smoking Behavior.

BACKGROUND: The act of extinguishing, saving, and later relighting unfinished cigarettes is a common yet understudied behavior that may have implications for tobacco treatment and health. METHODS: This paper presents four pilot studies investigating various aspects of this topic: (1) the prevalence of relighting among NJ and NY Quitline callers (n = 20,984); (2) the prevalence and correlates of relighting in two national surveys (n = 1008, n = 1018); (3) a within-subject (n = 16) laboratory experiment comparing cigarettes smoked per day and exhaled carbon monoxide when relighting and not relighting cigarettes; and (4) a national survey of tobacco treatment providers' (n = 150) perceptions of relighting. RESULTS: Relighting was found to be common (approximately 45% of smokers), and associated with lower socioeconomic status, heavier smoking and nicotine dependence, greater smoking-related concerns, as well as high levels of exhaled carbon monoxide. Providers noted the potential importance of relighting but reported that they do not regularly incorporate it into their assessment or tobacco treatment planning. CONCLUSIONS: These findings address a major research gap in the emerging research on this common behavior. Future research is needed to better understand the potential implications of relighting for policies and clinical practices related to tobacco cessation and health.

Persistent Misperceptions about Nicotine among US Physicians: Results from a Randomized Survey Experiment.

We conducted a survey experiment among US physicians to evaluate whether question wording impacted perceptions about the health effects of nicotine. 926 physicians were randomized to receive one of two versions of a question matrix that asked about the "extent to which they agree or disagree that 'nicotine' (Version 1) or 'nicotine, on its own,' (Version 2) directly contributes to" birth defects, cardiovascular disease (CVD), cancer, depression, and chronic obstructive pulmonary disease (COPD). We evaluated whether question condition predicted strong agreement and/or agreement with each statement, and assessed demographic correlates of each outcome while adjusting for question version. Physicians who received Version 2 were less likely to "strongly agree" that nicotine directly caused birth defects (Prevalence Ratio (PR) 0.84, 95% CI 0.72-0.98), CVD (PR 0.89, 95% CI 0.84-0.95), cancer (PR 0.81, 95% CI 0.75-0.87), and COPD (PR 0.78, 95% CI 0.72-0.84). Females were more likely to "strongly agree" that nicotine directly contributes to birth defects and cancer, and family physicians were most likely to "strongly agree" that nicotine directly contributes to CVD, cancer, and COPD. Question wording is important when measuring physicians' beliefs about nicotine; however, even after accounting for question version, misperceptions about the direct health effects of nicotine were common and varied by sex and specialty.

Fragmentation of Care Among Black Women With Breast Cancer and Comorbidities: The Role of Health Systems.

PURPOSE: Black women are disproportionately burdened by comorbidities and breast cancer. The complexities of coordinating care for multiple health conditions can lead to adverse consequences. Care coordination may be exacerbated when care is received outside the same health system, defined as care fragmentation. We examine types of practice setting for primary and breast cancer care to assess care fragmentation. MATERIALS AND METHODS: We analyzed data from a prospective cohort of Black women diagnosed with breast cancer in New Jersey who also had a prior diagnosis of diabetes and/or hypertension (N = 228). Following breast cancer diagnosis, we examined types of practice setting for first primary care visit and primary breast surgery, through medical chart abstraction, and identified whether care was used within or outside the same health system. We used multivariable logistic regression to explore sociodemographic and clinical factors associated with care fragmentation. RESULTS: Diverse primary care settings were used: medical groups (32.0%), health systems (29.4%), solo practices (23.7%), Federally Qualified Health Centers (8.3%), and independent hospitals (6.1%). Surgical care predominately occurred in health systems (79.8%), with most hospitals being Commission on Cancer-accredited. Care fragmentation was experienced by 78.5% of Black women, and individual-level factors (age, health insurance, cancer stage, and comorbidity count) were not associated with care fragmentation (P > .05). CONCLUSION: The majority of Black breast cancer survivors with comorbidities received primary care and surgical care in different health systems, illustrating care fragmentation. Strategies for care coordination and health care delivery across health systems and practice settings are needed for health equity.