Racial/Ethnic Disparities Impact the Real-World Effectiveness of a Multicomponent Maternal Smoking Cessation Program: Findings from the CTTP Cohort.

INTRODUCTION: Smoking during pregnancy adversely affects perinatal outcomes for both women and infants. We conducted a retrospective cohort study of the state-funded Comprehensive Tobacco Treatment Program (CTTP) - the largest maternal tobacco cessation program in San Bernardino County, California - to determine the real-world program effectiveness and to identify variables that can potentially improve effectiveness. METHODS: During 2012-2019, women who smoked during pregnancy were enrolled in CTTP's multicomponent behavioral smoking cessation program that implemented components of known efficacy (i.e., incentives, biomarker testing, feedback, and motivational interviewing). RESULTS: We found that 40.1% achieved prolonged abstinence by achieving weekly, cotinine-verified, 7-day abstinence during 6 to 8 weeks of enrollment. Using intention-to-treat analyses, we computed that the self-reported point prevalence abstinence rate (PPA) at the six-month telephone follow-up was 36.7%. Cohort members achieving prolonged abstinence during the CTTP were five times more likely to achieve PPA six months after CTTP. Several non-Hispanic ethnicities (Black, Native American, White, or More than one ethnicity) in the cohort were two-fold less likely (relative to Hispanics) to achieve prolonged abstinence during CTTP or PPA at six months after CTTP. This disparity was further investigated in mediation analysis. Variables such as quitting during the first trimester and smoking fewer cigarettes at enrollment were also associated with achieving PPA at six months. DISCUSSION: Racial/ethnic health disparities that have long been linked to a higher rate of maternal smoking persist even when the pregnant smoker enrolls in a smoking cessation program.

Participation in a workplace smoking cessation program incentivized by lowering the cost of health care coverage: Findings from the LLUH BREATHE cohort.

INTRODUCTION: Systematic analyses of workplace smoking cessation programs indicate that efficacy can be enhanced by using incentives. There is variation in the type of incentives used and their effect on participation and efficacy. The aim of our study was to examine whether lowering employee health plan costs (employee contributions, co-pays) encourage employee smokers to participate in workplace smoking cessation. METHODS: We conducted a 2014-2015 prospective cohort study of 415 employee smokers of Loma Linda University Health (LLUH). The employees were offered participation in a workplace smoking cessation program (LLUH BREATHE Initiative) with the incentive of enrollment in an employer-provided health plan that had a 50% lower employee monthly contribution and co-payment relative to the employer-provided health plan for non-participants. Participation rates and variables associated with participation were analyzed. RESULTS: In the LLUH BREATHE cohort, we found a very high rate of participation (72.7%; 95% CI: 69-77%) in workplace smoking cessation that was encouraged by a lower out-of-pocket health plan cost for the participating employee and/or spouse. Participation did, however, vary by gender and spouse, whereby female employee households with a qualifying smoker were more than two times more likely (employee: OR=2.89, 95% CI: 1.59-5.24; or spouse: OR=2.71, 95% CI: 1.47-5.00) to participate in smoking cessation than male employee households. The point prevalence, at four months, of abstinence from smoking among the participants was 48% (95% CI: 42-54%). CONCLUSIONS: Our findings indicate that a workplace smoking cessation program that uses a novel reward-based incentive of lower out-of-pocket health plan costs results in a participation rate that is much higher than US norms.

Maternal use of cigarettes, pipes, and smokeless tobacco associated with higher infant mortality rates in Cambodia.

In the Western Pacific Region, rural women use loose tobacco in betel quid chewing and pipe smoking. We examined the relation between maternal use of tobacco and infant mortality (IM) in a national sample of 24 296 birth outcomes in adult women (n = 6013) in Cambodia. We found that (1) age-adjusted odds of IM were higher for maternal use of any tobacco (odds ratio [OR] = 1.69; 95% confidence interval [CI] = 1.27-2.26); (2) age-adjusted odds of IM were higher for cigarette use (OR = 2.54; 95% CI = 1.54- 4.1), use of pipes (OR = 3.09; [95% CI = 1.86-5.11]), and betel quid chewing (OR = 1.55; 95% CI = 1.10-2.17); and (3) these associations remained after multivariable adjustment for environmental tobacco smoke, malnutrition, ethnicity, religion, marital status, education, income, occupation, and urban/rural dwelling. In addition to finding the established association with cigarettes, we also found that maternal use of smokeless tobacco and pipes was associated with higher rates of infant death in Cambodia.

Patterns of maternal tobacco use among Cambodian women: findings from a nationwide sample.

Although current trends indicate that the rate of cigarette smoking tends to be low among women in the Western Pacific Region (<10%), recent epidemiologic data from South Asia (India, Bangladesh) and Southeast Asia (Cambodia, Vietnam, Indonesia, Malaysia) identify that a large proportion of women of reproductive age and older chew tobacco--often as part of a betel quid mixture that includes other potentially harmful ingredients (eg, areca nut). Our findings from currently pregnant women identified during a nationwide survey of adult tobacco use in Cambodia indicate that 13.0% (95% confidence interval [CI] = 8% to 17%) were current users of smoked or smokeless (in the form of a betel quid) tobacco. Most pregnant women who used tobacco indicated that their habit was either initiated (29.1%; 95% CI = 16.3-46.3) or increased (33.7%; 95% CI = 18.3-53.5) during pregnancy. Pregnancy-related symptoms such as morning sickness were reported as the reason for more than half (54.9%; 95% CI = 34.8-73.4) of the currently pregnant users to have started a tobacco habit during their lifetime. Among those pregnant women who did not use tobacco, we found strong associations (odds ratios from 2 to 14) with beliefs about the harmful effects of tobacco on adult health, faith-based beliefs in addictive substances, and beliefs that influential members of the community, health professionals, and children should not use tobacco. Our findings indicate that tobacco cessation and prevention programs in Cambodia should specifically target pregnant and reproductive-age women.

Adult tobacco cessation in Cambodia: II. Determinants of intent to quit.

Identifying determinants of intent to quit may aid the design of antitobacco programs and promote effective tobacco control policies. In a nationwide survey in Cambodia, two thirds of tobacco smokers and 45% of female smokeless tobacco users planned to stop in the future. Multivariate determinants of intent in 2279 male smokers were age <37 years, age at initiation ≥ 18 years, Cham versus Khmer ethnicity (odds ratio [OR] = 6.93; 95% confidence interval[CI] = 1.38-34.89), longer education, and professional occupation. In 1188 female smokeless tobacco users, age <25 years, age at initiation ≥ 18 years, and tuberculosis (OR = 3.26; 95% CI = 1.61-6.61) were associated with intent. In female smokers (n = 321), age 18 to 25 years at initiation was associated with intent. In male smokers and female smokeless tobacco users, perceived physical advantages of tobacco were inversely associated with intent. These findings underscore the importance of policies and interventions to delay initiation and promote cessation in young people and counteract perceived physical benefits.

Adult tobacco cessation in Cambodia: I. Determinants of quitting tobacco use.

This study determined factors associated with quitting tobacco in Cambodia, a country with a high prevalence of men who smoke and women who use smokeless tobacco. As part of a nationwide survey, face-to-face interviews were conducted with 5145 current and 447 former tobacco users who had quit for ≥ 2 years. Determinants of quitting in multivariate analyses were age >48 years, age at initiation >25 years, ≥ 7 years of education, income ≥ 1 US dollar per day, professional (odds ratio [OR] = 2.52; 95% confidence interval [CI] = 1.27-5.01) or labor (OR = 1.98, 95% CI = 1.10-3.56) occupations, and heart disease (OR = 1.94; 95% CI = 1.10, 3.42). Smokeless tobacco users were 10-fold less likely to quit (OR = 0.10; 95% = CI 0.05-0.20) than smokers. In conclusion, tobacco cessation among Cambodians was lower than in nations with decades of comprehensive tobacco control policies. Tobacco cessation programs and policies should include all forms of tobacco and target young to middle-aged users before onset of disease and premature death.

Patterns of alcohol and tobacco use in Cambodia.

Few studies have considered whether the habitual use of tobacco in Southeast Asia is part of an established pattern of addiction that includes regular alcohol use. As part of a national survey of adult tobacco use in Cambodia (n = 13 988), we found that men who smoked were 2 times more likely to have drank alcohol in the past week (odds ratio = 2.53, 95% confidence interval = 2.10-3.03). By age 18 to 25 years, 47% of male smokers drank alcohol, and this pattern of alcohol and tobacco use increased to >55% through the fifth decade. Women using smokeless tobacco with betel quid were more likely to be alcohol drinkers (odds ratio = 1.49, 95% confidence interval = 1.12-1.98). Past week's drinking declined by late middle age and was associated with lower education and being currently married; the behavior was lower in some ethnic groups (ie, Cham). Our findings indicate an important association between alcohol and tobacco use, and raise the possibility that reducing alcohol consumption can be an important component of tobacco control.

Differences in health and religious beliefs about tobacco use among waterpipe users in the rural male population of Egypt.

Waterpipe use is a highly prevalent form of tobacco use in the Eastern Mediterranean Region that is rooted in long-held cultural traditions that predate the use of cigarettes and present a particular challenge for tobacco control efforts. We did a stratified sampling of 4,994 Egyptian men from rural households of Egypt in order to conduct an interviewer-administered prevalence survey to identify differences in attitudes and beliefs toward smoking and smoking cessation between waterpipe users, cigarette smokers, mixed users (cigarette + waterpipe), and non-smokers. We found that cigarette smokers, mixed users, and/or non-smokers were (1) two- to ninefold more likely to believe that smoking decreased adult life expectancy and harmed a fetus than waterpipe users, (2) significantly more likely to believe that smoking is a sin ("haram") than were waterpipe users. Among tobacco users, we found that cigarette smokers and/or mixed users were significantly more likely to indicate pre-contemplation, contemplation, or intention to quit tobacco than waterpipe users. Our findings from rural Egyptian men indicate that waterpipe users are distinct from cigarette smokers in their perception that their form of tobacco use is less harmful and/or less subject to religious proscription. These beliefs may explain why waterpipe users seem less inclined to quit their tobacco habit and need to be considered in the design of tobacco cessation and prevention methods in Egypt and the region.

Exposure to environmental tobacco smoke in the nonsmoking population of Cambodia.

OBJECTIVE: To estimate the extent of environmental tobacco smoke (ETS) exposure among nonsmokers in the adult population of Cambodia. METHODS: A cross-sectional survey was conducted on a nationally representative sample of 13,988 Cambodian adults in 2005. Information on smoking and exposure to ETS was obtained by trained interviewers using a standard questionnaire. RESULTS: Overall, 37.4% of the 10,263 nonsmoking responders, or an estimated 1,629,700 nonsmoking Cambodians, were exposed to ETS. One third of pregnant women (31.4%) were exposed to ETS at home. In both unadjusted and adjusted models, men were less likely to be exposed to ETS at home (OR=0.34; 95% CI=0.29-0.41) and more likely to be exposed to ETS at work and in public places (OR=3.08; 95% CI=2.14-4.43 and OR=2.17; 95% CI=1.82-2.59, respectively). Education was inversely related to ETS exposure at home (OR=0.51; 95% CI=0.27-0.96 for 10 years of education vs 5 years or less). Legislators, senior officials, and managers were less likely to be exposed to ETS at home than professionals (OR=0.13; 95% CI=0.04-0.46), but more likely to be exposed at work or in public places. Rural residence was associated with higher ETS exposure in the home (OR=2.52; 95% CI=1.71-3.71) and lower ETS exposure at work (OR=0.42; 95% CI=0.24-0.76) compared to urban residence. CONCLUSIONS: The high prevalence of ETS exposure among adult Cambodians indicates an urgent need for specific measures such as public awareness campaigns, policies, and regulations to protect nonsmokers in Cambodia.

Is colposcopic biopsy overused among women with a cytological diagnosis of atypical squamous cells of undetermined significance (ASCUS)?

BACKGROUND: The diagnosis of atypical squamous cells of undetermined significance (ASCUS) during cervical screening indicates cellular abnormality but is not sufficient for a definitive diagnosis of a squamous intraepithelial lesion (SIL). Before the 2001 consensus guidelines for the management of women with cervical cytological abnormalities are introduced, follow-up management of ASCUS women by colposcopic biopsy is done at patient and physician discretion. METHODS: In this study, we examined variables associated with the method of follow-up (colposcopic biopsy, repeat Pap smear) in a sample of 651 women(ages 18-82 years) who were diagnosed with ASCUS and were then referred for either a colposcopic biopsy or a repeat Pap smear at their next follow-up appointment. RESULTS: In a multivariate logistic regression analysis (outcome variable = follow-up by colposcopic biopsy or by repeat Pap smear), we found that the odds of follow-up by colposcopic biopsy were 8-fold (OR 8.5, 95% CI 4.4-16.3) higher for high-income (>47,117 US dollars vs. <24,767 US dollars) women, 2-fold higher (OR 2.8, 95% CI 1.5-5.1 ) for women with private insurance (relative to Medicaid), and 3-fold higher (OR 3.1, 95% CI 1.3-7.4) for middle-aged women (ages 36-45 vs. > 55 y). CONCLUSIONS: In stratified analyses, we found that high income was positively associated with odds of colposcopic biopsy in all strata of health coverage and that among those in the highest income category, private insurance remained an indicator of colposcopic biopsy use. Our findings raise the possibility that among women with ASCUS, there is an overuse of colposcopic biopsy by high-income and privately insured women who are likely to be at low risk of cervical malignancies.