In-Clinic vs. Online Recruitment of Women with a History of Cervical Intraepithelial Neoplasia or Cervical Cancer to a Smoking Cessation Trial: A Post-hoc Comparison of Participant Characteristics, Study Retention, and Cessation Outcomes.

INTRODUCTION: Recruiting special populations to smoking cessation trials is challenging and approaches beyond in-clinic recruitment may be beneficial. This secondary analysis of data from a smoking cessation RCT for individuals with a history of cervical cancer or cervical intraepithelial neoplasia (CIN) explored differences associated with in-clinic vs. online recruitment. METHODS: Participants were recruited from clinics within a university-based NCI-designated cancer center (n=87) and online nationally via Facebook (n=115). Baseline measures included sociodemographics, smoking history, and cancer or CIN history. Study retention and smoking abstinence were assessed 12 months post-baseline. Group differences in baseline characteristics were evaluated. Retention and abstinence were evaluated while controlling for group differences and predictors. RESULTS: Participants recruited online (vs. in-clinic) had higher educational attainment (p=.01) and health literacy (p=.003). They were more likely to have CIN vs. cancer, to be further from the time of diagnosis, and to have completed active treatment (p values<.001). While controlling for these group differences and independent predictors, retention was higher among participants recruited online (log-likelihood χ2(1)=11.41, p<.001). There were no recruitment differences in self-reported (p=.90) or biochemically confirmed smoking abstinence (p=.18). CONCLUSIONS: Compared to individuals recruited in-person, individuals recruited online were more educated, had higher health literacy, and presented with a different clinical profile (i.e., more likely to have CIN vs. cancer and to have completed active treatment). There were few differences in participant characteristics between recruitment approaches, and no differences on any smoking-related variables. Online recruitment has the potential to improve enrollment of cancer survivors to smoking cessation trials. IMPLICATIONS: People with a history of CIN or cervical cancer recruited to a smoking cessation RCT online (vs. in-clinic) were more likely to have a diagnosis of CIN vs. cancer and were more educated and health literate. Participants recruited online were more likely to be retained in the study and there were no differences in smoking abstinence rates at 12-months. Incorporating online recruitment increased the reach of tobacco treatment efforts to a larger and more diverse sample. This could reduce the burden of tobacco-related disease, improve CIN and cancer treatment outcomes, and reduce secondary malignancies and morbidity among this underserved group.

Comparison of an automated smartphone-based smoking cessation intervention versus standard quitline-delivered treatment among underserved smokers: protocol for a randomized controlled trial.

BACKGROUND: Smoking is the leading cause of preventable morbidity and mortality in the United States. Individuals with low socioeconomic status have disproportionately high smoking rates and greater difficulty quitting smoking. Efficiently connecting underserved smokers to effective tobacco cessation programs is crucial for disease prevention and the elimination of health disparities. Smartphone-based interventions have the potential to enhance the reach and efficacy of smoking cessation treatments targeting underserved smokers, but there is little efficacy data for these interventions. In this study, we will partner with a large, local hunger-relief organization to evaluate the efficacy and economic impact of a theoretically-based, fully-automated, and interactive smartphone-based smoking cessation intervention. METHODS: This study will consist of a 2-group randomized controlled trial. Participants (N = 500) will be recruited from a network of food distribution centers in West Central Florida and randomized to receive either Standard Treatment (ST, n = 250) or Automated Treatment (AT, n = 250). ST participants will be connected to the Florida Quitline for telephone-based treatment and will receive a 10-week supply of nicotine replacement therapy (NRT; transdermal patches and lozenges). AT participants will receive 10 weeks of NRT and a fully-automated smartphone-based intervention consisting of interactive messaging, images, and audiovisual clips. The AT intervention period will span 26 weeks, with 12 weeks of proactive content and 26 weeks of on-demand access. ST and AT participants will complete weekly 4-item assessments for 26 weeks and 3-, 6-, and 12-month follow-up assessments. Our primary aim is to evaluate the efficacy of AT in facilitating smoking abstinence. As secondary aims, we will explore potential mediators and conduct economic evaluations to assess the cost and/or cost-effectiveness of ST vs. AT. DISCUSSION: The overall goal of this project is to determine if AT is better at facilitating long-term smoking abstinence than ST, the more resource-intensive approach. If efficacy is established, the AT approach will be relatively easy to disseminate and for community-based organizations to scale and implement, thus helping to reduce tobacco-related health disparities. TRIAL REGISTRATION: Clinical Trials Registry NCT05004662 . Registered August 13, 2021.

Smoking Cessation by Cancer Treatment Status Among Cervical Cancer Survivors.

INTRODUCTION: Continued smoking following a cancer diagnosis is associated with poorer cancer treatment outcomes and survival times. Little is known about how cancer treatment status at the time of tobacco treatment enrollment impacts long-term smoking cessation outcomes. Using data from a smoking cessation RCT, this study compared long-term cessation outcomes of women undergoing active treatment for cervical cancer at trial enrollment (n=40) to outcomes of women with a history of cervical cancer or cervical intraepithelial neoplasia (CIN) who were not undergoing active cancer treatment at enrollment (n=154). METHODS: Participants (n=194) were randomized to Standard Treatment (ST) or ST plus a 6-session Motivation And Problem Solving (MAPS) telephone counseling protocol (data collected: 2017-2021; analyzed: 2023). Sociodemographic differences between participants undergoing (versus not undergoing) active cancer treatment at enrollment were examined. Significant covariates were included in a logistic regression analysis comparing the 2 groups' smoking cessation outcomes at 12 months, the end of the tobacco treatment period. RESULTS: Participants in active cancer treatment at enrollment were significantly younger and less educated than those not in active cancer treatment. Race/ethnicity, relationship status, household income, nicotine dependence, and tobacco treatment condition did not vary by cancer treatment status. After adjusting for tobacco treatment condition, age, and education, being in active cancer treatment at the time of enrollment was associated with lower odds of abstinence at 12 months (5% vs 20%, aOR=0.22, 95% CI [0.05-0.998]). CONCLUSIONS: Further research is necessary to identify and overcome barriers to abstinence among cancer survivors undergoing active treatment.

The implementation of ask-advise-connect in a federally qualified health center: a mixed methods evaluation using the re-aim framework.

Ask-Advise-Connect (AAC) efficiently links smokers in healthcare settings with evidence-based Quitline-delivered tobacco treatment through training clinic staff to systematically ask patients about smoking status, advise smokers to quit, and connect patients with state Quitlines using the electronic health record. This study utilized a mixed-methods approach, guided by the RE-AIM framework, to evaluate the implementation of AAC in a Federally Qualified Health Center (FQHC). AAC was implemented for 18 months at a FQHC serving primarily low-socioeconomic status (SES) Latinos and Latinas. Results are presented within the RE-AIM conceptual framework which includes dimensions of reach, effectiveness, adoption, implementation, and maintenance. Quantitative patient-level outcomes of reach, effectiveness, and Impact were calculated. Post-implementation, in-depth interviews were conducted with clinic leadership and staff (N = 9) to gather perceptions and inform future implementation efforts. During the implementation period, 12.0% of GNHC patients who reported current smoking both agreed to have their information sent to the Quitline and were successfully contacted by the Quitline (Reach), 94.8% of patients who spoke with the Quitline enrolled in treatment (Effectiveness), and 11.4% of all identified smokers enrolled in Quitline treatment (Impact). In post-implementation interviews assessing RE-AIM dimensions, clinic staff and leadership identified facilitators and advantages of AAC and reported that AAC was easy to learn and implement, streamlined existing procedures, and had a positive impact on patients. Staff and leadership reported enthusiasm about AAC implementation and believed AAC fit well in the clinic. Staff were interested in AAC becoming the standard of care and made suggestions for future implementation. Clinic staff at a FQHC serving primarily low-SES Latinos and Latinas viewed the ACC implementation process positively. Findings have implications for streamlining clinical smoking cessation procedures and the potential to reduce tobacco-related disparities.

Ask-Advise-Connect (AAC) simplifies and streamlines the process of asking patients about their smoking status, advising smokers to quit, and connecting patients through the electronic health record with free, evidence-based tobacco cessation treatment offered by state Quitlines. This study is the first to evaluate perceptions of AAC among clinic leadership and staff. After an 18-month implementation of AAC at a clinic serving mostly low-income Latinos and Latinas, clinic staff (e.g., medical assistants) and leaders were interviewed. Respondents reported that AAC streamlined their efforts to get patients to quit smoking, was easy to carry out, and fit well into the clinic flow. Staff wanted to keep AAC as the standard of care and made suggestions to improve how AAC works. They reported positive feedback from patients. In addition, a similar proportion of smokers enrolled in Quitline treatment as in other AAC trials. Thus, AAC worked well for patients and clinic staff. Having AAC in other clinics could improve enrollment in evidence-based smoking cessation treatment, facilitate successful smoking cessation among low-income primary care patients, and reduce burden on healthcare providers.

Ending Tobacco Use Through Interactive Tailored Messaging for Cambodian People With HIV (Project EndIT): Protocol for a Randomized Controlled Trial.

BACKGROUND: The prevalence of smoking remains high in many low- and middle-income countries (LMICs), including the Southeast Asian nation of Cambodia. Smoking is especially hazardous for people with HIV. In Cambodia, approximately 43%-65% of men with HIV and 3%-5% of women with HIV smoke cigarettes. Thus, there is a critical need for cost-effective smoking cessation interventions for Cambodian people with HIV. This paper describes the design, methods, and data analysis plans for a randomized controlled trial assessing the efficacy of a theory-based mobile health smoking cessation intervention in Cambodian people with HIV. OBJECTIVE: This 2-group randomized controlled trial compares the efficacy of a mobile health-based automated messaging (AM) intervention versus standard care (SC) in facilitating smoking cessation among Cambodian people with HIV. METHODS: Cambodian people with HIV who currently smoke and are receiving antiretroviral treatment (target, N=800) will be randomized to (1) SC or (2) the AM intervention. SC participants will receive brief advice to quit smoking, written self-help materials, nicotine patches, and will complete weekly app-delivered dietary assessments for 26 weeks. AM participants will receive all SC components (but will complete smoking-related weekly assessments instead of dietary assessments), in addition to a fully automated tailored messaging program driven by the weekly assessments to facilitate smoking cessation. In the Phase-Based Model of smoking cessation, the cessation process is partitioned into 4 phases: motivation, preparation (precessation), cessation (quit date to 2 weeks post quit), and maintenance (up to 6 months post quit). Our AM program targets processes within these phases, including increasing motivation to quit, enhancing self-efficacy, obtaining social support, skills to cope with nicotine withdrawal symptoms and stress, and skills to maintain abstinence. All participants will complete baseline and 3-, 6-, and 12-month in-person follow-up assessments. The primary outcome is biochemically confirmed abstinence at 12 months, with 3- and 6-month abstinence as secondary outcomes. Potential mediators and moderators underlying treatment effects will be explored, and cost-effectiveness will be assessed. RESULTS: This study was approved by all relevant domestic and international institutional and ethical review boards. Participant recruitment commenced in January 2023. Data collection is expected to conclude by the end of 2025. CONCLUSIONS: By demonstrating the greater efficacy and cost-effectiveness of AM relative to SC, this study has the potential to transform HIV care in Cambodia and prevent tobacco-related diseases. Furthermore, it may be adapted for use in other Cambodian populations and in other low- and middle-income countries. Ultimately, the AM approach to smoking cessation could greatly improve public health in the developing world and beyond. TRIAL REGISTRATION: ClinicalTrials.gov NCT05746442; https://clinicaltrials.gov/ct2/show/NCT05746442. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/48923.

Mindfulness and Mobile Health for Quitting Smoking: A Qualitative Study Among Predominantly African American Adults with Low Socioeconomic Status.

Low-income and African American adults experience severe tobacco-related health disparities. Mindfulness-based interventions show promise for promoting smoking cessation, but most mindfulness research has focused on higher income, Caucasian samples. "iQuit Mindfully" is a personalized, interactive text messaging program that teaches mindfulness for smoking cessation. This qualitative study sought feedback from predominantly low-income African American smokers, to improve the intervention for this priority population. After receiving 8 weekly group sessions of Mindfulness-Based Addiction Treatment for smoking cessation and between-session iQuit Mindfully text messages, participants (N=32) completed semi-structured interviews. Participants were adult cigarette smokers (90.6% African American, 62.6% annual income <$30,000, mean age 45.1 [±12.9]). Interviews inquired about participants' experiences with and suggestions for improving iQuit Mindfully, including message content, number, and timing. Interviews were audio-recorded, transcribed verbatim, and coded by a team of 5 coders in NVivo. The coding manual was developed based on response categories from the interview guide and themes emerging from the data. Themes were organized into a conceptual model of factors related to engagement with the mHealth program. Response categories included helpful aspects (e.g., themes of social support, mindfulness, personalization); unhelpful/disliked aspects (e.g., too many/repetitive messages); links between in-person sessions and texts; and suggestions (e.g., changes to number/timing and more personalization). Findings provide insight into participants' day-to-day experiences with iQuit Mindfully and suggest ways to improve mHealth programs among low-income and African American adults.

Heavy drinking and problem drinking among youth in Uganda: A structural equation model of alcohol marketing, advertisement perceptions and social norms.

INTRODUCTION: To determine the role of alcohol marketing, perceptions of marketing and social norms on heavy alcohol use and problem drinking among vulnerable youth in Uganda. METHODS: The Kampala Youth Survey is a cross-sectional study conducted in 2014 with service-seeking youth (ages 12-18 years) living in the slums of Kampala (n = 1134) who were participating in Uganda Youth Development Link drop-in centres. Survey measures assessed perceptions of alcohol advertisements, social norms regarding alcohol use, heavy alcohol use and problem drinking. Factor analyses and structural equation models were computed to determine the predictors (e.g. social norms and alcohol marketing exposure) for drinking amounts, heavy drinking and problem drinking. RESULTS: Alcohol marketing allure, perceptions of adults' alcohol attitudes and respondent's male gender were significantly predictive of heavy drinking. Similarly, in addition to drinking amount and heaviness, only alcohol marketing exposure and friends' alcohol attitudes, as well as respondent's own attitudes about alcohol, significantly predicted variation in problem drinking. DISCUSSION AND CONCLUSIONS: Alcohol marketing exposure and allure are significant predictors of heavy drinking and problem drinking among youth in Uganda. Prevention programs that reduce exposure to and allure of alcohol marketing may prove promising for reducing alcohol use and related problems among these vulnerable youth in a low-resource setting.

"When I Don't Have a Cigarette It's Helpful, but It Really Don't Satisfy:" Qualitative Study of Electronic Nicotine Delivery Systems (ENDS) Use among Low-Income Smokers.

BACKGROUND: Little is known about the use of electronic nicotine delivery systems (ENDS) among low-income adult cigarette smokers, who experience severe tobacco-related health disparities. METHODS: This study conducted interviews to examine experiences and perceptions associated with ENDS use among predominantly low-income adult smokers (n = 30; mean age 30.2 ± 12.9; 60% male, 46.7% African American, 30% white, 10% more than one race; 76.7% annual household income ≤USD 24,000). Interviews were transcribed verbatim and coded in NVivo 11. RESULTS: Overall, participants reported complementing rather than substituting their smoking with ENDS use (e.g., using ENDS only when smoking is not allowed). Predominant reasons for vaping were convenience, smoking reduction/cessation, stress management, social acceptability, lower long-term costs than smoking, and appealing flavors. Common reasons for not switching to exclusive vaping were that ENDS did not satisfy cigarette cravings and concerns about ENDS health effects. Participants indicated higher likelihood of switching to exclusive ENDS use if the products were more affordable, perceived as substantially less harmful, tasted and felt more like smoking a cigarette, and more effective for reducing cravings. CONCLUSIONS: Continued research is needed to maximize any harm reduction potential of ENDS and ensure that these products do not contribute to worsening health disparities.

Mobile Delivery of Mindfulness-Based Smoking Cessation Treatment Among Low-Income Adults During the COVID-19 Pandemic: Pilot Randomized Controlled Trial.

BACKGROUND: Smoking is the leading cause of premature death, and low-income adults experience disproportionate burden from tobacco. Mindfulness interventions show promise for improving smoking cessation. A text messaging program "iQuit Mindfully" was developed to deliver just-in-time support for quitting smoking among low-income adults. A pilot study of iQuit Mindfully was conducted in spring 2020, during the COVID-19 pandemic, among low-income and predominantly African American smokers. OBJECTIVE: This pilot study examined the acceptability and feasibility of delivering Mindfulness-Based Addiction Treatment via mHealth during the COVID-19 pandemic. METHODS: Participants were adult cigarette smokers (n=23), of whom 8 (34.8%) were female, 19 (82.6%) were African American, and 18 (78.3%) had an annual income of

Mindfulness-Based Smoking Cessation Enhanced With Mobile Technology (iQuit Mindfully): Pilot Randomized Controlled Trial.

BACKGROUND: Mindfulness training shows promise for improving smoking cessation and lapse recovery, and between-session mobile health messages could enhance treatment engagement and effectiveness. Personalized, in-the-moment text messaging support could be particularly useful for low-income smokers with fewer smoking cessation resources. OBJECTIVE: This pilot study examined the feasibility of a text messaging program (iQuit Mindfully) as an adjunct to in-person Mindfulness-Based Addiction Treatment (MBAT) for smoking cessation. METHODS: A total of 71 participants were randomly assigned to MBAT (n=33) or iQuit Mindfully (n=38; MBAT + between-session text messages); of these, 70% (50/71) were African American, and 61% (43/71) had an annual household income of US $30,000 or less. All participants received 8 weekly therapist-led group counseling sessions, nicotine patches, and self-help materials. Outcomes were feasibility (attrition, engagement, and participants' ratings), participants' feedback regarding the text messaging intervention, and smoking cessation (assessed in person). RESULTS: Strong retention was achieved (76% [54/71] at the end of treatment, and 89% [63/71] at 1-month follow-up). In the iQuit Mindfully group, engagement was high (88% [29/33] indicated reading all or most texts, and 89% [34/38] engaged in interactive texting), and participants provided positive ratings (on a 1-10 scale, average rating for recommending the program to others was 8.4 [SD 2.5]). Participants indicated benefiting from the texts (eg, appreciating encouraging reminders, coping strategies, and social support) and suggested improvements (eg, more personalization). Overall, biochemically confirmed smoking cessation rates were 22% (12/55) at the end of treatment and 19% (12/62) at 1-month follow-up, with no differences between conditions. Living below the poverty level predicted worse cessation outcomes at 1-month follow-up among participants receiving in-person only treatment (P=.03) but not among those receiving iQuit Mindfully. CONCLUSIONS: Text messaging appears to be a feasible and acceptable modality for supporting mindfulness-based smoking cessation treatment. The availability of 24/7 text messaging might be particularly helpful for low-income smokers who have access to fewer cessation resources and experience significant day-to-day barriers to quitting. TRIAL REGISTRATION: ClinicalTrials.gov NCT03029819; https://clinicaltrials.gov/ct2/show/NCT03029819.

Text Messaging to Enhance Mindfulness-Based Smoking Cessation Treatment: Program Development Through Qualitative Research.

BACKGROUND: Mindfulness-based programs show promise for promoting smoking cessation in diverse populations. Mobile health strategies could increase treatment engagement and in-the-moment support, thus enhancing the effects of mindfulness-based smoking cessation interventions. However, most mobile health programs have been developed without sufficient input from the target population. OBJECTIVE: By eliciting input from the target population, predominantly low socioeconomic status (SES) African American adult smokers, throughout the development of an SMS (short message service) text messaging program that teaches mindfulness for smoking cessation, we aimed for the resulting program to be optimally effective and consistent with participants' needs and preferences. METHODS: Two qualitative studies (N=25) were conducted with predominantly low SES, African American adult smokers. In Study 1 (initial qualitative input; n=15), participants engaged in focus groups to provide suggestions for program development. In Study 2 (abbreviated trial; n=10), participants received a 1-week version of the SMS text messaging program and provided feedback through in-depth interviews. RESULTS: In Study 1, participants suggested that the SMS text messaging program should be personalized and interactive (ie, involve two-way messaging); provide strategies for coping with cravings and recovering from smoking lapses; involve relatively short, to-the-point messages; and include pictures. In Study 2, participants were highly engaged with the texts, indicated that the program was useful, and provided additional suggestions for improvement. CONCLUSIONS: Eliciting feedback from the target population throughout the intervention development process allowed for iterative revisions to increase feasibility, acceptability, and effectiveness. Overall, SMS text messaging appears to be a feasible, appealing way to provide in-the-moment personalized support and encourage mindfulness among low-income African American smokers.

More Overweight Adolescents Think They Are Just Fine: Generational Shift in Body Weight Perceptions Among Adolescents in the U.S.

INTRODUCTION: As obesity prevalence has increased, adolescents' self-perceived body weight might have shifted accordingly. This study aims to investigate the generational shift in adolescents' perception of their body weight. METHODS: We used data from adolescents aged 12-16 years who participated in the National Health and Nutrition Examination Survey in 1988-1994 (early, n=1,720) or 2007-2012 (recent, n=2,518). Self-perceived weight status was assessed by face-to-face interviews, and BMI z-scores were calculated using directly measured weight and height with the 2000 CDC Growth Charts as the reference. The analysis was conducted in 2013. RESULTS: The median BMI z-score of self-perceived overweight adolescents increased from 1.32 (95% CI=1.18, 1.46) among adolescents interviewed early to 1.82 (1.74, 1.90) among adolescents interviewed recently. After adjusting for age, race/ethnicity, sex, and family income, the probability of self-perceiving as "overweight" declined by 29% for overweight/obese adolescents interviewed recently (probability ratio [PR]=0.71 [0.62, 0.82]) compared with adolescents with the same z-scores but interviewed early. The declining tendency of accurately self-perceiving as overweight was most pronounced among whites (PR=0.64 [0.48, 0.85]), and least among blacks (PR=0.76 [0.58, 0.99]). Both boys and girls interviewed recently were significantly less likely to accurately self-perceive as overweight (PR=0.70 [0.56, 0.89] and 0.73 [0.61, 0.87], respectively) compared with their counterparts who were interviewed early. CONCLUSIONS: Fewer overweight/obese adolescents self-perceived as such in the 2007-2012 survey compared with the 1988-1994 survey. The declining tendency among overweight or obese adolescents may be indicative of a generational shift in body weight perceptions.