A framework for building comprehensive cancer center's capacity for bidirectional engagement.

PURPOSE: Community engagement has benefits for cancer centers' work and for its researchers. This study examined the experiences and perceptions of community engagement by members of the Case Comprehensive Cancer Center (Case CCC) to create and implement a framework to meet the needs of the entire cancer center. METHODS: This study included three phases: 1) Semi-structured interviews with 12 researchers from a basic science program to identify needs and suggestions for the support of community engagement; 2) Preliminary interview results informed the development of a survey of 86 cancer center members' about their awareness of and readiness to integrate community outreach and engagement into their research; and 3) The Case CCC Office of Community Outreach and Engagement reviewed the results from phases 1 and 2 to develop and then utilize a framework of engagement opportunities. RESULTS: In the interviews and surveys, cancer center members recognized the importance of community engagement and expressed an interest in participating in COE-organized opportunities for bidirectional engagement. While participation barriers include communication issues, limited awareness of opportunities, and competing priorities, members were open to learning new skills, changing approaches, and utilizing services to facilitate engagement. The framework outlines engagement opportunities ranging from high touch, low reach to low touch, and high reach and was used to develop specific services. CONCLUSION: This study identified varying needs around community engagement using an approach aimed at understanding the perspectives of a community of scientists. Implementing the framework enables reaching scientists in different ways and facilitates scientists' recognition of and engagement with opportunities.

Assessing the Feasibility of Conducting Smoking Cessation Outreach in Food Pantries: A Pilot Intervention Study.

INTRODUCTION: Smoking prevalence is high among US adults with food insecurity. This study examined how food assistance settings, namely food pantries, can serve as a community-based venue to reach food insecure adults who smoke for smoking cessation. METHODS: Partnering with a local hunger relief organization, we conducted surveys and focus groups of food pantry clients in Greater Cleveland, Ohio, followed by food pantry-based outreach events to connect people who smoke to the Ohio Tobacco Quit Line. RESULTS: The survey included 132 participants who visited a food pantry (M age = 47; 74% women; 39% Black/African American), of whom 35% were using tobacco and 31% were smoking cigarettes. Among those currently smoking (M cigarettes/day = 9), 76% intended to quit in the next 6 months, and 82% had not used nor heard of the quitline. Informed by focus group themes, we conducted a total of 22 outreach events at four pantries. Among those interested in smoking cessation resources from the outreach events (n = 54), 78% were able to be subsequently contacted. Of them, 74% provided consent for quitline referral. The remainder either declined or were unable to participate. CONCLUSIONS: While it was feasible to leverage food pantries for smoking cessation outreach, the overall reach was low. Despite high interest in quitting, there was limited effectiveness of outreach efforts without adaptations to each pantry setting and in recognition of the immediate food needs and with challenges related to the COVID-19 pandemic. There remains a critical need to address high rates of smoking among populations experiencing food insecurity. IMPLICATIONS: Tobacco cessation services are increasingly recognizing the need to address food insecurity and other social needs that commonly occur in populations who use tobacco at higher rates. This research underscores both the value and the challenges related to leveraging food pantries as a community-based venue for smoking cessation outreach. In addition to improvements in outreach models, long-term investments in structural interventions are also needed to address underlying poverty and socioeconomic disadvantage that ultimately drive disparities in smoking and in food insecurity.

Come for the Tobacco, Stay for the Flavor: Flavored Cigarillo-Use Trajectories Among Young Adult Sexual Gender Minority Women.

INTRODUCTION: The purpose of this research was to identify how young adult sexual gender minority (SGM) women who use cigarillos may respond to cigar flavor restrictions. AIMS AND METHODS: Young adults aged 21-28 years in the United States who currently use cigarillos were recruited between October 2020 and April 2021 to participate in an online survey. Due to high prevalence of cigarillo use among individuals who identify as sexual and/or gender minority (SGM) women, their (n = 192) flavored tobacco-use behaviors and anticipated responses to cigarillo flavor restrictions were compared to cisgender heterosexual (CisHet) women (n = 110). Logistic regression was used to model cigarillo cessation and product-switching behaviors (flavored and unflavored). RESULTS: SGM women were significantly less likely to report the use of flavor at the initiation of cigarillo use (61.7% vs. 86.1%) but were no different in current flavor use compared to CisHet women, with more than 80% of all women using any flavor. SGM women were 2.36 times as likely to say they would discontinue using cigarillos if flavors were unavailable. Among those who would continue using cigarillos, SGM women were 4.53 times as likely to endorse switching to an unflavored tobacco product but had the same likelihood of saying they would switch to flavored product compared to CisHet women. CONCLUSIONS: Flavor restriction policies may not reduce the initiation of cigarillos among SGM women and may elicit differential cigarillo use and tobacco product substitution by SGM identity. Flavor restriction policies should be coupled with targeted cessation resources to address potential remaining disparities. IMPLICATIONS: SGM US women have a unique cigarillo-use trajectory. These women are more likely to initiate cigarillos without flavor and then later integrate it into their behavior. National cigar flavor restrictions are expected to have a greater impact decreasing cigarillo initiation among CisHet women and decreasing current cigarillo use among SGM women. However, for those who would continue using unflavored cigarillos, SGM women may remain at risk for nicotine dependence due to increased product substitution. SGM women should be prioritized for cessation resources to reduce tobacco-use disparities leading up to and following the implementation of cigar flavor restrictions.

What is (Un)Flavored? A Scoping Review of the Conceptualization of Flavored Cigarillos.

PURPOSE: To identify how flavor is conceptualized with respect to cigarillos to illuminate areas of concordance and discordance and provide a pathway for the harmonization of tobacco flavor measurement. METHODS: Three methods were used to identify research measuring flavors respective to cigarillo products including: 1) querying research databases using key words 'cigarillo,' 'tobacco' and 'flavor'/'flavour,' 2) sub-sampling of the eligible literature with backwards and forwards reference searching, and 3) a bibliographic search of key experts. Two reviewers independently screened titles, abstracts, and full texts. Inclusion criteria required manuscripts to be available in English, published prior to 3/1/2022, be original and peer-reviewed, and include a measure of flavor pertaining to cigarillo products. A total of 163 manuscripts met these criteria and were subsequently evaluated. RESULTS: Cigarillo flavor determinations were made based on the presence of flavoring agents, sensory characteristics, marketing or package characteristics, pre-defined lists, the absence of any of these, and/or were undefined. Individual flavors and their related classifications were not altogether mutually exclusive due to differences in conceptualization which has evolved over time. CONCLUSION: Flavor measures continue to evolve, likely in response to both tobacco control policies and industry shifts. There is a lack of standardization in flavor conceptualization that can be ameliorated through intentional integration of multiple forms of research such as identifying patterns of flavoring agents and/or marketing strategies that elicit a specific flavor profile. By doing this, we may more comprehensively evaluate the impact of flavors, their constituents, and related marketing strategies on broader population health. IMPLICATIONS: There are discrepancies in the conceptualization of flavor in tobacco and nicotine products. The lack of standardized, definitive language limits our ability to comprehensively evaluate the population-level health impact of flavors in addition to our ability to effectively inform, implement and enforce policies restricting flavors in tobacco and nicotine products.

Food Insecurity Trajectories in the US During the First Year of the COVID-19 Pandemic.

INTRODUCTION: The objective of this study was to characterize population-level trajectories in the probability of food insecurity in the US during the first year of the COVID-19 pandemic and to examine sociodemographic correlates associated with identified trajectories. METHODS: We analyzed data from the Understanding America Study survey, a nationally representative panel (N = 7,944) that assessed food insecurity every 2 weeks from April 1, 2020, through March 16, 2021. We used latent class growth analysis to determine patterns (or classes) of pandemic-related food insecurity during a 1-year period. RESULTS: We found 10 classes of trajectories of food insecurity, including 1 class of consistent food security (64.7%), 1 class of consistent food insecurity (3.4%), 5 classes of decreasing food insecurity (15.8%), 2 classes of increasing food insecurity (4.6%), and 1 class of stable but elevated food insecurity (11.6%). Relative to the class that remained food secure, other classes were younger, had a greater proportion of women, and tended to identify with a racial or ethnic minority group. CONCLUSION: We found heterogeneous longitudinal patterns in the development, resolution, or persistence of food insecurity during the first year of the COVID-19 pandemic. Experiences of food insecurity were highly variable across the US population, with one-third experiencing some form of food insecurity risk. Findings have implications for identifying population groups who are at increased risk of food insecurity and related health disparities beyond the first year of the pandemic.

The Role of Cigarillo Flavor in the Co-Use of Cigarillos and Cannabis among Young Adults.

Background: Research suggests flavor facilitates cigarillo use, but it is unknown if flavor impacts patterns of co-use of cigarillos and cannabis ("co-use"), which is common among young adult smokers. This study's aim was to determine the role of the cigarillo flavor in co-use among young adults. Methods: Data were collected (2020-2021) in a cross-sectional online survey administered to young adults who smoked ≥2 cigarillos/week (N = 361), recruited from 15 urban areas in the United States. A structural equation model was used to assess the relationship between flavored cigarillo use and past 30-day cannabis use (flavored cigarillo perceived appeal and harm as parallel mediators), including several social-contextual covariates (e.g., flavor and cannabis policies). Results: Most participants reported usually using flavored cigarillos (81.8%) and cannabis use in the past 30 days ("co-use") (64.1%). Flavored cigarillo use was not directly associated with co-use (p = 0.90). Perceived cigarillo harm (ß = 0.18, 95% CI = 0.06, 0.29), number of tobacco users in the household (ß = 0.22, 95% CI = 0.10, 0.33), and past 30-day use of other tobacco products (ß = 0.23, 95% CI = 0.15, 0.32) were significantly positively associated with co-use. Living in an area with a ban on flavored cigarillos was significantly negatively associated with co-use (ß = -0.12, 95% CI = -0.21, -0.02). Conclusions: Use of flavored cigarillos was not associated with co-use; however, exposure to a flavored cigarillo ban was negatively associated with co-use. Cigar product flavor bans may reduce co-use among young adults or have a neutral impact. Further research is needed to explore the interaction between tobacco and cannabis policy and use of these products.

Measuring Nicotine Dependence Among Adolescent and Young Adult Cigarillo Users.

INTRODUCTION: Current measures of nicotine dependence (ND) were developed and validated for cigarette smokers only, limiting their utility for other combustible tobacco users. This study evaluates the psychometric properties of a pool of new and adapted items to measure ND among cigarillo and multiple tobacco product users. AIMS AND METHODS: Items were drawn from the PROMIS Nicotine Dependence Item Bank which were adapted to be product neutral and new items were developed from a qualitative study of 60 adolescent and young adult cigarillo smokers. A total of 42 ND items were included in a web-based survey. Eligible participants were 14-28 year olds who smoked a minimum of 2 cigarillos per week. Analyses included confirmatory factor analysis, item response theory analysis, analysis of differential item functioning, and reliability. Ordinary least square regression was used to test the association of ND score with deciles of nicotine consumption. RESULTS: Among the 1089 participants, the median number of cigarillos smoked per week was 20; 54% of participants also smoked cigarettes. All PROMIS items and 8 of 10 new items met the item response theory fit criteria. Two PROMIS items had nonignorable differential item functioning. The pool of 40 items had good score reliability for a range of 2 SDs. Twenty-, eight-, and four-item short forms showed similarly good measurement properties; each was positively associated with decile of nicotine consumption, p < .001; R2 = 0.33. CONCLUSIONS: This adapted bank of ND items is psychometrically sound and includes items that are product neutral, making it suitable for assessing ND among cigarillo and polytobacco users. IMPLICATIONS: This study rigorously evaluates adapted items to measure ND among cigarillo and polytobacco users and reports the reliability initial evidence of validity of short form scores.

How cancer programs identify and address the financial burdens of rural cancer patients.

PURPOSE: Financial toxicity is associated with negative patient outcomes, and rural populations are disproportionately affected by the high costs of cancer care compared to urban populations. Our objective was to (1) understand cancer programs' perceptions of rural-urban differences in cancer patients' experiences of financial hardship, (2) evaluate the resources available to cancer patients across the rural-urban continuum, and (3) determine how rural and urban health care teams assess and address financial distress in cancer patients. METHODS: Seven research teams within the Cancer Prevention and Research Control Network conducted semi-structured interviews with cancer program staff who have a role in connecting cancer patients with financial assistance services in both rural and urban counties. Interviews were audio-recorded and transcribed. We identified themes using descriptive content and thematic analysis. RESULTS: We interviewed 35 staffs across 29 cancer care programs in seven states, with roughly half of respondents from programs in rural counties. Participants identified differences in rural and urban patients' experiences of financial hardship related to distance required to travel for treatment, underinsurance, and low socioeconomic status. Insufficient staffing was an identified barrier to addressing rural and urban patients' financial concerns. CONCLUSIONS: Improved financial navigation services could mitigate the effects of financial toxicity experienced by cancer patients, particularly rural patients, throughout treatment and survivorship. Future research is needed to improve how cancer programs assess financial hardship in patients and to expand financial navigation services to better serve rural cancer patients.

Flavour loyalty may predict cessation or substitution following a cigarillo flavour ban among young adults in the USA.

SIGNIFICANCE: The purpose of this research was to measure flavour loyalty and identify how current cigarillo users may respond to a hypothetical flavour ban in the USA. METHODS: Cigarillo users aged 21-28 (n=531) were recruited between October 2020 and April 2021 to participate in an online survey. Respondents categorised their preferred, usual and current cigarillo flavours. Individuals who preferred tobacco flavours were compared with individuals who preferred any other flavours. Strength of preferences, or flavour loyalty, was defined when an individual's preferred flavour matched what they use both usually and currently creating a spectrum of individuals with a strong tobacco preference (n=34), weak tobacco preference (n=20), weak flavour preference (n=162) and strong flavour preference (n=315). Those preferring tobacco were aggregated into any tobacco preference (n=54). RESULTS: Individuals who preferred any flavour scored higher on a scale of nicotine dependence. There was a dose-response relationship in those who said they would discontinue cigarillos if flavoured options were not available: 11.4% of individuals with any tobacco flavour preference, 27.8% of those with a weak flavour preference and 38.1% of those with a strong flavour preference. A similar trend was noted among those who would switch to another product: 19.2% of those with tobacco flavour preference, 34.3% of those with a weak flavour preference and 43.2% of those with a strong flavour preference. CONCLUSION: Individuals who display strong flavour preferences were more likely to say they would discontinue use or seek out alternative flavoured products following a ban on flavoured cigarillos.

Association between school-based tobacco retailer exposures and young adolescent cigarette, cigar and e-cigarette use.

BACKGROUND: Associations between retail tobacco availability and tobacco use have been mixed. This study examined associations between school-based retail environment exposures and current use of cigarettes, cigar products and e-cigarettes among middle school youth in Cleveland, OH. METHODS: Retailers selling tobacco products were identified using the 2015 Cleveland Food Retail Database (n=639 stores). Youth survey data were drawn from the 2016 Cleveland Youth Risk Behavior Survey, administered to all 7th/8th graders across the Cleveland Metropolitan School District (n=3778, response rate=83.0%). Past 30-day cigarette, cigar product and e-cigarette use were assessed. Student demographics, number of days walking to/from school each week and number of times youth stopped at a retailer to/from school each week were included. For each school (n=63), tobacco retail density (TRD) and proximity (TRP) to nearest retailer were calculated for each product. Multiple regression analysis assessed associations between retail exposures and youth tobacco use. RESULTS: Across all schools, 3.9%, 10.2% and 8.6% of students currently use cigarettes, cigar products and e-cigarettes, respectively, and 15.2% currently use at least one tobacco product. TRD and TRP were not associated with current use; frequency of walking to school and stopping at retailers were strongly associated with current use. CONCLUSIONS: Although TRD and TRP were not significantly associated with tobacco product use, youth who reported regularly walking to/from school or who reported stopping at a retail store before/after school were significantly more likely to be a current tobacco product user. This may be due to increased exposure to exterior and point-of-sale marketing.

Small Improvements in an Urban Food Environment Resulted in No Changes in Diet Among Residents.

Living in a low-income neighborhood with low access to healthy food retailers is associated with increased risk for chronic disease. The U.S. Healthy Food Financing Initiative (HFFI) provides resources to support the development of infrastructure to improve neighborhood food environments. This natural experiment examined a HFFI funded food hub that was designed to be implemented by a community development corporation in an urban neighborhood in Cleveland, Ohio. It was intended to increase access to affordable, local, and healthy foods; establish programs to increase social connections and support for healthy eating; and create job opportunities for residents. We used a quasi-experimental, longitudinal design to externally evaluate food hub implementation and its impact on changes to the built and social environment and dietary patterns among residents living in the intervention neighborhood (n = 179) versus those in a comparison (n = 150) neighborhood. Overall, many of the food hub components were not implemented fully, and dose and reach of the executed food hub components was low. There were statistically significant improvements in observed availability of healthy foods in the intervention neighborhood versus the comparison neighborhood. There were no changes over time in diet quality scores, total caloric intake, or fruit and vegetable intake in the intervention neighborhood. In conclusion, low dose implementation of a food hub led to small improvements in availability of healthy foods but not in dietary patterns. Findings highlight challenges to implementing a food hub in neighborhoods with low access to healthy food retailers.

Pulling Your Mask down to Smoke: Qualitative Themes from Young Adults on Nicotine Use during a Pandemic.

Introduction: The COVID-19 pandemic may have resulted in a change in life routines for tobacco users, but little is known about the rationale underlying these changes. Methods: A convenience sample of young adults ages 21-28 (n = 29) were recruited online May-July 2020 to participate in semi-structured interviews about nicotine use behaviors specific to cigarillos and e-cigarettes. Audio-recorded interviews were 60-90 min long and were conducted remotely. Participants were asked opinions and behavioral effects of the COVID-19 pandemic on tobacco use. Verbatim transcripts and field notes from each interview were coded by a trained researcher using a codebook developed using inductive and deductive approaches. Thematic analysis was used to examine product access, use frequency, stress and use triggers. Results: Most current users reported tobacco use stayed the same or increased since the pandemic and attributed this to being home more with greater time/boredom. COVID-19 impacted purchasing behaviors such as purchasing products in greater quantities, through the Internet, or at a different store due to perceived cleanliness. Few reported using tobacco products less frequently and not smoking in public due to the perception of risks associated with smoking and COVID-19, plus having to take off their mask to smoke. Lack of social use modified shared product use, flavors selected, and setting of use. Financial impacts included increased product costs and job loss. Few mentioned wanting to quit due to the pandemic. Discussion: Current tobacco users have experienced major changes in their tobacco use routines during the COVID-19 pandemic.

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

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

Effectiveness of Social Media Approaches to Recruiting Young Adult Cigarillo Smokers: Cross-Sectional Study.

BACKGROUND: The prevalence of social media use among youth and young adults suggests it is an appropriate platform for study recruitment from this population. Previous studies have examined the use of social media for recruitment, but few have compared platforms, and none, to our knowledge, have attempted to recruit cigarillo users. OBJECTIVE: The purpose of this study was to examine the effectiveness of different social media platforms and advertisement images for recruiting cigarillo users aged 14-28 years to complete a cigarillo use survey. METHODS: We obtained objective data for advertisement impressions for a 39-week social media recruitment campaign. Advertisements were targeted to users based on their age, geography, and interests. Effectiveness was defined as the percentage of approved surveys per advertising impression. Chi-square tests were performed to compare the effectiveness of different advertisement images and platforms. RESULTS: Valid survey completers (n=1089) were predominately older (25-28 years old, n=839, 77%). Of the 1089 survey completers, 568 (52%) identified as male, 335 (31%) as African American, and 196 (18%) as Hispanic. Advertisements delivered via Facebook/Instagram were more effective than Twitter; 311/1,027,738 (0.03%) vs 661/2,998,715 (0.02%); χ21=21.45, N=4,026,453); P<.001. Across platforms, ads featuring exclusively an image of cigarillos were more effective (397/682,994, 0.06%) than ads with images of individuals smoking (254/1,308,675, 0.02%), individuals not smoking (239/1,393,134, .02%), and groups not smoking (82/641,650, 0.01%); χ23133.73, N=4,026,453; P<.001. CONCLUSIONS: The campaign was effective in recruiting a diverse sample representative of relevant racial/ethnic categories. Advertisements on Facebook were more effective than Twitter. Advertisements that featured an image of a cigarillo were consistently the most effective and should be considered by others recruiting cigarillo users via social media.

Experiences and perspectives on the return of secondary findings among genetic epidemiologists.

PURPOSE: While there has been a recent increase in scholarship around developing policies for the return of results from genetic sequencing, it is not clear whether these approaches are appropriate for genetic epidemiology studies. Because genetic epidemiological research increasingly utilizes genome sequencing methods, particularly in large data sets where researchers did not directly ascertain the subjects, it is important to understand researchers' perspectives on the return of results. METHODS: We conducted an online survey of members of the International Genetic Epidemiology Society to document the diversity of experiences and impressions regarding return of results. The survey contained both closed and open-ended questions. RESULTS: Among our respondents who enroll their own research participants, only 21% return secondary findings. Most respondents do not search their sequence data for clinically actionable findings not associated with their disease of interest. Many feel that genetic epidemiologists have a unique perspective on the return of results and that research studies should not follow the same procedures as clinical sequencing studies. CONCLUSION: Precision medicine initiatives that rely on both clinical and "big data" genomic research should account for variation in researcher perspectives and study design limitations when developing policies and standard practices regarding the return of results.

Correction: Experiences and perspectives on the return of secondary findings among genetic epidemiologists.

In the original published version of Table 2 the number of respondents who said "No" to the question "Does your consent form distinguish between targeted and incidental findings?" was indicated as "4." It should have read "44." This has now been corrected in both the PDF and HTML versions of the Article.

"You Guys Really Care About Me ": a Qualitative Exploration of a Produce Prescription Program in Safety Net Clinics.

BACKGROUND: Although research shows produce prescription (PRx) programs increase fruit and vegetable (FV) consumption, little is known about how participants experience them. OBJECTIVE: To better understand how participants experience a PRx program for hypertensive adults at 3 safety net clinics partnered with 20 farmers' markets (FMs) in Cleveland, OH. DESIGN: We conducted semi-structured interviews with 5 program providers, 23 patient participants, and 2 FM managers. PARTICIPANTS: Patients interviewed were mainly middle-aged (mean age 62 years), African American (100%), and women (78%). Providers were mainly middle-aged men and women of diverse races/ethnicities. INTERVENTION: Healthcare providers enrolled adult patients who were food insecure and diagnosed with hypertension. Participating patients attended monthly clinic visits for 3 months. Each visit included a blood pressure (BP) check, dietary counseling for BP control, a produce prescription, and produce vouchers redeemable at local FMs. APPROACH: Patient interviews focused on (1) beliefs about food, healthy eating, and FMs; (2) clinic-based program experiences; and (3) FM experiences. Provider and market manager interviews focused on program provision. All interviews were audio-taped, transcribed, and analyzed thematically. KEY RESULTS: We identified four central themes. First, providers and patients reported positive interactions during program activities, but providers struggled to integrate the program into their workflow. Second, patients reported greater FV intake and FM shopping during the program. Third, social interactions enhanced program experience. Fourth, economic hardships influenced patient shopping and eating patterns, yet these hardships were minimized in some participants' views of patient deservingness for program inclusion. CONCLUSIONS: Our findings highlight promises and challenges of PRx programs for economically disadvantaged patients with a chronic condition. Patient participants reported improved interactions with providers, increased FV consumption, and incorporation of healthy eating into their social networks due to the program. Future efforts should focus on efficiently integrating PRx into clinic workflows, leveraging patient social networks, and including economic supports for maintenance of behavior change.

Implementing a Produce Prescription Program for Hypertensive Patients in Safety Net Clinics.

INTRODUCTION: Although community-clinical linkages can improve chronic disease management, little is known regarding strategies for program implementation. We describe implementation of a unique produce prescription program for patients with hypertension (PRxHTN) involving 3 safety net clinics and 20 farmers' markets (FMs). STRATEGY: Safety net clinics were invited to participate, and provider-leads received assistance in (1) developing a process flow to screen for food insecurity among hypertensive adults for program referral, (2) integrating the program into their electronic health record for scheduling, and (3) counseling patients on PRxHTN/FM use. Research staff met with clinics twice monthly. FM managers were trained on maintaining PRxHTN voucher redemption logs. DISCUSSION: A total of 7 diverse providers screened 266 patients over 3 months; 224 were enrolled. Twelve FM, including one newly established at a clinic through provider-FM manager collaboration, redeemed over $14,500 of the $10 PRxHTN vouchers. We describe several strategies that can be used to prepare for and overcome implementation challenges including organizational and staff selection, facilitative administration, and clinical training and consultation. CONCLUSION: The PRxHTN program offers a flexible implementation process allowing clinics to successfully adapt their workflow to suit their staffing and resources.

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

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

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

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