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

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

Duties When an Anonymous Student Health Survey Finds a Hot Spot of Suicidality.

Public health agencies regularly survey randomly selected anonymous students to track drug use, sexual activities, and other risk behaviors. Students are unidentifiable, but a recent project that included school-level analysis discovered a school with alarmingly prevalent student suicidality. Given confidentiality protocols typical of surveillance, the surveyors were uncertain whether and how to intervene. We searched literature for duties to warn at-risk groups discovered during public health surveillance, but we found no directly applicable guidance or cases. Reasoning by analogy, we conclude that surveyors should contact the school's leaders to call attention to its outlier status, but public warning is unwarranted. However, such an ad hoc decision to issue a warning, even if only to school leaders, raises significant practical, legal and ethical issues. National public health and education associations should produce guidance that clarifies ethical and legal duties owed to schools and students involved in population health-risk surveillance.

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

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

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

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

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

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

Adolescent Marijuana Use and Perceived Ease of Access Before and After Recreational Marijuana Implementation in Colorado.

BACKGROUND: As of January 1, 2017, eight states have approved laws for recreational marijuana use. While the social impacts of these changes remain under debate, the influence on adolescent marijuana use is a key policy and health issue across the U.S. OBJECTIVE: To examine changes in adolescent marijuana-use behaviors in the first year after recreational marijuana implementation in Colorado, and to analyze the effect of retail marijuana store proximity on youth use and perceptions. METHOD: Secondary analysis of Healthy Kids Colorado Survey data from 40 schools surveyed before and after recreational marijuana sales were implemented (2013 student n = 12,240; 2014 student n = 11,931). Self-reported marijuana use, ease of access, and perceived harms were compared between years and by proximity of recreational marijuana stores to surveyed schools. RESULTS: Adolescent marijuana use behaviors, wrongness of use, and perceptions of risk of harm were unchanged from baseline to one-year follow-up. Perceived ease of access to marijuana increased (from 46% to 52%). Proximity of recreational marijuana stores was not significantly associated with perceived ease of access to marijuana. Conclusions/Importance: In the first study of adolescent marijuana use and perceptions after state retail implementation of recreational marijuana, there was little change in adolescent marijuana use but a significant change in perception of ease of access. Public health workers and policymakers should continue to monitor these changes as essential for evaluating the impact of liberalization of marijuana policies.

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

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

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

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

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

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

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

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

Medicinal nicotine nonuse: smokers' rationales for past behavior and intentions to try medicinal nicotine in a future quit attempt.

INTRODUCTION: Nicotine replacement therapy (NRT) is a proven smoking cessation treatment. Previous research has reported low rates of NRT use among quit attempters. This study analyzed population-level nonuse rates and reasons for not using NRT. METHODS: Data were from the 2008 adult Colorado Tobacco Attitudes and Behaviors Survey (TABS), a population-based, random-digit-dialed telephone survey (n = 14,156). Primary measures were past NRT nonuse and future intentions regarding NRT use among current smokers intending to quit. Multiple logistic regression was used to identify reasons for past NRT nonuse associated with intention to use NRT in the future, adjusted for factors known to influence NRT use. RESULTS: Nearly, 80% of 1,095 current smokers who intended to quit had never used NRT. The most common reasons for nonuse were belief that "willpower" alone is sufficient for cessation (21.5%), perceived lack of NRT effectiveness (15.6%), and cost (14.3%). Willpower was more widely reported among Hispanics than Anglos (36.9% vs. 14.7%) and nondaily versus daily smokers (30.4% vs. 12.5%). Most previous NRT nonusers reported they would use cold turkey (65.2%) in their next quit attempt; NRT was the next most common choice (15.0%). In multivariate analysis, smokers identifying cost or willpower as a reason for previous nonuse had significantly lower odds of planning to use NRT in a future quit attempt. CONCLUSIONS: The majority of smokers have never used NRT and do not plan to use it in the future. Cost and belief in willpower alone are significant barriers to using NRT in future smoking cessation attempt.

The Living Well by Faith Health and wellness program for African Americans: an exemplar of community-based participatory research.

BACKGROUND: Using community-based participatory research (CBPR) as a guiding framework, a faith-based diet, nutrition and physical activity intervention for African Americans was implemented and evaluated as a small-scale randomized trial. METHODS: Five churches were recruited (intervention=3, control=2), resulting in an enrolled sample of 106 adults (intervention=74, control=32). The control group received a minimal intervention consisting of one educational workshop. The Living Well By Faith intervention group received a more intensive 8-week program. Classes were held twice a week and included educational workshops and exercise sessions. Both interventions were delivered at participating churches. Assessments for program evaluation occurred at baseline and 2-month follow-up. These included weight, blood pressure, percent body fat, and physical fitness using the step test. RESULTS: The sample was predominantly African American, female and well educated. At baseline, no significant differences between intervention and control groups were found for any of the primary endpoints. At 2-months follow up, the intervention group, compared to the control group, showed significant decreases in weight (P<.02), BMI (P<.05), and % body fat (P<.03), with a significant increase in physical fitness (P<.02). Systolic blood pressure also showed group differences in the predicted direction (P=.10). CONCLUSION: This study provides an exemplar of CBPR. The results obtained are sufficiently promising to support more research involving similar interventions of longer duration and with longer-term follow-up for evaluation.

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

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

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

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

Smoking cessation treatment preferences, intentions, and behaviors among a large sample of Colorado gay, lesbian, bisexual, and transgendered smokers.

INTRODUCTION: Little is known about preferences, intentions, and behaviors regarding evidence-based cessation treatment for smoking cessation among gay, lesbian, bisexual, and transgendered (GLBT) adults. METHODS: We obtained and analyzed questionnaire responses from GLBT smokers (n= 1,633) surveyed in 129 GLBT-identified Colorado venues and online during 2007. RESULTS: Most respondents (80.4%) smoked daily. Nearly one-third smoked 20 or more cigarettes/day. Fewer than half (47.2%) had attempted quitting in the previous year, and only 8.5% were preparing to quit in the next month. More than one-fourth (28.2%) of quit attempters had used nicotine replacement therapy (NRT), and a similar proportion said they intended to use NRT in their next quit attempt. Lesbians were significantly less likely than gay men to have used or intend to use NRT. One-fourth of respondents said they were uncomfortable talking to their doctor about quitting smoking. Four factors (daily smoking, ever having used NRT, a smoke-free home rule, and comfort asking one's doctor for cessation advice) were associated with preparation to quit smoking. CONCLUSIONS: GLBT self-identification was not associated with lower than average acceptance of evidence-based smoking cessation strategies, especially NRT, but a large minority of GLBT smokers were unlikely to seek cessation assistance through clinical encounters. Public health campaigns should focus on supporting motivation to quit and providing nonclinical access to evidence-based treatments.

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

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

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

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

Reaching Spanish-speaking smokers: state-level evidence of untapped potential for QuitLine utilization.

OBJECTIVES: We examined the effects of a Spanish-language media campaign on the reach and outcomes of a state-sponsored QuitLine among Latino smokers. METHODS: In this quasiexperimental (2-group, pre-post) study, we analyzed data from Colorado QuitLine callers before (April-August 2007) and during (September-November 2007) the media campaign. Call volume, service utilization, and quit rates at 7-month follow-up were compared between Latino (n = 243) and non-Latino (n = 527) callers. RESULTS: QuitLine calls increased among Latinos during the campaign by 57.6% (1169 vs 1842 in 3-month periods). Compared with precampaign Latino study respondents, Latino respondents during the campaign were significantly younger (younger than 45 years), more often Spanish speaking, uninsured, and less educated. Among Latino enrollees, program completion and nicotine replacement therapy use were similar before and during the campaign, and quit rates during the campaign improved marginally to significantly (7-day abstinence: 29.6% vs 41.0%, P = .07; 6-month abstinence: 9.6% vs 18.8%, P = .04). CONCLUSIONS: A well-designed, statewide Spanish-language media campaign increased QuitLine reach and improved cessation outcomes among a young Latino population of low socioeconomic status. QuitLine-supported cessation can be increased among these smokers.

Reduced NRT supplies through a quitline: smoking cessation differences.

INTRODUCTION: Quitlines (QLs) provide effective smoking cessation treatment. The most cost-effective protocol for nicotine replacement therapy (NRT) has not been established. The current study compares self-reported 7-day abstinence rates among light to moderate smokers (< or = 20 cigarettes per day [CPD]) when a state QL reduced NRT supplies from 8 to 4 weeks. METHODS: The study (n = 1,710) included Colorado QuitLine enrollees who requested free NRT. Analysis compared light to moderate smokers when 8- versus 4-week NRT supplies were available; the nonequivalent control group was heavy smokers (>20 CPD), who were consistently eligible for 8 weeks of NRT during the same time period. RESULTS: Under the reduced NRT protocol, abstinence declined by nearly one fourth among light to moderate smokers (29.9% vs. 39.3%, p < .01). Heavy smokers reported no difference in abstinence rates (28.6% vs. 28.4%, p = nonsignificant). DISCUSSION: Reducing NRT supplies from 8 to 4 weeks was associated with a one-fourth reduction in smoking abstinence rates among users of a state telephone QL. Future research should experimentally assess cost-effectiveness of 4- versus 8-week NRT protocols in QLs and should examine potentially mediating or moderating factors, such as history-affected expectancies regarding NRT and smoking cessation.