Testing and Refining Measures of Secondhand Smoke Exposure Among Smokers and Nonsmokers.

Introduction: Over the past few decades, tobacco control efforts have made great strides in making smoke-free air the norm; 30 states in the United States have implemented 100% smoke-free laws. Despite this progress, the evolution of the measurement of secondhand smoke (SHS) exposure has lagged. Methods: Cognitive testing was used to explore the functioning and limitations of current SHS surveillance items; many items are frequently used for statewide or national surveillance. A total of 20 nonsmokers and 17 smokers participated in a cognitive interview. Results: Overreporting of SHS was evidenced in our analysis as thirdhand smoke exposure was being included in the assessment of SHS exposure, likely due to the successful implementation of indoor smoking bans. Also asking about locations of SHS exposure outside of work, home, or a personal vehicle is important because these alternative locations were sometimes the only incidence of SHS exposure. Conclusions: Survey questions about SHS should: (1) reduce the ambiguity in words and phrases of items; (2) measure location of exposure; (3) measure duration of exposure; and (4) consider alternative strategies for asking smokers questions about SHS. Assessing location and duration of exposure can inform decision-makers about future SHS programming and policy work. Implications: Commonly accepted survey measures of SHS exposure need to be reevaluated to assure that the intended interpretation of them is still accurate given significant policy and social norm change. This paper assesses current SHS surveillance items and provides recommendations for revisions.

Infrastructure Availability for the Care of Congenital Heart Disease Patients and Its Influence on Case Volume, Complexity and Access Among Healthcare Institutions in 17 Middle-Income Countries.

The care for patients with congenital heart disease (CHD) is multi-disciplinary and resource intensive. There is limited information about the infrastructure available among programs that care for CHD patients in low and middle-income countries (LMIC). A survey covering the entire care-pathway for CHD, from initial assessment to inpatient care and outpatient follow-up, was administered to institutions participating in the International Quality Improvement Collaborative for Congenital Heart Disease (IQIC). Surgical case complexity-mix was collected from the IQIC registry and estimated surgical capacity requirement was based on population data. The statistical association of selected infrastructure with case volume, case-complexity and percentage of estimated case-burden actually treated, was analyzed. Thirty-seven healthcare institutions in seventeen countries with median annual surgical volume of 361 (41-3503) operations completed the survey. There was a median of two (1-16) operating room/s (OR), nine (2-80) intensive care unit (ICU) beds, three (1-20) cardiac surgeons, five (3-30) OR nurses, four (2-35) anesthesiologists, four (1-25) perfusionists, 28 (5-194) ICU nurses, six (0-30) cardiologists and three (1-15) interventional cardiologists. Higher surgical volume was associated with higher OR availability (p = 0.007), number of surgeons (p = 0.002), OR nurses (0.008), anesthesiologists (p = 0.04), perfusionists (p = 0.001), ICU nurses (p < 0.001), years of experience of the most senior surgeon (p = 0.03) or cardiologist (p = 0.05), and ICU bed capacity (p = 0.001). Location in an upper-middle income country (P = 0.04), OR availability (p = 0.02), and number of cardiologists (p = 0.004) were associated with performing a higher percentage of complex cases. This study demonstrates an overall deficit in the infrastructure available for the care of CHD patients among the participating institutions. While there is considerable variation across institutions surveyed, deficits in infrastructure that requires long-term investment like operating rooms, intensive care capacity, and availability of trained staff, are associated with reduced surgical capacity and access to CHD care.

The comparative effectiveness of clinic, work-site, phone, and Web-based tobacco treatment programs.

INTRODUCTION: Tobacco treatment programs may be offered in clinical settings, at work-sites, via telephone helplines, or over the Internet. Little comparative data exist regarding the real-world effectiveness of these programs. This paper compares the reach, effectiveness, and costs of these different modes of cessation assistance. METHODS: This is an observational study of cohorts of participants in Minnesota's QUITPLAN programs in 2004. Cessation assistance was provided in person at 9 treatment centers, using group counseling at 68 work-sites, via a telephone helpline, or via the Internet. The main outcomes of the study are enrollment by current smokers, self-reported 30-day abstinence, and cost per quit. Reach was calculated statewide for the helpline and Web site, regionally for the treatment centers, and for the employee population for work-site programs. RESULTS: Enrollment was greatest for the Web site (n = 4,698), followed by the helpline (n = 2,351), treatment centers (n = 616), and work-sites (n = 479). The Web site attracted younger smokers. Smokers at treatment centers had higher levels of nicotine dependence. The helpline reached more socially disadvantaged smokers. Responder 30-day abstinence rates were higher for the helpline (29.3%), treatment centers (25.8%), and work-sites (19.6%) compared with the online program (12.5%). These differences persisted after controlling for baseline differences in participant characteristics and use of pharmacological therapy. The cost per quit was lowest for the Web site program ($291 per quit, 95% CI = $229-$372). DISCUSSION: Treatment center, work-site, helpline, and Web site programs differ in their reach, effectiveness, and estimated cost per quit. Each program plays a part in assisting populations of tobacco users in quitting.

Quasi-Experimental Evaluation of LifeCourse on Utilization and Patient and Caregiver Quality of Life and Experience.

Whole-person care is a new paradigm for serious illness, but few programs have been robustly studied. We sought to test the effect of LifeCourse (LC), a person-centered program for patients living with serious illness, on health-care utilization, care experience, and quality of life, employing a quasi-experimental design with a Usual Care (UC) comparison group. The study was conducted 2012 to 2017 at an upper-Midwest not-for-profit health-care system with outcomes measured every 3 months until the end of life. Enrolled patients (N = 903) were estimated to be within 3 years of end of life and diagnosed with 1+ serious illness. Exclusion criteria included hospice enrollment at time of screening or active dying. Community health workers (CHWs) delivered standardized monthly 1-hour home visits based on palliative care guidelines and motivational interviewing to promote patients' physical, psychosocial, and financial well-being. Primary outcomes included health-care utilization and patient- and caregiver-experience and quality of life. Patients were elderly (LC 74, UC 78 years) and primarily non-Hispanic, white, living at home with cardiovascular disease as the primary diagnosis (LC 69%, UC 57%). A higher proportion of LC patients completed advance directives (N = 173, 38%) than UC patients (N = 66, 15%; P < .001). LifeCourse patients who died spent more days in hospice (88 ± 191 days) compared to UC patients (44 ± 71 days; P = .018). LifeCourse patients reported greater improvements than UC in communication as part of the care experience ( P = .016). Implementation of person-centered programs delivered by CHWs is feasible; inexpensive upstream expansion of palliative care models can yield benefits for patients and caregivers. Trial Registration: Trial NCT01746446 was registered on November 27, 2012 at ClinicalTrials.gov .

Price-Minimizing Behaviors in a Cohort of Smokers before and after a Cigarette Tax Increase.

Cigarette tax increases result in a reduced demand for cigarettes and increased efforts by smokers to reduce their cost of smoking. Less is known about how smokers think about their expenditures for cigarettes and the possible mechanisms that underlie price-minimizing behaviors. In-depth longitudinal interviews were conducted with Minnesota smokers to explore the factors that influence smokers' decisions one month prior to a $1.75 cigarette tax increase and again one and three months after the increase. A total of 42 were sampled with 35 completed interviews at all three time points, resulting in 106 interviews across all participants at all time points. A qualitative descriptive approach examined smoking and buying habits, as well as reasons behind these decisions. A hierarchy of ways to save money on cigarettes included saving the most money by changing to roll your own pipe tobacco, changing to a cheaper brand, cutting down or quitting, changing to cigarillos, and buying online. Using coupons, shopping around, buying by the carton, changing the style of cigarette, and stocking up prior to the tax increase were described as less effective. Five factors emerged as impacting smokers' efforts to save money on cigarettes after the tax: brand loyalty, frugality, addiction, stress, and acclimation.

Examining mixing methods in an evaluation of a smoking cessation program.

Three different methods were used in an evaluation of a smoking cessation study: surveys, focus groups, and phenomenological interviews. The results of each method were analyzed separately and then combined using both a pragmatic and dialectic stance to examine the effects of different approaches to mixing methods. Results show that the further apart the methods are philosophically, the more diverse the findings. Comparisons of decision maker opinions and costs of the different methods are provided along with recommendations for evaluators' uses of different methods.

Encoded exposure to tobacco use in social media predicts subsequent smoking behavior.

PURPOSE: Assessing the potential link between smoking behavior and exposure to mass media depictions of smoking on social networking Web sites. DESIGN: A representative longitudinal panel of 200 young adults in Connecticut. SETTING: Telephone surveys were conducted by using computer assisted telephone interviewing technology and electronic dialing for random digit dialing and listed samples. SUBJECTS: Connecticut residents aged 18 to 24 years. MEASURES: To measure encoded exposure, respondents were asked whether or not they had smoked a cigarette in the past 30 days and about how often they had seen tobacco use on television, in movies, and in social media content. Respondents were also asked about cigarette use in the past 30 days, and a series of additional questions that have been shown to be predictive of tobacco use. ANALYSIS: Logistic regression was used to test for our main prediction that reported exposure to social media tobacco depictions at time 1 would influence time 2 smoking behavior. RESULTS: Encoded exposure to social media tobacco depictions (B = .47, p < .05) was a significant predictor of time 2 smoking, even after controlling for all the aforementioned predictors. CONCLUSION: Our results suggest that social media depictions of tobacco use predict future smoking tendency, over and above the influence of TV and movie depictions of smoking. This is the first known study to specifically assess the role of social media in informing tobacco behavior.

Experience of smokers and recent quitters with smokefree regulations and quitting.

BACKGROUND: Bans on smoking in public areas have increased as knowledge of secondhand smoke dangers has grown. Restrictions on smoking in public areas may lead to less smoking and increased quitting. PURPOSE: This study examines the experiences of smokers and recent quitters with local smokefree regulations to better understand the possible mechanisms by which smokefree regulations affect individual tobacco users' patterns of tobacco consumption and quitting. METHODS: Fifteen in-depth interviews and thirteen focus groups were conducted with tobacco users and recent quitters formerly enrolled in cessation programs provided by ClearWay Minnesota(SM). Data were collected 3 months after smokefree legislation was adopted in the Minneapolis/St. Paul metropolitan area in 2006, and were stratified by tobacco use status and strength of regulation. Essential themes were extracted using NVivo 8 software in 2011. RESULTS: Study participants reported that smokefree legislation forced them to confront their addiction. They experienced apprehension, frustration, and panic anticipating smoking restrictions. This motivated some to attempt to quit, whereas others felt punished by and angry at government intrusion. Both current and former tobacco users felt smokefree regulations contributed to stigmatizing smokers. They also reported smokefree legislation reduced the temptation to smoke. The physical absence of cigarette smoke in bars and restaurants appeared to support quit attempts. The inconvenience of smoking outside was reported to have a similar effect. CONCLUSIONS: Essential mechanisms by which bans influenced patterns of tobacco use and quitting include confronting addiction, temptation, inconvenience, and social norms. These findings highlight the success of tobacco control advocates in denormalizing tobacco use, and suggest that some tobacco users may be internalizing negative messages about tobacco.

Minnesota's smokefree policies: impact on cessation program participants.

BACKGROUND: Smokefree policies are enacted to protect individuals from secondhand smoke; however, these laws may have broader cessation effects. PURPOSE: This study investigated the relationship between Minnesota's local and statewide smokefree policies and quitting outcomes among cessation program enrollees. METHODS: Data were collected from 2006 to 2008 from two groups of participants (n=1644 pre-statewide law; n=1273 post-statewide law) and analyzed in 2009. Website enrollees were surveyed by Internet or telephone 6 months post-enrollment. Others were surveyed by telephone 7 months post-enrollment. RESULTS: Those who enrolled in a cessation program after the statewide smokefree law were more likely to quit (p<0.05, relative risk [RR]=1.15) and were predicted to achieve a 30-day abstinence rate 4.1 percentage points greater than that achieved by those who quit pre-statewide law (30.9% vs 26.8%, respectively). Participants who quit post-statewide law were less likely to relapse and were predicted to have a relapse rate 6.4 percentage points below those who quit pre-statewide law (p<0.05, RR=0.87). Each additional year residing in or adjacent to a county with a local smokefree ordinance in place, up until the time of the statewide law, reduced the likelihood of achieving abstinence post-statewide law (p<0.001, RR=0.92) and increased the likelihood of relapse and the predicted relapse rate (p<0.05, RR=1.05). CONCLUSIONS: Abstinence and relapse rates for those enrolling in cessation programs appeared more favorable after the implementation of Minnesota's statewide smokefree law, suggesting that smokefree policies may have a small but beneficial impact on cessation outcomes. Previous exposure to local smokefree ordinances may lessen this effect.