Successful Optimization of Tobacco Dependence Treatment in the Emergency Department: A Randomized Controlled Trial Using the Multiphase Optimization Strategy.

STUDY OBJECTIVE: Tobacco dependence treatment initiated in the hospital emergency department (ED) is effective. However, trials typically use multicomponent interventions, making it difficult to distinguish specific components that are effective. In addition, interactions between components cannot be assessed. The Multiphase Optimization Strategy allows investigators to identify these effects. METHODS: We conducted a full-factorial, 24 or 16-condition optimization trial in a busy hospital ED to examine the performance of 4 tobacco dependence interventions: a brief negotiation interview; 6 weeks of nicotine replacement therapy with the first dose delivered in the ED; active referral to a telephone quitline; and enrollment in SmokefreeTXT, a free short-messaging service program. Study data were analyzed with a novel mixed methods approach to assess clinical efficacy, cost-effectiveness, and qualitative participant feedback. The primary endpoint was tobacco abstinence at 3 months, verified by exhaled carbon monoxide using a Bedfont Micro+ Smokerlyzer. RESULTS: Between February 2017 and May 2019, we enrolled 1,056 adult smokers visiting the ED. Odd ratios (95% confidence intervals) from the primary analysis of biochemically confirmed abstinence rates at 3 months for each intervention, versus control, were: brief negotiation interview, 1.8 (1.1, 2.8); nicotine replacement therapy, 2.1 (1.3, 3.2); quitline, 1.4 (0.9, 2.2); SmokefreeTXT, 1.1 (0.7, 1.7). There were no statistically significant interactions among components. Economic and qualitative analyses are in progress. CONCLUSION: The brief negotiation interview and nicotine replacement therapy were efficacious. This study is the first to identify components of ED-initiated tobacco dependence treatment that are individually effective. Future work will address the scalability of the brief negotiation interview and nicotine replacement therapy by offering provider-delivered brief negotiation interviews and nicotine replacement therapy prescriptions.

Tobacco Quitlines May Help Exclusive Vapers Quit: An Analysis of Data From an Employer-Sponsored Quitline.

Numerous studies have supported the effectiveness and cost-effectiveness of quitlines for cigarette smoking cessation, but how effective they are for vaping cessation has not been established. Our secondary analysis examined quitline data on participants in employer-sponsored quitlines in the US run by Optum, Inc to compare quit rates among callers who were exclusive vapers (n = 1,194) with those who were exclusive smokers (n = 22,845). We examined data from the time of quitline enrollment, January 2017, through October 2020. Before adjusting for differences in demographics, quitline treatment engagement, and unadjusted quit rates, the quit rates for vapers were significantly higher. However, after adjusting for demographic and treatment engagement variables, 6-month quit rates among vapers did not differ significantly from rates among smokers.

A Randomized Pilot of a Tailored Smoking Cessation Quitline Intervention for Individuals Who Smoke and Vape.

INTRODUCTION: Although e-cigarettes are not a federally approved tobacco cessation aid in the United States, many smokers use them to quit or cut down on smoking. Tailored behavioral support could improve rates of complete smoking cessation for those individuals. AIMS AND METHODS: A novel behavioral treatment to help dual cigarette and e-cigarette users quit smoking was tested in a randomized pilot with a state tobacco quitline. Ninety-six dual users of cigarettes and e-cigarettes were recruited from incoming state quitline callers and randomized to receive enhanced e-cigarette coaching (EEC) or quitline treatment as usual (TAU) to examine EEC feasibility and acceptability. Outcomes at 3 months were treatment satisfaction, engagement, beliefs, and smoking cessation. This pilot was not powered to detect differences in quit rates. RESULTS: Sixty-nine percent responded to the 3-month survey. EEC treatment satisfaction was noninferior to TAU: 93.8% (30/32) of EEC and 73.5% (25/34) of TAU reported being "very satisfied" or "satisfied" with treatment, respectively. EEC participants completed more coaching calls than TAU (M = 3.4 vs. M = 2.7, p = .03), and the majority in both groups elected to receive nicotine replacement therapy (EEC: 100%, TAU: 94%, p = .24). With missing data imputed as smoking, intent-to-treat 7-day point prevalence smoking abstinence rates were 41.3% (19/46) for EEC and 28.0% (14/50) for TAU (p = .20). CONCLUSIONS: The EEC quitline intervention for dual cigarette and e-cigarette users demonstrated high levels of treatment satisfaction and engagement. This pilot was not powered to detect significant differences in smoking cessation; however, cessation rates were promising and warrant evaluation in a fully powered trial. IMPLICATIONS: If this scalable behavioral treatment to help dual cigarette and e-cigarette users quit smoking proves to be effective in a larger trial, quitlines could implement this harm reduction approach to improve outcomes for callers who already use e-cigarettes and are planning to use them while quitting smoking.

Marijuana Use and Adherence to Smoking Cessation Treatment Among Callers to Tobacco Quitlines.

INTRODUCTION: Tobacco kills over half a million adults annually in the United States. Most smokers want to quit, and over 400,000 call state-funded quitlines for help each year. Marijuana use among tobacco users is common and may impede quitting, but co-use rates among quitline callers are unknown. The purpose of our observational study was to describe marijuana use among quitline callers in states with legalized marijuana. METHODS: Participants were 1,059 smokers aged 21 or older from Oregon, Alaska, and Washington, DC, who called quitlines from September through December 2016. Data on quitline callers' demographics, tobacco and marijuana use, and quitline use were collected. We used χ2 and regression analyses to compare marijuana users with nonusers on demographic characteristics and quitline use. RESULT: Among quitline callers in our study, 24% reported using marijuana in the past 30 days: 28.9% in Alaska, 16.7% in Washington, DC, and 25.0% in Oregon (P = .009). Current users, compared with non-users (n = 772), were less likely to be women (48.4% vs 62.0%, respectively, P < .001). Current marijuana users were less likely to be given nicotine replacement therapy (68.4%) than current nonusers (74.1%) (P < .001), but more likely to complete 3 or more counseling calls (P = .005). Of those who used marijuana in the past 30 days, 62.3% used marijuana on 1 to 19 days, 9.0% used on 20 to 29 days, and 28.7% on all 30 days. Among current marijuana users, the percentage who wanted to quit or reduce marijuana use (42.6%) was higher in Alaska (54.6%) and the District of Columbia (56.8%) than in Oregon (37.9%), P = .03. CONCLUSION: One in 4 quitline callers reported past 30-day marijuana use. Given that nearly half (43%) wanted to reduce marijuana use, addressing co-use may be an important addition to quitline treatment. Future studies should assess co-use effects on tobacco cessation outcomes and explore combined treatment or bidirectional referrals between quitlines and marijuana treatment providers.

Feasibility and Early Outcomes of a Tailored Quitline Protocol for Smokers With Mental Health Conditions.

INTRODUCTION: Adults with mental health conditions (MHCs) smoke at higher rates, are more nicotine dependent, and have more trouble quitting smoking than those without MHCs. About half of smokers who call state-funded quitlines report MHCs, and those with such conditions have cessation rates 8%-10% lower than those without MHCs. This article describes a clinical pilot of a tailored protocol for quitline callers with MHCs. METHODS: Callers to the Texas Tobacco Quit Line who self-reported MHCs were offered a tailored quitline program, offering up to 12 weeks of combination nicotine replacement (nicotine patch plus gum or lozenge) and seven counseling calls. Characteristics, program engagement, and 7-month outcomes for these pilot participants were compared to callers in the standard Texas Tobacco Quit Line program with and without MHCs not offered the tailored program. RESULTS: Eighty-eight percent of eligible quitline callers accepted enrollment in the tailored pilot. Pilot enrollees (n = 311) had high rates of comorbidity and serious mental illness, including bipolar disorder (59%). Those in the pilot sample participated in more coaching calls and used more nicotine replacement versus comparison groups. Early cessation outcomes showed numerically higher quit rates for pilot participants than those with MHCs in the standard program, but small sample size and low response rates prevent definitive statements about efficacy. CONCLUSIONS: Offering a tailored quitline protocol for callers with MHCs was feasible and acceptable to quitline callers and increased engagement in treatment. A larger study is needed to determine if the protocol increases cessation among this group. IMPLICATIONS: Nearly half of all quitline callers report a MHC. This clinical quality improvement pilot shows that delivering a tailored tobacco cessation program for smokers with MHCs is feasible and acceptable to quitline callers. Participants in the pilot group had higher engagement in treatment, doubling the number of coaching calls received and using more nicotine replacement than comparison groups. Further investigation is needed to determine the effect of this program on cessation rates, although preliminary outcomes are promising.

A Randomized Pilot Study of a Phone-Based Mindfulness and Weight Loss Program.

This study evaluated the feasibility and efficacy of integrating mindfulness training into a phone-based weight loss program to improve outcomes in those with high levels of emotional eating. Participants were 75 enrollees into an employer-sponsored weight loss program who reported high levels of overeating in response to thoughts and feelings. Seventy-five overweight and obese participants (92% female, 65% Caucasian, aged 26 to 68 years) were randomized to the new mindfulness weight loss program (n = 50) or the standard behavioral weight loss program (n = 25). Both programs consisted of 11 coaching calls with health coaches and registered dietitians with supplemental online materials. Satisfaction, engagement, and percent weight lost did not significantly differ for intervention vs. control at six months. Intervention participants had significantly better scores at six-month follow-up on mindful eating, binge eating, experiential avoidance, and one mindfulness subscale. Exploratory analyses showed that improvements on several measures predicted more weight loss in the intervention group. This pilot study found that integrating mindfulness into a brief phone-based behavioral weight loss program was feasible and acceptable to participants, but did not produce greater weight loss on average, despite hypothesized changes in mindful eating. Only one third of intervention participants reported participating in mindfulness exercises regularly. Mechanisms of change observed within the intervention group suggest that for adults with high levels of emotional eating those who embrace mindful eating and meditation may lose more weight with a mindfulness intervention.

Never Quit Trying: Reengaging Tobacco Users in Statewide Cessation Services.

CONTEXT: Tobacco dependence is well established as a chronic condition typically requiring numerous quit attempts. Tobacco users are unlikely to return to the same cessation program on their own. OBJECTIVE: This program evaluation examined the effectiveness of using multiple outreach methods to reengage tobacco users in a statewide cessation program at varying time points after their initial program enrollment. DESIGN: Participants were randomized to receive or not receive reengagement outreach. We conducted outreach via phone, e-mail, and/or text (based on methods participants agreed to receive) at 1, 2, or 3 months post-initial engagement. Participants were offered the opportunity to reenroll in QUITPLAN Services. SETTING: Minnesota's QUITPLAN Services PARTICIPANTS:: A total of 3020 tobacco users who enrolled in Minnesota's QUITPLAN Services and either received a 2-week starter kit of nicotine replacement therapy or completed 0-1 QUITPLAN Helpline calls. MAIN OUTCOME MEASURES: We explored group differences in the odds of reengagement (defined as enrolling in a phone cessation program or selecting 2 or more of nicotine replacement therapy starter kit, text messaging, e-mail program, or print materials), contributors to reengagement, and costs. RESULTS: 14.7% in the Reengagement Outreach (RO) group and 3.4% in the Comparison (no outreach) group reengaged. The majority (71%) reengaged during phone outreach. There were no significant differences in reengagement rates by follow-up time period (1, 2, or 3 months). Cost per reengagement was $546, mostly due to one-time setup costs; scaling to 10 000 tobacco users would cost approximately $101 per reengagement. CONCLUSIONS: Conducting proactive outreach through state-funded quitlines is an effective approach to reengaging tobacco users, yielding a 5-fold greater odds of reengagement compared with no outreach. Since most costs were for initial setup, the cost per reengagement would decrease as the outreach population size increases. Such outreach has the potential to foster treatment utilization and quit attempts.

Cessation Outcomes Among Quitline Callers in Three States During a National Tobacco Education Campaign.

INTRODUCTION: Antismoking mass media campaigns, such as the Centers for Disease Control and Prevention's Tips from Former Smokers (Tips) campaign, increase the number of tobacco users calling tobacco quitlines. Few studies have investigated long-term tobacco use cessation for callers during antismoking media campaigns. Studies have suggested that callers during campaigns may be less committed to quitting and have lower quit rates. This study examines tobacco user cessation outcomes 7 months after quitline enrollment during the 2012 Tips campaign (March 19 through June 10, 2012). METHODS: We analyzed data for 715 tobacco users who enrolled in the Nebraska, North Carolina, or Texas state quitline multiple-call programs during the 2012 Tips campaign and responded to a 7-month postenrollment survey (38.5% survey response rate). We used multivariable logistic regression analyses to determine whether 7-day and 30-day point prevalence abstinence rates 7 months after enrollment were related to level of exposure to the campaign. RESULTS: In multivariable models, only lower nicotine dependence and higher call completion were associated with higher odds of 7-day and 30-day abstinence 7 months after enrollment. Tips campaign exposure was not associated with abstinence. CONCLUSION: Once enrolled in quitline counseling, quitline callers achieved similar outcomes regardless of Tips campaign exposure levels. While the campaign did not appear to directly affect odds of tobacco abstinence through quitlines, antismoking mass media campaigns such as Tips are valuable in increasing tobacco users' exposure to quitlines and thus increasing their likelihood of making a quit attempt and eventually achieving tobacco abstinence.

Utilization of a Web-based vs integrated phone/Web cessation program among 140,000 tobacco users: an evaluation across 10 free state quitlines.

BACKGROUND: Phone-based tobacco cessation program effectiveness has been established and randomized controlled trials have provided some support for Web-based services. Relatively little is known about who selects different treatment modalities and how they engage with treatments in a real-world setting. OBJECTIVE: This paper describes the characteristics, Web utilization patterns, and return rates of tobacco users who self-selected into a Web-based (Web-Only) versus integrated phone/Web (Phone/Web) cessation program. METHODS: We examined the demographics, baseline tobacco use, Web utilization patterns, and return rates of 141,429 adult tobacco users who self-selected into a Web-Only or integrated Phone/Web cessation program through 1 of 10 state quitlines from August 2012 through July 2013. For each state, registrants were only included from the timeframe in which both programs were offered to all enrollees. Utilization data were limited to site interactions occurring within 6 months after registration. RESULTS: Most participants selected the Phone/Web program (113,019/141,429, 79.91%). After enrollment in Web services, Web-Only were more likely to log in compared to Phone/Web (21,832/28,410, 76.85% vs 23,920/56,892, 42.04%; P<.001), but less likely to return after their initial log-in (8766/21,832, 40.15% vs 13,966/23,920, 58.39%; P<.001). In bivariate and multivariable analyses, those who chose Web-Only were younger, healthier, more highly educated, more likely to be uninsured or commercially insured, more likely to be white non-Hispanic and less likely to be black non-Hispanic, less likely to be highly nicotine-addicted, and more likely to have started their program enrollment online (all P<.001). Among both program populations, participants were more likely to return to Web services if they were women, older, more highly educated, or were sent nicotine replacement therapy (NRT) through their quitline (all P<.001). Phone/Web were also more likely to return if they had completed a coaching call, identified as white non-Hispanic or "other" race, or were commercially insured (all P<.001). Web-Only were less likely to return if they started their enrollment online versus via phone. The interactive Tobacco Tracker, Cost Savings Calculator, and Quitting Plan were the most widely used features overall. Web-Only were more likely than Phone/Web to use most key features (all P<.001), most notably the 5 Quitting Plan behaviors. Among quitlines that offered NRT to both Phone/Web and Web-Only, Web-Only were less likely to have received quitline NRT. CONCLUSIONS: This paper adds to our understanding of who selects different cessation treatment modalities and how they engage with the program in a real-world setting. Web-Only were younger, healthier smokers of higher socioeconomic status who interacted more intensely with services in a single session, but were less likely to re-engage or access NRT benefits. Further research should examine the efficacy of different engagement techniques and services with different subpopulations of tobacco users.

A Randomized Clinical Trial of a Quitline Vaping Cessation Intervention: Baseline Characteristics of Young Adult Exclusive E-Cigarette Users Seeking Treatment.

Despite interest in quitting vaping among young adults (YAs), little is known about characteristics of e-cigarette (EC) users seeking treatment. In this study, YAs aged 18-24 living in the United States interested in vaping cessation treatment were recruited to complete an online survey regarding demographics and EC use. Primary eligibility criteria were EC use on at least 20 days per month (no other tobacco use), and interest in quitting in the next month. We report descriptive statistics for those who did and did not complete a mandatory coaching call (n = 981). In this sample, most EC users reported high nicotine dependence, a history of unsuccessful quit attempts (including 29.4% with previous NRT use), along with stress, anxiety, and depression. There were few meaningful differences in demographics, EC use behaviors, or behavioral health factors between those who engaged with a phone coaching call (fully enrolled in study; n = 508), and those who did not (n = 473). YAs demonstrated interest in vaping cessation support, but there were no clear characteristics for the half who did not complete a coaching call. Vaping cessation program designers should consider tailoring for the self-reported behavioral health concerns present in this population.

Use of electronic cigarettes among state tobacco cessation quitline callers.

INTRODUCTION: Little is known about the prevalence of electronic cigarette (e-cigarette) use among tobacco users who seek help from state tobacco quitlines, the reasons for its use, and whether e-cigarettes impact a user's ability to successfully quit tobacco. This study investigates these questions and describes differences among state quitline callers who used e-cigarettes for 1 month or more, used e-cigarettes for less than 1 month, or never tried e-cigarettes. METHODS: Data on e-cigarette use were collected from 2,758 callers to 6 state tobacco quitlines 7 months after they received intervention from the quitline program. RESULTS: Nearly one third (30.9%) of respondents reported ever using or trying e-cigarettes; most used for a short period of time (61.7% for less than 1 month). The most frequently reported reasons for use were to help quit other tobacco (51.3%) or to replace other tobacco (15.2%). Both e-cigarette user groups were significantly less likely to be tobacco abstinent at the 7-month survey compared with participants who had never tried e-cigarettes (30-day point prevalence quit rates: 21.7% and 16.6% vs. 31.3%, p < .001). Demographic differences between the 3 groups are discussed. CONCLUSIONS: This study offers a preliminary look at e-cigarette use among state quitline callers and is perhaps the first to describe e-cigarette use in a large group of tobacco users seeking treatment. The notable rates of e-cigarette use and use of e-cigarettes as cessation aids, even though the U.S. Food and Drug Administration has not approved e-cigarettes for this purpose, should inform policy and treatment discussions on this topic.

Dual Use of E-cigarettes and Cannabis among Young People in America: A New Public Health Hurdle?

In this commentary, we discuss the concerning prevalence of cannabis use among young people who use e-cigarettes. National data in the U.S., as well as our own local data, indicate that dual use (i.e., nicotine e-cigarette use and cannabis use) is more common than e-cigarette use alone. Our commentary discusses why this dual use is a major concern for public health. We argue that continuing to examine e-cigarettes in isolation is not only impractical but also problematic, as it misses out on opportunities to understand additive and multiplicative health impacts, to share cross-knowledge, and to inform prevention and treatment. This commentary calls for more attention to dual use and concerted, equity-enhancing efforts from funders and researchers.

Vaping and E-Cigarettes Within the Evolving Tobacco Quitline Landscape.

This article summarizes the vaping research literature as it pertains to tobacco quitlines and describes vaping assessment, treatment, and evaluation quitline practices. It also presents 2014-2018 registration data (vaping in the past 30 days, number of use days, use for quitting smoking, and intentions to quit vaping) from 24 public quitlines (23 states and District of Columbia) and 110,295 enrollees to employer-sponsored quitlines. Trends in vaping rates over time, by state, and by age group are described. Approximately 57,000 adult public quitline enrollees in the U.S. reported vaping at registration in 2018 (14.7% of enrollees). Most quitline participants who vape also smoke cigarettes and contact the quitline for smoking cessation support. Rates of reporting vaping and no combustible or smokeless tobacco use in the past 30 days are 0.5% of all public quitline participants (<3% of public quitline vaping product users). Data are not systematically available regarding the number of quitline participants who are seeking help quitting vaping and only vape (do not use combustible or smokeless tobacco). Few quitline participants (<1%) are youth aged <18 years, but more than a third (35%) report vaping. This paper outlines research and evaluation priorities to inform the future quitline treatment landscape with respect to vaping. The quitline community is positioned to increase the likelihood that vaping has a positive impact for adults who smoke through harm reduction or supporting cessation and has opportunities to expand impacts on youth and young adult vaping prevention and cessation.

Treatment development, implementation, and participant baseline characteristics: A randomized pilot study of a tailored quitline intervention for individuals who smoke and vape.

BACKGROUND: Approximately 57,000 dual users of cigarettes and e-cigarettes call state tobacco quitlines in the U.S. each year. METHODS: This paper describes a behavioral intervention for dual users of cigarettes and e-cigarettes designed to increase cigarette abstinence. It also presents baseline data from a randomized pilot comparing the Enhanced E-cigarette Coaching (EEC) intervention with quitline treatment as usual (TAU). Oklahoma Tobacco Helpline callers were recruited at registration and randomized to EEC (n = 46) or TAU (n = 50). Treatment included 5 coaching calls and free nicotine replacement therapy (NRT). EEC treatment included enhanced e-cigarette assessment, education, a shared decision-making quit plan development approach, and tailored behavioral support. RESULTS: Participants averaged 40.6 years of age and 19.2 cigarettes per day; 85% smoked daily, 48% vaped daily, and 53% reported medium to high e-cigarette dependence. Most reported using e-cigarettes to quit (43%) or to cut down (26%) on smoking. Most had previously tried to quit smoking (91%) and had tried FDA-approved cessation medications (79%). Beliefs about vaping, NRT, and smoking included misinformation. After discussing the relative risks of NRT, vaping, and smoking, most EEC participants (89%) selected a quit plan that incorporated both NRT and vaping. CONCLUSIONS: At baseline, most participants reported a history of failed quit attempts with NRT and were vaping to quit or cut down on smoking, but they may need more support to completely quit smoking. If the EEC improves smoking outcomes, it would provide needed guidance on behavioral support best practices for individuals who vape and want to quit smoking.

Trajectories of physical and emotional marital aggression in midlife couples.

This study used three-level generalized hierarchical linear modeling to examine trajectories of husbands' and wives' physical and emotional aggression over three assessments and the effects of years since marriage. In this community sample of 118 couples, physical aggression significantly decreased over time (43% per year). Emotional aggression did not significantly change over time, but trajectories significantly differed for husbands (3% increase) versus wives (10% decrease). Longer-duration marriages had lower physical aggression and, for wives only, lower emotional aggression. Aggression trajectories showed considerable variability: 44%-55% of physically aggressive spouses desisted from one assessment to the next; 5%-12% reported start-ups in physical aggression. Discussion addresses the role of gender and type of aggression in aggression trajectories.

Tobacco dependence treatment in the emergency department: A randomized trial using the Multiphase Optimization Strategy.

BACKGROUND: Tobacco dependence remains the leading preventable cause of death in the developed world. Smokers are disproportionately from lower socioeconomic groups, and may use the hospital emergency department (ED) as an important source of care. A recent clinical trial demonstrated the efficacy of a multicomponent intervention to help smokers quit, but the independent contributions of those components is unknown. METHODS: This is a full-factorial (16-arm) randomized trial in a busy hospital ED of 4 tobacco dependence interventions: brief motivational interviewing, nicotine replacement therapy, referral to a telephone quitline, and a texting program. The trial utilizes the Multiphase Optimization Strategy (MOST) and a novel mixed methods analytic design to assess clinical efficacy, cost effectiveness, and qualitative participant feedback. The primary endpoint is tobacco abstinence at 3months, verified by participants' exhaled carbon monoxide. RESULTS: Study enrollment began in February 2017. As of April 2017, 52 of 1056 planned participants (4.9%) were enrolled. Telephone-based semi-structured participant interviews and in-person biochemical verification of smoking abstinence are completed at the 3-month follow-up. Efficacy and cost effectiveness analyses will be conducted after follow-up is completed. DISCUSSION: The goal of this study is to identify a clinically efficacious, cost-effective intervention package for the initial treatment of tobacco dependence in ED patients. The efficacy of this combination can then be tested in a subsequent confirmatory trial. Our approach incorporates qualitative feedback from study participants in evaluating which intervention components will be tested in the future trial. TRIAL REGISTRATION: Trial (NCT02896400) registered in ClinicalTrials.gov on September 6, 2016.

Post-traumatic Stress in Children and Adolescents Exposed to Family Violence: II. Treatment.

Interventions for youth exposed to family violence recently have incorporated a trauma focus with the objective of reducing Posttraumatic Stress Disorder (PTSD) symptoms along with alleviating other wide-ranging childhood disorders. This paper describes generally agreed-upon treatment components for youth exposed to violence in the home, including re-exposure interventions, education about violence and cognitive restructuring, processing of emotional cues, social problem-solving skills, and parenting interventions. Empirically evaluated treatment programs for different developmental stages (preschool, school-age, and adolescence) are summarized and remaining questions about how to best focus treatment efforts for youth traumatized by family violence are presented.

Post-traumatic Stress in Children and Adolescents Exposed to Family Violence: I. Overview and Issues.

Exposure to child physical abuse and parents' domestic violence can subject youth to pervasive traumatic stress and lead to Post-traumatic Stress Disorder (PTSD). The often repeating and ongoing nature of family violence exposure may result in youth exhibiting problems in multiple domains of functioning and meeting criteria for multiple disorders in addition to PTSD. These characteristics as well as unique factors related to children's developmental level and symptom presentation complicate a PTSD diagnosis. This paper describes evolving conceptualizations in the burgeoning field of trauma related to family violence exposure, and reviews considerations that inform assessment and treatment planning for this population.

Electronic nicotine delivery system (ENDS) use during smoking cessation: a qualitative study of 40 Oklahoma quitline callers.

OBJECTIVES: Approximately 10% (40 000) of US quitline enrollees who smoke cigarettes report current use of electronic nicotine delivery systems (ENDS); however, little is known about callers' ENDS use. Our aim was to describe why and how quitline callers use ENDS, their beliefs about ENDS and the impact of ENDS use on callers' quit processes and use of FDA-approved cessation medications. DESIGN: Qualitative interviews conducted 1-month postregistration. Interviews were recorded, transcribed, double-coded and analysed to identify themes. SETTING: Oklahoma Tobacco Helpline. PARTICIPANTS: 40 callers aged ≥18 who were seeking help to quit smoking were using ENDS at registration and completed ≥1 programme calls. RESULTS: At 1-month postregistration interview, 80% of callers had smoked cigarettes in the last 7 days, almost two-thirds were using ENDS, and half were using cessation medications. Nearly all believed ENDS helped them quit or cut down on smoking; however, participants were split on whether they would recommend cessation medications, ENDS or both together for quitting. Confusion and misinformation about potential harms of ENDS and cessation medications were reported. Participants reported using ENDS in potentially adaptive ways (eg, using ENDS to cut down and nicotine replacement therapy to quit, and stepping down nicotine in ENDS to wean off ENDS after quitting) and maladaptive ways (eg, frequent automatic ENDS use, using ENDS in situations they did not previously smoke, cutting down on smoking using ENDS without a schedule or plan to quit), which could impact the likelihood of quitting smoking or continuing ENDS use. CONCLUSIONS: These qualitative findings suggest quitline callers who use ENDS experience confusion and misinformation about ENDS and FDA-approved cessation medications. Callers also use ENDS in ways that may not facilitate quitting smoking. Opportunities exist for quitlines to educate ENDS users and help them create a coordinated plan most likely to result in completely quitting combustible tobacco.