Relationships Between the Nicotine Metabolite Ratio (NMR) and Laboratory Assessments of Smoking Reinforcement and Craving Among Adults in a Smoking Cessation Trial.

INTRODUCTION: People who metabolize nicotine more quickly are generally less successful at quitting smoking. However, the mechanisms that link individual differences in the nicotine metabolite ratio (NMR), a phenotypic biomarker of the rate of nicotine clearance, to smoking outcomes are unclear. We tested the hypotheses that higher NMR is associated with greater smoking reinforcement, general craving, and cue-induced cigarette craving in a treatment-seeking sample. METHODS: Participants were 252 adults who smoke cigarettes enrolled in a randomized controlled smoking cessation trial (NCT03262662) conducted in Buffalo, New York, USA. Participants completed the Choice Behavior Under Cued Conditions (CBUCC) paradigm, a laboratory choice procedure, ~1 week before the first cessation treatment visit, at which time a saliva sample was collected for NMR assessment. On each CBUCC trial, participants reported cigarette craving during cue presentation (cigarette, water) and spent $0.01-0.25 for a chance (5%-95%) to sample the cue (1 puff, sip), providing measures of smoking reinforcement (spending for cigarettes vs. water), general cigarette craving (averaged across cigarette and water cues), and cue-specific craving (cigarette craving during cigarette vs. water cues). RESULTS: As observed in prior work, the NMR was significantly higher among white and female participants. As expected, both spending and cigarette craving were significantly greater on cigarette compared to water trials. However, contrary to our hypotheses, higher NMR was not associated with greater smoking reinforcement, general craving, or cue-specific craving. CONCLUSIONS: The present data do not support that smoking reinforcement or craving are related to nicotine metabolism among individuals seeking to quit smoking. IMPLICATIONS: Though greater smoking reinforcement, general craving, and cue-specific craving are hypothesized to be linked to faster nicotine metabolism, there was no evidence of such relationships in the present sample of adults seeking to quit smoking. Further research, including replication and consideration of alternate hypotheses, is warranted to elucidate the mechanisms by which the NMR is related to smoking cessation.

Association of tobacco product use with chronic obstructive pulmonary disease (COPD) prevalence and incidence in Waves 1 through 5 (2013-2019) of the Population Assessment of Tobacco and Health (PATH) Study.

BACKGROUND: We examined the association of non-cigarette tobacco use on chronic obstructive pulmonary disease (COPD) risk in the Population Assessment of Tobacco and Health (PATH) Study. METHODS: There were 13,752 participants ≥ 40 years with Wave 1 (W1) data for prevalence analyses, including 6945 adults without COPD for incidence analyses; W1-5 (2013-2019) data were analyzed. W1 tobacco use was modeled as 12 mutually-exclusive categories of past 30-day (P30D) single and polyuse, with two reference categories (current exclusive cigarette and never tobacco). Prevalence and incidence ratios of self-reported physician-diagnosed COPD were estimated using weighted multivariable Poisson regression. RESULTS: W1 mean (SE) age was 58.1(0.1) years; mean cigarette pack-years was similar for all categories involving cigarettes and exclusive use of e-cigarettes (all > 20), greater than exclusive cigar users (< 10); and COPD prevalence was 7.7%. Compared to P30D cigarette use, never tobacco, former tobacco, and cigar use were associated with lower COPD prevalence (RR = 0.33, (95% confidence interval-CI) [0.26, 0.42]; RR = 0.57, CI [0.47, 0.70]; RR = 0.46, CI [0.28, 0.76], respectively); compared to never tobacco use, all categories except cigar and smokeless tobacco use were associated with higher COPD prevalence (RR former = 1.72, CI [1.33, 2.23]; RR cigarette = 3.00, CI [2.37, 3.80]; RR e-cigarette = 2.22, CI [1.44, 3.42]; RR cigarette + e-cigarette = 3.10, CI [2.39, 4.02]; RR polycombusted = 3.37, CI [2.44, 4.65]; RR polycombusted plus noncombusted = 2.75, CI]1.99, 3.81]). COPD incidence from W2-5 was 5.8%. Never and former tobacco users had lower COPD risk compared to current cigarette smokers (RR = 0.52, CI [0.35, 0.77]; RR = 0.47, CI [0.32, 0.70], respectively). Compared to never use, cigarette, smokeless, cigarette plus e-cigarette, and polycombusted tobacco use were associated with higher COPD incidence (RR = 1.92, CI [1.29, 2.86]; RR = 2.08, CI [1.07, 4.03]; RR = 1.99, CI [1.29, 3.07]; RR = 2.59, CI [1.60, 4.21], respectively); exclusive use of e-cigarettes was not (RR = 1.36, CI [0.55, 3.39]). CONCLUSIONS: E-cigarettes and all use categories involving cigarettes were associated with higher COPD prevalence compared to never use, reflecting, in part, the high burden of cigarette exposure in these groups. Cigarette-but not exclusive e-cigarette-use was also strongly associated with higher COPD incidence. Compared to cigarette use, only quitting tobacco was protective against COPD development.

A Psychometric Evaluation of the Stanford Expectations of Treatment Scale (SETS) in the Context of a Smoking Cessation Trial.

INTRODUCTION: Although treatment outcome expectancies (TOEs) may influence clinical outcomes, TOEs are rarely reported in the smoking cessation literature, in part because of the lack of validated measures. Therefore, we conducted a psychometric evaluation of TOEs scores with the Stanford Expectations of Treatment Scale (SETS) in the context of a smoking cessation clinical trial. METHODS: Participants were 320 adults enrolled in a randomized controlled trial of extended versus standard pre-quit varenicline treatment for smoking cessation (clinicaltrials.gov ID: NCT03262662). Across an 8-week treatment period, we examined the nature and stability of the factor structure using confirmatory factor analysis (CFA), evaluated discriminant validity by examining correlations with abstinence self-efficacy and positive/negative affect (PA/NA), and assessed internal consistency and test-retest reliability of SETS scores. RESULTS: CFAs supported a 2-factor structure that was stable (ie, invariant) across weeks. Positive and negative TOEs were each reflected in three-item subscales that exhibited acceptable to excellent internal consistency (Cronbach's alphas ≥ .77). Positive and negative TOEs were modestly correlated with PA and NA (all |rs| <.27, p < .05). Positive TOEs, but not negative TOEs, were moderately correlated with abstinence self-efficacy (rs = .45 to .61, p < .01). Both positive and negative TOEs scores demonstrated moderate test-retest reliability between assessments (rs = .54 to .72). CONCLUSIONS: SETS scores generally reflect a valid and reliable assessment of positive and negative TOEs in a sample of adults enrolled in a smoking cessation trial. The SETS appears to be a reasonable option for assessing TOEs in future smoking treatment studies. IMPLICATIONS: Assessments of treatment outcome expectancies are rarely reported in the smoking cessation literature. The present results support the validity and reliability of the SETS scores among adults seeking treatment for their smoking behavior.

Evaluating Treatment Mechanisms of Varenicline: Mediation by Affect and Craving.

INTRODUCTION: Negative reinforcement models posit that relapse to cigarette smoking is driven in part by changes in affect and craving during the quit attempt. Varenicline may aid cessation by attenuating these changes; however, this mediational pathway has not been formally evaluated in placebo-controlled trials. Thus, trajectories of negative affect (NA), positive affect (PA), and craving were tested as mediators of the effect of varenicline on smoking cessation. AIMS AND METHODS: Secondary data analysis was conducted on 828 adults assigned to either varenicline or placebo in a randomized controlled trial for smoking cessation (NCT01314001). Self-reported NA, PA, and craving were assessed 1-week pre-quit, on the target quit day (TQD), and 1 and 4 weeks post-TQD. RESULTS: Across time, NA peaked 1-week post-quit, PA did not change, and craving declined. Less steep rises in NA (indirect effect 95% CI: .01 to .30) and lower mean craving at 1-week post-quit (CI: .06 to .50) were mediators of the relationship between varenicline and higher cessation rates at the end of treatment. PA was associated with cessation but was not a significant mediator. CONCLUSIONS: These results partially support the hypothesis that varenicline improves smoking cessation rates by attenuating changes in specific psychological processes and supported NA and craving as plausible treatment mechanisms of varenicline. IMPLICATIONS: The present research provides the first evidence from a placebo-controlled randomized clinical trial that varenicline's efficacy is due, in part, to post-quit attenuation of NA and craving. Reducing NA across the quit attempt and craving early into the attempt may be important treatment mechanisms for effective interventions. Furthermore, post-quit NA, PA, and craving were all associated with relapse and represent treatment targets for future intervention development.

Designing an exercise intervention for adult survivors of childhood cancers.

BACKGROUND: This study examined current physical activity levels and preferences for exercise settings and activities among adult survivors of childhood cancers as a strategy to inform the feasibility and design of such programs. METHODS: A mixed-methods design was used to investigate current activity levels as well as barriers to and preferences for physical activity among 20 adult survivors of pediatric cancer. RESULTS: One-half of participants reported engaging in regular physical activity, although the frequency, intensity, and duration varied. Overall, 17 of the 20 participants (85%) stated they would be interested in participating in a structured exercise intervention, and they expressed a strong interest in walking (76%), bicycling (53%), and weight training (53%). Common barriers to participation in a potential structured exercise program were insufficient time, current health issues, and program location/distance. Nearly all participants agreed that information on nutrition and diet should be included as part of an exercise intervention. CONCLUSIONS: These findings will help inform the design and implementation of future exercise programs to enhance physical activity among this high-risk group of cancer survivors.

Withdrawal Symptom, Treatment Mechanism, and/or Side Effect? Developing an Explicit Measurement Model for Smoking Cessation Research.

INTRODUCTION: Assessment of withdrawal symptoms, treatment mechanisms, and side effects is central to understanding and improving smoking cessation interventions. Though each domain is typically assessed separately with widely used questionnaires to separately assess each domain (eg, Minnesota Nicotine Withdrawal Scale = withdrawal; Questionnaire of Smoking Urges-Brief = craving; Positive and Negative Affect Schedule = affect; symptom checklist = side effects), there are substantial problems with this implicit "one questionnaire equals one construct" measurement model, including item overlap across questionnaires. This study sought to clarify the number and nature of constructs assessed during smoking cessation by developing an explicit measurement model. METHODS: Two subsamples were randomly created from 1246 smokers in a clinical trial. Exploratory and confirmatory factor analyses were conducted to identify and select a model that best represented the data. Measurement invariance was assessed to determine if the factors and their content were consistent prior to and during the quit. Improvement in construct overlap within this model was compared against the implicit measurement model using correlational analyses. RESULTS: A 5-factor measurement model composed of negative affect, somatic symptoms, sleep problems, positive affect, and craving fits the data well prior to and during quitting. All factor content except somatic symptoms was consistent over time. Correlational analyses indicated that the 5-factor model attenuated construct overlap compared to the implicit model. CONCLUSIONS: The models generated from data-driven approaches (eg, the 5-factor model) reduced overlap and better represented the constructs underlying these measures. This approach created distinct, stable constructs that span over measures of side effects and potential treatment mechanisms. IMPLICATIONS: This study demonstrated that measures assessing treatment mechanisms, withdrawal symptoms, and side effects contain problematic overlap that reduces the clarity of these key constructs. The use of data-driven approaches showed that these measures do not map on to their posited latent constructs (eg, the Minnesota Nicotine Withdrawal Scale does not yield a withdrawal factor). Rather, these measures form distinct, basic processes that may represent more meaningful constructs for future research on cessation and treatment. Assessments designed to individually examine these processes may improve the study of treatment mechanisms.

Habitual recreational physical activity is associated with significantly improved survival in cancer patients: evidence from the Roswell Park Data Bank and BioRepository.

PURPOSE: The association of recreational physical activity (RPA) with mortality is well established only for breast and colon cancers and few studies have evaluated relationships for exercising before and after diagnosis, across multiple disease sites. We examined the joint associations of pre- and post- diagnosis RPA with mortality in a cohort of 5,807 patients enrolled in the Data Bank and BioRepository at Roswell Park. METHODS: Patients were classified into one of four activity categories (habitually active, increased activity after diagnosis, decreased activity after diagnosis, habitually inactive). Cox proportional hazards models were used to estimate the associations of activity status with mortality. RESULTS: In comparison to patients who were habitually inactive, habitually active patients experienced a 39% decreased hazard of all-cause mortality (HR = 0.61, 95% CI 0.54-0.69) and a 36% decreased hazard of cancer-specific mortality (HR = 0.64, 95% CI 0.56-0.73). Previously inactive patients who began exercising after diagnosis experienced a 28% decreased hazard of all-cause (HR = 0.72, 95% CI 0.59-0.89) and cancer-specific mortality (HR = 0.72, 95% CI 0.57-0.91) in comparison to patients who remained inactive. Patients engaging in 3-4 sessions/week experienced the greatest survival advantages, but 1-2 sessions/week also yielded significant survival advantages in comparison to inactivity. CONCLUSION: Low-to-moderate frequency pre- and post-diagnosis RPA was associated with significantly decreased mortality in patients diagnosed with a variety of malignancies. These observations solidify the clinical and public health importance of the message that some regular activity is better than inactivity, which is particularly encouraging, given that cancer survivors can be overwhelmed by current daily physical activity recommendations.

Leveraging technology to promote smoking cessation in urban and rural primary care medical offices.

We examined the use of automated voice recognition (AVR) messages targeting smokers from primary care practices located in underserved urban and rural communities to promote smoking cessation. We partnered with urban and rural primary care medical offices (n = 7) interested in offering this service to patients. Current smokers, 18 years and older, who had completed an office visit within the previous 12 months, from these sites were used to create a smoker's registry. Smokers were recruited within an eight county region of western New York State between June 2012 and August 2013. Participants were contacted over six month intervals using the AVR system. Among 5812 smokers accrued 1899 (32%) were reached through the AVR system and 55% (n = 1049) continued to receive calls. Smokers with race other than white or African American were less likely to be reached (OR = 0.71, 0.57-0.90), while smokers ages 40 and over were more likely to be reached. Females (OR = 0.78, 0.65-0.95) and persons over age 40 years were less likely to opt out, while rural smokers were more likely to opt out (OR = 3.84, 3.01-4.90). Among those receiving AVR calls, 30% reported smoke free (self-reported abstinence over a 24 h period) at last contact; smokers from rural areas were more likely to report being smoke free (OR = 1.41, 1.01-1.97). An AVR-based smoking cessation intervention provided added value beyond typical tobacco cessation efforts available in these primary care offices. This intervention required no additional clinical staff time and served to satisfy a component of patient center medical home requirements for practices.

Content validity and electronic PRO (ePRO) usability of the Lung Cancer Symptom Scale-Mesothelioma (LCSS-Meso) in mesothelioma patients.

PURPOSE: Obtaining qualitative data directly from the patient perspective enhances the content validity of patient-reported outcome (PRO) instruments. The objective of this qualitative study was to evaluate the content validity of the Lung Cancer Symptom Scale for Mesothelioma (LCSS-Meso) and its usability on an electronic device. METHODS: A cross-sectional methodological study, using a qualitative approach, was conducted among patients recruited from four clinical sites. The primary target population included patients with pleural mesothelioma; data were also collected from patients with peritoneal mesothelioma on an exploratory basis. Semi-structured interviews were conducted consisting of concept elicitation, cognitive interviewing, and evaluation of electronic patient-reported outcome (ePRO) usability. RESULTS: Participants (n = 21) were interviewed in person (n = 9) or by telephone (n = 12); 71% were male with a mean age of 69 years (SD = 14). The most common signs and symptoms experienced by participants with pleural mesothelioma (n = 18) were shortness of breath, fluid build-up, pain, fatigue, coughing, and appetite loss. The most commonly described symptoms for those with peritoneal mesothelioma (n = 4) were bloating, changes in appetite, fatigue, fluid build-up, shortness of breath, and pain. Participants with pleural mesothelioma commonly described symptoms assessed by the LCSS-Meso in language consistent with the questionnaire and a majority understood and easily completed each of the items. The ePRO version was easy to use, and there was no evidence that the electronic formatting changed the way participants responded to the questions. CONCLUSIONS: Results support the content validity of the LCSS-Meso and the usability of the electronic format for use in assessing symptoms among patients with pleural mesothelioma.

Examining Hookah as an Introduction to Nicotine Products among College Students.

BACKGROUND: Limited data exist on what young adults report as their first-ever nicotine product; some evidence suggests that they report hookah as their first product smoked. OBJECTIVES: This study reports on the first nicotine product used among undergraduates who had ever tried tobacco, and explores correlates of hookah as that first product. METHODS: Participants included a convenience sample of undergraduate students (n = 1538) at four universities in upstate New York during fall 2013. Descriptive statistics assessed first nicotine product used and prevalence of current use. Logistic regression was used to examine correlates of hookah as the first nicotine product used. RESULTS: Among the 832 students who reported ever use of any nicotine product, 25.4% reported hookah as their first product smoked; only combustible cigarettes (39.5%) were reported more frequently. Among students who ever smoked cigarettes, most reported cigarettes as their introductory product. Among students who never smoked cigarettes, nearly half reported hookah as their introductory product. Among ever nicotine users, current hookah smoking was common (34.9%), and greater than current e-cigarette (25.9%) and current combustible cigarette (26.4%) use. Never users of cigarettes, females, and non-Hispanic African Americans, had higher adjusted odds of reporting hookah as their introductory product. CONCLUSIONS: The results of this study have implications for the identification of risk factors for tobacco initiation, the assessment of tobacco use patterns and behaviors, and the tailoring of tobacco prevention initiatives among youth. Our findings suggest that broadening prevention efforts beyond a focus on combustible cigarettes may be warranted.

Clinician and Parent Perspectives on Educational Needs for Increasing Adolescent HPV Vaccination.

Human papillomavirus (HPV)-related morbidity and mortality remain a significant public health burden despite the availability of HPV vaccines for cancer prevention. We engaged clinicians and parents to identify barriers and opportunities related to adolescent HPV vaccination within a focused geographic region. This mixed-method study design used an interviewer-administered semi-structured interview with clinicians (n = 52) and a written self-administered survey with similar items completed by parents (n = 54). Items focused on experiences, opinions, and ideas about HPV vaccine utilization in the clinical setting, family, and patient perceptions about HPV vaccination and potential future efforts to increase vaccine utilization. Quantitative items were analyzed using descriptive statistics, while qualitative content was analyzed thematically. Suggested solutions for achieving higher rates of HPV vaccination noted by clinicians included public health education, the removal of stigma associated with vaccines, media endorsements, and targeting parents as the primary focus of educational messages. Parents expressed the need for more information about HPV-related disease, HPV vaccines, vaccine safety, sexual concerns, and countering misinformation on social media. Results from this mixed-method study affirm that educational campaigns targeting both health care professionals and parents represent a key facilitator for promoting HPV vaccination; disease burden and cancer prevention emerged as key themes for this messaging.

Evaluation of a Dedicated Tobacco Cessation Support Service for Thoracic Cancer Center Patients.

CONTEXT: Cancer patients' continued tobacco use results in poorer therapeutic outcomes including decreased quality of life and survival. OBJECTIVE: To assess reach and impact of a free, opt-out, telephone-based tobacco cessation program for thoracic cancer center patients. DESIGN: Observational study. SETTING: Comprehensive Cancer Center in Western New York. PARTICIPANTS: Current or recent (within past 30 days) tobacco-using thoracic cancer center patients referred to a tobacco cessation support service between October 2010 and October 2012 at a Comprehensive Cancer Center (n = 942/1313 referrals were eligible for cessation support). INTERVENTION: A free, opt-out, telephone-based cessation service that was implemented as standard of care. Cessation specialists had patient-guided conversations that assessed readiness to quit; methods used in the past provided cessation strategies and worked to set up a quit date. There was an average of 35.9 days between referral and first contact. MAIN OUTCOME MEASURES: Program reach (referral and participation rates) and impact (as self-reported cessation outcomes measured twice after referral). RESULTS: Of 942 patients, 730 (77.5%) referred to and called by a tobacco cessation service participated in at least 1 cessation support call, of which 440 of 730 (60.3%) were called for follow-up and 89.5% (394/440) participated. In total, 20.2% (69/342) of current smokers at referral reported at least 7-day abstinence at follow-up. Among current smokers at referral and first contact, being married (odds ratio [OR] = 2.05; 95% confidence interval [CI], 1.01-4.18) and having a lower Eastern Cooperative Oncology Group (ECOG) performance score (OR = 4.05; 95% CI, 1.58-10.39) were associated with quitting at follow-up, after controlling for demographic, clinical, and health behavior characteristics. CONCLUSIONS: Our results demonstrate that 78% of thoracic cancer center patients, if contacted, participated at least once in this cessation support service; for current smokers at referral and first contact, being married and having a lower ECOG performance score were associated with self-reported quitting at follow-up. Other organizations may find our results useful while implementing a systematic way to identify tobacco-using patients as part of routine care and to improve available cessation support services.

Perspectives on Smoking Cessation in Northern Appalachia.

This study applies qualitative research methods to explore perspectives on cessation among smokers/former smokers recruited from an area of Northern Appalachia. Six focus groups, stratified by age group (18-39 years old and 40 years and older), were conducted among participants (n = 54) recruited from community settings. Participants described varied interest in and challenges with quitting smoking. Smokers 40 years and older more readily endorsed the health risks of smoking and had greater interest in quitting assistance. Participants expressed frustration with the US government for allowing a harmful product (e.g., cigarettes) to be promoted with minimal regulation. Use of social media was robust among both age groups; participants expressed limited interest in various social media/technology platforms for promoting smoking cessation. Findings from this understudied area of northern Appalachia reflect the heterogeneity of this region and contribute novel information about the beliefs, attitudes, and experiences of current and formers smokers with regard to cessation.

Breast Cancer Risk Reduction, Version 2.2015.

Breast cancer is the most frequently diagnosed malignancy in women in the United States and is second only to lung cancer as a cause of cancer death. To assist women who are at increased risk of developing breast cancer and their physicians in the application of individualized strategies to reduce breast cancer risk, NCCN has developed these guidelines for breast cancer risk reduction.

Snowstorm-Related Mortality - Erie County, New York, November 2014.

During November 18-21, 2014, a narrow band of central and southern Erie County in New York received unprecedented amounts of snowfall. The duration of the storm and amount of snowfall rapidly exceeded weather service forecasts, with some areas receiving 60-84 inches (1.5-2.1 meters) of snow. The rapid accumulation resulted in stranded drivers, travel bans, and logistical challenges associated with snow removal. Sporadic power outages affected a limited number of households. Eleven deaths were linked to the snowstorm, including one that was directly related, nine that were indirectly related, and one that was classified as possibly storm-related.

Does Extended Pre Quit Bupropion Aid in Extinguishing Smoking Behavior?

INTRODUCTION: Understanding the mechanisms by which bupropion promotes smoking cessation may lead to more effective treatment. To the extent that reduced smoking reinforcement is one such mechanism, a longer duration of pre quit bupropion treatment should promote extinction of smoking behavior. We evaluated whether 4 weeks of pre quit bupropion (extended run-in) results in greater pre quit reductions in smoking rate and cotinine and, secondarily, greater short-term abstinence, than standard 1 week of pre quit bupropion (standard run-in). METHODS: Adult smokers (n = 95; 48 females) were randomized to a standard run-in group (n = 48; 3-week placebo, then 1-week bupropion pre quit) or an extended run-in group (4-week pre quit bupropion; n = 47). Both groups received group behavioral counseling and 7 weeks of post quit bupropion. Smoking rate (and craving, withdrawal, and subjective effects) was collected daily during the pre quit period; biochemical data (cotinine and carbon monoxide) were collected at study visits. RESULTS: During the pre quit period, the extended run-in group exhibited a greater decrease in smoking rate, compared to the standard run-in group, interaction p = .03. Cigarette craving and salivary cotinine followed a similar pattern, though the latter was evident only among women. Biochemically verified 4-week continuous abstinence rates were higher in the extended run-in group (53%) than the standard run-in group (31%), p = .033. CONCLUSIONS: The extended use of bupropion prior to a quit attempt reduces smoking behavior during the pre quit period and improved short-term abstinence rates. The data are consistent with an extinction-of-reinforcement model and support further investigation of extended run-in bupropion therapy for smoking cessation.

Test-Retest Reliability and Stability of the Nicotine Metabolite Ratio Among Treatment-Seeking Smokers.

INTRODUCTION: The nicotine metabolite ratio (NMR), the ratio of 3-hydroxycotinine to cotinine, is a biomarker used in smoking cessation research, with several retrospective studies suggesting that NMR predicts treatment outcome. To be maximally useful in tailoring treatment, estimates of NMR should be stable over time. The present study is the first to examine the short-term test-retest reliability of NMR among treatment-seeking smokers. METHODS: Blood NMR was assessed at two time points, approximately 2-3 weeks apart and prior to intervention, among 72 healthy adult smokers (49% female; 35% non-White) enrolled in a cessation trial (http://ClinicalTrials.gov ID: NCT01314001). RESULTS: Mean NMR was stable from Time-1 to Time-2, with no significant change between assessments; test-retest reliability for NMR values was excellent (ICC[2,1] = 0.87). Test-retest reliability remained acceptable to high when NMR was categorized, as in recent clinical trials. Classification of participants as slow (quartile 1, NMR ≤ 0.24) or normal/fast NMR (quartiles 2-4, NMR ≥ 0.25) was consistent from Time-1 to Time-2 for 96% of participants (κ = 0.89). Though classification of participants into NMR quartiles was less consistent from Time-1 to Time-2 (67% agreement; weighted κ = 0.73), all reclassifications occurred between adjacent quartiles. CONCLUSIONS: Overall, these data support the use of a single NMR assessment for association studies with smoking phenotypes and in smokers seeking to quit, and they encourage large-scale efforts to determine optimal NMR cutpoints for tailoring treatment selection.

Engaging Immigrant and Refugee Women in Breast Health Education.

This project assessed the impact of a community-based educational program on breast cancer knowledge and screening among Buffalo (NY) immigrant and refugee females. Program participants completed language-matched pre- and post-test assessments during a single session educational program; breast cancer screening information was obtained from the mobile mammography unit to which participants were referred. Pre- and post-test knowledge scores were compared to assess changes in responses to each of the six individual knowledge items, as well as overall. Mammogram records were reviewed to identify Breast Imaging Reporting and Data System (BI-RADS) scores. The proportion of correct responses to each of the six knowledge items increased significantly on the post-program assessments; 33 % of women >40 years old completed mammograms. The findings suggest that a health education program for immigrant and refugee women, delivered in community-based settings and involving interpreters, can enhance breast cancer knowledge and lead to improvements in mammography completion.

Automated tobacco assessment and cessation support for cancer patients.

BACKGROUND: Tobacco assessment and cessation support are not routinely included in cancer care. An automated tobacco assessment and cessation program was developed to increase the delivery of tobacco cessation support for cancer patients. METHODS: A structured tobacco assessment was incorporated into the electronic health record at Roswell Park Cancer Institute to identify tobacco use in cancer patients at diagnosis and during follow-up. All patients who reported tobacco use within the past 30 days were automatically referred to a dedicated cessation program that provided cessation counseling. Data were analyzed for referral accuracy and interest in cessation support. RESULTS: Between October 2010 and December 2012, 11,868 patients were screened for tobacco use, and 2765 were identified as tobacco users and were referred to the cessation service. In referred patients, 1381 of those patients received only a mailed invitation to contact the cessation service, and 1384 received a mailing as well as telephone contact attempts from the cessation service. In the 1126 (81.4%) patients contacted by telephone, 51 (4.5%) reported no tobacco use within the past 30 days, 35 (3.1%) were medically unable to participate, and 30 (2.7%) declined participation. Of the 1381 patients who received only a mailed invitation, 16 (1.2%) contacted the cessation program for assistance. Three questions at initial consult and follow-up generated over 98% of referrals. Tobacco assessment frequency every 4 weeks delayed referral in < 1% of patients. CONCLUSIONS: An automated electronic health record-based tobacco assessment and cessation referral program can identify substantial numbers of smokers who are receptive to enrollment in a cessation support service.

Complementary and alternative medicine use among patients with thoracic malignancies.

PURPOSE: Complementary and alternative medicine (CAM) use has been increasing among cancer patients. This study characterizes the use of CAM among patients with thoracic malignancies. METHODS: This cross sectional study was conducted at a National Cancer Institute-designated comprehensive cancer center among adult patients diagnosed with thoracic malignancies. The primary outcome was a self-reported use of CAM, defined as the use of any type of CAM beyond routine vitamin/mineral supplementation alone. A logistic regression model was developed to explore predictors of CAM use. RESULTS: A total of 108 patients completed a standardized survey (59% response rate). Overall, 42% of respondents reported the use of at least one type of CAM. Users and non-users of CAM did not differ based upon demographics, diagnosis, staging, smoking status, quality of life, or perceived understanding of cancer diagnosis. In the multivariate analysis, patients who reported feeling fearful about their future were four times more likely to be CAM users when compared to those who did not specify this emotion (odds ratio=4.18; 95% CI=1.23-14.12; p=0.02). Commonly cited reasons for CAM use were to support one's self, boost immunity, and for improvements in emotional and/or spiritual well-being. CONCLUSIONS: Prevalence of CAM use among cancer patients in this study was similar to the general US population. Feeling fearful about the future was associated with CAM use. Results suggest that patients may be turning to CAM as a therapeutic adjunct to actively cope with emotional distress surrounding the cancer experience.