A tele-mentoring tobacco cessation case consultation and education model for healthcare providers in community mental health centers.

Smoking prevalence among individuals with mental and behavioral health needs is considerably higher compared to the general population, but evidence-based smoking cessation therapies are underutilized in mental and behavioral healthcare settings, despite the fact that these treatments are both safe and effective. The goal of this paper is to present the background, design and pilot of Project TEACH (Tobacco Education and Cessation in the Health System) developed to improve clinical practice by offering specialized training in the provision of smoking cessation interventions to care providers in community mental health centers in Texas. This is achieved through engaging the expertise of clinicians at the MD Anderson Cancer Center's Tobacco Treatment Program and disseminating this expertise to care providers by means of a novel tele-mentoring approach called Project ECHO (Extension for Community Healthcare Outcomes). Evaluation of our pilot ECHO training project demonstrated that the training was very well received and resulted in self-reported enhancement of the providers' professional practice. This is the first project to extend the collaborative ECHO model to train healthcare providers in smoking cessation. This approach has potential to reduce smoking rates among smokers with mental and behavioral health needs, and consequently contribute to the prevention of cancer and other chronic diseases in this vulnerable population.

A brief measure of Smokers' knowledge of lung cancer screening with low-dose computed tomography.

We describe the development and psychometric properties of a new, brief measure of smokers' knowledge of lung cancer screening with low-dose computed tomography (LDCT). Content experts identified key facts smokers should know in making an informed decision about lung cancer screening. Sample questions were drafted and iteratively refined based on feedback from content experts and cognitive testing with ten smokers. The resulting 16-item knowledge measure was completed by 108 heavy smokers in Houston, Texas, recruited from 12/2014 to 09/2015. Item difficulty, item discrimination, internal consistency and test-retest reliability were assessed. Group differences based upon education levels and smoking history were explored. Several items were dropped due to ceiling effects or overlapping constructs, resulting in a 12-item knowledge measure. Additional items with high item uncertainty were retained because of their importance in informed decision making about lung cancer screening. Internal consistency reliability of the final scale was acceptable (KR-20 = 0.66) and test-retest reliability of the overall scale was 0.84 (intraclass correlation). Knowledge scores differed across education levels (F = 3.36, p = 0.04), while no differences were observed between current and former smokers (F = 1.43, p = 0.24) or among participants who met or did not meet the 30-pack-year screening eligibility criterion (F = 0.57, p = 0.45). The new measure provides a brief, valid and reliable indicator of smokers' knowledge of key concepts central to making an informed decision about lung cancer screening with LDCT, and can be part of a broader assessment of the quality of smokers' decision making about lung cancer screening.

Dispositional Mindfulness Predicts Enhanced Smoking Cessation and Smoking Lapse Recovery.

BACKGROUND: Although mindfulness has been hypothesized to promote health behaviors, no research has examined how dispositional mindfulness might influence the process of smoking cessation. PURPOSE: The current study investigated dispositional mindfulness, smoking abstinence, and recovery from a lapse among African American smokers. METHODS: Participants were 399 African Americans seeking smoking cessation treatment (treatments did not include any components related to mindfulness). Dispositional mindfulness and other psychosocial measures were obtained pre-quit; smoking abstinence was assessed 3, 31 days, and 26 weeks post-quit. RESULTS: Individuals higher in dispositional mindfulness were more likely to quit smoking both initially and over time. Moreover, among individuals who had lapsed at day 3, those higher in mindfulness were more likely to recover abstinence by the later time points. The mindfulness-early abstinence association was mediated by lower negative affect, lower expectancies to regulate affect via smoking, and higher perceived social support. CONCLUSIONS: Results suggest that mindfulness might enhance smoking cessation among African American smokers by operating on mechanisms posited by prominent models of addiction.

Stress and morale of academic biomedical scientists.

Extensive research has shown high rates of burnout among physicians, including those who work in academic health centers. Little is known, however, about stress, burnout, and morale of academic biomedical scientists. The authors interviewed department chairs at one U.S. institution and were told that morale has plummeted in the past five years. Chairs identified three major sources of stress: fear of not maintaining sufficient funding to keep their positions and sustain a career; frustration over the amount of time spent doing paperwork and administrative duties; and distrust due to an increasingly adversarial relationship with the executive leadership.In this Commentary, the authors explore whether declining morale and concerns about funding, bureaucracy, and faculty-administration conflict are part of a larger national pattern. The authors also suggest ways that the federal government, research sponsors, and academic institutions can address these concerns and thereby reduce stress and burnout, increase productivity, and improve overall morale of academic biomedical scientists.

Positive smoking outcome expectancies mediate the relation between alcohol consumption and smoking urge among women during a quit attempt.

Social learning models of addiction hypothesize that situational factors interact with cognitive determinants to influence a person's motivation to use substances. Ecological momentary assessment was used to examine the association between alcohol consumption, smoking outcome expectancies, and smoking urge during the first 7 days of a smoking quit attempt. Participants were 113 female smokers who enrolled in a study that tested an individually tailored smoking cessation treatment. Participants carried a palm-top personal computer for 7 days and were instructed to complete 4 random assessments each day and to initiate an assessment when they were tempted to smoke. Multilevel mediational analyses were used to examine (a) the effects of alcohol consumption before time j and positive smoking outcome expectancies at time j on smoking urge at time j + 1 (Model 1) and (b) the effects of alcohol consumption before time j and smoking urge at time j on positive smoking outcome expectancies at time j + 1 (Model 2). Model 1 found a significant effect of alcohol consumption before time j on smoking urge at time j + 1 (p = .04), and this effect was significantly mediated by positive smoking outcome expectancies at time j (p < .0001). Model 2 failed to find a significant effect of alcohol consumption before time j on positive smoking outcome expectancies at time j + 1. The findings suggest that alcohol consumption is significantly associated with increased positive smoking outcome expectancies that, in turn, are associated with increased smoking urge in women seeking to quit smoking.

Individual and combined effects of multiple high-risk triggers on postcessation smoking urge and lapse.

INTRODUCTION: Negative affect, alcohol consumption, and presence of others smoking have consistently been implicated as risk factors for smoking lapse and relapse. What is not known, however, is how these factors work together to affect smoking outcomes. This paper uses ecological momentary assessment (EMA) collected during the first 7 days of a smoking cessation attempt to test the individual and combined effects of high-risk triggers on smoking urge and lapse. METHODS: Participants were 300 female smokers who enrolled in a study that tested an individually tailored smoking cessation treatment. Participants completed EMA, which recorded negative affect, alcohol consumption, presence of others smoking, smoking urge, and smoking lapse, for 7 days starting on their quit date. RESULTS: Alcohol consumption, presence of others smoking, and negative affect were, independently and in combination, associated with increase in smoking urge and lapse. The results also found that the relationship between presence of others smoking and lapse and the relationship between negative affect and lapse were moderated by smoking urge. CONCLUSIONS: The current study found significant individual effects of alcohol consumption, presence of other smoking, and negative affect on smoking urge and lapse. Combing the triggers increased smoking urge and the risk for lapse to varying degrees, and the presence of all 3 triggers resulted in the highest urge and lapse risk.

Mechanisms linking socioeconomic disadvantage and BMI in smokers.

OBJECTIVES: To evaluate a conceptual model of the psychosocial pathways linking socioeconomic status and body mass index (BMI) among smokers. METHODS: A latent variable modeling approach was used to evaluate the interrelationships among socioeconomic status, perceived neighborhood disadvantage, social support, negative affect, and BMI among smokers recruited from the Houston metropolitan area (N = 424). RESULTS: A total of 42.4% of participants were obese, with the highest prevalence of obesity among Latinos followed by African Americans. Across all racial/ethnic groups, perceived neighborhood disadvantage, social support, and negative affect functioned as pathways linking socioeconomic status and BMI. CONCLUSIONS: Findings indicate the need for interventions that target obesity among socioeconomically disadvantaged smokers and provide potential intervention targets for the prevention and treatment of obesity.

Alcohol consumption and urges to smoke among women during a smoking cessation attempt.

Laboratory and ad libitum smoking studies have indicated that alcohol consumption increases the frequency and intensity of smoking urges. However, few studies have examined the relation between smoking urges and alcohol use in natural settings during a quit attempt. The purpose of this study was to examine the relationships between smoking urge and alcohol use in women who reported drinking on at least one occasion during the first 7 days of a smoking quit attempt (N = 134). Participants were asked to use a palmtop computer to complete assessments that recorded smoking urges and recent alcohol use. Multilevel analyses examined the relation between smoking urge parameters and alcohol use. Smoking urges were higher during assessments where alcohol had been recently consumed compared to assessments where no alcohol had been consumed. Interestingly, the first urge rating of the day was higher and urges were more volatile on days where alcohol would eventually be consumed as compared to days where no alcohol was consumed. A closer examination of urge parameters on drinking days indicated that smoking urge trajectory was significantly flatter and urge volatility was significantly higher following alcohol consumption. However, smoking urge trajectory also flattened later in the day on nondrinking days. The findings suggest that there may be reciprocal relations between smoking urge and alcohol use (e.g., higher initial urges and more volatile urges may increase the likelihood of alcohol use, and alcohol use may impact within-day smoking urge parameters), and these relations could potentially impact smoking cessation and relapse.

The relation between social cohesion and smoking cessation among Black smokers, and the potential role of psychosocial mediators.

BACKGROUND: Social cohesion, the self-reported trust and connectedness between neighbors, may affect health behaviors via psychosocial mechanisms. PURPOSE: Relations between individual perceptions of social cohesion and smoking cessation were examined among 397 Black treatment-seeking smokers. METHODS: Continuation ratio logit models examined the relation of social cohesion and biochemically verified continuous smoking abstinence through 6 months post-quit. Indirect effects were examined in single mediator models using a nonparametric bootstrapping procedure. All analyses controlled for sociodemographics, tobacco dependence, and treatment. RESULTS: The total effect of social cohesion on continuous abstinence was non-significant (ß = 0.05, p = 0.10). However, social cohesion was associated with social support, positive affect, negative affect, and stress, which, in turn, were each associated with abstinence in adjusted models (ps < 0.05). CONCLUSIONS: Results suggest that social cohesion may facilitate smoking cessation among Black smokers through desirable effects on psychosocial mechanisms that can result from living in a community with strong interpersonal connections.

Pathways linking socioeconomic status and postpartum smoking relapse.

BACKGROUND: Low socioeconomic status (SES) exacerbates the high rate of smoking relapse in women following childbirth. PURPOSE: This study examined multiple models of potential mechanisms linking SES and postpartum smoking relapse among women who quit smoking due to pregnancy. METHODS: Participants were 251 women enrolled in a randomized clinical trial of a new postpartum smoking relapse prevention intervention. Four models of the prepartum mechanisms linking SES and postpartum smoking relapse were evaluated using a latent variable modeling approach. RESULTS: Each of the hypothesized models were a good fit for the data. As hypothesized, SES indirectly influenced postpartum smoking relapse through increased prepartum negative affect/stress, reduced sense of agency, and increased craving for cigarettes. However, the model that included craving as the sole final pathway between SES and relapse demonstrated superior fit when compared with all other models. CONCLUSIONS: Findings have implications for future interventions that aim to reduce postpartum relapse.

Associations between indicators of acculturation and tobacco dependence among Spanish-speaking Latino smokers.

The current study utilized regression analyses to explore the relationships among demographic and linguistic indicators of acculturation, gender, and tobacco dependence among Spanish-speaking Latino smokers in treatment. Additionally, bootstrapping analyses were used to examine the role of dependence as a mediator of the relationship between indicators of acculturation and cessation. Indicators of time spent in the United States were related to indicators of physical dependence. Preferred media language was related to a multidimensional measure of dependence. Gender did not impact the relationships between acculturation indicators and dependence. A multidimensional measure of dependence significantly mediated the relationship between preferred media language and cessation. Future research would benefit from consideration of acculturation and multidimensional measures of dependence when studying smoking cessation among Latinos, and from further examination of factors accounting for relationships among acculturation, dependence, and cessation.

Individual- and area-level unemployment influence smoking cessation among African Americans participating in a randomized clinical trial.

African Americans suffer disproportionately from the adverse health consequences of smoking, and also report substantially lower socioeconomic status than Whites and other racial/ethnic groups in the U.S. Although socioeconomic disadvantage is known to have a negative influence on smoking cessation rates and overall health, little is known about the influence of socioeconomic status on smoking cessation specifically among African Americans. Thus, the purpose of the current study was to characterize the impact of several individual- and area-level indicators of socioeconomic status on smoking cessation among African Americans. Data were collected as part of a smoking cessation intervention study for African American smokers (N = 379) recruited from the Houston, Texas, metropolitan area, who participated in the study between 2005 and 2007. The separate and combined influences of individual-level (insurance status, unemployment, education, and income) and area-level (neighborhood unemployment, education, income, and poverty) indicators of socioeconomic status on continuous smoking abstinence were examined across time intervals using continuation ratio logit modeling. Individual-level analyses indicated that unemployment was significantly associated with reduced odds of smoking abstinence, while higher income was associated with greater odds of abstinence. However, only unemployment remained a significant predictor of abstinence when unemployment and income were included in the model together. Area-level analyses indicated that greater neighborhood unemployment and poverty were associated with reduced odds of smoking abstinence, while greater neighborhood education was associated with higher odds of abstinence. However, only neighborhood unemployment remained significantly associated with abstinence status when individual-level income and unemployment were included in the model. Overall, findings suggest that individual- and area-level unemployment have a negative impact on smoking cessation among African Americans. Addressing unemployment through public policy and within smoking cessation interventions, and providing smoking cessation treatment for the unemployed may have a beneficial impact on tobacco-related health disparities.

Mediators of the association of major depressive syndrome and anxiety syndrome with postpartum smoking relapse.

OBJECTIVE: Based on conceptual models of addiction and affect regulation, this study examined the mechanisms linking current major depressive syndrome (MDS) and anxiety syndrome (AS) to postpartum smoking relapse. METHOD: Data were collected in a randomized clinical trial from 251 women who quit smoking during pregnancy. Simple and multiple mediation models of the relations of MDS and AS with postpartum relapse were examined using linear regression, continuation ratio logit models, and a bootstrapping procedure to test the indirect effects. RESULTS: Both MDS and AS significantly predicted postpartum smoking relapse. After adjusting for MDS, AS significantly predicted relapse. However, after adjusting for AS, MDS no longer predicted relapse. Situationally based self-efficacy, expectancies of controlling negative affect by means other than smoking, and various dimensions of primary and secondary tobacco dependence individually mediated the effect of both MDS and AS on relapse. In multiple mediation models, self-efficacy in negative/affective situations significantly mediated the effect of MDS and AS on relapse. CONCLUSIONS: The findings underscore the negative impact of depression and anxiety on postpartum smoking relapse and suggest that the effects of MDS on postpartum relapse may be largely explained by comorbid AS. The current investigation provided mixed support for affect regulation models of addiction. Cognitive and tobacco dependence-related aspects of negative and positive reinforcement significantly mediated the relationship of depression and anxiety with relapse, whereas affect and stress did not. The findings emphasize the unique role of low agency with respect to abstaining from smoking in negative affective situations as a key predictor of postpartum smoking relapse.

Increasing information-seeking about human papillomavirus vaccination through community partnerships in African American and Hispanic communities.

This study tested the feasibility of promoting 1-800-4-CANCER through partnerships with organizations serving African American and Hispanic communities. Small-media and client reminders about human papillomavirus vaccination were made available through local agents to 28 community organizations. Organizations ordered 79 932 resources and distributed them to young women and parents of girls-;African Americans in St Louis, Missouri, and Hispanics in the Lower Rio Grande Valley of Texas. Pre- to postintervention calls to 1-800-4-CANCER increased 38% in these communities, while declining 15% in comparison communities of Kansas City, Missouri, and El Paso, Texas (F = 8.6, P = .004) and 1.4% in the United States as a whole.

Neighborhood perceptions are associated with tobacco dependence among African American smokers.

INTRODUCTION: The animal and human research literatures suggest that deprived environmental conditions may be associated with drug dependence, but the relation of neighborhood perceptions with a multidimensional measure of tobacco dependence has not been previously studied. The purpose of this study was to examine the associations between neighborhood perceptions (neighborhood problems and neighborhood vigilance) and tobacco dependence among smokers as measured by the Wisconsin Inventory of Smoking Dependence Motives-68 (WISDM). METHODS: Participants were 384 African American smokers (49% men, 80% < $30,000 annual household income) enrolled in a randomized clinical trial of a smoking cessation intervention. A series of regression models were conducted to examine the associations between neighborhood perceptions and tobacco dependence using a generalized estimating equation approach, which accounted for potential correlation in tobacco dependence between participants from the same neighborhood. RESULTS: Results indicated that more self-reported neighborhood problems and greater neighborhood vigilance were significantly associated with tobacco dependence as measured by the WISDM total score in analyses adjusted for age, gender, income, education, employment status, and partner status (p ≤ .002). Neighborhood perceptions were related to both primary and secondary dependence motives (p ≤ .005). CONCLUSIONS: Results suggest that the neighborhood context is associated with dependence on tobacco among African American smokers but longitudinal studies are needed to assess causation. Future research should also explore the mechanisms that account for the associations between neighborhood perceptions and tobacco dependence to better inform intervention development.

The role of prepartum motivation in the maintenance of postpartum smoking abstinence.

OBJECTIVE: Motivation plays an important role in a variety of behaviors, including smoking cessation, and is integral to theory and treatment of smoking. For many women, pregnancy offers a motivational shift that helps them stop smoking and maintain abstinence during pregnancy. However, women's motivation to maintain smoking abstinence postpartum is not well-understood and may play a role in high postpartum relapse rates. The current study utilized multiple measures of prepartum motivation to maintain smoking abstinence to predict postpartum smoking abstinence. METHODS: As part of a randomized clinical trial on postpartum smoking relapse prevention, pregnant women who quit smoking during pregnancy reported their motivation to continue smoking abstinence at a prepartum baseline session. Biochemically verified continued smoking abstinence was assessed at 8 and 26 weeks postpartum. RESULTS: Direct relationships among multiple measures of motivation were significant, and ranged in strength from weak to moderate. All motivation measures individually predicted continuous smoking abstinence, after controlling for treatment group, demographics, and prequit tobacco use. When tested simultaneously, a global motivation measure and parenthood motives for quitting remained significant predictors of abstinence. Backward selection modeling procedures resulted in a reduced model of prepartum predictors of postpartum abstinence including global motivation, parenthood motives, and stage of change. CONCLUSIONS: Global motivation for smoking abstinence and parenthood motives for quitting are particularly important motivational constructs for pregnant women's continued smoking abstinence.

Differential effects of depression on smoking cessation in a diverse sample of smokers in treatment.

BACKGROUND: Recent cross-sectional evidence suggests that the effect of depression on smoking prevalence and quit ratios differs by race/ethnicity. PURPOSE: This study prospectively examined the main and interactive effects of race/ethnicity and depressive symptoms on smoking cessation during a specific quit attempt among smokers receiving cessation treatment. METHODS: Data from a longitudinal study of smokers in treatment were examined using continuation ratio logit modeling. Continuous abstinence across Weeks 1, 2, and 4 post-quit was the outcome variable. Data were collected between March 2005 and November 2007, and the current study analyses were conducted in April 2010. RESULTS: Depressive symptoms predicted significantly lower cessation rates for whites and African Americans. In contrast, among Latinos there was no relationship between depression and cessation. CONCLUSIONS: This research is the first to prospectively demonstrate a racially/ethnically differentiated effect of depressive symptoms on smoking cessation, and it has implications for targeted smoking-cessation treatments as it indicates that depression may not be a key treatment target for Latinos.

The efficacy of computer-delivered treatment for smoking cessation.

BACKGROUND: The current study evaluated the efficacy of an individualized, hand-held computer-delivered treatment (CDT) versus standard treatment (ST) for the maintenance of smoking abstinence following a quit attempt. METHODS: Participants were 303 adult daily smokers randomized to CDT or ST, plus pharmacotherapy. Abstinence though 1 year was examined using logistic random intercept models, a type of generalized linear mixed model regression. RESULTS: Results did not support the efficacy of the CDT program through 1 year postquit in analyses adjusted for time and study site (OR = 0.84, 95% CI = 0.55-1.30), or after further adjusting for race/ethnicity, age, gender, education, marital status, and the number of cigarettes smoked per day before quitting (OR = 0.89, 95% CI = 0.57-1.39). CONCLUSIONS: CDT did not increase short- or long-term abstinence rates over ST in this study. IMPACT: Findings differ from some in the literature and suggest the need for continued research on the use of CDT for smoking cessation.

Race/ethnicity moderates the effect of prepartum menthol cigarette use on postpartum smoking abstinence.

INTRODUCTION: Little is known about the influence of prepartum menthol cigarette use on postpartum smoking abstinence or how race/ethnicity might moderate this relationship. The current study addressed that gap by testing these relationships among racially/ethnically diverse women who quit smoking during pregnancy (N = 244; 33% African American, 31% Latina, 36% White). METHODS: Continuation ratio logit models were used to examine the effects of prepartum menthol cigarette use on biochemically confirmed, continuous abstinence through 26 weeks postpartum using an intent-to-treat approach. Analyses controlled for age, race/ethnicity, partner status, income, education, treatment, number of prequit cigarettes smoked per day, time to the first cigarette of the day, and time (Week 8 or 26 data collection timepoint). An additional model tested the moderating effects of race/ethnicity by including an interaction term. RESULTS: Prepartum menthol cigarette use was not significantly associated with postpartum smoking abstinence in the overall sample. However, the interaction between menthol use and race/ethnicity was significant (p = .02). Among White women, menthol use was associated with significantly lower odds of maintaining postpartum smoking abstinence (p = .03; odds ratio = .19 [.04-.89]), and the effect approached significance among African American women (p = .08). CONCLUSIONS: This study provides the first evidence that prepartum menthol cigarette use may increase the risk of postpartum smoking relapse among White, and possibly African American, women who quit smoking during or immediately before pregnancy. Results suggest that White and African American prepartum menthol users may require different or more intensive cessation services to aid in the maintenance of postpartum smoking abstinence. Replication with larger samples, and a focus on understanding the mechanisms that underlie these relationships, are warranted.

Early cessation success or failure among women attempting to quit smoking: trajectories and volatility of urge and negative mood during the first postcessation week.

Aversive symptoms of abstinence from nicotine have been posited to lead to smoking relapse and research on temporal patterns of abstinence symptoms confirms this assumption. However, little is known about the association of symptom trajectories early after quitting with postcessation smoking or about the differential effects of tonic (background) versus phasic (temptation-related) symptom trajectories on smoking status. The current study examined trajectories of urge and negative mood among 300 women using the nicotine patch during the first postcessation week. Ecological momentary assessments collected randomly and during temptation episodes were analyzed using hierarchical linear modeling yielding four individual trajectory parameters: intercept (initial symptom level), linear slope (direction and rate of change), quadratic coefficient (curvature), and volatility (scatter). Early lapsers, who lapsed during the first postcessation week, exhibited more severe tonic urge and phasic negative mood immediately after quitting, and more volatile tonic and phasic urge compared to abstainers. Late lapsers, who were abstinent during the first week but lapsed by 1 month, exhibited more severe tonic urge immediately after quitting compared to abstainers. These results demonstrate the importance of early postcessation urge and negative affect and highlight the value of examining both tonic and phasic effects of abstinence from nicotine.