Adverse Childhood Experiences, Resilience, and Cardiovascular Disease in Adult Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study.

BACKGROUND: The impact of adverse childhood experiences (ACE, e.g., abuse, neglect, and/or household dysfunction experienced before the age of 18) and resilience on risk for cardiovascular disease (CVD) has not previously been investigated in adult survivors of childhood cancer. METHODS: We conducted a nested case-control study among long-term, adult-aged survivors of childhood cancer from the Childhood Cancer Survivor Study. Self-report questionnaires ascertained ACEs and resilience, and scores were compared between cases with serious/life-threatening CVD and controls without CVD matched on demographic and cardiotoxic treatment factors. RESULTS: Among 95 cases and 261 controls, the mean ACE score was 1.4 for both groups; 53.4% of survivors endorsed ≥1 ACE. No association was observed between ACEs or resilience and CVD in adjusted models. CONCLUSIONS: ACEs and resilience do not appear to contribute to CVD risk for adult survivors of childhood cancer with cardiotoxic treatment exposures. IMPACT: Although not associated with CVD in this population, ACEs are associated with serious health issues in other populations. Therefore, future studies could investigate the effects of ACEs on other health outcomes affecting childhood cancer survivors.

Perceptions of family functioning impact smoking during pregnancy.

BACKGROUND: Although socio-environmental factors are known to contribute to the maintenance of smoking behavior, few studies have examined the impact of family functioning on smoking during pregnancy. OBJECTIVE: The current study examined the relationship between perceptions of family functioning and smoking during pregnancy. METHODS: Pregnant women (N = 345, 59% ethnic/racial minority) completed the Family Assessment Device, a gold-standard assessment examining perceptions of family functioning in seven domains. Multinomial logistic regressions analyzed associations between clinically determined suboptimal levels of family functioning by domain and smoking status during pregnancy (smoking, ≥28 continuous days quit, nonsmoking), with stratified analyses exploring ethnic/racial differences (non-Hispanic/White vs. racial/ethnic minority). RESULTS: Participants who reported suboptimal levels of family functioning in domains of Affective Involvement, Affective Responsiveness, Behavioral Control, and Roles were significantly more likely to have been smoking than nonsmoking during pregnancy. Stratified analyses revealed differing effects by ethnic/racial identity, with perceptions of Roles remaining the only significant effect on smoking outcomes for both groups. No significant effects were found regarding the impact of family functioning on whether participants were smoking vs. quit during pregnancy. CONCLUSIONS: Suboptimal family functioning may contribute to smoking during pregnancy, but effects may differ based on domain of family functioning and by ethnic/racial identity.

Challenges and Opportunities in Diagnosis and Management of Cardiometabolic Risk in Adolescents.

PURPOSE OF REVIEW: This review aims to elucidate the limitations of diagnosing metabolic syndrome in adolescents as well as challenges and opportunities in the identification and reduction of cardiometabolic risk in this population. RECENT FINDINGS: There are multiple criticisms of how we define and approach obesity in clinical practice and scientific research, and weight stigma further complicates the process of making and communicating weight-related diagnoses. While the goal of diagnosing and managing metabolic syndrome in adolescents would be to identify individuals at elevated future cardiometabolic risk and intervene to reduce the modifiable component of this risk, there is evidence that identifying cardiometabolic risk factor clustering may be more useful in adolescents than establishing a cutoff-based diagnosis of metabolic syndrome. It has also become clear that many heritable factors and social and structural determinants of health contribute more to weight and body mass index than do individual behavioral choices about nutrition and physical activity. Promoting cardiometabolic health equity requires that we intervene on the obesogenic environment and mitigate the compounding effects of weight stigma and systemic racism. The existing options to diagnose and manage future cardiometabolic risk in children and adolescents are flawed and limited. While striving to improve population health through policy and societal interventions, there are opportunities to intervene at all levels of the socioecological model in order to decrease future morbidity and mortality from the chronic cardiometabolic diseases associated with central adiposity in both children and adults. More research is needed to identify the most effective interventions.

Addressing Tobacco Use in Underserved Communities Outside of Primary Care: The Need to Tailor Tobacco Cessation Training for Community Health Workers.

Individuals from communities with a low socioeconomic status have the highest rates of tobacco use but are less likely to receive assistance with quitting. Community health workers (CHWs) are well-positioned to engage these communities; however, CHWs face barriers in receiving relevant tobacco cessation training. The objective of this study was to conduct a mixed methods needs assessment to describe tobacco practices and the desire for training among CHWs. After incorporating CHW feedback, we developed a needs assessment survey to understand knowledge, practices, and attitudes about tobacco cessation in Chicago, IL. CHWs (N = 23) recruited from local community-based organizations completed the survey online or in-person. We then conducted a focus group with CHWs (N = 6) to expand upon the survey and used the Framework Method to analyze the qualitative data. CHWs reported that their clients had low incomes, low literacy levels, and high smoking rates (e.g., "99%" of patients). About 73.3% reported discussing tobacco use during visits, but fewer reported that they had provided cessation advice (43%) or intervened directly (9%). CHWs described high variability in their work environments (e.g., location, duration, content of visits, etc.) and greater continuity of care. CHWs discussed that existing training on how to conduct tobacco interventions is ineffective, because of its stand-alone design. Our findings illustrate how CHWs adapt to their clients' needs, and that the currently available "gold-standard" cessation curricula are incompatible with the training needs and flexible care delivery model of CHWs. A curriculum tailored to the CHW experience is needed to maximize the strengths of the CHW care model by training CHWs to adaptively intervene regarding tobacco use in their highly burdened patients.

Advance Care Planning With Black Women with Breast Cancer: A Community Health Worker Model.

BACKGROUND: Despite the importance of advance care planning (ACP), a process that optimizes future medical treatment and end-of-life care, for at-risk populations, rates of patient-provider ACP conversations are extremely low among Black women with breast cancer. Community health workers (CHWs) are well-positioned to support patients in engaging in ACP conversations with their providers; yet research on integrating CHWs to promote ACP is scant. The current study examined multilevel facilitators and barriers to successful ACP conversations among Black women from the perspective of providers and CHWs who serve this community. METHODS: Providers and CHWs were recruited from an academic medical center in a large urban city. Retrospective qualitative data on barriers and facilitators to ACP conversations, as well as CHWs' training needs, were collected from two focus groups (N = 5 providers, N = 5 CHWs) and one individual interview (N = 1 provider), and transcribed and coded for themes. RESULTS: All providers reported working primarily with Black patients, and identified stigma and time constraints as major barriers to ACP discussions; they also identified the structural barriers and injustices that their patients face during medical care. CHWs reported having a trusted relationship with their patients and flexibility in their care that would allow for ongoing ACP conversations, discussing their ability to serve as a bridge between the patient and provider. However, CHWs discussed that they lacked the tools and skills to have ACP conversations, largely because existing formal trainings in ACP are cost prohibitive. DISCUSSION: Competing priorities of the provider to discuss/treat the patient's disease and medical mistrust were major barriers to successful ACP conversations among Black women with breast cancer, leading to ACP completion occurring late in treatment. CHWs are uniquely qualified to overcome multilevel barriers to ACP and establish trusting relationships with patients in order to facilitate earlier and ongoing communication between patients and providers.

Adverse childhood experiences and resilience in childhood and adolescent and young adult cancer patients.

Childhood and adolescent and young adult (AYA) cancer survivors experience poor health outcomes in adulthood. Adverse childhood experiences (ACEs) also portend poor health outcomes for the general population. Resilience can mitigate effects of ACEs. We examined the feasibility of assessing ACEs and resilience in childhood and AYA cancer patients. We also described occurrences of ACEs, resilience, and poor health outcomes. Of 52 participants, most rated their study experience favorably, with privacy in answering sensitive questions. Half reported ACEs, and those with ACEs had lower resilience; X2 (3, N = 52) = 9.4, p = .02. Further investigations of ACEs and resilience in larger cohorts are warranted to delineate associations with long-term health outcomes.

The role of smoking history in longitudinal changes in C-reactive protein between Black and White older adults in the US.

Smoking cessation is associated with decreases in C-reactive protein (CRP), a biomarker of systemic inflammation and cancer risk; yet CRP levels remain higher long-term in individuals who quit vs. those who never smoked. While non-Hispanic, Black/African American (NHB) have higher levels of CRP vs. non-Hispanic, White/Caucasian (NHW) adults, the association between CRP and race has not been examined in individuals with smoking history. Utilizing longitudinal data from the Health and Retirement Study (HRS), the current study examined the effects of race and smoking history on CRP in older adults. NHB (n = 242) and NHW (n = 1529) participants completed HRS assessments in 2006, 2010, and 2014. Dried blood spots collected at each wave were assayed for CRP. Linear mixed models were used to examine the effect of race and smoking history on CRP across waves - controlling for sociodemographics, physical activity, body mass index (BMI), and current smoking. Overall, results showed no significant effects of race or current smoking on CRP; rather age, sex, education, BMI, physical activity, smoking history, and time × race predicted CRP (ps<.04). However, while age, sex, education, BMI, physical activity, and smoking history were also predictive of CRP in NHWs (ps<.04) in race-stratified models, only BMI was a significant predictor of CRP in NHBs (p=.012). BMI may be important in explaining inflammation-related disease risk in NHBs with a history of smoking. NHBs may not experience the same reductions in CRP with smoking cessation as NHWs - potentially contributing to tobacco-related health disparities.

Gaps in Knowledge and Practice in Treating Tobacco Use Among Non-physician Healthcare Professionals and Lay Health Workers in Chicago, Illinois.

OBJECTIVE: To conduct a needs assessment for lay health workers and non-physician healthcare professionals [i.e., community health workers (CHW) and lung health professionals who spend more time face-to-face with tobacco-related disparity populations] to describe current gaps in tobacco cessation practices and knowledge. METHODS: A 46-item needs assessment survey was developed to understand knowledge, practices, and confidence about tobacco cessation among non-physician health professionals in a large, urban city in the U.S. Participants, recruited from local community-based organizations and email listservs, completed the online or paper survey, which included a 10-item investigator-initiated tobacco knowledge questionnaire. RESULTS: About 61.5% of participants (N = 53) asked each client/patient about tobacco use at initial visit, 41.8% reported extreme likelihood of discussing tobacco during a visit, and 43.1% reported addressing tobacco use directly. Despite assisting with cessation, tobacco-related knowledge and confidence was low, with respondents scoring an average of 4.08 out of 10 (SD = 2.21) on the tobacco knowledge questionnaire. CONCLUSION: There was a clear lack of knowledge about tobacco cessation in the U.S. among non-physician healthcare professionals. These professionals could benefit from trainings that are relevant to their model of care and better equip them to assist the disparity populations that they serve.

Race differences in predictors of weight gain among a community sample of smokers enrolled in a randomized controlled trial of a multiple behavior change intervention.

African Americans have disproportionate rates of post-cessation weight gain compared to non-Hispanic whites, but few studies have examined this weight gain in a multiracial sample of smokers receiving evidence-based treatment in a community setting. We examined race differences in short-term weight gain during an intervention to foster smoking cessation plus weight management. Data were drawn from the Best Quit Study, a randomized controlled trial conducted via telephone quitlines across the U.S. from 2013 to 2017. The trial tested the effects on cessation and weight gain prevention of adding a weight control intervention either simultaneously with or sequentially after smoking cessation treatment. African Americans (n = 665) and whites (n = 1723) self-reported smoking status and weight during ten intervention calls. Random effects longitudinal modeling was used to examine predictors of weight change over the intervention period (average 16 weeks). There was a significant race × treatment effect; in the simultaneous group, weight increased for African Americans at a faster rate compared to whites (b = 0.302, SE = 0.129, p < 0.05), independent of smoking status, age, baseline obesity, and education. After stratifying the sample, the effect of treatment group differed by race. Education level attenuated the rate of weight gain for African Americans in the simultaneous group, but not for whites. African Americans receiving smoking and weight content simultaneously gained weight faster than whites in the same group; however, the weight gain was slower for African Americans with higher educational attainment. Future studies are needed to understand social factors associated with treatment receptivity that may influence weight among African American smokers.

Menthol Cigarettes, Tobacco Dependence, and Smoking Persistence: The Need to Examine Enhanced Cognitive Functioning as a Neuropsychological Mechanism.

INTRODUCTION: Despite the overall decline in the prevalence of cigarette use in the United States, menthol cigarette use among smokers is rising, and evidence shows that it may lead to more detrimental effects on public health than regular cigarette use. One of the mechanisms by which nicotine sustains tobacco use and dependence is due to its cognitive enhancing properties, and basic science literature suggests that menthol may also enhance nicotine's acute effect on cognition. AIMS AND METHODS: The purpose of this review is to suggest that the cognitive enhancing effects of menthol may be a potentially important neuropsychological mechanism that has yet to be examined. In this narrative review, we provide an overview of basic science studies examining neurobiological and cognitive effects of menthol and menthol cigarette smoking. We also review studies examining menthol essential oils among humans that indicate menthol alone has acute cognitive enhancing properties. Finally, we present factors influencing the rising prevalence of menthol cigarette use among smokers and the importance of this gap in the literature to improve public health and smoking cessation treatment. CONCLUSIONS: Despite the compelling evidence for menthol's acute cognitive enhancing and reinforcing effects, this mechanism for sustaining tobacco dependence and cigarette use has yet to be examined and validated among humans. On the basis of the basic science evidence for menthol's neurobiological effects on nicotinic receptors and neurotransmitters, perhaps clarifying menthol's effect on cognitive performance can help to elucidate the complicated literature examining menthol and tobacco dependence. IMPLICATIONS: Menthol cigarette use has continued to be a topic of debate among researchers and policy makers, because of its implications for understanding menthol's contribution to nicotine dependence and smoking persistence, as well as its continued use as a prevalent flavoring in tobacco and nicotine products in the United States and internationally. As international tobacco regulation policies have begun to target menthol cigarettes, research studies need to examine how flavoring additives, specifically menthol, may acutely influence neurobiological and cognitive functioning as a potential mechanism of sustained smoking behavior to develop more effective treatments.

Six Month Abstinence Heterogeneity in the Best Quit Study.

BACKGROUND: Understanding the characteristics of smokers who are successful in quitting may help to increase smoking cessation rates. PURPOSE: To examine heterogeneity in cessation outcome at 6 months following smoking cessation behavioral counseling with or without weight management counseling. METHODS: 2,540 smokers were recruited from a large quitline provider and then randomized to receive proactive smoking cessation behavioral counseling without or with two versions of weight management counseling. A Classification and Regression Tree (CART) analysis was conducted to identify the individual pretreatment and treatment characteristics of groups of smokers with different quitting success (as measured by point prevalence of self-reported smoking of any amount at 6 months). RESULTS: CART analysis identified 10 subgroups ranging from 25.5% to 70.2% abstinent. The splits in the CART tree involved: the total number of counseling and control calls received, whether a smoking cessation pharmacotherapy was used, and baseline measures of cigarettes per day, confidence in quitting, expectation that the study would help the participant quit smoking, the motivation to quit, exercise minutes per week, anxiety, and lack of interest or pleasure in doing things. Costs per quitter ranged from a low of $US270 to a high of $US630. Specific treatment recommendations are made for each group. CONCLUSIONS: These results indicate the presence of a substantial variation in abstinence following treatment, and that the total extent of contact via counseling calls of any type and baseline characteristics, rather than assigned treatment, were most important to subgroup membership and abstinence. Tailored treatments to subgroups who are at high risk for smoking following a quit attempt could increase successful smoking cessation.

Simultaneous vs. sequential treatment for smoking and weight management in tobacco quitlines: 6 and 12 month outcomes from a randomized trial.

BACKGROUND: Smoking cessation often results in weight gain which discourages many smokers from quitting and can increase health risks. Treatments to reduce cessation-related weight gain have been tested in highly controlled trials of in-person treatment, but have never been tested in a real-world setting, which has inhibited dissemination. METHODS: The Best Quit Study (BQS) is a replication and "real world" translation using telephone delivery of a prior in-person efficacy trial. DESIGN: randomized control trial in a quitline setting. Eligible smokers (n = 2540) were randomized to the standard 5-call quitline intervention or quitline plus simultaneous or sequential weight management. Regression analyses tested effectiveness of treatments on self-reported smoking abstinence and weight change at 6 and 12 months. RESULTS: Study enrollees were from 10 commercial employer groups and three state quitlines. Participants were between ages 18-72, 65.8% female, 68.2% white; 23.0% Medicaid-insured, and 76.3% overweight/obese. The follow-up response rate was lower in the simultaneous group than the control group at 6 months (p = 0.01). While a completers analysis of 30-day point prevalence abstinence detected no differences among groups at 6 or 12 months, multiply imputed abstinence showed quit rate differences at 6 months for:simultaneous (40.3%) vs. sequential (48.3%), p = 0.034 and simultaneous vs. control (44.9%), p = 0.043. At 12 months, multiply imputed abstinence, was significantly lower for the simultaneous group (40.7%) vs. control (46.0%), p < 0.05 and vs. sequential (46.3%), p < 0.05. Weight gain at 6 and 12 months was minimal and not different among treatment groups. The sequential group completed fewer total calls (3.75) vs. control (4.16) and vs. simultaneous group (3.83), p = 0.01, and fewer weight calls (0.94) than simultaneous (2.33), p < 0.0001. The number of calls completed predicted 30-day abstinence, p < 0.001, but not weight outcomes. DISCUSSION: This study offers a model for evaluating population-level public health interventions conducted in partnership with tobacco quitlines. CONCLUSIONS: Simultaneous (vs. sequential) delivery of phone/web weight management with cessation treatment in the quitline setting may adversely affect quit rate. Neither a simultaneous nor sequential approach to addressing weight produced any benefit on suppressing weight gain. This study highlights the need and the challenges of testing intensive interventions in real-world settings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01867983 . Registered: May 30, 2013.

Association between smoking cessation and weight gain in treatment-seeking African Americans.

INTRODUCTION: Research has shown that African Americans gain more than average weight after smoking cessation. However, African Americans have been underrepresented in post-cessation weight gain research. The current study examined 1) the pattern of weight gain and 2) the association between smoking status and weight gain in a sample of African Americans seeking smoking cessation treatment. METHODS: Data were drawn from a randomized controlled trial testing the efficacy of a 4-week culturally specific smoking cessation cognitive behavioral therapy (CBT) intervention among African American smokers (N = 342). Weight was measured and self-reported smoking status was biochemically verified at baseline, end of counseling, 3-, 6-, and 12-month follow-ups. Random effects multilevel modeling was used to examine weight gain over twelve months post CBT, and a fully unconditional model tested the pattern of weight gain over time. Smoking status was included as a time-varying factor to examine its effect on weight gain, controlling for potential confounding variables. RESULTS: Weight significantly increased among those who remained abstinent over 12 months post CBT [average gain of seven lbs. (three kg)]. Controlling for covariates, abstinence was predictive of the rate of weight gain for those with high weight concern. CONCLUSIONS: Weight gain among African American abstainers was comparable to the average post-cessation weight gain observed among the general population. It is possible that exposure to CBT (culturally specific or standard) may have mitigated excessive weight gain. Future research should assess predictors of weight gain in African American smokers to inform future smoking cessation interventions and help elucidate factors that contribute to tobacco- and obesity-related health disparities.