Improving Point-of-Sale Warnings for Single Cigars: Implications for Premium Cigars.

INTRODUCTION: For cigars sold individually without packaging, including many premium cigars, the US Food and Drug Administration (FDA) proposed that retailers display six warning statements on a sign at the point-of-sale (POS). AIMS AND METHODS: To examine the potential effectiveness of cigar warning signs, we conducted a between-subjects online experiment. Participants were 809 U.S. adults who reported using cigars (78% ever large cigar use, 49% past 30-day large cigar use) recruited from a probability-based panel. Participants viewed an image of a cigar store countertop with randomization to one of four conditions: (1) no warning sign, (2) a sign with six FDA proposed text-only warnings, (3) a sign with six novel text-only warnings, or (4) a sign with six novel text + image warnings. We used analysis of variance (ANOVA) models and post hoc Tukey tests to examine the results. RESULTS: The FDA-proposed text-only warning sign was perceived as less effective in discouraging participants from smoking cigars (M: 3.26, SD: 1.39; scale range: 1-5, where five indicates higher discouragement) compared with the novel text-only warning sign (M = 3.38, SD = 1.40) and the novel text + image warning sign (M = 3.65, SD = 1.34). The novel text + image warning sign increased discouragement from smoking cigars versus the FDA-proposed text-only warning sign (p = .02) and decreased the perceived satisfaction of smoking cigars versus no warning sign (p = .04). In a sensitivity analysis, the novel text + image warning sign decreased the perceived satisfaction of smoking cigars (p = .01), decreased cigar purchase intentions (p = .03), decreased the urge to smoke (p = .03), and increased discouragement from smoking cigars (p = .006) compared with all other study conditions. CONCLUSIONS: Results provide new evidence that policymakers, such as the FDA, could use when proposing POS warning signs for cigars. IMPLICATIONS: The US FDA proposed that retailers display a warning sign at the POS for cigars sold individually without packaging. We conducted an online experiment concerning the potential effectiveness of this regulatory policy with people who use cigars recruited from a probability-based panel. Results provide the first evidence that the FDA-proposed text-only warning sign was perceived as less effective than other types of warning signs and that adding images could potentially increase the effectiveness of warning signs. These findings are particularly relevant for premium cigars, which are often sold individually in brick-and-mortar retail settings.

Black Smokers' Preferences for Features of a Smoking Cessation App: Qualitative Study.

BACKGROUND: Mobile health (mHealth) interventions for smoking cessation have grown extensively over the last few years. Although these interventions improve cessation rates, studies of these interventions consistently lack sufficient Black smokers; hence knowledge of features that make mHealth interventions attractive to Black smokers is limited. Identifying features of mHealth interventions for smoking cessation preferred by Black smokers is critical to developing an intervention that they are likely to use. This may in turn address smoking cessation challenges and barriers to care, which may reduce smoking-related disparities that currently exist. OBJECTIVE: This study aims to identify features of mHealth interventions that appeal to Black smokers using an evidence-based app developed by the National Cancer Institute, QuitGuide, as a reference. METHODS: We recruited Black adult smokers from national web-based research panels with a focus on the Southeastern United States. Participants were asked to download and use QuitGuide for at least a week before participation in remote individual interviews. Participants gave their opinions about features of the QuitGuide app and other mHealth apps they may have used in the past and suggestions for future apps. RESULTS: Of the 18 participants, 78% (n=14) were women, with age ranging from 32 to 65 years. Themes within five major areas relevant for developing a future mHealth smoking cessation app emerged from the individual interviews: (1) content needs including health and financial benefits of quitting, testimonials from individuals who were successful in quitting, and strategies for quitting; (2) format needs such as images, ability to interact with and respond to elements within the app, and links to other helpful resources; (3) functionality including tracking of smoking behavior and symptoms, provision of tailored feedback and reminders to users, and an app that allows for personalization of functions; (4) social network, such as connecting with friends and family through the app, connecting with other users on social media, and connecting with a smoking cessation coach or therapist; and (5) the need for inclusivity for Black individuals, which may be accomplished through the inclusion of smoking-related information and health statistics specific for Black individuals, the inclusion of testimonials from Black celebrities who successfully quit, and the inclusion of cultural relevance in messages contained in the app. CONCLUSIONS: Certain features of mHealth interventions for smoking cessation were highly preferred by Black smokers based on their use of a preexisting mHealth app, QuitGuide. Some of these preferences are similar to those already identified by the general population, whereas preferences for increasing the inclusivity of the app are more specific to Black smokers. These findings can serve as the groundwork for a large-scale experiment to evaluate preferences with a larger sample size and can be applied in developing mHealth apps that Black smokers may be more likely to use.

Stagnant daily smoking prevalence between 2008 and 2019 among Black and Hispanic adults with serious psychological distress.

BACKGROUND: Racial/ethnic minority status and mental illness independently drive inequity in cigarette smoking and related morbidity. Racial/ethnic minority groups suffer a disproportionate burden of tobacco-related diseases. People with serious mental illness (SMI) smoke at up to 7 times the rate of the general population. There is a need to quantify smoking prevalence and trends among people at the intersection of both groups. METHODS: This study analyzes 2008-2019 data from the National Survey on Drug Use and Health. Linear time trends of daily smoking prevalence were assessed among people with serious psychological distress (SPD; marker for SMI) and people without SPD reporting White, Black, Hispanic, and Other race/ethnicity using logistic regression, with survey year as the predictor. Models with year-by-smoking status interaction terms and F-tests assessed differential time trends. RESULTS: The prevalence of daily smoking among people without SPD decreased over time among people reporting White (aOR=0.96, p<0.001), Black (aOR=0.96, p<0.001), Hispanic (aOR=0.95, p<0.001), and Other (aOR=0.97, p=0.002) race/ethnicity. Among people with SPD, the smoking prevalence decreased among people with White race/ethnicity (aOR=0.95, p<0.001), with no significant changes among people of Black, Hispanic, and Other race/ethnicity. CONCLUSIONS: Smoking among people with SPD who report Black and Hispanic race/ethnicity has not changed significantly in the past 11 years, despite decreasing among non-SPD and White groups. People who are Black/Hispanic and people with SPD struggle to quit smoking, which is amplified intersectionally. Tailored interventions may be a better mechanism to reduce barriers to smoking cessation in this population.

Preferences for different features of ENDS products by tobacco product use: a latent class analysis.

BACKGROUND: From a public health perspective, electronic nicotine delivery devices (ENDS) use may be beneficial for some populations (e.g., smokers who fully switch to ENDS) but detrimental for others (e.g., nonsmokers). Understanding the importance placed on different ENDS product features by user groups can guide interventions and regulations. METHODS: Participants were US adults who had used ENDS at least once and from a convenience sample drawn from a market research software in 2016. Participants chose between 9 different ENDS product features (harms of use, general effects of use, use as a cessation aid, initial purchase price, monthly cost, nicotine content, flavor availability, device design, and modifiability). A latent class analysis (LCA) identified subgroups of feature preferences and examined differences between groups by socio-demographics and tobacco product use. RESULTS: Of the 636 participants, 81% were White, the median age was 42, and 65% were current cigarette smokers. The LCA identified a 4-class solution as the most appropriate model: (1) people with high nicotine dependence who preferred ENDS similar to combustible cigarettes, (2) people with moderate tobacco use who were interested in low nicotine ENDS (3) people who use ENDS and combustible tobacco who preferred lower price and flavored ENDS products, and (4) people who used ENDS predominantly, without a strong preference for any of the features presented. CONCLUSIONS: Tobacco use classes were associated with differences in preferences for ENDS features. These findings can inform regulations to reduce ENDS use among specific groups of people who use ENDS products.

Effectiveness of Mobile Phone and Web-Based Interventions for Diabetes and Obesity Among African American and Hispanic Adults in the United States: Systematic Review.

BACKGROUND: Mobile health (mHealth) and web-based technological advances allow for new approaches to deliver behavioral interventions for chronic diseases such as obesity and diabetes. African American and Hispanic adults experience a disproportionate burden of major chronic diseases. OBJECTIVE: This paper reviews the evidence for mHealth and web-based interventions for diabetes and obesity in African American and Hispanic adults. METHODS: Literature searches of PubMed/Medline, The Cochrane Library, EMBASE, CINAHL Plus, Global Health, Scopus, and Library & Information Science Source were conducted for relevant English-language articles. Articles identified through searches were reviewed by 2 investigators and, if they met the inclusion criteria, were extracted and assessed for risk of bias. Findings were summarized in tabular and narrative format. The overall strength of the evidence was assessed as high, moderate, low, or insufficient on the basis of risk of bias, consistency of findings, directness, precision, and other limitations. RESULTS: Searches yielded 2358 electronic publications, 196 reports were found to be eligible for inclusion, and 7 studies met the eligibility criteria. All 7 included studies were randomized control trials. Five studies evaluated the effectiveness of an mHealth intervention for weight loss, including one that evaluated the effectiveness for diabetes and two studies focused on diabetes. Of all the studies that focused on weight loss, 3 reported significant differences in weight loss in participants in the intervention group compared with those in the usual care group. Although all studies on diabetes control showed greater improvement in glycemic control for the intervention group compared to that in the control group, only one study showed a significant difference between the 2 groups. CONCLUSIONS: This analysis indicates that there are few published studies that assessed mHealth interventions among minority populations and focused on weight or diabetes. Although the overall strength of evidence was low for diabetes control, it was moderate for weight loss, and our findings suggest that mHealth and web-based interventions may provide a promising approach for interventions among African American and Hispanic adults who have obesity or diabetes.

Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline.

PURPOSE: To inform overprescribing and antibiotic stewardship in nursing homes (NHs), we examined the concordance between clinicians' (NH primary care providers and registered nurses) diagnosis of suspected UTI with a clinical guideline treated as the gold standard, and whether clinician characteristics were associated with diagnostic classification. METHODS: We conducted a cross-sectional web-based survey of a U.S. national convenience sample of NH clinicians. The survey included a discrete choice experiment with 19 randomly selected clinical scenarios of NH residents with possible UTIs. For each scenario, participants were asked if they thought a UTI was likely. Responses were compared to the guideline to determine the sensitivity and specificity of clinician judgment and performance indicators. Multivariable logistic mixed effects regression analysis of demographic, work, personality, and UTI knowledge/attitudes characteristics was conducted. RESULTS: One thousand seven hundred forty-eight NH clinicians responded to 33,212 discrete choice scenarios; 867 (50%) were NH primary care providers and 881 (50%) were NH registered nurses, 39% were male, and the mean age was 45 years. Participants were uncertain about diagnosis in 30% of scenarios. Correct classification occurred for 66% of all scenarios (providers: 70%; nurses: 62%). Respondent judgment had a sensitivity of 78% (providers: 81%; nurses: 74%) and specificity of 54% (providers: 59%; nurses: 49%) compared to the clinical guideline. Adjusting for covariates in multivariable models, being a nurse and having higher closemindedness were associated higher odds of false positive UTI (odds ratio [OR] 1.61, p < 0.001; and OR 1.09, p = 0.039, respectively), although higher UTI knowledge and conscientiousness were associated with lower odds of false positive UTI ratings (OR 0.80, p < 0.001; OR 0.90, p = 0.005, respectively). CONCLUSIONS: Clinicians tend to over-diagnose urinary tract infections, necessitating systems-based interventions to augment clinical decision-making. Clinician type, UTI knowledge, and personality traits may also influence behavior and deserve further study.

Screening for Lung Cancer With Low-Dose Computed Tomography: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Lung cancer is the leading cause of cancer-related death in the US. Objective: To review the evidence on screening for lung cancer with low-dose computed tomography (LDCT) to inform the US Preventive Services Task Force (USPSTF). Data Sources: MEDLINE, Cochrane Library, and trial registries through May 2019; references; experts; and literature surveillance through November 20, 2020. Study Selection: English-language studies of screening with LDCT, accuracy of LDCT, risk prediction models, or treatment for early-stage lung cancer. Data Extraction and Synthesis: Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings. Data were not pooled because of heterogeneity of populations and screening protocols. Main Outcomes and Measures: Lung cancer incidence, lung cancer mortality, all-cause mortality, test accuracy, and harms. Results: This review included 223 publications. Seven randomized clinical trials (RCTs) (N = 86 486) evaluated lung cancer screening with LDCT; the National Lung Screening Trial (NLST, N = 53 454) and Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON, N = 15 792) were the largest RCTs. Participants were more likely to benefit than the US screening-eligible population (eg, based on life expectancy). The NLST found a reduction in lung cancer mortality (incidence rate ratio [IRR], 0.85 [95% CI, 0.75-0.96]; number needed to screen [NNS] to prevent 1 lung cancer death, 323 over 6.5 years of follow-up) with 3 rounds of annual LDCT screening compared with chest radiograph for high-risk current and former smokers aged 55 to 74 years. NELSON found a reduction in lung cancer mortality (IRR, 0.75 [95% CI, 0.61-0.90]; NNS to prevent 1 lung cancer death of 130 over 10 years of follow-up) with 4 rounds of LDCT screening with increasing intervals compared with no screening for high-risk current and former smokers aged 50 to 74 years. Harms of screening included radiation-induced cancer, false-positive results leading to unnecessary tests and invasive procedures, overdiagnosis, incidental findings, and increases in distress. For every 1000 persons screened in the NLST, false-positive results led to 17 invasive procedures (number needed to harm, 59) and fewer than 1 person having a major complication. Overdiagnosis estimates varied greatly (0%-67% chance that a lung cancer was overdiagnosed). Incidental findings were common, and estimates varied widely (4.4%-40.7% of persons screened). Conclusions and Relevance: Screening high-risk persons with LDCT can reduce lung cancer mortality but also causes false-positive results leading to unnecessary tests and invasive procedures, overdiagnosis, incidental findings, increases in distress, and, rarely, radiation-induced cancers. Most studies reviewed did not use current nodule evaluation protocols, which might reduce false-positive results and invasive procedures for false-positive results.

Tobacco Use and Treatment among Cancer Survivors.

Tobacco use is causally associated with the risk of developing multiple health conditions, including over a dozen types of cancer, and is responsible for 30% of cancer deaths in the U [...].

Assessment of Lung Cancer Screening Program Websites.

Importance: The US Preventive Services Task Force recommends that individuals at high risk for lung cancer consider benefits and harms before pursuing lung cancer screening. Medical centers develop websites for their lung cancer screening programs, but to date little is known about the websites' portrayal of benefits and harms or what next steps they recommend for individuals considering screening. Objective: To assess the presentation of potential benefits and harms and recommended next steps on lung cancer screening program websites. Design, Setting, and Participants: Cross-sectional content analysis of 162 lung cancer screening program websites of academic medical centers (n = 81) and state-matched community medical centers (n = 81) that were randomly selected from American College of Radiology lung cancer screening-designated centers was conducted. The study was performed from December 1, 2018, to January 31, 2019. Main Outcomes and Measures: Website presentation of screening-associated benefits and harms was the primary outcome. Benefit was defined as any description related to the potential reduction in lung cancer mortality. Harms were based on the US Preventive Services Task Force recommendations and included false positives, false negatives, overdiagnosis, radiation exposure, and incidental findings. The secondary outcome was next steps that are recommended by websites. Results: Overall, the 162 lung cancer screening program websites described the potential benefits more frequently than they described any potential harms (159 [98%] vs 78 [48%], P < .01). False-positive findings were the most frequently reported (72 [44%]) potential harm. Community centers were less likely than academic centers to report any potential harm (32 [40%] vs 46 [57%], P = .03), potential harm from radiation (20 [25%] vs 35 [43%], P = .01), and overdiagnosis (0% vs 11 [14%], P < .01). One hundred nineteen websites (73%) did not explicitly recommend that individuals personally consider the potential benefits and harms of screening; community centers were less likely than academic centers to give this recommendation (15 [19%] vs 28 [35%], P = .02). Most institutions (157 [97%]) listed follow-up steps for screening, but few institutions (35 [22%]) recommended that individuals discuss benefits and harms with a health care professional. Conclusions and Relevance: Information on public-facing websites of US lung cancer screening programs appears to lack balance with respect to portrayal of potential benefits and harms of screening. Important harms, such as overdiagnosis, were commonly ignored in the sites evaluated, and most of the centers did not explicitly guide individuals toward a guideline-recommended, shared decision-making discussion of harms and benefits.

Product attributes important to US adult consumers' use of electronic nicotine delivery systems: a discrete choice experiment.

OBJECTIVE: To understand the importance of electronic nicotine delivery systems (ENDS) product attributes to adult consumers in the USA by age and gender. DESIGN: Cross-sectional survey with a discrete choice experiment (best-worst, case 2, scaling) of 19 choice tasks in which participants answered what would make them most want to use and least want to use an ENDS product. SETTING AND PARTICIPANTS: A national sample of adults (aged 18+ years) in the USA who had tried an ENDS product at least once. MEASURES: We included 9 ENDS attributes with levels that varied across 19 choice tasks. We performed a multinomial logistic regression to obtain overall importance scores, attribute-level part-worth utilities and most important attribute. RESULTS: Of 660 participants, 81% were white, 51% women and 37% had at least a 4-year college degree with an average age of 42.0 years (SD ±19.4). The attributes had the following importance: harms of use 17.6%; general effects 14.1%; cessation aid 12.6%; purchase price 12.1%; monthly cost 12.0%; nicotine content 11.4%; flavour availability 8.4%; device design 7.2%; modifiability 4.6%. Harms of use was the most important attribute for all ages and genders (p<0.05); variation in other important attributes existed by age though not by gender. CONCLUSION: This study identified the importance of nine ENDS attributes. Perceived harms of use of ENDS use appeared most important, and modifiability was least important. Variation by consumer group existed, which may allow for targeted interventions to modify ENDS use.

Effects of a Brief Psychosocial Intervention on Inpatient Satisfaction: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Increasing attention is being paid to patients' experience of hospitalization. BATHE (a brief psychosocial intervention that addresses Background, Affect, Trouble, Handling, and Empathy) has been found to improve patients' outpatient experiences but has not yet been studied in inpatient settings. This randomized controlled trial (RCT) examined whether daily administration of BATHE would improve patients' satisfaction with their hospital experience. METHODS: BATHE is a brief psychosocial intervention designed to reduce distress and strengthen the physician-patient relationship. In February through March 2015 and February through March 2016, 25 patients admitted to the University of Virginia Family Medicine inpatient service were randomized to usual care or to the BATHE intervention. Participants completed a baseline measure of satisfaction at enrollment. Those in the intervention group received the BATHE intervention daily for five days or until discharge. At completion, participants completed a patient satisfaction measure. RESULTS: Daily administration of BATHE had strong effects on patients' likelihood of endorsing their medical care as "excellent." BATHE did not improve satisfaction by making patients feel more respected, informed or attended to. Rather, effects on satisfaction were mediated by patients' perception that their physician showed "a genuine interest in me as a person." CONCLUSIONS: Our study suggests that patients are more satisfied with their hospitalization experience when physicians take a daily moment to check in with the patient "as a person" and not just as a medical patient. The brevity of the BATHE intervention indicates that this check-in need not be lengthy or overly burdensome for the already busy inpatient physician.

Genetic diversity and population structure of Trypanosoma brucei in Uganda: implications for the epidemiology of sleeping sickness and Nagana.

BACKGROUND: While Human African Trypanosomiasis (HAT) is in decline on the continent of Africa, the disease still remains a major health problem in Uganda. There are recurrent sporadic outbreaks in the traditionally endemic areas in south-east Uganda, and continued spread to new unaffected areas in central Uganda. We evaluated the evolutionary dynamics underpinning the origin of new foci and the impact of host species on parasite genetic diversity in Uganda. We genotyped 269 Trypanosoma brucei isolates collected from different regions in Uganda and southwestern Kenya at 17 microsatellite loci, and checked for the presence of the SRA gene that confers human infectivity to T. b. rhodesiense. RESULTS: Both Bayesian clustering methods and Discriminant Analysis of Principal Components partition Trypanosoma brucei isolates obtained from Uganda and southwestern Kenya into three distinct genetic clusters. Clusters 1 and 3 include isolates from central and southern Uganda, while cluster 2 contains mostly isolates from southwestern Kenya. These three clusters are not sorted by subspecies designation (T. b. brucei vs T. b. rhodesiense), host or date of collection. The analyses also show evidence of genetic admixture among the three genetic clusters and long-range dispersal, suggesting recent and possibly on-going gene flow between them. CONCLUSIONS: Our results show that the expansion of the disease to the new foci in central Uganda occurred from the northward spread of T. b. rhodesiense (Tbr). They also confirm the emergence of the human infective strains (Tbr) from non-infective T. b. brucei (Tbb) strains of different genetic backgrounds, and the importance of cattle as Tbr reservoir, as confounders that shape the epidemiology of sleeping sickness in the region.

Central lymph node dissection in patients with papillary thyroid cancer: a population level analysis of 14,257 cases.

BACKGROUND: This study analyzes the impact of demographics and tumor size on the use of central compartment lymph node dissection (CLND) for papillary thyroid cancer (PTC) in the United States. METHODS: Adult patients with PTC and the follicular variant of PTC who underwent thyroidectomy with or without CLND and were reported in the Surveillance Epidemiology and End Results (SEER) database from 2004 to 2008 were included. Bivariate and multivariate analyses were performed to determine the effects of demographic and clinical characteristics on the likelihood of a patient undergoing CLND. RESULTS: Of 14,257 patients included, 80.3% were women, 84.3% were white, average age was 50.1 years, and 37.1% had CLND. Over 5 years, there was an 18.3% increase in CLND, with the greatest increase seen in patients with T1 tumors (23.2%). Patients who were older, men, black, and from the South were less likely to undergo CLND; however, there were no differences in the total number of lymph nodes examined based on patient demographics or the year of their thyroid cancer diagnoses. CONCLUSIONS: Being older, black, and from the South are negatively associated with CLND. This practice variation suggests potential disparity in access and quality of surgical care for PTC in the United States.