Collaborative care psychiatrists' views on treating bipolar disorder in primary care: a qualitative study.

OBJECTIVE: To understand collaborative care psychiatric consultants' views and practices on making the diagnosis of and recommending treatment for bipolar disorder in primary care using collaborative care. METHOD: We conducted a focus group at the University of Washington in December 2013 with nine psychiatric consultants working in primary-care-based collaborative care in Washington State. A grounded theory approach with open coding and the constant comparative method revealed categories where emergent themes were saturated and validated through member checking, and a conceptual model was developed. RESULTS: Three major themes emerged from the data including the importance of working as a collaborative care team, the strengths of collaborative care for treating bipolar disorder and the need for psychiatric consultants to adapt specialty psychiatric clinical skills to the primary care setting. Other discussion topics included gathering clinical data from multiple sources over time, balancing risks and benefits of treating patients indirectly, tracking patient care outcomes with a registry and effective care. CONCLUSION: Experienced psychiatric consultants working in collaborative care teams provided their perceptions regarding treating patients with bipolar illness including identifying ways to adapt specialty psychiatric skills, developing techniques for providing team-based care and perceiving the care delivered through collaborative care as high quality.

Tobacco use treatment in primary care patients with psychiatric illness.

The prevalence of smoking is higher in patients with psychiatric illness compared with the general population. Smoking causes chronic illnesses, which lead to premature mortality in those with psychiatric illness, is associated with greater burden of psychiatric symptoms, and contributes to the social isolation experienced by individuals with psychiatric disorders. Most patients with a psychiatric illness present initially to primary care rather than specialty care settings, and some patients receive care exclusively in the primary care setting. Therefore, family physicians and other primary care clinicians have an important role in the recognition and treatment of tobacco use disorders in patients with psychiatric illnesses. In this article we review common myths associated with smoking and psychiatric illness, techniques for implementing evidence-based tobacco use treatments, the evidence base for tobacco use treatment for patients with specific psychiatric diagnoses, and factors to consider when treating tobacco use disorders in patients with psychiatric illness.

Effect of nicotine replacement therapy on quitting by young adults in a trial comparing cessation services.

CONTEXT: Young adult smokers have the highest smoking prevalence among all US age groups but are least likely to use evidence-based cessation counseling or medication to quit. OBJECTIVE: Use and effectiveness of nicotine patch were explored in a randomized trial evaluating smoking cessation interventions with this population. PARTICIPANTS: Smokers aged 18 to 30 (n = 3094) were recruited through online and off-line methods and from telephone quit lines and analyzed. DESIGN: Smokers were enrolled in a pretest-posttest trial, and randomized to 1 of 3 cessation services. SETTING: Trial delivering counseling services by self-help booklet, telephone quit lines, or online expert system in the 48 continental United States. INTERVENTION: Smokers could request a free 2-week course of nicotine replacement therapy (NRT) patches from the project. MAIN OUTCOME MEASURE: Follow-up surveys at 12 and 26 weeks assessed smoking abstinence, use of NRT, counseling, and other cessation medications, and smoking-related variables. RESULTS: Overall, 69.0% of smokers reported using NRT (M = 3.2 weeks) at 12 weeks and 74.8% (M = 3.3 weeks) at 26 weeks. More smokers who were sent the free nicotine patches (n = 1695; 54.8%) reported using NRT than those who did not receive them (12 weeks: 84.3% vs 41.9%, P < .001; 26 weeks: 87.6% vs 51.1%, P < .001). The use of NRT was associated with greater smoking abstinence at 12 weeks (P < .001) and 26 weeks (P < .05), especially if used for more than 2 weeks (P < .001). Smokers assigned to a self-help booklet or cessation Web site and heavier smokers were most likely to use NRT (P < .05), whereas those reporting marijuana use and binge drinking used NRT less (P < .05). CONCLUSIONS: Many young adults were willing to try NRT, and it appeared to help them quit in the context of community-based cessation services. Strategies should be developed to make NRT available to this age group and support them in using it to prevent lifelong smoking.

Health professional advice for smoking and weight in adults with and without diabetes: findings from BRFSS.

Health risk behaviors including smoking and weight-gain can cause and exacerbate chronic diseases like diabetes. Brief provider advice is an effective intervention to reduce risk from these behaviors. However, behavioral advice is provided more often to those who already have a chronic illness when compared with those who are at risk. The purpose of this study is to determine whether the frequency of provider advice for smoking cessation and weight loss varies between overweight or obese smokers with and without diabetes. BRFSS data from a subset of overweight and obese smokers with (n = 848) and without (n = 6,279) diabetes were analyzed to determine differences in reported provider advice. Overweight and obese smokers with diabetes reported receiving more advice for both weight (46.4% vs. 23.4%, P < 0.001) and smoking (84.5% vs. 72.8%, P < 0.001) compared to those without diabetes. Advice for smoking cessation was reported two to three times more often than advice for weight. Nearly a quarter of those with diabetes and almost half of those without reported no receipt of advice about weight. Results indicate that providers are not adequately addressing overweight and obesity in patients with and at risk for diabetes.

Association of maternal smoking during pregnancy with infant hospitalization and mortality due to infectious diseases.

BACKGROUND: Maternal smoking is associated with infant respiratory infections and with increased risk of low birth weight infants and preterm birth. This study assesses the association of maternal smoking during pregnancy with both respiratory and nonrespiratory infectious disease (ID) morbidity and mortality in infants. METHODS: We conducted 2 retrospective case-control analyses of infants born in Washington State from 1987 to 2004 using linked birth certificate, death certificate and hospital discharge records. One assessed morbidity--infants hospitalized due to IDs within 1 year of birth (47,404 cases/48,233 controls). The second assessed mortality--infants who died within 1 year due to IDs (627 cases/2730 controls). RESULTS: Maternal smoking was associated with both hospitalization (adjusted odds ratio [AOR] = 1.52; 95% confidence interval [CI]: 1.46, 1.58) and mortality (AOR = 1.51; 95% CI: 1.17, 1.96) due to any ID. In subgroup analyses, maternal smoking was associated with hospitalization due to a broad range of IDs including both respiratory (AOR = 1.69; 95% CI: 1.63, 1.76) and nonrespiratory IDs (AOR = 1.27; 95% CI: 1.20, 1.34). Further stratification by birth weight and gestational age did not appreciably change these estimates. In contrast, there was no association of maternal smoking with ID infant mortality when only low birth weight infants were considered. CONCLUSIONS: Maternal smoking was associated with a broad range of both respiratory and nonrespiratory ID outcomes. Despite attenuation of the mortality association among low birth weight infants, ID hospitalization was found to be independent of both birth weight and gestational age. These findings suggest that full-term infants of normal weight whose mothers smoked may suffer an increased risk of serious ID morbidity and mortality.

Comparison of 4 recruiting strategies in a smoking cessation trial.

OBJECTIVES: To compare 4 online and off-line recruiting methods. METHODS: Young adult smokers (n=3353) were recruited to a trial comparing smoking cessation services with an online health risk assessment (HRA), online ads, offline materials, and quit-line screening. RESULTS: Online ads (n=1426; $41.35) and off-line materials recruited the most smokers (n=1341; $56.23) for the lowest cost. Quitline screening was more expensive (n=189; $132.22), but enrollees used cessation services the most (34%-82%). Online HRA was least successful and most costly (n=397; $630.85) but had the highest follow-up (45%-55%). CONCLUSIONS: Online ads and off-line materials were most effective and cost-effective methods.

Personalized medicine and tobacco-related health disparities: is there a role for genetics?

Genetic testing has been proposed as a means to increase smoking cessation rates and thus reduce smoking prevalence. To understand how that might be practically possible, with appreciation of the current social context of tobacco use and dependence, we performed a contextual analysis of smoking-related genetics and smoking cessation. To provide added value, genetics would need to inform and improve existing interventions for smokers (including behavioral and pharmacological treatments). Pharmacogenetics offers the most promising potential, because it may improve the efficacy of medication-based smoking cessations strategies. All proven interventions for treating tobacco dependence, however, including simple cost-effective measures, such as quit lines and physician counseling, are underutilized. As tobacco use occurs disproportionately among disadvantaged populations, efforts to improve smokers' access to health care, and to the tools that are known to help them quit, represent the most promising approaches for reducing smoking prevalence within these groups. Similar considerations apply to other chronic diseases contributing to population-level health disparities. We conclude that although genetics offers increasing opportunities to tailor drug treatment, and may in some cases provide useful risk prediction, other methods of personalizing care are likely to yield greater benefit to populations experiencing health disparities related to tobacco use.

Cigarette smoking and outcomes after allogeneic hematopoietic stem cell transplantation.

Abnormal lung function is a known risk factor for poor outcomes in the allogeneic hematopoietic stem cell transplantation (HSCT) population, although the specific causes of these abnormalities have not been well explored. There is limited data on the effect of cigarette smoking on transplantation outcomes. We conducted a retrospective observational cohort study of 845 consecutive patients age ≥ 18 years who underwent allogeneic HSCT at the Seattle Cancer Care Alliance/Fred Hutchinson Cancer Research Center. Smoking exposure was defined by quit time, smoking status (never, former, and current), and log(2)-transformed pack-years. The main outcomes were time to respiratory failure within 100 days of transplantation, relapse, and nonrelapse mortality. In multivariable analyses, a 2-fold increase in pack-years smoked was associated with an increased risk of early respiratory failure (hazard ratio [HR] 1.33, 95% confidence interval [CI] 1.09 to 1.64, P = .006). This association was observed independent of pretransplantation lung function. A 2-fold increase in pack-years smoked was associated with an increased risk of relapse, but this finding was not statistically significant (HR 1.16, 95% CI 0.92-1.46, P = .21). An association was not observed between cigarette smoking and nonrelapse mortality. Cigarette smoking is associated with an increased risk of respiratory failure and relapse within 100 days of allogeneic HSCT. The association with respiratory failure is mediated in part by abnormal lung function before transplantation and likely through other mechanisms as well. Given the adverse effects associated with cigarette smoking before transplantation, future studies should focus on obtaining accurate smoking histories, tracking prospective changes in smoking status, and assessing the benefits of tobacco cessation on outcomes in this population.

Inside the physician's black bag: critical ingredients of brief alcohol interventions.

Brief primary care interventions structured around patient workbooks have been shown to be effective in modifying hazardous drinking behavior. However, the critical ingredients of such interventions are not well understood, possibly contributing to their underutilization. Seventeen campus-based clinicians trained in a brief, workbook-based alcohol intervention participated in a qualitative study to identify the most promising clinician-patient interaction components within this shared approach, utilizing a focus group with the clinicians and ranking of the 24 workbook ingredients. Based on the clinicians' collective experience, consensus emerged around the perceived strength of 5 main components: (1) providing a summary of the patient's drinking level, (2) discussing drinking likes and dislikes, (3) discussing life goals, (4) encouraging a risk-reduction agreement, and (5) asking patients to track their drinking (on cards provided for this purpose). This is the first paper to examine primary care physician perspectives on potentially critical components of effective brief alcohol intervention.

Cigarette smoking and associated health risks among students at five universities.

INTRODUCTION: While most college students and other young adults who smoke fall into the light and intermittent smoking (LITS) category, they remain at risk for tobacco dependence and other adverse health effects from their smoking. This study examines smoking patterns, tobacco dependence, and other health variables among students at five universities to better understand how to identify and address tobacco use and related risks in a college health clinic setting. METHODS: A health screening survey was completed by 2,091 college and graduate student volunteers seeking routine care at their university health centers or participating in a health class. Independent health variables were analyzed descriptively and in regression analyses with three levels of smoking (none, non-daily, and daily) and tobacco dependence to determine predictors and associated risks. RESULTS: Nearly a quarter of students reported any current smoking, 41% of whom reported smoking less than 1 cigarette/day (cpd). Of the daily smokers, 80% smoked less than 10 cpd but 45% met criteria for tobacco dependence. Any smoking was associated with high-risk alcohol use, risky driving, relational abuse, depression, less exercise, and utilization of emergency and mental health services. In regression analyses, students who experienced depression had more than double the odds of being dependent smokers (odds ratio [OR] = 2.32), as did those who reported abuse (OR = 2.07) or sought mental health counseling (OR = 2.09). DISCUSSION: Student health providers should be alerted to the multiple risks and comorbidities that occur among all smokers, including LITS, and intervene concurrently to help prevent or mitigate adverse outcomes that result from these conditions and behaviors.

Impact of symptoms experienced by varenicline users on tobacco treatment in a real world setting.

This article examines reported symptoms, nonsmoking rates, and medication use among 1,018 smokers using varenicline in a randomized trial comparing three forms of behavioral support for smoking cessation (phone, Web, or phone + Web). One month after beginning varenicline, 168 people (17%) had discontinued the medication. Most (53%) quit due to side effects and other symptoms. The most common side effect among all users was nausea (reported by 57% of users). At 1 month post medication initiation, those not taking varenicline were more likely to report smoking than those who continued the medication (57% vs. 16%, p < .001). Women reported more symptoms but did not discontinue medication at higher rates. Participants who received any telephone counseling (n = 681) were less likely to discontinue their medication than those with Web support only (15% vs. 21%, p < .01). Counseling may improve tolerance of this medication and reduce the rate of discontinuation due to side effects.

A qualitative study of attitudes, beliefs, and practices among 40 undergraduate smokers.

OBJECTIVE: Because little is known about college-age smokers, the authors conducted a qualitative study to better understand this population. PARTICIPANTS: Forty college student smokers from 12 Pacific Northwest colleges participated in the study. METHODS: The authors identified themes and built models to ascertain important factors related to smoking and smoking cessation. Four models emerged: smoking facilitators, smoking barriers, cessation facilitators, and cessation barriers. RESULTS: The authors observed physical, psychological, and social influences across models, and social influences were strongly associated with both smoking and cessation. Many smokers were unlikely to define themselves as regular smokers. Most smokers had made prior quit attempts. CONCLUSIONS: College students are a unique category of smoker and colleges can play a role in helping them achieve cessation.

Prevalence and characteristics of smokers at 30 Pacific Northwest colleges and universities.

College is an important transition period during which young adults explore tobacco use. Few large-scale studies have been conducted among college students regarding tobacco use. We initiated a study examining tobacco use in 30 colleges and universities in the Pacific Northwest. We conducted a baseline survey among students. Sample size varied by the school size; for the 14 largest schools, we drew a random sample of all students, oversampling freshmen (n approximately 750) so that we could recruit and follow a cohort to assess smoking onset during the college years. Of the remaining students, we sampled equivalent numbers of sophomores, juniors, and seniors (n = 200 each). For the 16 schools with fewer than 1,350 students, we surveyed all students. We found overall smoking rates of 17.2%. Males (18.6%) were more likely to smoke than females (16.6%; p = .03), and public college students were more likely to smoke (20.5%) than those who attended private independent schools (18.9%; p = .61), whose rates were higher than those of private religious schools (11.6%; p = .001). Overall, college students are light smokers who do not smoke every day of the month. Further, they tend not to be highly dependent on tobacco, do not consider themselves regular smokers, and plan to quit before they graduate (56.8%). School type should be considered when estimating smoking rates among 4-year college students. Data indicate that college smokers wish and plan to quit before graduation, suggesting that efforts to assist smokers in quitting during the college years may be fruitful.

The tobacco industry's response to the COMMIT Trial: an analysis of legacy tobacco documents.

We analyzed internal tobacco industry documents that describe the industry's response to the Community Intervention Trial for Smoking Cessation (COMMIT), a multi-center community-based tobacco intervention project funded by the National Cancer Institute from 1988 to 1992. Our analysis of documents from the Legacy Tobacco Documents Library (www.legacy.library.ucsf.edu) suggests that the tobacco industry reacted to COMMIT by (1) closely monitoring trial activities, (2) confronting COMMIT in communities where it was most active, (3) distorting COMMIT findings on underage smoking data reported in the media, and (4) using COMMIT activities as practice to strengthen their attack against the subsequent ASSIST trial, falsely accusing both studies of illegal political lobbying with taxpayers' money. The tobacco industry closely monitored COMMIT activities and organized local responses to findings and activities perceived as threatening to the industry's public image or interests. Although we could not document a concerted attack by the tobacco industry that impacted the results of the COMMIT trial, data suggest that the industry used COMMIT as a learning opportunity to mount a well orchestrated and potentially damaging response to the larger American Stop Smoking Intervention Study for Cancer Prevention Trial.

Building an academic tobacco control program while forging links with practice: the University of Washington Tobacco Studies Program.

Despite the tremendous impact that tobacco use and tobacco smoke exposure have on morbidity, mortality, and health disparities, few schools of public health in the U.S. offer courses of study on tobacco control or make it a priority in their curricula. An academic concentration in tobacco studies and a master's-level scholarship program were developed at the University of Washington School of Public Health and Community Medicine to support and encourage students to pursue tobacco-related coursework, seminars, internships, and thesis work. This article discusses the goals, strategies, and accomplishments of the programs, emphasizing a collaborative approach between the university and state and local health departments, nongovernmental agencies, and research organizations as instrumental to the program's success and ultimate continuation.

A case-based clinician training program for treating tobacco use in college students.

Tobacco use rates are high among college students, and while many of them try to quit every year, only a small percentage are successful at maintaining abstinence. Most colleges have campus health centers that offer treatment for tobacco cessation, but few students access these resources. Little is known about how to motivate young adult college students to seek treatment or assist them in their attempts to quit smoking. In the context of a comprehensive, group-randomized intervention study to decrease smoking among college students, a case-based tobacco cessation training program for campus health center providers and staff was developed and conducted at 14 intervention colleges during the 2003-2004 academic year. Six case studies were created for this training, using responses from 39 student elicitation interviews conducted at 12 colleges in Spring 2002. Common themes relating to smoking, quitting, and relapse experiences reported by students in the elicitation interviews were woven into the cases and integrated into the training program.

US public universities' compliance with recommended tobacco-control policies.

To address the rise in tobacco use among college students, several national health organizations, including the American College Health Association, recommend that colleges enact smoking bans in and around all campus buildings, including student housing, and prohibit the sale, advertisement, and promotion of tobacco products on campus. Key informants at 50 US public universities, one from each state, were interviewed during the 2001/2002 academic year to assess the prevalence of these recommended policies. More than half (54%) of the colleges banned smoking in all campus buildings and student residences, 68% had no tobacco sales on campus, and 32% of the schools' newspapers did not accept tobacco advertising. Regional differences in adoption of these campus tobacco-control policies were present. Although this national sample of public universities had implemented some of the recommended policies, they must take further actions to comply fully with campus tobacco-control guidelines.