Effect of the Communities that HEAL intervention on receipt of behavioral therapies for opioid use disorder: A cluster randomized wait-list controlled trial.

BACKGROUND: The U.S. opioid overdose crisis persists. Outpatient behavioral health services (BHS) are essential components of a comprehensive response to opioid use disorder and overdose fatalities. The Helping to End Addiction Long-Term® (HEALing) Communities Study developed the Communities That HEAL (CTH) intervention to reduce opioid overdose deaths in 67 communities in Kentucky, Ohio, New York, and Massachusetts through the implementation of evidence-based practices (EBPs), including BHS. This paper compares the rate of individuals receiving outpatient BHS in Wave 1 intervention communities (n = 34) to waitlisted Wave 2 communities (n = 33). METHODS: Medicaid data included individuals ≥18 years of age receiving any of five BHS categories: intensive outpatient, outpatient, case management, peer support, and case management or peer support. Negative binomial regression models estimated the rate of receiving each BHS for Wave 1 and Wave 2. Effect modification analyses evaluated changes in the effect of the CTH intervention between Wave 1 and Wave 2 by research site, rurality, age, sex, and race/ethnicity. RESULTS: No significant differences were detected between intervention and waitlisted communities in the rate of individuals receiving any of the five BHS categories. None of the interaction effects used to test the effect modification were significant. CONCLUSIONS: Several factors should be considered when interpreting results-no significant intervention effects were observed through Medicaid claims data, the best available data source but limited in terms of capturing individuals reached by the intervention. Also, the 12-month evaluation window may have been too brief to see improved outcomes considering the time required to stand-up BHS. TRIAL REGISTRATION: Clinical Trials.gov http://www. CLINICALTRIALS: gov: Identifier: NCT04111939.

Differences in perceptions of community stigma towards opioid use disorder between community substance use coalition members and the general public.

INTRODUCTION: To examine differences in perceptions about community stigma towards individuals with opioid use disorder (OUD) between community members involved in the opioid response (i.e., coalition members) and the general public, and how community geography may moderate this relationship. METHODS: This study administered identical cross-sectional surveys about perceived community opioid-related stigma to two distinct populations in 66 communities participating in the HEALing Communities Study prior to the intervention period (i.e., coalition members, November 2019-January 2020; residents, March-April 2020). Linear-mixed models compared survey responses of populations, including the moderating effect of community rural/urban location. RESULTS: A total of 826 coalition members and 1131 residents completed the surveys. The study found no differences between the coalition members and residents for general perceived community opioid-related stigma. In both urban and rural communities, coalition members reported greater perceived community stigma than residents reported towards medication for opioid use disorder (MOUD), naloxone, and drug treatment as an alternative to incarceration. CONCLUSION: Our findings suggest similar perceived community opioid-related stigma between coalition members and residents, yet differences emerge related to evidence-based practices (i.e., MOUD, naloxone, and drug treatment as an alternative to incarceration) to reduce opioid overdose deaths. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04111939.

U.S. Women's Knowledge of Reproductive Biology.

BACKGROUND: Having accurate knowledge of reproductive biology can help women to improve their general, sexual, and reproductive health and assert their sexual and reproductive rights. METHODS: This cross-sectional study examined knowledge of three topics (age-related fertility decline, egg supply, fertile period) among a national probability sample of 1,779 nonsterilized, English-speaking women (aged 18-29 years) in the U.S. general population. Using bivariate and multivariable regressions, we assessed associations between knowledge of these topics and individual characteristics. RESULTS: Most respondents were unmarried (63%), childless (78%), and intended to have children (65%); 51% did not know whether they would have difficulty conceiving, and 44% had discussed fertility-related topics with a health care provider. More respondents knew the age of marked fertility decline (62%) than the fertile period (59%) or that ovaries do not continuously produce new eggs (45%); 22% knew all three topics, and 13% knew none. In multivariable analysis, knowledge was positively associated (p < .001) with education, income, and having regular periods. Black and Asian respondents and those for whom religion was very important were less likely (all p values < .01) than White and nonreligious respondents to know all three topics. Knowledge was unrelated to relationship status, parity, childbearing intentions, receipt of fertility-related counseling or services, self-perceived infertility risk, or health status; the relationship with Hispanic ethnicity approached but did not reach significance (p = .08). CONCLUSIONS: Young U.S. women have incomplete knowledge of aspects of their reproductive biology; these knowledge gaps could increase their risk of adverse health and reproductive outcomes. Policy-, provider-, and client-level interventions are warranted to address these knowledge gaps.

Disparities in Cessation Behaviors Between Hispanic and Non-Hispanic White Adult Cigarette Smokers in the United States, 2000-2015.

INTRODUCTION: Hispanic adults make up a growing share of US adult smokers, and smoking is a major preventable cause of disease and death among Hispanic adults. No previous study has compared trends in smoking cessation behaviors among Hispanic adults and non-Hispanic white adults over time. We examined trends in cessation behaviors among Hispanic and non-Hispanic white adult cigarette smokers during 2000-2015. METHODS: Using self-reported data from the National Health Interview Survey, we compared trends in quit attempts, receipt of advice to quit from a health professional, and use of cessation treatment (counseling and/or medication) among Hispanic and non-Hispanic white adult smokers. We also assessed these behaviors among 4 Hispanic subgroups. We conducted analyses in 2018-2019. RESULTS: Past-year quit attempts increased during 2000-2015 among both non-Hispanic white and Hispanic smokers, with no significant differences between these groups. Receiving advice to quit increased significantly among non-Hispanic white adults but did not increase significantly among Hispanic adults. Cessation treatment use increased among both non-Hispanic white and Hispanic adults. Throughout 2000-2015, the prevalence of receiving advice to quit and using cessation treatments was lower among Hispanic adults than non-Hispanic white adults. In 2015, a higher proportion of Hispanic than non-Hispanic white smokers visited a health care provider without receiving advice to quit. CONCLUSION: Hispanic adult smokers are less likely to receive advice to quit and to use proven cessation treatments than non-Hispanic white smokers, and this pattern persisted over time. Culturally competent educational initiatives directed at both providers and Hispanic communities could help eliminate this marked and persistent disparity.

Smoking cessation behaviors among older U.S. adults.

Smoking cessation is a critical component of cancer prevention among older adults (age ≥ 65 years). Understanding smoking cessation behaviors among older adults can inform clinical and community efforts to increase successful cessation. We provide current, national prevalence estimates for smoking cessation behaviors among older adults, including interest in quitting, quitting attempts, quitting successes, receiving advice to quit from a healthcare provider, and use of evidence-based tobacco cessation treatments. The 2015 National Health Interview Survey and Cancer Control Supplement were used to estimate cigarette smoking status and cessation behaviors among older US adults across selected socio-demographic and health characteristics. We found that four in five older adults who had ever smoked cigarettes had quit and more than half who currently smoked were interested in quitting but fewer than half made a past-year quit attempt. Two-thirds of older adults said that a healthcare provider advised them to quit smoking, but just over one-third who tried to quit used evidence-based tobacco cessation treatments and only one in 20 successfully quit in the past year. Prevalence estimates for smoking cessation behaviors were similar across most characteristics. Our study demonstrates that few older adults, across most levels of characteristics examined, successfully quit smoking, underscoring the importance of assisting smoking cessation efforts. Healthcare providers can help older adults quit smoking by offering or referring evidence-based cessation treatments. States and communities can implement population-based interventions including tobacco price increases, comprehensive smoke-free policies, high-impact tobacco education media campaigns, and barrier-free access to evidence-based tobacco cessation counseling and medications.

Cessation Behaviors and Treatment Use Among U.S. Smokers by Insurance Status, 2000-2015.

INTRODUCTION: Variations exist in insurance coverage of smoking-cessation treatments and cigarette smokers' use of these treatments. Recent trends in cessation behaviors by health insurance status have not been reported. This study examines trends in quit attempts, provider advice to quit, and use of cessation counseling and/or medications among adult cigarette smokers by insurance status. Demographic correlates of these cessation behaviors are also identified. METHODS: Data from the 2000-2015 National Health Interview Surveys were used to estimate the prevalence of and trends in past-year quit attempts, receipt of health professional advice to quit, and use of counseling and/or medication among cigarette smokers aged 18-64 years by insurance status (private, Medicaid, or uninsured). Multivariable logistic regression models were used to identify demographic correlates. The analysis was conducted in 2017. RESULTS: Past-year quit attempts increased linearly among all insurance groups (p<0.05), whereas provider advice to quit remained unchanged. Use of cessation treatment increased linearly among smokers with Medicaid (18.1% [95% CI=13.4%, 22.8%] in 2000 to 34.9% [95% CI=28.5%, 40.5%] in 2015, p<0.05), whereas nonlinear increases were observed among those with private insurance (26.2% [95% CI=24.0%, 28.4%] in 2000 to 32.3% [95% CI=29.0%, 35.6%] in 2015; quadratic trend, p<0.05) and uninsured smokers (13.9% [95% CI=11.0%, 16.8%] in 2000 to 21.8% [95% CI=17.1%, 26.5%] in 2015; quadratic trend, p<0.05). Regardless of insurance status, adults aged 18-24 years had lower odds than older adults of receiving advice to quit and using cessation treatments. CONCLUSIONS: Despite increased use of cessation treatments among Medicaid enrollees, disparities by insurance status persist in adult cessation behaviors. Opportunities exist to increase cessation by making comprehensive, barrier-free cessation coverage available to all smokers.

Tobacco Product Use Among Adults - United States, 2017.

Cigarette smoking harms nearly every organ of the body and causes adverse health consequences, including heart disease, stroke, and multiple types of cancer (1). Although cigarette smoking among U.S. adults has declined considerably, tobacco products have evolved in recent years to include various combustible, noncombustible, and electronic products (1,2). To assess recent national estimates of tobacco product use among U.S. adults aged ≥18 years, CDC, the Food and Drug Administration (FDA), and the National Institutes of Health's National Cancer Institute analyzed data from the 2017 National Health Interview Survey (NHIS). In 2017, an estimated 47.4 million U.S. adults (19.3%) currently used any tobacco product, including cigarettes (14.0%; 34.3 million); cigars, cigarillos, or filtered little cigars (3.8%; 9.3 million); electronic cigarettes (e-cigarettes) (2.8%; 6.9 million); smokeless tobacco (2.1%; 5.1 million); and pipes, water pipes, or hookahs (1.0%; 2.6 million). Among current tobacco product users, 86.7% (41.1 million) smoked combustible tobacco products, and 19.0% (9.0 million) used ≥2 tobacco products. By univariate analyses, the prevalence of current use of any tobacco product was higher among males than among females; adults aged <65 years than among those aged ≥65 years; non-Hispanic American Indian/Alaska Natives, whites, blacks, or multiracial adults than among Hispanics or non-Hispanic Asians; adults who lived in the South or Midwest than among those in the West or Northeast; adults who had a general educational development certificate (GED) than among those with other levels of education; adults who earned an annual household income of <$35,000 than among those with those with higher income; lesbian, gay, or bisexual adults than among heterosexual/straight adults; and adults who were divorced/separated/widowed or single/never married/not living with a partner than among those who were married/living with a partner. Prevalence was also higher among those who were uninsured, insured by Medicaid, or had some other public insurance than among those with private insurance or Medicare only; those who had a disability/limitation than among those who did not; and those who had serious psychological distress than among those who did not. Full implementation of evidence-based tobacco control interventions that address the diversity of tobacco products used by U.S. adults, in coordination with regulation of tobacco product manufacturing, marketing, and sales, can reduce tobacco-related disease and death in the United States (1-3).

Quitting Smoking Among Adults - United States, 2000-2015.

Quitting cigarette smoking benefits smokers at any age (1). Individual, group, and telephone counseling and seven Food and Drug Administration-approved medications increase quit rates (1-3). To assess progress toward the Healthy People 2020 objectives of increasing the proportion of U.S. adults who attempt to quit smoking cigarettes to ≥80.0% (TU-4.1), and increasing recent smoking cessation success to ≥8.0% (TU-5.1),* CDC assessed national estimates of cessation behaviors among adults aged ≥18 years using data from the 2000, 2005, 2010, and 2015 National Health Interview Surveys (NHIS). During 2015, 68.0% of adult smokers wanted to stop smoking, 55.4% made a past-year quit attempt, 7.4% recently quit smoking, 57.2% had been advised by a health professional to quit, and 31.2% used cessation counseling and/or medication when trying to quit. During 2000-2015, increases occurred in the proportion of smokers who reported a past-year quit attempt, recently quit smoking, were advised to quit by a health professional, and used cessation counseling and/or medication (p<0.05). Throughout this period, fewer than one third of persons used evidence-based cessation methods when trying to quit smoking. As of 2015, 59.1% of adults who had ever smoked had quit. To further increase cessation, health care providers can consistently identify smokers, advise them to quit, and offer them cessation treatments (2-4). In addition, health insurers can increase cessation by covering and promoting evidence-based cessation treatments and removing barriers to treatment access (2,4-6).

State Medicaid Expansion Tobacco Cessation Coverage and Number of Adult Smokers Enrolled in Expansion Coverage - United States, 2016.

In 2015, 27.8% of adult Medicaid enrollees were current cigarette smokers, compared with 11.1% of adults with private health insurance, placing Medicaid enrollees at increased risk for smoking-related disease and death (1). In addition, smoking-related diseases are a major contributor to Medicaid costs, accounting for about 15% (>$39 billion) of annual Medicaid spending during 2006-2010 (2). Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)-approved medications are effective treatments for helping tobacco users quit (3). Insurance coverage for tobacco cessation treatments is associated with increased quit attempts, use of cessation treatments, and successful smoking cessation (3); this coverage has the potential to reduce Medicaid costs (4). However, barriers such as requiring copayments and prior authorization for treatment can impede access to cessation treatments (3,5). As of July 1, 2016, 32 states (including the District of Columbia) have expanded Medicaid eligibility through the Patient Protection and Affordable Care Act (ACA),*,† which has increased access to health care services, including cessation treatments (5). CDC used data from the Centers for Medicare and Medicaid Services (CMS) Medicaid Budget and Expenditure System (MBES) and the Behavioral Risk Factor Surveillance System (BRFSS) to estimate the number of adult smokers enrolled in Medicaid expansion coverage. To assess cessation coverage among Medicaid expansion enrollees, the American Lung Association collected data on coverage of, and barriers to accessing, evidence-based cessation treatments. As of December 2015, approximately 2.3 million adult smokers were newly enrolled in Medicaid because of Medicaid expansion. As of July 1, 2016, all 32 states that have expanded Medicaid eligibility under ACA covered some cessation treatments for all Medicaid expansion enrollees, with nine states covering all nine cessation treatments for all Medicaid expansion enrollees. All 32 states imposed one or more barriers on at least one cessation treatment for at least some enrollees. Providing barrier-free access to cessation treatments and promoting their use can increase use of these treatments and reduce smoking and smoking-related disease, death, and health care costs among Medicaid enrollees (4,6-8).

Trends in the Average Age of Quitting Among U.S. Adult Cigarette Smokers.

INTRODUCTION: Quitting smoking at any age confers health benefits. However, studies have suggested that quitting by age 35 years leads to mortality rates similar to never smokers. This study assessed whether the mean and median ages of past-year quitting and prevalence of past-year quit attempts and successful quitting by age group changed over time. METHODS: Data came from 113,599 adult cigarette smokers participating in the 1997-2012 National Health Interview Survey, an annual, cross-sectional household survey of U.S. adults aged ≥18 years. Mean and median ages of past-year successful abstinence (quit 6-12 months) were computed. Orthogonal polynomial logistic regression models tested for trends in quit attempts and successful quitting. Data were analyzed in 2014. RESULTS: The average age of quitting (40.0 years in 1997-1998, 39.5 years in 2011-2012, p=0.80) and median age of quitting (35.9 years in 1997-1998, 36.9 years in 2011-2012, p=0.62) did not change over time. During 1997-2012, the percentage of smokers making a past-year quit attempt increased among those aged 25-34, 35-44, and 45-64 years; the percentage of smokers who reported quitting successfully increased among those aged 25-34 and 35-44 years (p<0.001). CONCLUSIONS: Although the average age of quitting did not change over time, increases in past-year quit attempts and successful quitting occurred among adults aged 25-44 years. Proven population-level interventions--including price increases, mass media campaigns, comprehensive smoke-free policies, and health systems interventions--should be continued to further increase cessation, particularly among younger adults.

Relapse among cigarette smokers: the CARDIA longitudinal study - 1985-2011.

RATIONALE: There is little information about long-term relapse patterns for cigarette smokers. OBJECTIVE: To describe long-term prevalence of relapse and related smoking patterns by sex, race, age, and education level among a community-based cohort of young adults followed for 25 years. METHODS: We examined 25 years of data from Coronary Artery Risk Development in Young Adults (CARDIA), an ongoing study of a community-based cohort of 5115 men and women aged 18 to 30 years at baseline with periodic re-examinations. At each examination smoking, quitting, and relapse were queried. We examined prevalence of smoking relapse among 3603 participants who attended at least 6 of the 8 examinations. RESULTS: About 53% of 3603 participants never reported smoking on a regular basis. Among the remaining 1682 ever smokers, 52.8% of those who reported current smoking at baseline were still smoking by the end of the study, compared to 10.7% of those who initiated smoking by year 5. Among those classified as former smokers at baseline, 39% relapsed at least once; of these, 69.5% had quit again by the end of the study. Maximum education level attained, age at study baseline, and race were associated with failure to quit smoking by the end of the study and relapse among those who did quit. Maximum education level attained and age at study baseline were also associated with ability to successfully quit after a relapse. CONCLUSIONS: Smoking relapse after quitting is common, especially in those with lower education level. Education was the strongest predictor of all three outcomes. Improvements in access to treatment and treatment options, especially for underserved populations, are needed to prevent relapse when smokers quit.

Quit attempt correlates among smokers by race/ethnicity.

INTRODUCTION: Cigarette smoking is the leading preventable cause of premature deaths in the U.S., accounting for approximately 443,000 deaths annually. Although smoking prevalence in recent decades has declined substantially among all racial/ethnic groups, disparities in smoking-related behaviors among racial/ethnic groups continue to exist. Two of the goals of Healthy People 2020 are to reduce smoking prevalence among adults to 12% or less and to increase smoking cessation attempts by adult smokers from 41% to 80%. Our study assesses whether correlates of quit attempts vary by race/ethnicity among adult (≥ 18 years) smokers in the U.S. Understanding racial/ethnic differences in how both internal and external factors affect quit attempts is important for targeting smoking-cessation interventions to decrease tobacco-use disparities. METHODS: We used 2003 Tobacco Use Supplement to the Current Population Survey (CPS) data from 16,213 adults to examine whether the relationship between demographic characteristics, smoking behaviors, smoking policies and having made a quit attempt in the past year varied by race/ethnicity. RESULTS: Hispanics and persons of multiple races were more likely to have made a quit attempt than whites. Overall, younger individuals and those with >high school education, who smoked fewer cigarettes per day and had smoked for fewer years were more likely to have made a quit attempt. Having a smoke-free home, receiving a doctor's advice to quit, smoking menthol cigarettes and having a greater time to when you smoked your first cigarette of the day were also associated with having made a quit attempt. The relationship between these four variables and quit attempts varied by race/ethnicity; most notably receiving a doctor's advice was not related to quit attempts among Asian American/Pacific Islanders and menthol use among whites was associated with a lower prevalence of quit attempts while black menthol users were more likely to have made a quit attempt than white non-menthol users. CONCLUSIONS: Most correlates of quit attempts were similar across all racial/ethnic groups. Therefore population-based comprehensive tobacco control programs that increase quit attempts and successful cessation among all racial/ethnic groups should be continued and expanded. Additional strategies may be needed to encourage quit attempts among less educated, older, and more addicted smokers.

Menthol cigarette use among racial and ethnic groups in the United States, 2004-2008.

INTRODUCTION: Understanding the patterns of menthol cigarette use can be useful in developing and justifying policies designed to prevent and reduce cigarette use and exposure to tobacco smoke. This report provides an update and summary of the demographic distribution and trends of menthol cigarette use in the United States. METHODS: Data from the 2004-2008 National Survey on Drug Use and Health were analyzed to estimate menthol cigarette use among current smokers by race/ethnicity, sex, and age (12 years and older). A t-test was used to compare estimates for menthol and nonmenthol use by demographic group. Trend analyses were conducted to examine differences in menthol cigarette use by race/ethnicity and age from 2004 to 2008. RESULTS: Over half of menthol cigarette smokers were female (52.2%), and approximately 29.4% of all menthol smokers were Black, which was almost 10 times the percentage of nonmenthol smokers who were Black (3.0%, p < .01). Prevalence of past month menthol cigarette use was highest among current smokers aged 12-17 years (44.7%) and decreased as age group increased. From 2004 to 2008, menthol cigarette use increased significantly among White smokers aged 12-17 years (from 40.3% in 2004 to 46.0% in 2008, p < .01). Menthol cigarette use among young adult smokers aged 18-25 years increased for Hispanics (from 33.9% in 2004 to 42.4% in 2008, p < .01) and Whites (from 26.7% to 32.5%, p < .01). CONCLUSIONS: Demographic disparities in menthol cigarette use persist in the United States. Continued monitoring and improvement of existing surveillance systems to identify patterns and trends in menthol cigarette use are needed.

Monitoring polytobacco use among adolescents: do cigarette smokers use other forms of tobacco?

The extent of concurrent use of cigarettes and one or more other tobacco products (polytobacco use) is important to explore because users may be at an increased risk for adverse health effects and nicotine dependency. We determined national population estimates of current cigarette and current polytobacco use for at least 50,000 students from the 2002 and 2004 National Youth Tobacco Surveys. We identified which tobacco products were most often used in conjunction with cigarettes and used multivariate analyses to identify factors associated with polytobacco use. The overall prevalence was 16.0% for current cigarette smoking among all respondents and 15.0% for current cigarette smoking among respondents with complete information on concurrent cigarette and other tobacco product use: 8.1% used cigarettes only, and 6.9% were polytobacco users. Among current male cigarette smokers, 62.0% used other tobacco products; among current female cigarette smokers, 30.9% did. Among current cigarette smokers using one other tobacco product, cigars or smokeless tobacco were the most frequently used products. In multivariate analysis, polytobacco use was associated with being male; being in middle school; residing in the Midwest, South, or West; being able to obtain cigarettes from a retailer; being subject to peer influence; having favorable beliefs about tobacco; being willing to use tobacco promotional items; being exposed to tobacco advertisements; and having higher levels of lost autonomy (an indicator of nicotine dependency). Youth interventions need to broaden their focus to address the use of all tobacco products, paying particular attention to adolescent males and youth living outside of the Northeast.

Long-term trends in adolescent and young adult smoking in the United States: metapatterns and implications.

OBJECTIVES: We sought to describe long-term adolescent and young adult smoking trends and patterns. METHODS: We analyzed adolescent data from Monitoring the Future, 1976 to 2005, and young adult (aged 18-24 years) data from the National Health Interview Survey, 1974 to 2005, overall and in subpopulations to identify trends in current cigarette smoking prevalence. RESULTS: Five metapatterns emerged: we found (1) a large increase and subsequent decrease in overall smoking over the past 15 years, (2) a steep decline in smoking among Blacks through the early 1990s, (3) a gender gap reversal among older adolescents and young adults who smoked over the past 15 years, (4) similar trends in smoking for most subgroups since the early 1990s, and (5) a large decline in smoking among young adults with less than a high school education. CONCLUSIONS: Long-term patterns for adolescent and young adult cigarette smoking were decidedly nonlinear, and we found evidence of a cohort effect among young adults. Continued strong efforts and a long-term societal commitment to tobacco use prevention are needed, given the unprecedented declines in smoking among most subpopulations since the mid- to late 1990s.