Randomised trial of two nicotine patch protocols distributed through a state quitline.

BACKGROUND: Most telephone quitlines provide free nicotine replacement therapy (NRT). An 8-week course is recommended, but few users complete it. Information is needed to help quitlines distribute NRT cost-effectively. DESIGN: Randomised two-group trial. SETTING/PARTICIPANTS: Colorado QuitLine callers who smoked 16-20 cigarettes per day at enrolment and who were eligible for and agreed to receive free NRT. INTERVENTION: Provision of 4-week versus 8-week NRT supply; the 8-week supply was shipped in halves and required participants to request the second half (split-shipment protocol). Enrolment occurred during March 2010-February 2011, follow-up concluded in November 2011, and analysis was performed in 2012. MAIN OUTCOME MEASURES: Point abstinence (7 and 30 day) and prolonged abstinence (6 month) from tobacco use. RESULTS: Overall, 1495 study participants were enrolled and 57.7% completed follow-up. Abstinence rates did not differ significantly between study conditions: 13.8% versus 12.4% in 4-week versus 8-week arms, respectively, (30-day point abstinence, non-respondents treated as smokers). NRT duration was similar in both groups, due in part to purchase of additional patches in the 4-week group. About one-third of the 8-week group requested the full 8-week supply and had higher abstinence rates. Cost per quit was lower in the 4-week (compared to 8-week) group. CONCLUSIONS: A randomised trial did not find worse cessation outcomes among quitline users who received half the minimum recommended course of NRT, but offering the full recommended course using a split-shipment protocol may be reasonably cost-effective and supportive of NRT adherers. TRIAL REGISTRATION NUMBER: NCT01889771.

Community characteristics associated with smokefree park policies in the United States.

INTRODUCTION: Outdoor smokefree (SF) policies have the potential to decrease secondhand smoke exposure and denormalize smoking. In order to inform dissemination and evaluation of this emergent tobacco control strategy, this study examined the prevalence of SF park policies in the United States and the community-level characteristics associated with enactment of such policies. METHODS: Counties with existing SF park policies in one or more jurisdictions were identified using passive surveillance data from the American Nonsmokers' Rights Foundation (ANR). ANR data were validated in a random subsample of counties. County-level characteristics were obtained from public data sources and included population demographics, socioeconomic status (SES), urbanicity, and voter affiliation. State-level tobacco control variables included presence of indoor SF policies and adult smoking prevalence. General estimating equations were used to identify predictors of having a SF park policy while accounting for clustering of counties within states. RESULTS: Eleven percent (n = 355) of counties in the United States (n = 3,143) had at least 1 jurisdiction with a SF park policy. The odds of a county having a SF park policy decreased as the percentage of older residents, recent movers, and smokers increased, and the odds increased as the percentage of Democratic voters increased. Odds were higher for counties with higher SES versus low-SES counties and urban/suburban versus rural counties. CONCLUSIONS: SF park policies are currently limited to relatively few jurisdictions, and there is evidence of disparities in adoption of these policies. Public health practitioners should focus promotion of SF park policies on low-SES communities with children and youth and rural areas.

Associations between self-reported in-home smoking behaviours and surface nicotine concentrations in multiunit subsidised housing.

INTRODUCTION: Smoke-free policies are being increasingly promoted and adopted in subsidised multiunit housing to address disparities in residential secondhand smoke exposure. In order to inform the planning and evaluation of these policies, this study examined associations between self-reported in-home smoking and surface nicotine concentrations. METHODS: A face-to-face, cross-sectional survey was conducted from August to October 2011 with leaseholders in a probability sample of private subsidised housing units in Columbus, Ohio, without an existing smoke-free housing policy (n=301, 64% response rate). After the survey, a wipe sample was collected from a wood surface in the living room to measure surface nicotine concentrations (n=279). RESULTS: In-home smoking was reported by 56.6% of respondents. Geometric mean surface nicotine concentrations differed between non-smoking and smoking homes (11.4 vs 90.9 µg/m(2); p<0.001), and between homes with complete, partial and no voluntary home smoking restrictions (8.9 vs 56.3 vs 145.6 µg/m(2); p<0.001). Surface nicotine concentrations were moderately correlated (r=.52) with the total number of cigarettes smoked indoors per week. Smoking behaviours of respondents, other household members and visitors, and length of stay were independently associated with surface nicotine concentrations in a multivariable model, explaining 52% of the variance. CONCLUSIONS: Surface nicotine concentrations were significantly associated with a range of self-reported in-home smoking behaviours. This measure should be considered for evaluating changes in in-home smoking behaviours after implementation of smoke-free policies by subsidised housing providers. More research is needed about how surface nicotine concentrations differ over space, time and various indoor surfaces.

Individual, social, and environmental factors associated with support for smoke-free housing policies among subsidized multiunit housing tenants.

INTRODUCTION: Mandatory smoke-free policies in subsidized, multiunit housing (MUH) may decrease secondhand smoke exposure in households with the highest rates of exposure. Ideally, policies should be based on a strong understanding of factors affecting support for smoke-free policies in the target population to maximize effectiveness. METHODS: A face-to-face survey was conducted from August to October 2011 using a stratified random sample of private subsidized housing units in Columbus, OH, without an existing smoke-free policy (n = 301, 64% response rate). Lease holders were asked to report individual, social, and environmental factors hypothesized to be related to support for smoke-free policies. Multiple logistic regression models were used to identify factors independently associated with policy support. RESULTS: Most tenants supported smoke-free policies in common areas (82.7%), half supported policies inside units (54.5%), and one third supported a ban outside the building (36.3%). Support for smoke-free policies in units and outdoors was more common among nonsmokers than smokers (71.5% vs. 35.7%, p < .001 and 46.2% vs. 25.4%, p < .001, respectively). Several individual and social, but no environmental, factors were independently associated with policy support. Smokers who intended to quit within 6 months or less were more likely than other smokers to support in-unit policies (45.3% vs. 21.1%; p = .003). CONCLUSIONS: More than half of subsidized MUH tenants supported smoke-free policies inside their units. Strategies to address individual- and social-level barriers to behavior change should be implemented in parallel with smoke-free policies. Policies should be evaluated with objective measures to determine their effectiveness.

Smoking behaviors and cessation interests among multiunit subsidized housing tenants, Columbus, Ohio, 2011.

INTRODUCTION: Cessation services have been recommended to complement smoke-free policies in subsidized multiunit housing, but little is known about smoking- and cessation-related characteristics among subsidized housing tenants. This study examined smoking behaviors and cessation-related interests in a population of subsidized housing tenants. METHODS: A face-to-face survey was conducted in August to October 2011 with a probability sample of private subsidized housing lease holders in Columbus, Ohio (N = 301, 64% response rate). RESULTS: Almost half (47.5%) of respondents were current smokers, including smokers of cigarettes or small cigars. Smokers were less likely than nonsmokers to have health insurance and more likely to be at risk for food insecurity. Among smokers, 20.3% did not smoke daily and 35.0% smoked 5 or fewer cigarettes per day. More than half (61.3%) purchased single cigarettes in the past month, with higher rates among nondaily smokers. Most smokers intended to quit within 6 months or less (60.1%) and were interested in using nicotine replacement therapy (NRT) (65.0%). Most respondents had Medicaid but only 30.4% knew Medicaid covered cessation medications. CONCLUSIONS: This population of subsidized housing tenants had high rates of smoking, including light smoking. Interest in NRT was high and access can be improved by increasing awareness of Medicaid coverage among clients and health care providers. However, more research is needed about scalable, evidence-based cessation strategies for low-socioeconomic status and light smokers. Strategies to address environmental factors such as availability of single cigarettes should also be considered in parallel with smoke-free policies.

The smoking ban next door: do hospitality businesses in border areas have reduced sales after a statewide smoke-free policy?

INTRODUCTION: Despite numerous studies demonstrating no significant economic effects on hospitality businesses following a statewide smoke-free (SF) policy, regional concerns suggest that areas near states without SF policies may experience a loss of hospitality sales across the border. The present study evaluated the impact of Ohio's statewide SF policy on taxable restaurant and bar sales in border and non-border areas. METHODS: Spline regression analysis was used to assess changes in monthly taxable sales at the county level in full-service restaurants and bars in Ohio. Data were analyzed from four years prior to policy implementation to three years post-policy. Change in the differences in the slope of taxable sales for border (n = 21) and non-border (n = 67) counties were evaluated for changes following the statewide SF policy enforcement, adjusted for unemployment rates, general trends in the hospitality sector, and seasonality. RESULTS: After adjusting for covariates, there was no statistically significant change in the difference in slope for taxable sales for either restaurants (ß = 0.9, p = 0.09) or bars (ß = 0.2, p = 0.07) following the SF policy for border areas compared to non-border areas of Ohio. CONCLUSIONS: Border regions in Ohio did not experience a significant change in bar and restaurant sales compared to non-border areas following a statewide SF policy. Results support that Ohio's statewide SF policy did not impact these two areas differently, and provide additional evidence for the continued use of SF policies to provide protection from exposure to secondhand smoke for both workers and the general public.

Physical activity breaks and facilities in US secondary schools.

BACKGROUND: Research on physical activity breaks and facilities (indoor and outdoor) in secondary schools is relatively limited. METHODS: School administrators and students in nationally representative samples of 8th (middle school) and 10th/12th grade (high school) students were surveyed annually from 2008-2009 to 2011-2012. School administrators reported information about physical activity breaks and facilities. Students self-reported height, weight, and physical activity. RESULTS: The prevalence of physical activity breaks and indoor and outdoor facilities (dichotomized by median split) differed significantly by region of the country, school size, student race/ethnicity, and school socioeconomic status (SES). Breaks were associated with lower odds of overweight (adjusted odds ratio [AOR] = 0.91, 95% confidence interval [CI]: 0.83-1.00) and obesity (AOR = 0.86, 95% CI: 0.75-0.99) among middle school students. Among low-SES middle school students and schools, higher indoor facilities were associated with lower rates of overweight and obesity. Among high school students, higher indoor and outdoor facilities were associated with 19-42% higher odds of moderate-to-vigorous physical activity. CONCLUSIONS: Physical activity breaks and school facilities may help to address high rates of overweight/obesity and low physical activity levels among secondary students, especially lower-SES students. Students in all schools should have equal access to these resources.

Availability of drinking water in US public school cafeterias.

This study examined the availability of free drinking water during lunchtime in US public schools, as required by federal legislation beginning in the 2011-2012 school year. Data were collected by mail-back surveys in nationally representative samples of US public elementary, middle, and high schools from 2009-2010 to 2011-2012. Overall, 86.4%, 87.4%, and 89.4% of students attended elementary, middle, and high schools, respectively, that met the drinking water requirement. Most students attended schools with existing cafeteria drinking fountains and about one fourth attended schools with water dispensers. In middle and high schools, respondents were asked to indicate whether drinking fountains were clean, and whether they were aware of any water-quality problems at the school. The vast majority of middle and high school students (92.6% and 90.4%, respectively) attended schools where the respondent perceived drinking fountains to be clean or very clean. Approximately one in four middle and high school students attended a school where the survey respondent indicated that there were water-quality issues affecting drinking fountains. Although most schools have implemented the requirement to provide free drinking water at lunchtime, additional work is needed to promote implementation at all schools. School nutrition staff at the district and school levels can play an important role in ensuring that schools implement the drinking water requirement, as well as promote education and behavior-change strategies to increase student consumption of water at school.

Profits, commercial food supplier involvement, and school vending machine snack food availability: implications for implementing the new competitive foods rule.

BACKGROUND: The 2013-2014 school year involved preparation for implementing the new US Department of Agriculture (USDA) competitive foods nutrition standards. An awareness of associations between commercial supplier involvement, food vending practices, and food vending item availability may assist schools in preparing for the new standards. METHODS: Analyses used 2007-2012 questionnaire data from administrators of 814 middle and 801 high schools in the nationally representative Youth, Education, and Society study to examine prevalence of profit from and commercial involvement with vending machine food sales, and associations between such measures and food availability. RESULTS: Profits for the school district were associated with decreased low-nutrient, energy-dense (LNED) food availability and increased fruit/vegetable availability. Profits for the school and use of company suppliers were associated with increased LNED availability; company suppliers also were associated with decreased fruit/vegetable availability. Supplier "say" in vending food selection was associated with increased LNED availability and decreased fruit/vegetable availability. CONCLUSIONS: Results support (1) increased district involvement with school vending policies and practices, and (2) limited supplier "say" as to what items are made available in student-accessed vending machines. Schools and districts should pay close attention to which food items replace vending machine LNED foods following implementation of the new nutrition standards.

Predictors of voluntary home-smoking restrictions and associations with an objective measure of in-home smoking among subsidized housing tenants.

PURPOSE: Examine predictors of voluntary home-smoking restrictions (HSRs) and associations with an objective measure of in-home smoking. DESIGN: Cross-sectional. SETTING: Publicly subsidized multiunit housing units managed by private company in Columbus, Ohio, without a smoke-free housing policy. SUBJECTS: Probability sample of primary leaseholders (N = 301, 64% response rate). MEASURES: Self-reported knowledge, attitudes, and behaviors collected during face-to-face survey in fall 2011, including individual (e.g., knowledge of health effects), social (e.g., number of friends who smoke), and environmental (e.g., safety) factors hypothesized to be related to having HSRs. Surface nicotine concentration (µg/m(2)) based on samples collected from wood surface in respondents' living rooms (n = 279). ANALYSIS: Multiple linear and logistic regression were used to identify factors associated with having HSRs and with indoor surface nicotine concentrations. RESULTS: Fewer than one-third (29.2%) of tenants had complete HSRs, while more than half (55.8%) had partial restrictions. Several individual and social factors, but no environmental/community factors, were associated with having HSRs. Type of HSRs (p < .001) and smoking status (p < .001) were independently associated with mean surface nicotine concentrations. CONCLUSION: Few subsidized housing tenants voluntarily limit in-home smoking. Partial restrictions could be considered as a harm reduction strategy but may be less effective among smokers. Strategies to change social norms are also needed to modify in-home smoking behavior among subsidized housing tenants.

School wellness policies and foods and beverages available in schools.

BACKGROUND: Since 2006-2007, education agencies (e.g., school districts) participating in U.S. federal meal programs are required to have wellness policies. To date, this is the only federal policy that addresses foods and beverages sold outside of school meals (in competitive venues). PURPOSE: To examine the extent to which federally required components of school wellness policies are associated with availability of foods and beverages in competitive venues. METHODS: Questionnaire data were collected in 2007-2008 through 2010-2011 school years from 892 middle and 1019 high schools in nationally representative samples. School administrators reported the extent to which schools had required wellness policy components (goals, nutrition guidelines, implementation plan/person responsible, stakeholder involvement) and healthier and less-healthy foods and beverages available in competitive venues. Analyses were conducted in 2012. RESULTS: About one third of students (31.8%) were in schools with all four wellness policy components. Predominantly white schools had higher wellness policy scores than other schools. After controlling for school characteristics, higher wellness policy scores were associated with higher availability of low-fat and whole-grain foods and lower availability of regular-fat/sugared foods in middle and high schools. In middle schools, higher scores also were associated with lower availability of 2%/whole milk. High schools with higher scores also had lower sugar-sweetened beverage availability and higher availability of 1%/nonfat milk, fruits/vegetables, and salad bars. CONCLUSIONS: Because they are associated with lower availability of less-healthy and higher availability of healthier foods and beverages in competitive venues, federally required components of school wellness policies should be encouraged in all schools.

Risk factors for smoking in rural women.

BACKGROUND: This study examined the association between social, demographic, and psychologic factors and smoking status among Appalachian Ohio women. A secondary aim examined whether specific factors could be identified and segmented for future tailored treatment of tobacco dependence. METHODS: A cross-sectional survey (n=570) obtained information about social, demographic, and psychologic factors and smoking. Logistic regression described associations between these characteristics and smoking status. Chi-square automatic interaction detection (CHAID) analyses identified subgroups at risk for smoking. RESULTS: Fifty-two percent never smoked, with 20.5% and 27.5% categorized as former and current smokers, respectively. Women with low adult socioeconomic position (SEP) were more likely to smoke (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.74-5.34) compared to high SEP women. Other factors associated with current smoking included age 31-50 (OR 2.30, 95% CI 1.22-4.33), age 18-30 (OR 3.29, 95% CI 1.72-5.34), Center for Epidemiologic Studies Depression scale (CES-D) score≥16 (OR 1.99, 95% CI 1.31-3.05), and first pregnancy at age<20 (OR 1.74, 95% CI 1.14-2.66). The prevalence of smoking was 50% among those with four or more risk factors compared to 10% for those reporting no risk factors. CHAID analyses identified low adult SEP and depressive symptoms as the combination of risk factors most strongly associated with smoking; 49.3% of women in this subgroup currently smoked. CONCLUSIONS: Low SEP in adulthood, maternal circumstances, and depressive symptoms are associated with current smoking. Tailored cessation interventions that address these risk factors should be developed and further evaluated in an attempt to reduce disparities in smoking prevalence among this vulnerable group of women.

Enabling distributed electronic research data collection for a rural Appalachian tobacco cessation study.

Tobacco use is increasingly prevalent among vulnerable populations, such as people living in rural Appalachian communities. Owing to limited access to a reliable internet service in such settings, there is no widespread adoption of electronic data capture tools for conducting community-based research. By integrating the REDCap data collection application with a custom synchronization tool, the authors have enabled a workflow in which field research staff located throughout the Ohio Appalachian region can electronically collect and share research data. In addition to allowing the study data to be exchanged in near-real-time among the geographically distributed study staff and centralized study coordinator, the system architecture also ensures that the data are stored securely on encrypted laptops in the field and centrally behind the Ohio State University Medical Center enterprise firewall. The authors believe that this approach can be easily applied to other analogous study designs and settings.

Survey of community engagement in NIH-funded research.

Community engagement is an innovative and required component for Clinical and Translational Science Awards (CTSAs) funded by the National Institutes of Health (NIH). However, the extent of community engagement in NIH-funded research has not been previously examined. This study assessed baseline prevalence of community engagement activities among NIH-funded studies at a large Midwestern university with a CTSA. An online survey was e-mailed to principal investigators of recent NIH-funded studies (N = 480). Investigators were asked to identify what types of community engagement activities had occurred for each study. Responses were received for 40.4% (194/480) of studies. Overall, 42.6% reported any community engagement activities. More collaborative types of engagement (e.g., community advisory board) were less common than activities requiring less engagement (e.g., sharing study results with community members). Studies with more collaborative community engagement were less likely to be described as basic or preclinical research compared to all other studies. Given NIH's inclusive call for community engagement in research, relatively few NIH-funded studies reported community engagement activities, although this study used a broad definition of community and a wide range of types of engagement. These findings may be used to inform the goals of CTSA community engagement programs.

Clinical faxed referrals to a tobacco quitline: reach, enrollment, and participant characteristics.

BACKGROUND: Faxed referrals from healthcare providers may provide a sustainable, low-cost mechanism for enrolling tobacco users in statewide quitlines, but few studies have evaluated implementation in real-world settings. This study evaluated the reach rates, enrollment rates, and participant characteristics of faxed referrals to the Ohio Tobacco Quit Line. METHODS: This observational study analyzed reach and enrollment rates from June 2006 to October 2007. Demographics and tobacco-use characteristics of 1616 Quit Line enrollees recruited through faxed referrals were compared to those of enrollees who were not fax-referred. RESULTS: A total of 6951 faxed referrals were received during the study period, increasing from an average of 68 per month before promotional initiatives to 412 per month during the study period. However, almost 60% of fax-referred individuals could not be reached for enrollment. Compared to other enrollees (n=36,273), fax-referred enrollees (n=1616) were more likely to be women, aged >/=35 years, have less than a high school education, have at least one comorbid condition, and be uninsured or publicly insured. CONCLUSIONS: Faxed referrals from healthcare providers are widely promoted to increase quitline participation and to assist providers in implementing cessation treatment. This study found low enrollment rates from faxed referrals; substantial efforts led to relatively few patients receiving quitline services. However, faxed referrals may reach populations who traditionally have less access to cessation aids. More research is needed to determine how to efficiently and effectively solicit faxed referrals from healthcare providers and to increase quitline enrollment rates among fax-referred smokers as well as to determine the extent to which faxed referrals influence quit outcomes.