Faculty Bibliography

INTRODUCTION/BACKGROUND:People with serious mental illness (SMI) have a high smoking prevalence and low quit rates. Few cessation treatments are tested in smokers with SMI. Mental health (MH) providers are reluctant to address smoking. Proactive tobacco cessation treatment strategies reach out directly to smokers to offer counseling and medication and improve treatment utilization and quit rates. The current study is a secondary analysis of a randomized controlled trial of proactive outreach for tobacco cessation treatment in VA MH patients. METHODS:Participants (N=1938, 83% male, mean age 55.7) across 4 recruitment sites, who were current smokers and had a MH visit in the past 12 months, were identified using the electronic medical record. Participants were randomized to Intervention (telephone outreach call plus invitation to engage in MH tailored telephone counseling and assistance obtaining nicotine replacement therapy [NRT]) or Control (usual care). The current study assessed outcomes in participants with SMI (N=982). RESULTS:Compared to the Control group, participants assigned to the Intervention group were more likely to engage in telephone counseling (22% vs. 3%) and use NRT (51% vs. 41%). Participants in the Intervention group were more likely to be abstinent (7-day point prevalence; 18%) at 12 months than participants in the Control group; 11%) but equally likely to make quit attempts. CONCLUSIONS:Proactive tobacco cessation treatment is an effective strategy for tobacco users with SMI. Proactive outreach had a particularly strong effect on counseling utilization. Future randomized clinical trials examining proactive tobacco treatment approaches in SMI treatment settings are needed. IMPLICATIONS/CONCLUSIONS:Few effective treatment models exist for smokers with serious mental illness. Proactive tobacco cessation outreach with connections to mental health tailored telephone counseling and medication promotes tobacco abstinence among smokers with serious mental illness and is an effective treatment strategy for this underserved population.

Background/UNASSIGNED:The impact of tobacco use on perioperative complications, hospital costs, and survivorship in total joint arthroplasty (TJA) is well established. The aim of this study is to report the impact of tobacco cessation on outcomes after TJA and to measure the impact of a voluntary smoking cessation program (SCP) on self-reported smoking quit rates in a premier academic medical center. Methods/UNASSIGNED:A seven-year (2013-2019) SCP database was provided by the Integrative Health Promotion Department and Infection Prevention and Control Department. We evaluated program and smoking status, patient demographics, length of stay (LOS), and 90-day post-operative infection rates and readmission rates. The primary outcome was quit rates based on SCP enrollment status. The secondary outcomes measured infection rates, readmission rates, and LOS based on enrollment status and/or quit rate. Results/UNASSIGNED:A total of 201 eligible patients were identified: 137 patients in the SCP (intervention) group and 64 in the self-treatment (control) group. SCP patients trended towards higher quit rates (43% vs 33%, p = 0.17), shorter LOS (2.47 vs 2.62 days, p = 0.52), lower infection rates (7.3% vs 12.5%, p = 0.27) and slightly higher readmission rates (5.8% vs 4.7%, p = 0.73). In a sub-analysis, self-reported smokers demonstrated statistically significant decrease in infection (3.7% vs 12.5%, p = 0.03). Conclusion/UNASSIGNED:There was a statistically significant decrease in infection rates in patients who self-reported quitting tobacco prior to TJA. Additionally, quit rates for patients who participated in a voluntary SCP trended towards increased pre-operative cessation. Further efforts to increase tobacco cessation prior to TJA and examine the impact on patient outcomes are needed.

INTRODUCTION/BACKGROUND:Smoking is a key determinant of mortality among people living with HIV (PLWH). METHODS:To better understand the effects of smoking cessation interventions in PLWH, we conducted a pooled analysis of four randomized controlled trials of hospital-initiated smoking interventions conducted through the Consortium of Hospitals Advancing Research on Tobacco (CHART). In each study, cigarette smokers were randomly assigned to usual care or a smoking cessation intervention. The primary outcome was self-reported past 30-day tobacco abstinence at 6-month follow-up. Abstinence rates were compared between PLWH and participants without HIV and by treatment arm, using both complete-case and intention-to-treat analyses. Multivariable logistic regression was used to determine the effect of HIV status on 6-month tobacco abstinence and to determine predictors of smoking cessation within PLWH. RESULTS:Among 5550 hospitalized smokers, there were 202 (3.6%) PLWH. PLWH smoked fewer cigarettes per day and were less likely to be planning to quit than smokers without HIV. At 6 months, cessation rates did not differ between intervention and control groups among PLWH (28.9% vs. 30.5%) or smokers without HIV (36.1% vs. 34.1%). In multivariable regression analysis, HIV status was not significantly associated with smoking cessation at 6 months. Among PLWH, confidence in quitting was the only clinical factor independently associated with smoking cessation (OR 2.0, 95% CI = 1.4 to 2.8, p < .01). CONCLUSIONS:HIV status did not alter likelihood of quitting smoking after hospital discharge, whether or not the smoker was offered a tobacco cessation intervention, but power was limited to identify potentially important differences. IMPLICATIONS/CONCLUSIONS:PLWH had similar quit rates to participants without HIV following a hospital-initiated smoking cessation intervention. The findings suggest that factors specific to HIV infection may not influence response to smoking cessation interventions and that all PLWH would benefit from efforts to assist in quitting smoking. TRIAL REGISTRATION/BACKGROUND:(1) Using "warm handoffs" to link hospitalized smokers with tobacco treatment after discharge: study protocol of a randomized controlled trial: NCT01305928. (2) Web-based smoking cessation intervention that transitions from inpatient to outpatient: NCT01277250. (3) Effectiveness of smoking-cessation interventions for urban hospital patients: NCT01363245. (4) Effectiveness of Post-Discharge Strategies for Hospitalized Smokers (HelpingHAND2): NCT01714323.

Background-Financial incentives for smoking cessation and use of evidence-based therapy may increase quit rates and reduce health and economic disparities. Methods-We randomized a low-income population of 182 hospitalized patients (mean age 58 years, 45% with high school education or less) to enhanced usual care, which included hospital-directed cessation care and Quitline referral, or enhanced usual care plus financial incentives. All patients received enhanced usual care, while participants randomized to the financial incentives group were also eligible to receive up to $550 for participation in Quitline counseling ($50), participation in a community-based cessation program ($50), use of pharmacotherapy ($50), and biochemically-confirmed smoking cessation at 2 months ($150) and 6 months ($250). Primary outcome was biochemically-confirmed smoking cessation at 6 months after hospital discharge. Results-Total mean payment was $84 (SD=$133) in the incentive group. The 6-month rate of biochemically-confirmed smoking cessation was 19.6% in the incentive group and 8.9% in the enhanced usual care group (odds ratio, 2.56; 95% CI, 0.84 to 7.83, P=0.10). Participants in the incentive group had higher rates of nicotine replacement therapy use (57.3% versus 31.3%, P=0.002). Financial incentives did not improve subjective social status but did increase financial stress. Conclusions-Rates of bioconfirmed smoking cessation were higher among hospitalized patients randomized to financial incentives compared to usual care alone, but the difference was not significant. Considering the frequency of low payouts and the importance of assistance for successful quitting, future studies should explore the effectiveness of financial incentives sufficiently large to overcome barriers to evidence-based therapy.

Background: Electronic dance music (EDM) party attendees are at high risk for use of various illegal drugs; however, little is known about their tobacco use. Understanding tobacco use patterns in this population at high risk for illegal drug use can inform multi-product interventions. Objectives: 954 EDM party attendees (ages 18-40) were surveyed in New York City in 2017. We estimated prevalence of use of cigarettes, hookah, cigars, other tobacco, and e-cigarettes and delineated correlates of current (past-month) use using bivariable and multivariable models. Results: Past-month use of cigarettes (36.2%), e-cigarettes (15.6%), cigars (12.5%), and hookah (11.7%) in particular was prevalent. In multivariable models, females were less likely to use e-cigarettes than males (adjusted prevalence ratio [aPR] = 0.63, p = .030), and those who attended graduate school were less likely to use cigarettes (aPR = 0.55, p = .003) and/or e-cigarettes (aPR = 0.33, p = .026). Past-year ecstasy/MDMA/Molly use was a risk factor for past-month use of cigarettes (aPR = 1.38, p = .013) and/or cigars (aPR = 1.61, p = .032), and past-year cocaine use was a risk factor for past-month use of cigarettes (aPR = 1.80, p < .001), cigars (aPR = 1.80, p = .013), other tobacco products (aPR = 3.05, p = .003), and/or e-cigarettes (aPR = 2.39, p = .003). 55.4% of ecstasy users and 60.3% of cocaine users were current cigarette smokers, but use of other products among users of these drugs was less prevalent (9.8-27.9%). Conclusions: Results suggest that current tobacco use is prevalent in this population who is also at high risk for use of drugs such as ecstasy and cocaine. Prevention and cessation efforts need to target tobacco users in this scene while incorporating components addressing illegal drug use.

BACKGROUND:Evidence shows community health workers (CHWs) can effectively deliver proven behavior-change strategies to prevent type 2 diabetes mellitus (diabetes) and enhance preventive care efforts in primary care for minority and low-income populations. However, operational details to integrate CHWs into primary care practice remain less well known. OBJECTIVE:To examine clinicians' perceptions about working with CHWs for diabetes prevention in safety-net primary care. SETTING/METHODS:Clinicians are primary care physicians and nurses at two New York City safety-net hospitals participating in CHORD (Community Health Outreach to Reduce Diabetes). CHORD is a cluster-randomized trial testing a CHW intervention to prevent diabetes. DESIGN/METHODS:Guided by the Consolidated Framework for Implementation Research, we studied how features of the CHW model and organizational context of the primary care practices influenced clinicians' perspectives about the acceptability, appropriateness, and feasibility of a diabetes-prevention CHW program. Data were collected pre-intervention using semi-structured interviews (n = 18) and a 20-item survey (n = 54). APPROACH/METHODS:Both survey and interview questions covered clinicians' perspectives on diabetes prevention, attitudes and beliefs about CHWs' role, expectations in working with CHWs, and use of clinic- and community-based diabetes- prevention resources. Survey responses were descriptively analyzed. Interviews were coded using a mix of deductive and inductive approaches for thematic analysis. KEY RESULTS/RESULTS:Eighty-seven percent of survey respondents agreed CHWs could help in preventing diabetes; 83% reported interest in working with CHWs. Ninety-one percent were aware of clinic-based prevention resources; only 11% were aware of community resources. Clinicians supported CHWs' cultural competency and neighborhood reach, but expressed concerns about the adequacy of CHWs' training; public and professional emphasis on diabetes treatment over prevention; and added workload and communication with CHWs. CONCLUSIONS:Clinicians found CHWs appropriate for diabetes prevention in safety-net settings. However, disseminating high-quality evidence about CHWs' effectiveness and operations is needed to overcome concerns about integrating CHWs in primary care.

Colorectal cancer (CRC) screening has increased substantially in New York City in recent years. However, screening uptake measured by telephone surveys may not fully capture rates among underserved populations. We measured screening completion within one year of a primary care visit among previously unscreened patients in a large urban safety-net hospital and identified sociodemographic and health-related predictors of screening. We identified 21,256 patients aged 50-75 who were seen by primary care providers (PCPs) in 2014, of whom 14,425 (67.9%) were not up-to-date with screening. Since PCPs facilitate the majority of screening, we compared patients who received screening within one year of an initial PCP visit to those who remained unscreened using multivariable logistic regression. Among patients not up-to-date with screening at study outset, 11.5% (1,658 patients) completed screening within one year of a PCP visit. Asian race, more PCP visits, and higher area-level income were associated with higher screening completion. Factors associated with remaining unscreened included morbid obesity, ever smoking, Elixhauser comorbidity index of 0, and having Medicaid/Medicare insurance. Age, sex, language, and travel time to the hospital were not associated with screening status. Overall, 39.9% of patients were up-to-date with screening by 2015. In an underserved urban population, CRC screening disparities remain, and overall screening uptake was low. Since more PCP visits were associated with modestly higher screening completion at one year, additional community-level education and outreach may be crucial to increase CRC screening in underserved populations.

INTRODUCTION:Though many interventions have been shown to be effective in helping smokers quit, outcomes may differ between light and heavy smokers. We identified differences in baseline characteristics and post-intervention cessation rates among smoker groups at two safety-net hospitals. METHODS:We retrospectively analyzed cessation rates in 1604 patients randomized to either a quitline referral (1-2 telephone counseling sessions) or intensive counseling program (seven telephone sessions). Participants were stratified into light-intermittent (smoked on ≤24 of last 30 days), light-daily (smoked on >24/30 days, 1-9 cigarettes per day [CPD]), or heavy smokers (smoked on >24/30 days, ≥10 CPD). We compared baseline characteristics between smoker types using chi-squared tests, then identified predictors of 30-day abstinence using a multivariable model. RESULTS:Compared with light-daily and light-intermittent smokers, heavy smokers were more likely to be white, male, concomitant e-cigarette users, to have high-risk alcohol use, to have used quitting aids previously, to have current or lifetime substance use (excluding cannabis), and have lower confidence in quitting. However, in multivariable analysis, smoker type was not significantly associated with cessation. The statistically significant predictors of cessation at 6 months were higher confidence in quitting and enrollment in the intensive counseling intervention. CONCLUSIONS:Smoker type (light-intermittent, light-daily, or heavy) does not independently predict success in a cessation program. However, smoker type is strongly associated with patients' confidence in quitting, which may be one predictor of cessation. IMPLICATIONS:This study of two safety-net hospitals emphasizes that the number of cigarettes smoked per day does not independently predict smoking cessation. Additionally, heavy smokers are at highest risk for the detrimental health effects of tobacco, yet have lower confidence and motivation to quit. Confidence in quitting may be one factor that affects cessation rates; however, further study is needed to identify which other attributes predict cessation. These findings suggest that smoker type may still be a useful proxy for predicting cessation and that interventions specifically designed for and validated in heavy smokers are needed to better aid these individuals.

INTRODUCTION/BACKGROUND:Race, ethnicity, and socioeconomic status are known to influence staging and survival in colorectal cancer (CRC). It is unclear how these relationships are affected by geographic factors and changes in insurance coverage for CRC screening. We examined the temporal trends in the association between sociodemographic and geographic factors and staging and survival among Medicare beneficiaries. METHODS:We identified patients 65 years or older with CRC using the 1991-2010 Surveillance, Epidemiology, and End Results-Medicare database and extracted area-level sociogeographic data. We constructed multinomial logistic regression models and the Cox proportional hazards models to assess factors associated with CRC stage and survival in 4 periods with evolving reimbursement and screening practices: (i) 1991-1997, (ii) 1998-June 2001, (iii) July 2001-2005, and (iv) 2006-2010. RESULTS:We observed 327,504 cases and 102,421 CRC deaths. Blacks were 24%-39% more likely to present with distant disease than whites. High-income areas had 7%-12% reduction in distant disease. Compared with whites, blacks had 16%-21% increased mortality, Asians had 32% lower mortality from 1991 to 1997 but only 13% lower mortality from 2006 to 2010, and Hispanics had 20% reduced mortality only from 1991 to 1997. High-education areas had 9%-12% lower mortality, and high-income areas had 5%-6% lower mortality after Medicare began coverage for screening colonoscopy. No consistent temporal trends were observed for the associations between geographic factors and CRC survival. DISCUSSION/CONCLUSIONS:Disparities in CRC staging and survival persisted over time for blacks and residents from areas of low socioeconomic status. Over time, staging and survival benefits have decreased for Asians and disappeared for Hispanics.

AIM/OBJECTIVE:To identify barriers to implementing the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) Article 14 guidelines on tobacco dependence treatment (TDT). DESIGN/METHODS:Cross-sectional survey conducted from December 2014 to July 2015 to assess implementation of Article 14 recommendations. SETTING AND PARTICIPANTS/METHODS:Survey respondents (n = 127 countries) who completed an open-ended question on the 26-item survey. MEASUREMENTS/METHODS:The open-ended question asked the following: 'In your opinion, what are the main barriers or challenges to developing further tobacco dependence treatment in your country?'. We conducted thematic analysis of the responses. FINDINGS/RESULTS:The most frequently reported barriers included a lack of health-care system infrastructure (n = 86) (e.g. treatment not integrated into primary care, lack of health-care worker training), low political priority (n = 66) and lack of funding (n = 51). The absence of strategic plans and national guidelines for Article 14 implementation emerged as subthemes of political priority. Also described as barriers were negative provider attitudes towards offering offer TDT (n = 11), policymakers' lack of awareness about the effectiveness and affordability of TDT (n = 5), public norms supporting tobacco use (n = 11), a lack of health-care leadership and expertise in the area of TDT (n = 6) and a lack of grassroots and multi-sector networks supporting policy implementation (n = 8). The analysis captured patterns of co-occurring themes that linked, for example, low levels of political support with a lack of funding necessary to develop health-care infrastructure and capacity to implement Article 14. CONCLUSION/CONCLUSIONS:Important barriers to implementing the Framework Convention on Tobacco Control Article 14 guidelines include lack of a health-care system infrastructure, low political priority and lack of funding.