Faculty Bibliography

PURPOSE/UNASSIGNED:To identify rates and sociodemographic correlates of food insecurity among low-income smokers. DESIGN/UNASSIGNED:Cross-sectional analysis of baseline survey data from a randomized controlled trial (N = 403) testing a smoking cessation intervention for low-income smokers. SETTING/UNASSIGNED:Two safety-net hospitals in New York City. SAMPLE/UNASSIGNED:Current smokers with annual household income <200% of the federal poverty level. MEASURES/UNASSIGNED:Food insecurity was measured using the United States Department of Agriculture 6-item food security module. Participant sociodemographics were assessed by self-reported survey responses. ANALYSIS/UNASSIGNED:We used frequencies to calculate the proportion of smokers experiencing food insecurity and multivariable logistic regression to identify factors associated with being food insecure. RESULTS/UNASSIGNED:Fifty-eight percent of participants were food insecure, with 29% reporting very high food insecurity. Compared to married participants, separated, widowed, or divorced participants were more likely to be food insecure (adjusted odds ratio [AOR] = 2.33, 95% confidence interval [CI]: 1.25-4.33), as were never married participants (AOR = 2.81, 95% CI: 1.54-5.14). CONCLUSIONS/UNASSIGNED:food access) may be needed for low-income populations. Interventions which seek to alleviate food insecurity may benefit from targeting socially isolated smokers.

Mobile technology has created the opportunity for health systems to provide low cost tobacco cessation assistance to patients. The goal of the present study was to examine the feasibility and effectiveness of an intervention (Text2Connect) that uses text messages to offer proactive connection to the New York State Smokers' Quitline. The electronic health record at two urban health systems was queried for patients who were current smokers and who had an outpatient visit between March 2015 and February 2016. Smokers (N = 4000) were sent an informational letter. Those who did not opt out (N = 3719) were randomized to one of 6 message sequences in order to examine the effect of theoretically informed message frames on response rates. Participants were sent a series of text messages at baseline and at 1 month and were asked to reply in order to be contacted by the state quitline (QL). After removing 1403 nonworking numbers, texts were sent to 2316 patients, and 10.0% (205/2060) responded with a QL request. Almost one quarter (23.6%, 486/2060) replied STOP and 66.4% (1369/2060) never responded. QL request rates were significantly higher when response efficacy messages were not used (p < .001). There were no differences by message framing on STOP requests (p > .05). The Text2Connect intervention was well accepted with a minority opting out. A 10% QL response rate is noteworthy given that only 5-7 brief outreach text messages were used. Results indicate that simple self-efficacy-focused messaging is most effective at supporting response rates.

Tobacco use is rarely addressed in community mental healthcare despite high patient smoking prevalence. Community mental health centers have systems in place that could be used to comprehensively address tobacco use. This study tested feasibility of, satisfaction with, and safety of proactive tobacco treatment (tobacco outreach to offer connection to tobacco cessation treatment). Behavioral health home patients who smoke were randomly assigned to usual care (UC; N = 11) or proactive care (PC; N = 9). All participants were called 3-months post-randomization for follow-up. PC patients reported high satisfaction with the program and experienced no adverse events or mental health symptom exacerbation during treatment. PC patients reported greater reductions in cigarettes per day, more quit attempts, and more cessation medication utilization than UC patients. Proactive outreach for tobacco cessation is feasible in a behavioral health home, acceptable to patients, and may reduce smoking heaviness and promote quit attempts.

GOALS/BACKGROUND/OBJECTIVE:Patients who "no-show" for colonoscopy or present with poor bowel preparation waste endoscopic resources and do not receive adequate examinations for colorectal cancer (CRC) screening. Using the Health Belief Model, we modified an existing patient education pamphlet and evaluated its effect on nonattendance rates and bowel preparation quality. STUDY/METHODS:We implemented a color patient education pamphlet to target individual perceptions about CRC and changed bowel preparation instructions to include a low-residue diet instead of the previous clear liquid diet. We compared the nonattendance rate over a 2-month period before and after the introduction of the pamphlet, allowing for a washout period during which pamphlet use was inconsistent. We compared the Boston Bowel Preparation Scale (BBPS) in 100 consecutive patients who underwent colonoscopy during each of the 2 periods. RESULTS:Baseline characteristics between the 2 groups were similar, although patients who received the pamphlet were younger (P=0.03). The nonattendance rate was significantly lower in patients who received the pamphlet (13% vs. 21%, P=0.01). The percentage of patients with adequate bowel preparation increased from 82% to 86% after introduction of the pamphlet, although this was not statistically significant (P=0.44). The proportion of patients with a BBPS score of 9 was significantly higher in the pamphlet group (41% vs. 27%, P=0.03). There was no difference in adenoma and sessile serrated adenoma detection rates before and after pamphlet implementation. CONCLUSIONS:After implementing a theory-based patient education intervention with a low-residue diet, our absolute rate for colonoscopy nonattendance decreased by 8% and the proportion of patients with a BBPS score of 9 increased by 14%. The Health Belief Model appears to be a useful construct for CRC screening interventions.

In 2017, the NYU Clinical and Translational Science Institute's Recruitment and Retention Unit created a Patient Advisory Council for Research (PACR) to provide feedback on clinical trials and health research studies. We collaborated with our clinical research informatics team to generate a random sample of patients, based on the International Classification of Diseases, Tenth Revision codes and demographic factors, for invitation via the patient portal. This approach yielded in a group that was diverse with regard to age, race/ethnicity, sex, and health conditions. This report highlights the benefits and limitations of using an electronic health record-based strategy to identify and recruit members for a PACR.

Background/UNASSIGNED:Cigarette smoking is the most common form of tobacco consumption but other methods have grown in popularity. In the United Arab Emirates and other Gulf countries, smoking dokha, a form of tobacco mixed with herbs and spices in a midwakh pipe, is common. Aims/UNASSIGNED:The aim of this study was to determine the prevalence of midwakh use in school students in Lebanon and factors associated with its use. Methods/UNASSIGNED:Data on tobacco use from the Lebanon Global School-based Student Health Survey (GSHS), 2017 were analysed, including current midwakh use (defined as midwakh use at least once in the 30 days before the survey). The survey includes school students in grades 7-12 (12-18 years). Current midwakh use was analysed according to sociodemographic and tobacco-related variables using bivariate and logistic regression analyses. Results/UNASSIGNED:Of the 5590 students included in the analysis, 4.6% were current midwakh users. Current midwakh use was significantly more prevalent in students 13 years and older and in male students (P < 0.01). Current use was also statistically significantly more prevalent in students in public than private schools. Current cigarette smoking (OR = 15.22; 95% CI: 11.08-20.90), ever use of a waterpipe (OR = 9.61; 95% CI: 6.66-13.86) and parental smoking (OR = 1.56; 95% CI: 1.05-2.31) were also significantly associated with current midwakh use. Conclusion/UNASSIGNED:Although midwakh use is low in Lebanon, the patterns of association of midwakh use are similar to those of cigarette and waterpipe smoking in young people. Further research is needed to understand the context of midwakh use and prevent it from spreading.

Despite the efficacy of nicotine replacement therapy (NRT) in promoting smoking cessation, no studies have been done to evaluate NRT prescribing rates among immigrants, a vulnerable minority population in the United States. The aim of this study is to explore for differences in NRT prescribing behavior by immigrant status. Participants were enrolled in a smoking cessation trial for hospitalized patients between July 2011 and April 2014 at two NYC hospitals. For this analysis, we used baseline data from patient surveys and electronic medical-record reviews to examine associations between immigrant status and prescription of NRT in-hospital and on discharge, as well as acceptance of NRT in-hospital. We included age, gender, education, health literacy, race, ethnicity, English language ability, inpatient service, and site insurance in the models as potential confounders. Our study population included 1,608 participants, of whom 21% were not born in the United States. Bivariate analysis found that nonimmigrants were more likely than immigrants to be prescribed NRT in the hospital (46.1% vs. 35.7%, p = .0006) and similarly on discharge (19.4% vs. 15.3%, p = .09). Both groups were equally likely to accept NRT in-hospital when prescribed. On multivariable analysis, being an immigrant (OR 0.65), Black race (OR 0.52), and Hispanic ethnicity (OR 0.63) were associated with lower likelihood of being prescribed NRT in-hospital. Multivariable analysis for provision of NRT prescription at discharge showed no significant difference between immigrants and nonimmigrants. These findings show differences in in-hospital smoking cessation treatment between immigrants and nonimmigrants.

BACKGROUND:People with a psychiatric diagnosis smoke at high rates, yet are rarely treated for tobacco use. Health care systems often use a 'no treatment' default for tobacco, such that providers must actively choose (opt-in) to treat their patients who express interest in quitting. Default bias theory suggests that opt-in systems may reinforce the status quo to not treat tobacco use in psychiatry. We aim to conduct a pilot study testing an opt-out system for implementing a 3A's (ask, advise, assist) tobacco treatment model in outpatient psychiatry. METHODS:We will use a mixed-methods, cluster-randomized study design. We will implement a tobacco use clinical reminder for outpatient psychiatrists at the VA New York Harbor Healthcare System. Psychiatrists (N = 20) will be randomized 1:1 to one of two groups: (1) Opt-In Treatment Approach: Psychiatrists will receive a reminder that encourages them to offer cessation medications and referral to cessation counseling; or (2) Opt-Out Treatment Approach: Psychiatrists will receive a clinical reminder that includes a standing cessation medication order and a referral to cessation counseling that will automatically generate unless the provider cancels. Prior to implementation of the reminders, we will hold a 1-hour training on tobacco treatment for psychiatrists in both arms. We will use VA administrative data to calculate the study's primary outcomes: 1) the percent of smokers prescribed a cessation medication and 2) the percent of smokers referred to counseling. During the intervention period, we will also conduct post-visit surveys with a cluster sample of 400 patients (20 per psychiatrist) to assess psychiatrist fidelity to the 3 A's approach and patient perceptions of the opt-out system. At six months, we will survey the clustered patient sample again to evaluate the study's secondary outcomes: 1) patient use of cessation treatment in the prior 6 months and 2) self-reported 7-day abstinence at 6 months. At the end of the intervention period, we will conduct semi-structured interviews with 12-14 psychiatrists asking about their perceptions of the opt-out approach. DISCUSSION/CONCLUSIONS:This study will produce important data on the potential of opt-out systems to overcome barriers in implementing tobacco use treatment in outpatient psychiatry. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov Identifier NCT04071795 (registered August 28, 2019). https://www.clinicaltrials.gov/ct2/show/NCT04071795.

Brazil was a low and middle-income country (LMIC) in the late-1980s when it implemented a robust national tobacco-control program (NTCP) amidst rapid gains in national incomes and gender equality. We assessed changes in smoking prevalence between 1989 and 2013 by education level and related these changes to trends in educational inequalities in smoking. Data were from four nationally representative cross-sectional surveys (1989, n = 25,298; 2003 n = 3845; 2008 n = 28,938; 2013 n = 47,440, ages 25-69 years). We estimated absolute (slope index of inequality, SII) and relative (relative index of inequality, RII) educational inequalities in smoking prevalence, separately for males and females. Additional analyses stratified by birth-cohort to assess generational differences. Smoking declined significantly between 1989 and 2013 in all education groups but declines in females were steeper in higher-educated groups. Consequently, both absolute and relative educational inequalities in female smoking widened threefold between 1989 and 2013 (RII: 1.31 to 3.60, SII: 5.3 to 15.0), but absolute inequalities widened mainly until 2003 (SII: 15.8). Conversely, in males, declines were steeper in higher-educated groups only relative terms. Thus, relative educational inequalities in male smoking widened between 1989 and 2013 (RII: 1.58 to 3.19) but mainly until 2008 (3.22), whereas absolute inequalities were unchanged over the 24-year period (1989: 21.1 vs. 2013: 23.2). Younger-cohorts (born ≥1965) had wider relative inequalities vs. older-cohorts at comparable ages, particularly in the youngest female-cohorts (born 1978-1988). Our results suggest that younger lower-SES groups, especially females, may be particularly vulnerable to differentially higher smoking uptake in LMICs that implement population tobacco-control efforts amidst rapid societal gains.

Introduction: The use of electronic cigarettes (e-cigarettes) in smokers with mental health conditions (MHC) is not well understood. Aims: This study aims to compare e-cigarette users and non-users among veteran smokers with MHC to characterize differences in smoking behavior, motivation to quit, psychological distress, primary psychiatric diagnosis, and other factors. Methods: Baseline survey data were used from a randomized smoking cessation trial enrolling smokers with MHC from four Veterans Health Administration hospitals. Participants were categorized as current, former (having ever tried an e-cigarette), or never e-cigarette users. Pearson's chi2 and