Faculty Bibliography

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.