Faculty Bibliography

Background/UNASSIGNED:Tobacco spending may exacerbate financial hardship in low-income populations by using funds that could go toward essentials. This study examined post-quit spending plans among low-income smokers and whether financial hardship was positively associated with motivation to quit in the sample. Methods/UNASSIGNED:= 410). Linear regression was used to examine the relationship between financial distress, food insecurity, smoking-induced deprivation (SID) and motivation to quit (measured on a 0-10 scale). We performed summative content analyses of open-ended survey questions to identify the most common plans among participants with and without SID for how to use their tobacco money after quitting. Results/UNASSIGNED:The top three spending plans among participants with and without SID were travel, clothing and savings. There were three needs-based spending plans unique to a small number of participants with SID: housing, health care and education. Conclusions/UNASSIGNED:Financial distress and food insecurity did not enhance overall motivation to quit, while smokers with SID were less motivated to quit. Most low-income smokers, including those with SID, did not plan to use their tobacco money on household essentials after quitting.

INTRODUCTION/BACKGROUND:Non-cigarette tobacco products are an increasing public health concern globally. Little is known about midwakh, a pipe indigenous to the United Arab Emirates (UAE). This study aimed to assess the prevalence, attitudes, behaviours and policy evaluation of midwakh smoking among 13 to 15 year olds in the UAE. METHODS:We conducted secondary analyses of the 2013 UAE Global Youth Tobacco Survey. The main three outcomes were ever use, current use (past-30 days), and the number of midwakhs smoked per day. We assessed cessation, attitude, and policy measures. Regression models identified the association between each outcome measure and sex, school grade, nationality, weekly spending money, cigarette use, and parent and peer tobacco use. RESULTS:The prevalence of ever and current midwakh use were 18.5% and 9.0%, respectively. Daily midwakh users smoked a median of 8.0 per day while non-daily users smoked 3.8 per month. Higher midwakh prevalence was reported among wealthier males, older age groups, concurrent cigarette users and among participants having peers or parents who use tobacco. There was also variation by nationality. Reduced harm perception was greater among midwakh users than non-users. About 39.6% reported being declined a midwakh purchase due to age, and 35.5% reported noticing health warnings on packages. CONCLUSIONS:Midwakh use is prevalent among 13 to 15 year olds in the UAE, and burden lies mainly with daily users. Further needed research should not delay implementation and evaluation of policies known to curb tobacco use among youth, including taxation, media campaigns, and provision of cessation services.

Background/UNASSIGNED:Smoking remains a major public health burden among persons with opioid and/or alcohol use disorder. Methods/UNASSIGNED:A 49-item semi-structured survey was conducted among urban, inpatient detoxification program patients eliciting demographic and clinical characteristics, smoking profile, technology use patterns, and preferences for adopting technology-based smoking cessation interventions. Multivariate logistic regression models further evaluated the association between participant demographic and clinical characteristics and technology preferences. Results/UNASSIGNED:Participants were mostly male (91%), and admitted for detoxification for alcohol (47%), heroin (31%), or both alcohol and heroin (22%). Past 30-day smoking was reported by 78% of the sample. Mobile phone ownership was common (89%); with an average past-year turnover of 3 mobile phones and 3 phone numbers. Computer ownership was low (28%) and one third reported daily internet use (34%). Telephone (41%) and text message-based interventions (40%) were the most popular platforms to facilitate smoking cessation. Conclusions/UNASSIGNED:Despite concurrent AUD-OUD, most respondents had attempted to quit smoking in the last year and preferred telephone- and text message-based interventions to facilitate smoking cessation. High turnover of mobile phones, phone numbers, and limited access to computers pose barriers to dissemination of technology-based smoking cessation interventions in this vulnerable population.

Background/UNASSIGNED:Goals for Eating and Moving (GEM) is a technology-assisted health coaching intervention to improve weight management in primary care at the Veterans Health Administration (VHA) that we designed through prior rigorous formative studies. GEM is integrated within the patient-centered medical home and utilizes student health coach volunteers to counsel patients and encourage participation in VHA's intensive weight management program, MOVE!. The primary aim of this study was to determine the feasibility and acceptability of GEM when compared to Enhanced Usual Care (EUC). Our secondary aim was to test the impact of GEM on weight, diet and physical activity when compared to EUC. Methods/UNASSIGNED: = 23). We collected process measures (e.g. number of coaching calls completed, number and types of lifestyle goals, counseling documentation) and qualitative feedback on quality of counseling and acceptability of call duration. We also measured weight and behavioral outcomes. Results/UNASSIGNED: = 21) tended to lose more weight at 3-, 6-, and 12-months as compared to EUC, but this was not statistically significant. There were no significant differences in diet or physical activity. Conclusions/UNASSIGNED:We found that a technology assisted health coaching intervention delivered within primary care using student health coaches was feasible and acceptable to Veteran patients. This pilot study helped elucidate challenges such as low provider engagement, difficulties with health coach continuity, and low patient attendance in MOVE! which we have addressed and plan to test in future studies. Trial registration/UNASSIGNED:NCT03006328 Retrospectively registered on December 30, 2016.

Adults with medical multimorbidity (≥2 chronic conditions) present challenges for health care systems to provide coordinated care. Substance use can complicate the management of chronic medical conditions, but little research has focused on the intersection of medical multimorbidity and substance use. This study uses cross-sectional analysis of 115,335 adult respondents of the 2012-2014 administrations of the National Survey on Drug Use and Health to estimate the prevalence and correlates of past-year drug use among adults with multimorbidity. The prevalence of past-year drug use was compared between individuals reporting 0, 1, and ≥2 chronic medical conditions. We used multivariable logistic regression to determine correlates of past-year drug use among adults with ≥2 chronic medical conditions. 53.1% reported no chronic conditions, 29.5% reported one chronic condition, and 17.4% reported ≥2 chronic conditions. Past-year drug use was reported by 18.3% of those with no chronic conditions, 14.8% with 1 chronic condition, and 11.6% with ≥2 chronic conditions. Cannabis and opioid analgesics (nonmedical use) were the most common drugs used across all three groups. In the adjusted model, among adults with medical multimorbidity, adults with past-year drug use were more likely to be younger, male, have lower income, and report current tobacco use, alcohol dependence, past-year depression, and having received mental health treatment in the past year. In this national cohort, fewer adults with multimorbidity reported substance use compared to adults with no or one chronic condition, however, this population with high multimorbidity may be particularly vulnerable to the negative effects of drug use.

BACKGROUND:Smoking is the leading preventable cause of death in the United States, but evidence-based smoking cessation therapy is underutilized. Financial incentive strategies represent an innovative approach for increasing the use of counseling and pharmacotherapy. If effective, they could supplement or supplant resource-intensive policy options, particularly in populations for whom smoking has substantial societal costs. FIESTA (Financial IncEntives for Smoking TreAtment) will randomize hospitalized smokers to receive usual smoking cessation care alone or usual smoking care augmented with financial incentives. We aim to compare the impact of these two strategies on 1) smoking abstinence, 2) use of counseling and nicotine replacement therapy, and 3) quality of life of participants. We also will evaluate the short-term and long-term return on the investment of incentives. The FIESTA Oral Microbiome Substudy will compare the oral microbiome of smokers and nonsmokers to longitudinally assess whether smoking cessation changes oral microbiome composition. METHODS:We will enroll 182 inpatient participants from the Manhattan campus of the Veterans Affairs New York Harbor Healthcare System. All participants receive enhanced usual care, including screening for tobacco use, counseling while hospitalized, access to nicotine replacement therapy, and referral to a state Quitline. Patients in the financial incentive arm receive enhanced usual care and up to $550 for participating in the New York Smoker's Quitline, using nicotine replacement therapy (NRT), and achieving biochemically confirmed smoking cessation at 2 months and 6 months. In the microbiome substudy, we enroll nonsmoking control participants matched to each recruited smoker's hospital ward, sex, age, diabetes status, and antibiotic use. After discharge, participants are asked to complete periodic phone interviews at 2 weeks, 2 months, 6 months, and 12 months and provide expired carbon monoxide and saliva samples at 2 months, 6 months, and 12 months for cotinine testing and oral microbiome analysis. DISCUSSION/CONCLUSIONS:The incentive interventions of FIESTA may benefit hospitalized smokers, an objective made all the more critical because smoking rates among hospitalized patients are higher than those in the general population. Moreover, the focus of FIESTA on evidence-based therapy and bioconfirmed smoking cessation can help guide policy efforts to reduce smoking-related healthcare costs in populations with high rates of tobacco use and costly illnesses. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov, NCT02506829 . Registered on 1 July 2014.

Men who have sex with men (MSM) commonly use inhaled nitrites, or poppers, though their use is a risk factor HIV seroconversion. Pre-exposure prophylaxis, or PrEP, is effective for HIV prevention, but is not widely used, and little is known regarding PrEP use and acceptability among MSM who use inhaled nitrites. We surveyed 580 MSM in Paris, France in 2016 about popper use, sexual behaviors including condomless anal intercourse (CAI), serosorting, and sexual positioning, PrEP use, PrEP candidacy, and interest in alternate PrEP delivery modalities. We included 444 HIV negative participants for the current study. 46.2% reported popper use in the prior 3 months. Using multivariate adjusted logistic regression, we found that popper users were more likely than non-users to consider themselves candidates for PrEP [adjusted relative risk ratio (aRRR) = 2.73; 95% CI 1.54-4.83], but they were not more likely to be current (aRRR = 1.54; 95% CI 0.71-3.33) or past (aRRR = 1.37; 95% CI 0.44-4.28) PrEP users. Mediation analyses indicated that increased CAI and serosorting partly explained the relationship between popper use and PrEP candidacy. There was considerable interest in alternate proposed PrEP delivery modalities, particularly long-acting injectable PrEP [adjusted risk ratio (aRR) = 1.43; 95% CI 1.15-1.79].

Introduction: Veterans with mental health disorders smoke at high rates, but encounter low rates of tobacco treatment. We sought to understand barriers and facilitators to treating tobacco use in VA mental health clinics. Methods: This qualitative study was part of a trial evaluating a telephone care coordination program for smokers using mental health services at 6 VA facilities. We conducted semi-structured interviews with 14 staff: 12 mental health clinic staff working at the parent study's intervention sites (n=6 psychiatrists, 3 psychologists, 2 social workers, 1 NP), as well as one psychiatrist and one psychologist on the VA's national tobacco advisory committee. Interviews were transcribed and inductively coded to identify themes. Results: Five "barriers" themes emerged: 1) competing priorities, 2) patient challenges/resistance, 3) complex staffing/challenging cross-discipline coordination, 4) mixed perceptions about whether tobacco is a mental health care responsibility, and 5) limited staff training/comfort in treating tobacco. Five "facilitators" themes emerged: 1) reminding mental health staff about tobacco, 2) staff belief in the importance of addressing tobacco, 3) designating a cessation medication prescriber, 4) linking tobacco to mental health outcomes and norms, and 5) limiting mental health staff burden. Conclusions: VA mental health staff struggle with knowing that tobacco use is important, but they face competing priorities, encounter patient resistance, are conflicted on their role in addressing tobacco, and lack tobacco training. They suggested strategies at multiple levels that would help overcome those barriers that can be used to design interventions that improve tobacco treatment delivery for mental health patients. IMPLICATIONS: This study builds upon the existing literature on the high rates of smoking, but low rates of treatment, in people with mental health diagnoses. This study is one of the few qualitative evaluations of mental health clinic staff perceptions of barriers and facilitators to treating tobacco. The study results provide a multi-level framework for developing strategies to improve the implementation of tobacco treatment programs in mental health clinics.

Introduction/UNASSIGNED:There is evidence suggesting that certain subgroups of people who use tobacco do not receive tobacco pharmacology as consistently as others. Methods/UNASSIGNED:This retrospective, cohort study examined the trend in the use of cessation pharmacotherapy from 2004 to 2013 using Veterans Health Administration (VHA) administrative data. Among Veterans who used tobacco in the fiscal year (FY) 2011 and had not received pharmacotherapy in the prior year, multivariable Cox regression was used to assess the independent associations between patient clinical and demographic characteristics and pharmacotherapy initiation in the 6-months follow-up period. Results/UNASSIGNED:Smoking cessation pharmacotherapy in the VHA increased from 13.8% in 2004 to 25.6% in 2013. In 2011, Veterans (N = 838309) who were more likely to newly receive pharmacotherapy included those with psychiatric disorders (depression, bipolar disorder, non-alcohol substance use disorder, other anxiety, and post-traumatic stress disorder), chronic pulmonary disease, peripheral vascular disorders, and younger Veterans (adjusted rate ratios (ARRs) ranged from 1.03 to 1.92, all p < .001). Veterans less likely to receive pharmacotherapy were those with schizophrenia or other psychosis, males, Hispanics, and those with a medical condition (uncomplicated diabetes, uncomplicated hypertension, fluid and electrolyte disorders, cardiac arrhythmia, valvular disease, hypothyroidism, acquired immunodeficiency syndrome/human immunodeficiency virus, deficiency anemia, renal failure, paralysis, coagulopathy, metastatic cancer, and other neurological disorders) (ARRs ranged from 0.74 to 0.93, all p < .001). Conclusions/UNASSIGNED:Although VHA cessation pharmacotherapy use nearly doubled from 13.8% in 2004 to 25.6% in 2013, reaching undertreated subgroups, especially those with medical comorbidities, may improve cessation outcomes. Implications/UNASSIGNED:Despite evidence that demographics influence the use of pharmacotherapy in smoking cessation, there is limited and contradictory information regarding how psychiatric and chronic medical illnesses affect pharmacotherapy use. Administrative data were used to determine trends and patient characteristics of those receiving pharmacotherapy to aid in smoking cessation in the Veterans Health Administration. From 2004 to 2013, pharmacotherapy use increased from 13.8% to 25.6% of current smokers. Factors associated with increased pharmacotherapy initiation were psychiatric disorders, chronic pulmonary disease, peripheral vascular disorders, and younger age. Veterans with schizophrenia or other psychosis, males, Hispanics, and most medical conditions were less likely to receive pharmacotherapy.

Importance/UNASSIGNED:Prostate cancer imaging rates appear to vary by health care setting. With the recent extension of the Veterans Access, Choice, and Accountability Act, the government has provided funds for veterans to seek care outside the Veterans Health Administration (VA). It is important to understand the difference in imaging rates and subsequent differences in patterns of care in the VA vs a traditional fee-for-service setting such as Medicare. Objective/UNASSIGNED:To assess the association between prostate cancer imaging rates and a VA vs fee-for-service health care setting. Design, Setting, and Participants/UNASSIGNED:This cohort study included data for men who received a diagnosis of prostate cancer from January 1, 2004, through March 31, 2008, that were collected from the VA Central Cancer Registry, linked to administrate claims and Medicare utilization records, and the Surveillance, Epidemiology, and End Results Program database. Three distinct nationally representative cohorts were constructed (use of VA only, use of Medicare only, and dual use of VA and Medicare). Men older than 85 years at diagnosis and men without high-risk features but missing any tumor risk characteristic (prostate-specific antigen, Gleason grade, or clinical stage) were excluded. Analysis of the data was completed from March 2016 to February 2018. Exposures/UNASSIGNED:Patient utilization of different health care delivery systems. Main Outcomes and Measures/UNASSIGNED:Rates of prostate cancer imaging were analyzed by health care setting (Medicare only, VA and Medicare, and VA only) among patients with low-risk prostate cancer and patients with high-risk prostate cancer. Results/UNASSIGNED:Of 98 867 men with prostate cancer (77.4% white; mean [SD] age, 70.26 [7.48] years) in the study cohort, 57.3% were in the Medicare-only group, 14.5% in the VA and Medicare group, and 28.1% in the VA-only group. Among men with low-risk prostate cancer, the Medicare-only group had the highest rate of guideline-discordant imaging (52.5%), followed by the VA and Medicare group (50.9%) and the VA-only group (45.9%) (P < .001). Imaging rates for men with high-risk prostate cancer were not significantly different among the 3 groups. Multivariable analysis showed that individuals in the VA and Medicare group (risk ratio [RR], 0.87; 95% CI, 0.76-0.98) and VA-only group (RR, 0.79; 95% CI, 0.67-0.92) were less likely to receive guideline-discordant imaging than those in the Medicare-only group. Conclusions and Relevance/UNASSIGNED:The results of this study suggest that patients with prostate cancer who use Medicare rather than the VA for health care could experience more utilization of health care services without an improvement in the quality of care.