Faculty Bibliography

OBJECTIVES: We conducted two parallel studies evaluating the effectiveness of proactive and reactive engagement approaches to telephone treatment for smoking cessation. METHODS: Patients who smoked and were interested in quitting were referred to this study and were eligible if they were current smokers and had an address and a telephone number. The data were collected at 35 Department of Veterans Affairs (VA) sites, part of four VA medical centres in both California and Nevada. In study 1, participants received multisession counselling from the California Smokers' Helpline (quitline). In study 2, they received self-help materials only. Patients were randomly assigned by week to either proactive or reactive engagement, and primary care staff were blind to this assignment. Providers gave brief advice and referred them via the electronic health record to a tobacco co-ordinator. All patients were offered cessation medications. OUTCOME: Using complete case analysis, in study 1 (quitline), patients in the proactive condition were more likely than those in the reactive condition to report abstinence at 6 months (21.0% vs 16.4%, p=0.03). No difference was found between conditions in study 2 (self-help) (16.9% vs 16.5%, p=0.88). Proactive outreach resulted in increased use of cessation medications in both the quitline (70.1% vs 57.6%, p<0.0001) and the self-help studies (74.5% vs 48.2%, p<0.0001). CONCLUSION: Proactive outreach with quitline intervention was associated with greater long-term abstinence. Both studies resulted in high rates of medication use. Sites should use a proactive outreach approach and provide counselling whenever possible. TRIAL REGISTRATION NUMBER: NCT00123682.

INTRODUCTION: Individuals with (vs. without) mental illness use tobacco at higher rates and have more difficulty quitting. Treatment models for smokers with mental illness are needed. METHODS: This secondary analysis of the Victory Over Tobacco study [a pragmatic randomized clinical trial (N=5123) conducted in 2009-2011 of Proactive Care (proactive outreach plus connection to smoking cessation services) vs. Usual Care] tests the effectiveness of treatment assignment in participants with and without a mental health diagnosis on population-level, 6month prolonged abstinence at one year follow-up. RESULTS: Analyses conducted in 2015-6 found that there was no interaction between treatment group and mental health group on abstinence (F(1,3300=1.12, p=0.29)). Analyses stratified by mental health group showed that those without mental illness, assigned to Proactive Care, had a significantly higher population-level abstinence rate than those assigned to Usual Care (OR=1.40, 95% CI=1.17-1.67); in those with mental illness, assignment to Proactive Care produced a non-significant increase in abstinence compared to Usual Care (OR=1.18, 95% CI=0.98-1.41). Those with mental illness reported more medical visits, cessation advice and treatment (p<0.001), similar levels of abstinence motivation (p>0.05), but lower abstinence self-efficacy (p<0.001). CONCLUSIONS: Those with a mental health diagnosis benefitted less from proactive outreach regarding tobacco use. VA primary care patients with mental illness may not need additional outreach because they are connected to cessation resources during medical appointments. This group may also require more intensive cessation interventions targeting self-efficacy to improve cessation rates. Clinicaltrials.gov registration # NCT00608426.

INTRODUCTION/BACKGROUND:Self-reported tobacco use in the United Arab Emirates is among the highest in the region. Use of tobacco products other than cigarettes is widespread, but little is known about specific behavior use patterns. There have been no studies that have biochemically verified smoking status. METHODS:The UAE Healthy Future Study (UAEHFS) seeks to understand the causes of non-communicable diseases through a 20,000-person cohort study. During the study pilot, 517 Emirati nationals were recruited to complete a questionnaire, provide clinical measurements and biological samples. Complete smoking data were available for 428 participants. Validation of smoking status via cotinine testing was conducted based on complete questionnaire data and matching urine samples for 399 participants, using a cut-off of 200ng/ml to indicate active smoking status. RESULTS:Self-reported tobacco use was 36% among men and 3% among women in the sample. However, biochemical verification of smoking status revealed that 42% men and 9% of women were positive for cotinine indicating possible recent tobacco use. Dual and poly-use of tobacco products was fairly common with 32% and 6% of the sample reporting respectively. CONCLUSIONS:This is the first study in the region to biochemically verify tobacco use self-report data. Tobacco use in this study population was found to be higher than previously thought, especially among women. Misclassification of smoking status was more common than expected. Poly-tobacco use was also very common. Additional studies are needed to understand tobacco use behaviors and the extent to which people may be exposed to passive tobacco smoke. IMPLICATIONS/CONCLUSIONS:This study is the first in the region to biochemically verify self-reported smoking status.

United States Veterans are at excess risk for type 2 diabetes, but population differentials in risk have not been characterized. We determined risk of type 2 diabetes in relation to prediabetes and dyslipidemic profiles in Veterans at the VA New York Harbor (VA NYHHS) during 2004-2014. Prediabetes was based on American Diabetes Association hemoglobin A1c (HbA1c) testing cut-points, one of several possible criteria used to define prediabetes. We evaluated transition to type 2 diabetes in 4,297 normoglycemic Veterans and 7,060 Veterans with prediabetes. Cox proportional hazards regression was used to relate HbA1c levels, lipid profiles, demographic, anthropometric and comorbid cardiovascular factors to incident diabetes (Hazard Ratio [HR] and 95% confidence intervals). Compared to normoglycemic Veterans (HbA1c: 5.0-5.6%; 31-38 mmol/mol), risks for diabetes were >2-fold in the moderate prediabetes risk group (HbA1c: 5.7-5.9%; 39-41 mmol/mol) (HR 2.37 [1.98-2.85]) and >5-fold in the high risk prediabetes group (HbA1c: 6.0-6.4%; 42-46 mmol/mol) (HR 5.59 [4.75-6.58]). Risks for diabetes were increased with elevated VLDL (≥40mg/dl; HR 1.31 [1.09-1.58]) and TG/HDL (≥1.5mg/dl; HR 1.34 [1.12-1.59]), and decreased with elevated HDL (≥35mg/dl; HR 0.80 [0.67-0.96]). Transition to diabetes in Veterans was related in age-stratified risk score analyses to HbA1c, VLDL, HDL and TG/HDL, BMI, hypertension and race, with 5-year risk differentials of 62% for the lowest (5-year risk, 13.5%) vs. the highest quartile (5-year risk, 21.9%) of the risk score. This investigation identified substantial differentials in risk of diabetes in Veterans, based on a readily-derived risk score suitable for risk stratification for type 2 diabetes prevention.

AIMS: To estimate the prevalence and predictors of failed biochemical verification of self-reported abstinence among participants enrolled in trials of hospital-initiated smoking cessation interventions. DESIGN: Comparison of characteristics between participants who verified and those who failed to verify self-reported abstinence. SETTINGS: Multi-site randomized clinical trials conducted between 2010 and 2014 in hospitals throughout the United States. PARTICIPANTS: Recently hospitalized smokers who reported tobacco abstinence 6 months post-randomization and provided a saliva sample for verification purposes (n = 822). MEASUREMENTS: Outcomes were salivary cotinine-verified smoking abstinence at 10 and 15 ng/ml cut-points. Predictors and correlates included participant demographics and tobacco use; hospital diagnoses and treatment; and study characteristics collected via surveys and electronic medical records. FINDINGS: Usable samples were returned by 69.8% of the 1178 eligible trial participants who reported 7-day point prevalence abstinence. The proportion of participants verified as quit was 57.8% [95% confidence interval (CI) = 54.4, 61.2; 10 ng/ml cut-off] or 60.6% (95% CI = 57.2, 63.9; 15 ng/ml). Factors associated independently with verification at 10 ng/ml were education beyond high school education [odds ratio (OR) = 1.51; 95% CI = 1.07, 2.11], continuous abstinence since hospitalization (OR = 2.82; 95% CI = 2.02, 3.94), mailed versus in-person sample (OR = 3.20; 95% CI = 1.96, 5.21) and race. African American participants were less likely to verify abstinence than white participants (OR = 0.64; 95% CI = 0.44, 0.93). Findings were similar for verification at 15 ng/ml. Verification rates did not differ by treatment group. CONCLUSIONS: In the United States, high rates (40%) of recently hospitalized smokers enrolled in smoking cessation trials fail biochemical verification of their self-reported abstinence.

Aims/UNASSIGNED:The transformation of the United Arab Emirates (UAE) from a semi-nomadic to a high income society has been accompanied by increasing rates of obesity and Type 2 diabetes mellitus. We examined if the AGE-RAGE (receptor for advanced glycation endproducts) axis is associated with obesity and diabetes mellitus in the pilot phase of the UAE Healthy Futures Study (UAEHFS). Methods/UNASSIGNED:517 Emirati subjects were enrolled and plasma/serum levels of AGE, carboxy methyl lysine (CML)-AGE, soluble (s)RAGE and endogenous secretory (es)RAGE were measured along with weight, height, waist and hip circumference (WC/HC), blood pressure, HbA1c, Vitamin D levels and routine chemistries. The relationship between the AGE-RAGE axis and obesity and diabetes mellitus was tested using proportional odds models and linear regression. Results/UNASSIGNED:After covariate adjustment, AGE levels were significantly associated with diabetes status. Levels of sRAGE and esRAGE were associated with BMI and levels of sRAGE were associated with WC/HC. Conclusions/UNASSIGNED:The AGE-RAGE axis is associated with diabetes status and obesity in this Arab population. Prospective serial analysis of this axis may identify predictive biomarkers of obesity and cardiometabolic dysfunction in the UAEHFS.

Medical-legal partnerships-collaborations between legal professionals and health care providers that help patients address civil legal problems that can affect health and well-being-have been implemented at several Veterans Affairs (VA) medical centers to serve homeless and low-income veterans with mental illness. We describe the outcomes of veterans who accessed legal services at four partnership sites in Connecticut and New York in the period 2014-16. The partnerships served 950 veterans, who collectively had 1,384 legal issues; on average, the issues took 5.4 hours' worth of legal services to resolve. The most common problems were related to VA benefits, housing, family issues, and consumer issues. Among a subsample of 148 veterans who were followed for one year, we observed significant improvements in housing, income, and mental health. Veterans who received more partnership services showed greater improvements in housing and mental health than those who received fewer services, and those who achieved their predefined legal goals showed greater improvements in housing status and community integration than those who did not. Medical-legal partnerships represent an opportunity to expand cross-sector, community-based partnerships in the VA health care system to address social determinants of mental health.

OBJECTIVE: To investigate the state-specific prevalence, regional differences and correlates of hookah use among US adults. METHODS: We analyzed the most recent nationally representative data of adults from the National Adult Tobacco Survey (NATS) 2012-2013 (n=60,192). State-specific prevalence of lifetime and current hookah use were calculated and mapped. Multivariate logistic regression was performed to determine the association between socio-demographic characteristics, regional differences, and hookah use. RESULTS: Among US adults (>/= 18 years), overall prevalence of lifetime hookah use was 12.3%, while current use was 3.9%. Mapping of state-specific prevalence revealed that the West tended to have higher rates of use, while the South tended to have lower ones. In the adjusted model, we observed that current hookah use was positively associated with younger adults, males, non-Hispanic adults, those with higher education and income statuses, being single, those living in the West, and current cigarette use. CONCLUSION: The prevalence of hookah use varies by state, region, and socio-demographic characteristics among adults. Future research, including longitudinal studies, are needed to identify geographic and socio-demographic characteristics and trends among hookah users, investigate hookah-related health outcomes, and evaluate targeted public health efforts aimed at this emerging threat. IMPLICATIONS: This study investigates state-level prevalence, regional differences and socio-demographic characteristics of hookah use among US adults, using the most recent National Adult Tobacco Survey (NATS). Hookah use was positively associated with younger adults, and those living in the West. This study adds to the understanding of the geographic and socio-demographic factors underlying hookah use, which can be used to develop much needed evidence-based regulations and programs that are responsive to the needs of different risk groups.

BACKGROUND: Tobacco use continues to be the leading cause of preventable death worldwide. OBJECTIVE: To assess perceived tobacco educational preparation of undergraduate and graduate nurses in a large urban university. DESIGN: A cross-sectional web-based survey of all nursing students in an urban college of nursing was conducted to assess perceived tobacco educational content, skills, and self-efficacy for cessation counseling with patients who smoke cigarettes and use alternative tobacco products (e.g., hookah and e-cigarettes). RESULTS: Participants reported the most education about health effects of tobacco use (67%), and less than 6% reported education about alternative tobacco products. While the majority of nurses agreed that advising patients to quit is a priority, less than 40% reported receiving sufficient training in cessation counseling. CONCLUSIONS: There continues to be a compelling need articulated by leaders in tobacco policy and research over the past decade for a more vigorous response by nurses to the tobacco epidemic.