Faculty Bibliography

INTRODUCTION: Electronic medical records represent a new source of longitudinal data on tobacco use. METHODS: Electronic medical records of the U.S. Department of Veterans Affairs were extracted to find patients' tobacco use status in 2009 and at another assessment 12-24 months later. Records from the year prior to the first assessment were used to determine patient demographics and comorbidities. These data were analyzed in 2015. RESULTS: An annual quit rate of 12.0% was observed in 754,504 current tobacco users. Adjusted tobacco use prevalence at follow-up was 3.2% greater with alcohol use disorders at baseline, 1.9% greater with drug use disorders, 3.3% greater with schizophrenia, and lower in patients with cancer, heart disease, and other medical conditions (all differences statistically significant with p<0.05). Annual relapse rates in 412,979 former tobacco users were 29.6% in those who had quit for <1 year, 9.7% in those who had quit for 1-7 years, and 1.9% of those who had quit for >7 years. Among those who had quit for <1 year, adjusted relapse rates were 4.3% greater with alcohol use disorders and 7.2% greater with drug use disorders (statistically significant with p<0.05). CONCLUSIONS: High annual cessation rates may reflect the older age and greater comorbidities of the cohort or the intensive cessation efforts of the U.S. Department of Veterans Affairs. The lower cessation and higher relapse rates in psychiatric and substance use disorders suggest that these groups will need intensive and sustained cessation efforts.

PURPOSE: In 2015, both ASCO and the European Society for Medical Oncology (ESMO) proposed frameworks to quantify the benefit of antineoplastic drugs in the face of rising costs. We applied these frameworks to drugs approved by the US Food and Drug Administration over the past 12 years and examined relationships between costs and benefits. METHODS: We searched FDA.gov for drugs that received initial approval for solid tumors from 2004 to 2015 and calculated the ASCO Net Health Benefit version 2016 (NHB16) and 2015 (NHB15) and the ESMO Magnitude of Clinical Benefit Scale scores for each drug. We calculated descriptive statistics and explored correlations and associations among benefit scores, cost, and independent variables. RESULTS: We identified 55 drug approvals supported by phase II (18.2%) and III (81.8%) trials, with primary outcomes of overall survival (36.4%), progression-free survival (43.6%), or response rate (20.0%). No significant association was found between NHB16 and year of approval ( P = .81), organ system ( P = .20), or trial comparator arm ( P = .17), but trials with progression-free survival outcomes were associated with higher scores ( P = .007). Both NHB15 and Magnitude of Clinical Benefit Scale scores were approximately normally distributed, but only a moderate correlation existed between them ( r = 0.40, P = .006). No correlation between benefit score and cost (NHB16, r = 0.19; ESMO, r = -0.07) was found. Before 2010, two (15.3%) of 13 approved drugs exceeded $500/NHB point x month compared with 10 (25.0%) of 40 drugs subsequently approved. CONCLUSION: Our analysis of the ASCO and ESMO value frameworks illuminates the heterogeneous benefit of new medications and highlights challenges in constructing a unified concept of drug value. Drug benefit does not correlate with cost, and the number of high cost/benefit outliers has increased.

Numerous epidemiological accounts suggest that waterpipe smoking (aka hookah, shisha, narghile) has become a global phenomenon, especially among youth. The alarming spread of waterpipe and accumulating evidence of its addictive and harmful effects represent a new threat in the global fight to limit tobacco-related morbidity and mortality. In response to waterpipe's alarming trends, major public health and tobacco control organisations have started or are considering systematic collection of data about waterpipe smoking to monitor its trends and assess its harmful effects in different societies. Such plans require coordination and agreement on epidemiological measurement tools that reflect the uniqueness of this tobacco use method, and at the same time allow comparison of waterpipe trends across time and place, and with other tobacco use methods. We started a decade ago our work to develop standardised measures and definitions for the assessment of waterpipe smoking in epidemiological studies. In this communication, we try to expand and update these assessment tools in light of our increased knowledge and understanding of waterpipe use patterns, its context and marketing, as well as the need for evidence-guided policies and regulations to curb its spread. We have assembled for this purpose a group of leading waterpipe researchers worldwide, and worked through an iterative process to develop the suggested instruments and definitions based on what we know currently about the waterpipe epidemic. While the suggested measures are by no means comprehensive, we hope that they can provide the building blocks for standard and comparable surveillance of waterpipe smoking globally.

Significance: Limited data exist regarding tobacco and nicotine containing product (TNCP) use and their association with other drugs of abuse in high-risk settings. The purpose of this study was to examine the associations between TNCP use and other common illicit drug use among adults attending Electronic Dance Music (EDM) parties at nightclubs and festivals in New York City (NYC).
Method(s): Adults (age 18-40) were recruited outside of EDM events in NYC between May and August 2016 and completed a computer-assisted personal interview on a tablet. The survey took approximately 10 minutes and queried sociodemographic characteristics, and self-reported use of TNCPs (e-cigarettes, hookah, and "tobacco") and other drugs. Among recent (12-month) TNCP users, we compared illicit drug use according to the number of TNCPs reportedly used with the use of 1 TNCP representing mono-use, any 2 representing dual-use, and all 3 representing poly-use.
Result(s): More than half the overall sample (54%; N = 524 of 965) reported past year use of a TNCP. Participants' mean age was (25.1+4.5) years, and 55.2% were male. Almost half (46%) were mono users, 27% were dual TNCP users, and 27% were poly TNCP users. Sociodemographic characteristics were not associated with a number of TNCPs used; however, a number of products was significantly different regarding the past-year use of marijuana, powder cocaine, ecstasy (MDMA, "Molly"), LSD, and psilocybin ("magic mushrooms"). Poly users were more likely to report use of marijuana (94.4% vs 87.9% dual and 68.3% mono; P < 0.001), cocaine (69.2% vs 56.7% dual and 32.1% mono; P < 0.001), ecstasy (65.0% vs 61.0% dual and 49.6% mono; P = 0.007), LSD (46.9% vs 34.8% dual and 19.6% mono; P< 0.001), and psilocybin (44.8% vs 31.2% dual and 16.7% mono; P< 0.001).
Conclusion(s): Among this sample of EDM attendees in NYC, past-year use of TNCPs was strongly associated with the use of illicit drugs suggesting the use of more TNCPs is associated with risky behavior in high-risk settings. A limitation was that "tobacco" included all other TNCPs other than e-cigarettes and hookah. Adults' TNCP use patterns might be indicative of the extent of illicit drug use, especially among those frequenting high-risk settings. Future research needs to probe in the reasons behind the patterns of TNCP use among those in high-risk settings

Medical-legal partnerships (MLPs) represent an innovative service model in which lawyers are integrated into health care teams to address diverse legal problems that affect vulnerable populations. The Veterans Health Administration (VHA) operates the largest safety-net health care system in the country and serves many low-income and disabled veterans who could benefit from MLP services. In this column, the authors describe the development and operations of MLPs at four VHA medical centers that serve veterans who are homeless or who have serious mental illness. The authors also briefly report on the characteristics of 700 veterans served by these MLPs from 2014 to 2016. MLPs can fit within the interdisciplinary, comprehensive system of care provided by VHA, and they offer opportunities to expand VHA-community partnerships to address social determinants of health.

BACKGROUND AND AIMS: The ageing United States (US) population is providing an unprecedented population of older adults who use recreational drugs. We aimed to estimate the trends in the prevalence of past-year use of cannabis, describe the patterns and attitudes, and determine correlates of cannabis use by adults age 50 and older. DESIGN: Secondary analysis of the National Survey on Drug Use and Health survey from 2006 to 2013, a cross-sectional survey given to a nationally representative probability sample of populations living in US households. SETTING: USA. PARTICIPANTS: 47,140 survey respondents age >/=50. MEASURES: Estimates and trends of past-year use of cannabis. FINDINGS: The prevalence of past-year cannabis use among adults age >/=50 significantly increased from 2006/2007 through 2012/2013, with a 57.8% relative increase for adults ages 50-64 (linear trend p < 0.001), and a 250% relative increase for those >/=65 (linear trend p = 0.002). When combining data from 2006 to 2013, 6.9% of older cannabis users met criteria for cannabis abuse or dependence, and the majority of the sample reported perceiving no risk or slight risk associated with monthly cannabis use (85.3%) or weekly use (79%). Past-year users were more likely to be younger, male, non-Hispanic, not have multiple chronic conditions, and use tobacco, alcohol, or other drugs compared with non-past-year cannabis users. Conclusions The prevalence of cannabis use has increased significantly in recent years among US adults >/=50 years of age.

BACKGROUND: As healthcare moves towards technology-driven population health management, clinicians must adopt complex digital platforms to access health information and document care. OBJECTIVES: This study explored information literacy, a set of skills required to effectively navigate population health information systems, among primary care providers in one Veterans' Affairs (VA) medical center. METHODS: Information literacy was assessed during an 8-month randomized trial that tested a population health (panel) management intervention. Providers were asked about their use and comfort with two VA digital tools for panel management at baseline, 16 weeks, and post-intervention. An 8-item scale (range 0-40) was used to measure information literacy (Cronbach's alpha=0.84). Scores between study arms and provider types were compared using paired t-tests and ANOVAs. Associations between self-reported digital tool use and information literacy were measured via Pearson's correlations. RESULTS: Providers showed moderate levels of information literacy (M= 27.4, SD 6.5). There were no significant differences in mean information literacy between physicians (M=26.4, SD 6.7) and nurses (M=30.5, SD 5.2, p=0.57 for difference), or between intervention (M=28.4, SD 6.5) and control groups (M=25.1, SD 6.2, p=0.12 for difference). Information literacy was correlated with higher rates of self-reported information system usage (r=0.547, p=0.001). Clinicians identified data access, accuracy, and interpretability as potential information literacy barriers. CONCLUSIONS: While exploratory in nature, cautioning generalizability, the study suggests that measuring and improving clinicians' information literacy may play a significant role in the implementation and use of digital information tools, as these tools are rapidly being deployed to enhance communication among care teams, improve health care outcomes, and reduce overall costs.

BACKGROUND: Alcohol use is common among older adults, and this population has unique risks with alcohol consumption in even lower amounts than younger persons. No recent studies have estimated trends in alcohol use including binge alcohol use and alcohol use disorders (AUD) among older adults. METHODS: We examined alcohol use among adults age >/=50 in the National Survey on Drug Use and Health (NSDUH) from 2005 to 2014. Trends of self-reported past-month binge alcohol use and AUD were estimated. Logistic regression models were used to examine correlates of binge alcohol use and AUD. RESULTS: The prevalence of both past-month binge alcohol use and AUD increased significantly among adults age >/=50 from 2005/2006 to 2013/2014, with a relative increase of 19.2% for binge drinking (linear trend p<0.001) and a 23.3% relative increase for AUD (linear trend p=0.035). While males had a higher prevalence of binge alcohol use and AUD compared to females, there were significant increases in both among females. In adjusted models of aggregated data, being Hispanic, male, and a smoker or illicit drug user were associated with binge alcohol use, while being male, a smoker, an illicit drug user, or reporting past-year depression or mental health treatment were associated with AUD. CONCLUSIONS: Alcohol use among older adults is increasing in the US, including past-month binge alcohol use and AUD with increasing trends among females. Providers and policymakers need to be aware of these changes to address the increase of older adults with unhealthy drinking.