Faculty Bibliography

INTRODUCTION: Little is known about the pattern of electronic cigarette (e-cigarette) use over time or among smokers with medical comorbidity. METHODS: We assessed current cigarette smokers' use of e-cigarettes during the 30 days before admission to 9 hospitals in 5 geographically dispersed US cities: Birmingham, AL; Boston, MA; Kansas City, KS; New York, NY; and Portland, OR. Each hospital was conducting a randomized controlled trial as part of the NIH-sponsored Consortium of Hospitals Advancing Research on Tobacco (CHART). We conducted a pooled analysis using multiple logistic regression to examine changes in e-cigarette use over time and to identify correlates of e-cigarette use. RESULTS: Among 4,660 smokers hospitalized between July 2010 and December 2013 (mean age 57 years, 57% male, 71% white, 56% some college, average 14 cigarettes/day), 14% reported using an e-cigarette during the 30 days before admission. The prevalence of e-cigarette use increased from 1.1% in 2010 to 10.3% in 2011, 10.2% in 2012, and 18.4% in 2013; the increase was statistically significant (p < .0001) after adjustment for age, sex, education, and CHART study. Younger, better educated, and heavier smokers were more likely to use e-cigarettes. Smokers who were Hispanic, non-Hispanic black, and who had Medicaid or no insurance were less likely to use e-cigarettes. E-cigarette use also varied by CHART project and by geographic region. CONCLUSIONS: E-cigarette use increased substantially from 2010 to 2013 among a large sample of hospitalized adult cigarette smokers. E-cigarette use was more common among heavier smokers and among those who were younger, white, and who had higher socioeconomic status.

Few published studies describe processes in the development of mobile health interventions. This study reports data from a formative evaluation of a text messaging intervention being developed to increase adherence to smoking cessation medication (varenicline) among tobacco-dependent persons with HIV/AIDS. Four focus groups were conducted (N = 29) using a mixed-methods approach to assess: (a) beliefs and preferences regarding the use of varenicline, (b) preferences for receiving tobacco-related texts, and (c) the acceptability of draft text messages. Themes that emerged from the focus groups were that (a) participants were cautious and wanted to discuss varenicline carefully with health care providers, (b) participants preferred simple messages that were positive and encouraging, (c) messages should emphasize tobacco cessation and not varenicline adherence, and (d) texts would serve as a reminder about goals and foster support and connectedness with the health care team. Overall, 47 out of the 100 messages received a grade of C or less (rated on a 5-point grade scale: A, B, C, D, or F), the majority of which focused on medication adherence. All participants reported that they were likely to read the messages. The majority (64%) indicated that they preferred receiving 2 or more messages per day. Gathering systematic participant feedback provides critical input in intervention planning.

BACKGROUND: Obesity affects 37 % of patients at Veterans Health Administration (VHA) medical centers. The VHA offers an intensive weight management program (MOVE!) but less than 10 % of eligible patients ever attend. However, VHA patients see their primary care provider about 3.6 times per year, supporting the development of primary care-based weight management interventions. To address gaps in the literature regarding Veterans' experiences with weight management and determine whether and how to develop a primary care-based weight management intervention to both improve obesity counseling and increase attendance to MOVE!, we conducted a qualitative study to assess: 1) Veterans' personal experiences with healthy weight-related behavior change (including barriers and facilitators to behavior change and experiences with primary care providers, staff, and the MOVE! program), and 2) potential new approaches to improve weight management within primary care at the VHA including goal setting and technology. METHODS: Overweight/obese VHA patients (aged 18-75, BMI greater than 30 or greater than 25 with at least 1 co-morbidity) were recruited for focus group sessions stratified by gender, MOVE! referral, and attendance. Each session was facilitated by a trained moderator, audio-recorded, and professionally transcribed. Using an iterative coding approach, two coders separately reviewed and coded transcripts, and met frequently to negotiate codes and synthesize emerging themes. RESULTS: Of 161 eligible patients, 54 attended one of 6 focus groups (2 female, 4 male, 9-11 participants per session): 63 % were male, 46 % identified as African-American, 32 % White/Caucasian, 74 % were college-educated or higher, and 61 % reported having attended MOVE!. We identified two major themes: Impact of Military Service and Promotion and Sustainability of Healthy Behaviors. After service in a highly structured military environment, Veterans had difficulty maintaining weight on their own. They perceived physical activity as having more impact than diet, but chronic pain was a barrier. We identified individual/interpersonal-, community/environment-, and healthcare system-related factors affecting healthy behaviors. We also received input about Veteran's preferences and experiences with technology and setting health goals. CONCLUSIONS: Unique factors influence weight management in Veterans. Findings will inform development of a technology-assisted weight management intervention with tailored counseling and goal-setting within primary care at the VHA.

BACKGROUND: Persons with a mental health diagnosis have high rates of tobacco use and face numerous barriers to cessation including high levels of nicotine dependence, low rates of tobacco treatment referrals from mental health providers, and limited availability of tobacco treatment targeted to their needs. This manuscript describes the rationale and methods of a clinical trial with the following aims: 1) Compare the reach and efficacy of a proactive telephone-based tobacco cessation program for Veterans Health Administration (VHA) mental health clinic patients to VHA usual care and 2) Model longitudinal associations between baseline patient characteristics and long-term abstinence. METHODS/DESIGN: We will use the electronic medical record to identify patients across four VHA healthcare facilities who have a clinical reminder code indicating current tobacco use in the past six months and who have had a mental health clinic visit in the past 12 months. We will send each patient an introductory letter and baseline survey. Survey respondents (N = 3840) will be randomized in a 1:1 fashion to intervention or control. Control participants will receive VHA usual care. Intervention participants will receive proactive motivational telephone outreach to offer tobacco treatment. Intervention participants interested in treatment will receive eight weeks of nicotine replacement therapy plus eight sessions of specialized telephone counseling over two months, followed by monthly maintenance counseling for four months. We will conduct telephone surveys with participants at six and 12 months to assess study outcomes. We will collect a mailed saliva sample from patients reporting 7-day abstinence on the telephone surveys. The primary outcome will be cotinine-validated abstinence at 12-month follow-up. DISCUSSION: Mental health patients are a high-risk smoking population with significant barriers to cessation. This study will evaluate the efficacy of a program that proactively reaches out to smokers with a mental health treatment history to engage them into telephone cessation counseling targeted to the needs of mental health patients. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01737281 (registered November 5, 2012).

Objectives. We examined whether a proactive care smoking cessation intervention designed to overcome barriers to treatment would be especially effective at increasing cessation among African Americans receiving care in the Veterans Health Administration. Methods. We analyzed data from a randomized controlled trial, the Veterans Victory over Tobacco study, involving a population-based electronic registry of current smokers (702 African Americans, 1569 Whites) and assessed 6-month prolonged smoking abstinence at 1 year via a follow-up survey of all current smokers. We also examined candidate risk adjustors for the race effect on smoking abstinence. Results. The interaction between patient race and intervention condition (proactive care vs usual care) was not significant. Overall, African Americans had higher quit rates than Whites (13% vs 9%; P < .006) regardless of condition. Conclusions. African Americans quit at higher rates than Whites. These findings may be a result of the large number of veterans receiving smoking cessation services and the lack of racial differences in receipt of these services as well as racial differences in smoking history, self-efficacy, and motivation to quit that favor African Americans.

The purpose of this review is to examine the rapidly expanding literature regarding the effects of prenatal tobacco and postnatal secondhand smoke (SHS) exposure on child health and development. Mechanisms of SHS exposure are reviewed, including critical periods during which exposure to tobacco products appears to be particularly harmful to the developing fetus and child. The biological, biochemical, and neurologic effects of the small fraction of identified components of SHS are described. Research describing these adverse effects of both in utero and childhood exposure is reviewed, including findings from both animal models and humans. The following adverse physical outcomes are discussed: sudden infant death syndrome, low birth weight, decreased head circumference, respiratory infections, otitis media, asthma, childhood cancer, hearing loss, dental caries, and the metabolic syndrome. In addition, the association between the following adverse cognitive and behavioral outcomes and such exposures is described: conduct disorder, attention-deficit/hyperactivity disorder, poor academic achievement, and cognitive impairment. The evidence supporting the adverse effects of SHS exposure is extensive yet rapidly expanding due to improving technology and increased awareness of this profound public health problem. The growing use of alternative tobacco products, such as hookahs (a.k.a. waterpipes), and the scant literature on possible effects from prenatal and secondhand smoke exposure from these products are also discussed. A review of the current knowledge of this important subject has implications for future research as well as public policy and clinical practice.

OBJECTIVES: Prevalence of hookah use is increasing significantly among adolescents. This study aimed to delineate demographic and socioeconomic correlates of hookah use among high school seniors in the United States. We hypothesized that more impoverished adolescents and those who smoked cigarettes would be more likely to use hookahs.METHODS: Data were examined for 5540 high school seniors in Monitoring the Future (years 2010-2012), an annual nationally representative survey of high school students in the United States. Using data weights provided by Monitoring the Future, we used multivariable binary logistic regression to delineate correlates of hookah use in the last 12 months.RESULTS: Eighteen percent of students reported hookah use in the past year. Compared with white students, black students were at lower odds for use (adjusted odds ratio [AOR] = 0.27, P < .0001). High parent education increased the odds for use (AOR = 1.58, P < .001), and student weekly income from a job of >$50/week (AOR = 1.26, P < .05) or $11 to $50 per week from other sources (AOR = 1.35, P < .01) also increased odds for use. Males and urban students were also at higher odds for use, as were users of alcohol, marijuana, and other illicit substances. Former cigarette smokers were at higher risk, and current smokers were at highest risk for use.CONCLUSIONS: Adolescents of higher socioeconomic status appear to be at particularly high risk for hookah use in the United States. Prevention efforts must target this group as prevalence continues to increase.

BACKGROUND: Standardized Patients (SPs) are actors trained to portray health care patients during the training and assessment of health care providers. This paper describes the methods and costs associated with using SPs to evaluate the skills of telephone counselors working on a clinical trial that evaluated a telephone smoking cessation program tailored for smokers using Department of Veterans Affairs mental health clinics. FINDINGS: Conducting the SP exercises required five main steps: (1) Write a SP case description detailing patient demographics, demeanor, clinical symptoms and history, and instructions on how to respond to counseling, (2) Identify, select and train actors to portray the SP cases; (3) Conduct audio-taped counseling encounters between the SPs and counselors, (4) Rate the counselors on their core counseling competencies, (5) Provide feedback to counselors. The SPs and study supervisors reported that the checklist was easy to use when rating the counselors. Counselors reported that the SP encounters were realistic and helpful for practicing their clinical work and for building self-efficacy for working with real patients. The labor costs of developing two SP cases and training two SP actors was approximately $1,475. The per-session labor cost of conducting a 1-hour counseling session between one SP and one counselor was approximately $314. CONCLUSIONS: Using SPs to train telephone counselors working on a clinical trial was feasible and offered training benefits beyond those provided by didactic instruction and role plays. Our research group is now routinely using SPs for the training of incoming telephone counselors.

IMPORTANCE Current tobacco use treatment approaches require smokers to request treatment or depend on the provider to initiate smoking cessation care and are therefore reactive. Most smokers do not receive evidence-based treatments for tobacco use that include both behavioral counseling and pharmacotherapy. OBJECTIVE To assess the effect of a proactive, population-based tobacco cessation care model on use of evidence-based tobacco cessation treatments and on population-level smoking cessation rates (ie, abstinence among all smokers including those who use and do not use treatment) compared with usual care among a diverse population of current smokers. DESIGN, SETTING, AND PARTICIPANTS The Veterans Victory Over Tobacco Study, a pragmatic randomized clinical trial involving a population-based registry of current smokers aged 18 to 80 years. A total of 6400 current smokers, identified using the Department of Veterans Affairs (VA) electronic medical record, were randomized prior to contact to evaluate both the reach and effectiveness of the proactive care intervention. INTERVENTIONS Current smokers were randomized to usual care or proactive care. Proactive care combined (1) proactive outreach and (2) offer of choice of smoking cessation services (telephone or in-person). Proactive outreach included mailed invitations followed by telephone outreach to motivate smokers to seek treatment with choice of services. MAIN OUTCOMES AND MEASURES The primary outcome was 6-month prolonged smoking abstinence at 1 year and was assessed by a follow-up survey among all current smokers regardless of interest in quitting or treatment utilization. RESULTS A total of 5123 participants were included in the primary analysis. The follow-up survey response rate was 66%. The population-level, 6-month prolonged smoking abstinence rate at 1 year was 13.5% for proactive care compared with 10.9% for usual care (P = .02). Logistic regression mixed model analysis showed a significant effect of the proactive care intervention on 6-month prolonged abstinence (odds ratio [OR], 1.27 [95% CI, 1.03-1.57]). In analyses accounting for nonresponse using likelihood-based not-missing-at-random models, the effect of proactive care on 6-month prolonged abstinence persisted (OR, 1.33 [95% CI, 1.17-1.51]). CONCLUSIONS AND RELEVANCE Proactive, population-based tobacco cessation care using proactive outreach to connect smokers to evidence-based telephone or in-person smoking cessation services is effective for increasing long-term population-level cessation rates. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00608426.