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Background: Opioid use disorder (OUD) remains a significant health care need for women, particularly those involved in the criminal legal system (CLS). There are no studies to date that focus on the utilization of telehealth as a platform for assessment and linkage to medications to treat opioid use disorder (MOUD) at community re-entry for women, despite the fact that women have unique risk factors that may contribute to opioid relapse in the community. The purpose of this mixed-methods study is to provide an overview of the innovative use of telehealth for linking incarcerated women to community MOUD treatment in the Kentucky-hub of the Justice Community Opioid Innovation Network (JCOIN)., Methods: This study incorporates qualitative and quantitative data collection with MOUD providers, recovery staff involved in peer navigation services, and women who are incarcerated to understand perceptions of the use of telehealth prior to jail release as a linkage to community services., Results: Findings from this study suggest overall support for the use of telehealth between community MOUD treatment providers and women who are incarcerated using videoconferencing technology. On average, there was very little variation in provider favorable feedback related to clinical engagement or in face-to-face comparability, as well as how telehealth allowed the participant to discuss personal and sensitive issues during the clinical assessment., Conclusions: Study findings suggest benefits associated with the use of telehealth in increasing access to treatment for women with OUD. Jails are critical venues for telehealth interventions because they provide the opportunity to reach women who have been actively using illicit substances, often have advanced-stage substance use disorders which have compromised their health and mental health, and often have not been previously identified as needing treatment., Trial Registration: This study was originally registered on 8/23/19, ClinicalTrials.gov, #NCT04069624., (© 2024. The Author(s).)

At the intersection of drug policy, the opioid crisis, and fragmented care systems, persons with opioid use disorder (OUD) in the United States are significantly vulnerable to contact with the criminal legal system (CLS). In CLS settings, provision of evidence-based treatment for OUD is variable and often secondary to punitive approaches. Linkage facilitation at every touch point along the CLS Sequential Intercept Model has potential to redirect persons with OUD into recovery-oriented systems of care, increase evidence-based OUD treatment connections, and therefore reduce CLS re-exposure risk. Research in this area is still nascent. Thus, this narrative review explores the state of the science on linkage facilitation across the varied CLS contexts, including general barriers, facilitators, and opportunities for using linkage facilitation for OUD treatment and related services. Following the CLS Sequential Intercept Model, the specific CLS contexts examined include community services, police encounters, the courts (pre- and post-disposition), incarceration (pre-trial detention, jail, and prison), reentry (from jails, prisons, and unified systems), and community supervision (probation and parole). Examples of innovative linkage facilitation interventions are drawn from the Justice Community Opioid Innovation Network (JCOIN). Areas for future research and policy change are highlighted to advance the science of linkage facilitation for OUD services in the CLS., (© 2024. The Author(s).)

Background: Personal syringe reuse (i.e., reuse of one's own syringes) can place people who inject drugs at increased risk for infectious disease but has received relatively little attention in published literature. The purpose of this study is to identify factors associated with syringe reuse among people who inject drugs in rural Kentucky., Methods: Participants (n = 238) completed interviewer-administered questionnaires on syringe reuse and demographic, behavioral, and service access characteristics. Unadjusted negative binomial regression with cluster-robust standard errors was used to model the associations with a logged offset for number of injections in the past 30 days., Results: The average age of the sample was 35 and 59.7 % were male. Most participants (77.7 %) reused syringes at least once in the past 30 days, using each syringe a median of three times. Reuse was higher among those who were older and reported a higher street price for syringes. Syringe reuse was lower among people who were within walking distance to a syringe service program (SSP) and who obtained most of their syringes from SSPs or pharmacies., Conclusion: Syringe reuse among people who inject drugs in rural Kentucky is common. However, these data suggest that increased access to syringes from SSPs and pharmacies, as well as policy-level interventions that reduce street syringe price, might reduce syringe reuse and related harms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: Many rural communities bear a disproportionate share of drug-related harms. Innovative harm reduction service models, such as vending machines or kiosks, can expand access to services that reduce drug-related harms. However, few kiosks operate in the USA, and their implementation, impact and cost-effectiveness have not been adequately evaluated in rural settings. This paper describes the Kentucky Outreach Service Kiosk (KyOSK) Study protocol to test the effectiveness, implementation outcomes and cost-effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C and overdose risk in rural Appalachia., Methods and Analysis: KyOSK is a community-level, controlled quasi-experimental, non-randomised trial. KyOSK involves two cohorts of people who use drugs, one in an intervention county (n=425) and one in a control county (n=325). People who are 18 years or older, are community-dwelling residents in the target counties and have used drugs to get high in the past 6 months are eligible. The trial compares the effectiveness of a fixed-site, staffed syringe service programme (standard of care) with the standard of care supplemented with a kiosk. The kiosk will contain various harm reduction supplies accessible to participants upon valid code entry, allowing dispensing data to be linked to participant survey data. The kiosk will include a call-back feature that allows participants to select needed services and receive linkage-to-care services from a peer recovery coach. The cohorts complete follow-up surveys every 6 months for 36 months (three preceding kiosk implementation and four post-implementation). The study will test the effectiveness of the kiosk on reducing risk behaviours associated with overdose, HIV and hepatitis C, as well as implementation outcomes and cost-effectiveness., Ethics and Dissemination: The University of Kentucky Institutional Review Board approved the protocol. Results will be disseminated in academic conferences and peer-reviewed journals, online and print media, and community meetings., Trial Registration Number: NCT05657106., Competing Interests: Competing interests: AF-B is a co-founder of Voices of Hope, the contracted recovery community organisation providing the recovery coaching services. The device to facilitate syringe disposal and dispensing that will be installed in conjunction with the kiosk is intellectual property of the University of Kentucky, with AMY designated as the inventor. CC is a paid consultant on the implementation of harm reduction vending machines, including on the described project., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Medication treatment for opioid use disorder (MOUD) decreases opioid overdose risk and is the standard of care for persons with opioid use disorder (OUD). Recovery coach (RC)-led programs and associated training curriculums to improve outcomes around MOUD are limited. We describe our comprehensive training curriculum including instruction and pedagogy for novel RC-led MOUD linkage and retention programs and report on its feasibility., Methods–pedagogy and Training Development: The Kentucky HEALing (Helping to End Addiction Long-term SM ) Communities Study (HCS) created the Linkage and Retention RC Programs with a local recovery community organization, Voices of Hope-Lexington. RCs worked to reduce participant barriers to entering or continuing MOUD, destigmatize and educate on MOUD and harm reduction (e.g., safe injection practices), increase recovery capital, and provide opioid overdose education with naloxone distribution (OEND). An extensive hybrid (in-person and online, both synchronous and asynchronous), inclusive learning-focused curriculum to support the programs (e.g., motivational interviewing sessions, role plays, MOUD competency assessment, etc.,) was created to ensure RCs developed the necessary skills and could demonstrate competency before deployment in the field. The curriculum, pedagogy, learning environment, and numbers of RCs trained and community venues receiving a trained RC are reported, along with interviews from three RCs about the training program experience., Results: The curriculum provides approximately 150 h of training to RCs. From December 2020 to February 2023, 93 RCs and 16 supervisors completed the training program; two were unable to pass a final competency check. RCs were deployed at 45 agencies in eight Kentucky HCS counties. Most agencies (72%) sustained RC services after the study period ended through other funding sources. RCs interviewed reported that the training helped them better explain and dispel myths around MOUD., Conclusion: Our novel training and MOUD programs met a current unmet need for the RC workforce and for community agencies. We were able to train and deploy RCs successfully in these new programs aimed at saving lives through improving MOUD linkage and retention. This paper addresses a need to enhance the training requirements around MOUD for peer support specialists., Competing Interests: AF-B is a co-founder of Voices of Hope. JB is a contracted trainer for Voices of Hope and employed by Arthur Street Hotel, a non-profit harm reduction informed housing program for marginalized populations. SW has served as a scientific advisor/consulting related to novel MOUD development to Astra Zeneca, Cerevel, Titan Pharmaceuticals, and Braeburn Pharmaceuticals. ML has served as a research consultant to Berkshire Biomedical, Braeburn, Journey Colab and Titan Pharmaceuticals in the last 3 years. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Moffitt, Fallin-Bennett, Fanucchi, Walsh, Cook, Oller, Ross, Gallivan, Lauckner, Byard, Wheeler-Crum and Lofwall.)

Recovery coaches are individuals with lived experience with recovery from substance use disorder who typically engender a greater sense of trust than found with other types of healthcare providers. However, there currently are no validated tools that measure the connection between recovery coaches and their participants. The purpose of this study was to describe the initial development of the Scales for Participant Alliance with Recovery Coach (SPARC) to measure recovery coach connection or alliance, including initial psychometric analyses. Measurement development began with five scales of the Client Evaluation of Self Treatment (treatment participation, treatment satisfaction, rapport, peer support, and social support). Adapted items were pre-tested with focus groups ( n = 8) to ensure they were meaningful and accurately reflected the domains (Study 1). After modifications, the SPARC has six scales (engagement, satisfaction, rapport, motivation and encouragement, role model and community linkage). The survey was piloted with 100 individuals (Study 2) age 18 or over who had met with a recovery coach within the last six months. Most study participants were male (60%) and white (87%) with less than two years in recovery. After removing two low performing items, the items for five of the domains had acceptable internal consistency. The items for the engagement domain had a slightly lower reliability. Findings suggest that items cover relevant recovery coach roles, are internally consistent within domains, and can be easily administered to individuals engaging in recovery coaching services. Additional research is needed with a larger, more heterogenous sample to further refine items.

Although informal peer support has been a central feature of recovery for people with substance use disorder (SUD), more recently there has been a stark increase in formal models of peer support. In the infancy of formalized peer support, researchers warned of potential threats to the integrity of the peer support role. Now, almost two decades into the rapid expansion of peer support, research has yet to evaluate the extent to which peer support is being implemented with fidelity and role integrity. The present study aimed to assess peer workers' perceptions of peer role integrity. Qualitative interviews were conducted with 21 peer workers in Central Kentucky. Results suggest that the role of peers is not well understood by onboarding organizations, and thus, the integrity of peer support is diluted. Findings from this study suggest room for improvement in the training, supervision, and implementation of peer support., (© 2023. The Author(s).)

Competing Interests: Declaration of competing interest Amanda Fallin-Bennett is a co-founder and Program Director of Voices of Hope. Alex Elswick is a co-founder and member of the Board of Directors at Voices of Hope.

Background: People with substance use disorders (SUD), especially opioid use disorder (OUD) have the highest rates of unintended pregnancies (80-95%) and report unmet reproductive health needs. Women of childbearing age have some of the highest death rates from opioids and are notably rising the most rapidly, and when pregnancy does occur overdose is one of the leading causes of maternal mortality. There are numerous gender-based health disparities and social determinants of health shaped by the distribution of power and privilege that influence the risk trajectories of people who can get pregnant or are pregnant with a substance use disorder (SUD)., Purpose: The purpose of this paper is to describe how reproductive health is essential to recovery and building recovery capital for people who can get pregnant, (1) introduce a pilot implementation science study working with trained peer support coaches to promote reproductive autonomy in the community, and (2) make policy and advocacy recommendations relevant to the new reproductive health landscape in the United States. We will also describe the adaptation and feasibility of the initial pilot study where we partnered with a recovery community center to train peer recovery coaches to provide low barrier resources (contraception, pregnancy tests and prenatal vitamins) and referrals to health care., Methods: This initiative is the merging of best practices in recovery and community-based global reproductive health, to empower people with SUD who can get pregnant in an implementation science framework. The pilot study will last 3 months in each city and aims to (1) assess and describe the effectiveness of the training of local peer recovery coaches on the link between recovery capital and reproductive health, and (2) assess the feasibility, acceptability, appropriateness, scalability, sustainability, and uptake and reach of low barrier reproductive health resources (pregnancy tests, prenatal vitamins, and emergency contraception). In this paper we are only reporting the initial findings regarding adaptation and feasibility., Findings: Informed by qualitative interviews with stakeholders and participants, the method of contraception was adapted from injectable to emergency to meet the needs and context of the community with SUD. Early outcomes such as uptake and acceptability indicate that this is a feasible model with peer recovery coaches and recovery community centers, with the greatest uptake of emergency contraception and pregnancy tests., Conclusion: Considering recent policies limiting access to reproductive health, innovative community-based solutions are needed to engage and empower people who can get pregnant or are pregnant while in active drug use and in recovery. Providing low barrier reproductive health items by people with lived experience with SUD can serve as a valuable harm reduction model and improve recovery capital., Clinical Relevance: This is the first study to propose a methodology and context to implement a community-based study merging best practices in recovery with those in reproductive health with the potential to improve recovery capital and maternal/child health trajectories for people with SUD., (© 2022 Sigma Theta Tau International.)

Introduction: Opioid-involved overdose deaths continue to surge in many communities, despite numerous evidence-based practices (EBPs) that exist to prevent them. The HEALing Communities Study (HCS) was launched to develop and test an intervention (ie, Communities That HEAL (CTH)) that supports communities in expanding uptake of EBPs to reduce opioid-involved overdose deaths. This paper describes a protocol for a process foundational to the CTH intervention through which community coalitions select strategies to implement EBPs locally., Methods and Analysis: The CTH is being implemented in 67 communities (randomised to receive the intervention) in four states in partnership with coalitions (one per community). Coalitions must select at least five strategies, including one to implement each of the following EBPs: (a) overdose education and naloxone distribution; expanded (b) access to medications for opioid use disorder (MOUD), (c) linkage to MOUD, (d) retention in MOUD and (e) safer opioid prescribing/dispensing. Facilitated by decision aid tools, the community action planning process includes (1) data-driven goal setting, (2) discussion and prioritisation of EBP strategies, (3) selection of EBP strategies and (4) identification of next steps. Following review of epidemiologic data and information on existing local services, coalitions set goals and discuss, score and/or rank EBP strategies based on feasibility, appropriateness within the community context and potential impact on reducing opioid-involved overdose deaths with a focus on three key sectors (healthcare, behavioural health and criminal justice) and high-risk/vulnerable populations. Coalitions then select EBP strategies through consensus or majority vote and, subsequently, suggest or choose agencies with which to partner for implementation., Ethics and Dissemination: The HCS protocol was approved by a central Institutional Review Board (Advarra). Results of the action planning process will be disseminated in academic conferences and peer-reviewed journals, online and print media, and in meetings with community stakeholders., Trial Registration Number: NCT04111939., Competing Interests: Competing interests: Competing interest disclosures include the following: LSM is a consultant for the Boston Public Health Commission, Action for Boston Area development and the Young Foundation, SLW has served as a scientific advisor to Opiant Pharmaceuticals, Titan Pharmaceuticals, Astra Zeneca, Cerevel, Arbor Pharmaceuticals, Brainsway, Summit Biosciences, Trevi and Camurus. JLB ad ML receive investigator-initiated support paid to the institution from Gilead Sciences, Inc. MRL has consulted for Titan Pharmaceuticals and Camurus. AF-B is the Program Director of Voices of Hope, a University of Kentucky HCS partner organisation. PF, HLS, AMY, EO, LMG, RC, JG, CK and LF have no competing interests., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: Justice system-involved women with opioid use disorder (OUD) experience layered health risks and stigma, yet peer navigation services during reentry may support positive outcomes. This manuscript offers a program description of a women's peer navigation intervention delivered pre- and post-release from jail to remove barriers to women's access to OUD treatment, including medications for opioid use disorder (MOUD)., Methods: All data were collected as part of a NIH/NIDA-funded national cooperative, the Justice Community Opioid Innovation Network (JCOIN) project. Through the larger study's intervention, women in jail with OUD are connected via videoconference to a peer navigator, who provides an initial reentry recovery assessment and 12+ weeks of recovery support sessions post-release. Qualitative analyses examined peers' notes from initial sessions with women (N = 50) and in-depth interviews with peers (N = 3)., Results: Peers' notes from initial sessions suggest that women anticipate challenges to successful recovery and community reentry. More than half of women (51.9%) chose OUD treatment as their primary goal, while others selected more basic needs (e.g. housing, transportation). In qualitative interviews, peers described women's transitions to the community as unpredictable, creating difficulties for reentry planning, particularly for rural women. Peers also described challenges with stigma against MOUD and establishing relationships via telehealth, but ultimately believed their role was valuable in providing resource referrals, support, and hope for recovery., Conclusions: For women with OUD, peer navigation can offer critical linkages to services at release from jail, in addition to hope, encouragement, and solidarity. Findings provide important insights for future peer-based interventions., (© The Author(s) 2022.)

Objective: In 2019, the Youth Risk Behavioral Survey (YRBS) collected sexual orientation data for the first time in Kentucky. Tobacco use behaviors and mental health status among Lesbian, Gay, and Bisexual (LGB) youth is infrequently documented in southern states such as Kentucky. This study aimed to analyze self-reported tobacco use and mental health in youth by sexual orientation., Design: Cross-sectional survey., Sample: All participants, aged 12-19, of the 2019 Kentucky YRBS that indicated a sexual orientation., Measurements: Differences in response distributions for tobacco use and mental health measures were analyzed via chi square by sexual orientation, with additional stratification by sex., Results: A total of n = 1996 respondents were 12.8% LGB-identified and 82.1% heterosexual-identified. No disparities between LGB and heterosexual youth were observed in tobacco-related behaviors for male students, but disparities were persistent for female students (p = .005 for "tried tobacco before age 13"; p = .007 for "current smoking", p = .012 for "ever smoked"). Mental health disparities between LGB and heterosexual youth were significant for males and females (p < .05, all mental health measures)., Conclusions: Findings suggest that tobacco disparities in this most recent data are narrower than in previous years; however, mental health disparities persist between LGB and heterosexual youth in Kentucky., (© 2021 Wiley Periodicals LLC.)

Objective: To describe the perceived effects of clinical research and program evaluation on perceptions of clinical care among women with opioid use disorder (OUD) and their health care providers., Design: Qualitative descriptive., Setting: Four specialty clinics in academic medical centers that provide care for pregnant women with OUD., Participants: Women with OUD during pregnancy or the postpartum period ("women participants"; n = 20) and health care providers ("provider participants"; n = 37). All staff in the clinics were invited to participate in focus groups., Methods: We conduced focus groups and interviews with the women and provider participants to understand the perceived effects of clinical research and program evaluation on their perceptions of clinical care among women with OUD. We audio recorded, transcribed, and analyzed sessions using qualitative content analysis., Results: Overall, nine themes emerged from the data. Two themes emerged in common among data from the providers and women data: Demands on Women's Time and Challenging Research Topics. Seven additional themes emerged only from the provider data: Potential to Improve Clinical Practice, FundingOpportunities to Provide Services, Burden to Clinical Flow, Overwhelming Number of Studies, Pressure to Engage in Research, Clinic Level Controls to Reduce Research Burden and Potential for Coercion, and Meaningful Input on the Research Process., Conclusion: Providers and women shared similar opinions about the opportunities and challenges of research focused on women with OUD. Providers suggested ways to improve the integration of research activities into clinical settings., (Copyright © 2021 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Opioid use in the perinatal period has escalated rapidly, with potentially devastating outcomes for perinatal persons and infants. Substance use treatment is effective and has the potential to greatly improve clinical outcomes; however, characteristics of care received from providers including nurses have been described as a barrier to treatment. Our purpose was to describe supportive perinatal care experiences of persons with opioid use disorder. A qualitative descriptive study design was used to examine experiences of 11 postpartum persons (ages 22-36 years) in medication-assisted treatment for opioid use disorder at an academic medical center in the southern region of the United States. Participants were interviewed about experiences with perinatal and neonatal care during the child's hospitalization for neonatal abstinence syndrome surveillance and/or treatment. Four themes of supportive care experiences emerged: informing, relating, accepting, and holistic supporting. Participants reported a range of positive and negative perinatal care experiences, with examples and counterexamples provided. This fuller understanding of perceptions and lived experiences of care can inform practice changes and educational/training priorities. Future research is needed to facilitate development of comprehensive care models geared to address perinatal care needs of persons with opioid use disorder., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

The opioid crisis has disproportionately affected women, but research on approaches to increase initiation of medications for opioid use disorder (MOUD) among women is limited. The Kentucky Justice Community Opioid Innovation Network (JCOIN) will implement a type 1 hybrid effectiveness and implementation trial to examine an innovative MOUD pretreatment model using telehealth (alone and in combination with peer navigators) for justice-involved women in transition from jail to the community. The overall goal of the project is to increase initiation and maintenance of MOUD among high-risk justice-involved women during community reentry to reduce opioid relapse and overdose. This project and other studies through the JCOIN network have the potential to significantly impact the OUD treatment field by contributing empirical evidence about the effectiveness and implementation of innovative technologies to increase initiation and maintenance of MOUD during a critical, high-risk time of community reentry among vulnerable, justice-involved individuals in both urban and nonurban communities., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Opioid use during pregnancy is a significant public health issue. The standard of care for treating opioid use disorder during pregnancy includes medications for opioid disorder (MOUD). However, tobacco use often goes unaddressed among pregnant women on MOUD. In 2018, our team received a National Institute on Drug Abuse (NIDA) funded R34 to conduct a three year-randomized trial to test the feasibility of a novel tobacco intervention for pregnant women receiving MOUD., Aims: The aims of this study are: (1) to determine the impact of the B-EPIC intervention on maternal tobacco use and stage of change; (2) to determine the impact of B-EPIC on tobacco-related maternal and infant health outcomes including gestational age at birth, birthweight, NAS diagnosis and severity, and number of ear and respiratory infections during the first six months; (3) to compare healthcare utilization and costs incurred by pregnant patients that receive the B-EPIC intervention versus TAU., Methods: We plan to enroll 100 pregnant women on MOUD for this randomized controlled trial (B-EPIC intervention n = 50 and treatment as usual n = 50). A major strength of this study is its wide range of health and economic outcomes assessed on mother, neonate and the infant., Conclusions: Despite the very high rates of smoking among pregnant women with OUD, there are few tobacco treatment interventions that have been tailored for this high - risk population. The overall goal of this study is to move towards a tobacco treatment standard for pregnant women receiving treatment for OUD., Competing Interests: 1) We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. 2) We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. 3) We confirm that neither the entire paper nor any of its content has been submitted, published, or accepted by another journal. The paper will not be submitted elsewhere if accepted for publication in the Journal. 4) We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property. 5) We confirm that any aspect of the work covered in this manuscript that has involved either experimental animals or human patients has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript. 6) We understand that the Corresponding Author is the sole contact for the Editorial process (including Editorial Manager and direct communications with the office). He/she is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs., (© 2020 Published by Elsevier Inc.)

Background: Substance use disorders (SUDs) are chronic disorders frequently managed with crisis stabilization or short-term treatment. To improve rates of sustained remission from SUD, there is a need to shift the existing treatment paradigm away from an acute care model and toward a model of ongoing recovery management. Telephone recovery support (TRS) is a promising recovery management tool, consisting of weekly calls from volunteers, including peer workers, to people in recovery to offer support and connect participants with resources. The aim of this study was to evaluate feasibility and acceptability of a TRS program in Central Kentucky, United States., Methods: Participants (n = 506) were recruited for the program from a variety of settings, such as sober living/halfway houses, drug court, residential treatment transitional living, and outpatient and intensive outpatient treatment. For each call, participant status (e.g., experiencing psychosocial stressors, concerned about relapse) was recorded. To assess acceptability, we performed semi-structured interviews with participants (n = 7), which were subsequently transcribed and analyzed via content analysis., Results: Volunteers completed 35.7% of calls (a completed call was defined as either answered or returned) with 88% of participants reporting being okay, 9% reporting psychosocial stressors, and 3% reporting relapse or concerns about relapse. Participants reported that TRS provided a felt sense of support and consistent recovery engagement, and appreciated that volunteers took the initiative to reach out to them. Multiple participants reported a desire to increase the frequency of TRS contact., Conclusion: TRS holds promise as a resource to promote long-term recovery support. More research is needed to determine the efficacy and adequate dosing of TRS calls., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Perinatal opioid use disorder (OUD) has increased drastically since 2000 and is associated with myriad adverse outcomes. The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends using peer support services to promote sustained remission from substance use disorders (SUDs). Integrating peer support specialists into perinatal OUD treatment has the potential to improve maternal and child health. However, there is limited published research on the experiences of pregnant and parenting women with peer support specialists during SUD treatment. The purpose of this study was to: (1) describe experiences of perinatal women undergoing OUD treatment with peer support specialists; (2) describe recommendations for improving or enhancing peer support services. For this qualitative descriptive study, we conducted two focus groups in a private location in a clinic that serves postpartum women with OUD (N = 9) who were parenting a child under the age of 5. The focus groups were voice recorded, professionally transcribed, and analyzed in MAXQDA using content analysis. Four themes emerged from the data: Feeling Supported by Peer Support Specialists, Qualities of an 'Ideal' Peer Support Specialist, Strategies to Improve Interactions with Peer Support Specialists, and Importance of Communication Across the Perinatal Period. Participants reported that PSSs had a strong, positive impact on their recovery. Postpartum women report overall positive experiences receiving peer support services during their pregnancy and postpartum period. However, participants offered suggestions to improve their interactions with PSSs, such as clarifying the boundaries between peer supporters and clients. Pregnant and postpartum women in OUD treatment have the potential to benefit from access to PSS throughout their perinatal period. Future research is needed to determine the impact of PSS on sustained recovery for perinatal women with OUD., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Kentucky Medicaid enrollees, particularly those in the rural Appalachian region, face disproportionate smoking rates and tobacco-related disease burden relative to the rest of the United States (US). The Affordable Care Act (ACA) mandated tobacco cessation treatment coverage by the US public health insurance program Medicaid. Medicaid coverage was also expanded in Kentucky, in 2013, with laxer income eligibility requirements. This short report describes tobacco use incidence and tobacco cessation treatment utilization, comparing by Appalachian status before and after ACA-mandated cessation treatment coverage., Methods: The study design was a retrospective cross-sectional analysis from 2013 to 2015. Subjects were Medicaid enrollees with 1) diagnosis of any tobacco use (2013 n = 541,349; 2014 n = 864,183; 2015 n = 1,090,274); and/or (2) procedure claim for tobacco cessation counseling, and/or (3) pharmaceutical claim for varenicline or any nicotine replacement product. Primary measures included tobacco use incidence and proportion of users receiving cessation treatment. Analysis was via chi square testing of change by year., Results: Overall, the proportion of tobacco users utilizing cessation treatment decreased (4.75% tobacco users in 2013; 3.15% in 2015). Tobacco users receiving counseling decreased from 2.06% pre-ACA (2013) to 1.06% post-ACA (2015, p < 0.001), as did the proportion receiving nicotine replacement products post-ACA (2.69% in 2013 to 1.55% by 2015; p < 0.001). More Appalachians received cessation treatment than non-Appalachians in 2013 (2.72% vs. 2.03%), but by 2015 non-Appalachians received more treatment overall (1.50% vs. 1.65%; p < 0.001). Appalachians received more counseling and NRT, but less varenicline, than non-Appalachians., Conclusions: Utilization of all forms of tobacco cessation treatment throughout Kentucky, and particularly in rural Appalachia, remained limited despite Medicaid enrollment as well as coverage expansions. These findings suggest that barriers persist in access to tobacco cessation treatment for individuals in Medicaid.

Purpose: To describe the practice of e-cigarette marketing to vulnerable populations and to suggest strategies to help reduce e-cigarette use., Conclusions: E-cigarette companies target vulnerable populations through civil rights, freedom marketing, and advertising strategies, which may perpetuate continued tobacco disparities in these populations., Practice Implications: Health care providers have the responsibility as social justice advocates to engage in efforts to reduce e-cigarette use among vulnerable populations. We must increase knowledge, education, and training specific to e-cigarettes. Awareness of marketing strategies related to vulnerable populations is necessary to develop and implement counter strategies., (© 2019 Wiley Periodicals, Inc.)

Purpose: This study aimed to describe lesbian, gay, bisexual, and transgender (LGBT) friendly providers' (1) smoking cessation recommendations to LGBT patients and (2) tobacco treatment practices for transgender patients., Design and Methods: In-depth, semistructured phone interviews were conducted with 13 healthcare providers., Findings: Four overarching themes emerged: (1) providing tobacco treatment services for LGBT patients; (2) barriers to LGBT smoking cessation; (3) prescribing practices for transgender individuals taking estrogen hormone therapy; (4) provider community outreach to promote LGBT smoking cessation., Practice Implications: Holistic tobacco treatment services are needed to address LGBT-specific barriers to tobacco cessation, such as stress, identity-related factors, and inadequate healthcare access., (© 2019 Wiley Periodicals, Inc.)

Purpose: To examine disparities in mental health and high-risk alcohol use among high school students by sexual orientation, and the impact of having access to an adult with whom to talk., Design and Methods: Cross-sectional survey, from the 2015 Kentucky Youth Risk Behavior Survey. Logistic regression estimated the relationship between being "non-heterosexual" on mental health (e.g, suicidal ideation/attempt) and alcohol behaviors (e.g, binge drinking), controlling for demographics and "having an adult to talk to.", Findings: Non-heterosexual students were more likely to report all adverse outcomes and risk was lower among students who report "having an adult to talk to.", Practice Implications: Psychiatric nurses need to assess sexual minority youth for access to positive adult relationships., (© 2019 Wiley Periodicals, Inc.)

Tobacco use is a leading preventable cause of adverse maternal and child health outcomes. However, many women in the United States still report smoking during the third trimester of pregnancy. Smoking rates during pregnancy are particularly high among vulnerable women, such as those who experience mental illness, substance use disorder, homelessness, or interpersonal violence. The Tobacco Control Vaccine is a model based on population-level, evidence-based practices to reduce tobacco use. The four elements of the Tobacco Control Vaccine are access to treatment for tobacco dependence, smoke-free policies, increased tobacco taxes, and media campaigns. The purpose of this commentary is a call to action for health care providers to advocate for increased access to treatment for tobacco dependence; stay up-to-date on innovative, tailored treatment practices; and advocate for comprehensive, smoke-free policies, higher tobacco taxes, and media campaigns to help pregnant women quit smoking and avoid relapse in the postpartum period., (Copyright © 2019 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Women who smoke during pregnancy face psychosocial barriers to cessation, and women with opioid use disorder (OUD) face amplified barriers. We pilot tested a Perinatal Wellness Navigator (PWN) program for a group of high-risk perinatal women ( N = 50; n = 42 with OUD) that consisted of (a) one-on-one tobacco treatment, (b) comprehensive assessment of cessation barriers, and (c) linkage to clinical/social services. Outcome measures were assessed at baseline and postintervention. Participants smoked 10 fewer cigarettes per day ( p = .05) at postintervention and were less dependent on nicotine ( p < .01). Mean postnatal depression scores ( p = .03) and perceived stress ( p = .03) decreased postintervention. Participants received at least one referral at baseline ( n = 106 total), and 10 participants received an additional 18 referrals at postintervention to address cessation barriers. The PWN program was minimally effective in promoting total tobacco abstinence in a high-risk group of perinatal women, but participants experienced reductions in cigarettes smoked per day, nicotine dependence, stress, and depression.

Purpose: This study aims to describe the association of first trimester co-use of tobacco and cannabis with maternal immune response and psychosocial well-being, relative to tobacco use only., Methods: A preliminary midpoint analysis included 138 pregnant women with biologically verified tobacco use, 38 of whom (28%) also tested positive for recent cannabis use. Maternal perceived stress (Perceived Stress Scale), depressive symptoms (Edinburgh Postnatal Depression Scale), and serum immune markers (IL-1β, IL-2, IL-6, IL-8, IL-10, TNFα, CRP, MMP8), were collected, although cytokine data were only available for 122 women., Results: Participant average age was 29.1 years, approximately half had a high school education or less, and half were unemployed. Compared to tobacco only users, co-users were more likely to be non-White, younger and more economically disadvantaged. In the adjusted linear regression models, TNF-α levels were significantly lower among co-users relative to tobacco only users, after adjusting for age, race/ethnicity, body mass index and tobacco use group (tobacco cigarettes, electronic nicotine delivery devices [ENDS] or both). TNF-α was the only immune marker found to be significant in this analysis. Measured stress levels (M = 5.9, SD = 3.3; potential range 0-16) and depression scores (M = 7.8, SD = 5.8; potential range 0-30) were low across all participants and did not differ as a function of co-use., Conclusion: Preliminary results suggest women co-using during the first trimester exhibit decreased pro-inflammatory immune responsivity on one out of eight markers. Further research is needed to determine the impact of this immune modulation on fetal health outcomes and the unique contribution of cannabis., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Previous research found that exposure to health-oriented language (e.g., natural, organic) on tobacco product packages is associated with reduced perceptions of harm and intention to purchase the product. However, how lesbian, gay, bisexual (LGB) individuals, who use tobacco products at a higher rate than heterosexual peers, respond to health-oriented labels has not yet been examined. This analysis examines whether responses to health-oriented labels differ between LGB persons and heterosexual individuals., Methods: Secondary analysis was completed from an experimental study that exposed US adult smokers to a non-US cigarette (Study 1) or e-cigarette (Study 2) package that displayed either health-oriented language ('100% organic,' 'all natural' or 'no additives'), traditional marketing language ('fine quality,' 'premium blend' or '100% original') or no language., Results: No significant differences were found between LGB smokers and heterosexual smokers in responses to cigarette packages with health-oriented labels (Study 1). However, LGB smokers had less favorable attitudes toward the e-cigarette product after viewing health-oriented labels (versus no language control label) while heterosexual smokers' attitudes did not differ across health-oriented and control labels (Study 2). In addition, LGB smokers had lower intention to purchase and vape e-cigarettes, and less favorable attitudes in response to health-oriented labels than heterosexual smokers., Conclusions: Findings suggest that LGB smokers process pro-tobacco messages differently than heterosexual smokers, and that product type (i.e., cigarette vs. e-cigarette) may be a factor to consider. Further research is needed to uncover underlying mechanisms., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Tobacco, alcohol, and illicit drug use among lesbian, gay, and bisexual (LGB) high school students as well as related environment and school-level risk and protective factors were examined., Methods: Data was acquired from the 2015 CDC's Youth Behavior Risk Survey for Kentucky (N = 2577). Prevalence of substance use was calculated for all high school respondents by reported sexual orientation. Multivariate analyses estimated the relationship between school and environmental-level factors (eg, having an adult to talk to) and tobacco, alcohol, and illicit drug use via logistic regressions. Sexual orientation, gender, age, and race/ethnicity were covariates., Results: LGB students used tobacco, alcohol, and illicit drugs more frequently than their heterosexual counterparts. More LGB teens report facing school risk factors (eg, 37% LGB vs 20% heterosexual bullied at school, p ≤ .001; 17% LGB vs 5% heterosexual ever threatened or injured at school, p < .001; 13% LGB vs 7% heterosexual involved in a school fight, p = .001). Adjusting for school related risk factors, having an adult to talk to was associated with a reduced likelihood of daily smoking (adjusted odds ratio [aOR]: 0.43; 95% confidence interval [CI]: 0.26-0.73), past 30-day alcohol use (aOR: 0.71; 95% CI: 0.50-0.95), and ever marijuana use (aOR: 0.71; 95% CI: 0.50-1.00)., Conclusion: Innovative strategies are needed to create safe, supportive school environments. These strategies are particularly needed in predominately rural states like Kentucky., (© 2019, American School Health Association.)

The purpose of this article is to review the current literature describing primary care providers' (PCPs) attitudes related to lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) people. LGBTQ individuals experience significant health disparities, and these inequities may be better understood via an ecological systems framework. PCPs' actual or perceived discriminatory attitudes can lead to suboptimal treatment or health outcomes for LGBTQ people. A review of the literature from 2005 through January 2017 was completed using the Cumulative Index for Nursing and Allied Health Literature and PubMed (Medline) databases. The purpose, sample, measure(s), design, findings, strengths, and weaknesses of each study were examined; and findings were synthesized, summarized, and critically appraised. Eight articles were eligible for review. There was significant heterogeneity in the studies' purposes, research questions, LGBTQ population(s) of focus, and findings. Many PCPs' attitudes toward LGBTQ people were positive, but a minority of each studies' participants had negative attitudes toward LGBTQ people. Stigma and health care barriers negatively affect LGBTQ health. Interventions must address LGBTQ health disparities at the individual, mesosytem, exosystem, and macrosystem levels. Research, education, and practice strategies all must be integrated across socioecological levels as components of a population-based approach to eliminate health disparities for LGBTQ persons.

Objective: To test the feasibility, acceptability, and efficacy of Get Fit and Quit (GFAQ), a community-engaged, holistic tobacco treatment program for women of childbearing age in a residential substance use disorder treatment facility., Design: A quasi-experimental, one-group, longitudinal design., Setting: A local Young Men's Christian Association (YMCA) location., Participants: Twenty-three women of childbearing age were enrolled in the study. Nearly all (21/23) participants were White, and most were nonpartnered and unemployed. More than one third of participants had more than high school educations, and five (22%) were pregnant at enrollment., Methods: The program was conducted in 10 sessions over 6 months. For each 90-minute session, approximately 45 minutes were dedicated to smoking cessation, and 45 minutes were dedicated to group physical activity. Means and 95% confidence intervals were used to summarize nicotine dependence, expired carbon monoxide, urine cotinine, and exercise self-efficacy at baseline and 5-week, 8-week, and 6-month assessments. Cigarettes smoked per day were summarized using medians and interquartile ranges over time. Program satisfaction and regular exercise were presented as percentages with 95% confidence intervals., Results: Of the 23 women who enrolled in GFAQ, 7 (30%) completed the program. Compared with baseline results, participants who completed GFAQ had lower nicotine dependence and smoked fewer cigarettes per day. Additionally, at 5 weeks, more GFAQ participants exercised regularly (64%) compared with baseline (14%). Most participants viewed the program favorably., Conclusion: Smoking in women of childbearing age with substance use disorders is an important public health issue. GFAQ is a promising intervention for tobacco treatment for this high-risk population, although the number of initial participants who completed the program was low., (Copyright © 2018 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Introduction: The purpose of this study was to (1) describe the role of smoking in the lives of women in residential substance use disorder (SUD) treatment and (2) explore perceptions of the facilitators and barriers to tobacco-free policy among women in residential SUD treatment., Methods: This was a community-engaged study using qualitative descriptive methods. We first recruited women in a residential SUD treatment facility to participate on a community research team. Interviews with staff (N = 10) and focus groups with clients (N = 42) were conducted using guides informed by the community research team. Interviews and focus groups were analyzed using content analysis., Results: There were two themes related to the role of smoking in the women's lives: (1) smoking facilitates socialization and (2) smoking as a coping mechanism. There were three themes related to the benefits of tobacco-free policy: (1) improved health, (2) support for continued abstinence from a previous tobacco-free placement (eg, prison), and (3) less grounds up-keep. Barriers to tobacco-free policy included (1) lack of an alternative coping mechanism to smoking, (2) fear that a tobacco-free policy would drive clients away, and (3) anticipation of implementation challenges., Conclusions: Many women in residential SUD treatment smoke, which they attribute to the fact that smoking is used to facilitate socialization and cope with stress. Future research is needed to develop and test messages to counter the misperception that smoking is an effective method to cope with stress. Ultimately, evidence-based tobacco-free policies are needed to reduce tobacco-related disease among women with SUDs., Implications: To promote smoking cessation among women with substance use disorders through evidence-based tobacco policy, it is necessary to first understand the role of smoking in their lives as well as facilitators and barriers to tobacco-free policy in residential treatment facilities. Participants reported that smoking facilitated socialization and served as a coping mechanism. Tobacco-free policies have many benefits, including improved health, support for continued abstinence from a previous tobacco-free placement (eg, prison), and less grounds up-keep. Barriers include the lack of an alternative coping mechanism, fear that a tobacco-free policy would drive away clients and anticipation of implementation challenges. To reduce the burden of tobacco-related morbidity and mortality among women and their children, it is necessary to catalyze a culture change in behavioral health settings to prioritize the treatment of tobacco alongside treatment of other addictions.

Introduction: Substance use disorders (SUDs) are chronic, relapsing brain disorders associated with morbidity, mortality, and high healthcare costs. Emerging adults are particularly vulnerable, with twice the risk of developing an SUD relative to their adult or adolescent counterparts. Emerging adults in addiction and recovery are understudied. Accordingly, the concept of recovery capital has been developed to account for the internal and external resources that an individual can mobilize to recover from an SUD. To better understand the barriers that contribute to relapse, we explored recovery capital among emerging adults. The aims of this phenomenological study were to explore and describe the experience of emerging adults in recovery and to identify the barriers and facilitators to their recovery., Methods: The informants (n = 8) were 18-25 years old in recovery from SUDs. Data were collected in 2016 using semistructured interviews and subsequently analyzed in 2017 for emerging themes., Results: Informants in this study reported challenges that may be unique to their age and stage of development. Informants reported residential and financial instability as barriers to recovery. Alternatively, informants reported spirituality and visible role models in recovery as facilitators of recovery. Finally, informants reported that the role of their families changed temporally throughout the course of their addiction to facilitate their recovery., Conclusion: The results from this study suggest that the developmental tasks facing emerging adults are exacerbated in addiction and recovery, which increases the likelihood of SUD relapse.

Background: Pharmacists' role in harm reduction is expanding in many states, yet there are limited data on pharmacists' willingness to participate in harm reduction activities. This study assessed community pharmacists' willingness to participate in one harm reduction initiative: syringe/needle exchange., Methods: In 2015, all Kentucky pharmacists with active licenses were emailed a survey that examined attitudes towards participation in syringe/needle exchange. Response frequencies were calculated for community pharmacist respondents. Ordinal logistic regression estimated the impact of community pharmacist characteristics and attitudes on willingness to provide clean needles/syringes to people who inject drugs and to dispose of used syringes/needles, where both dependent variables were defined as Likert-type questions on a scale of 1 (not at all willing) to 6 (very willing)., Results: Of 4699 practicing Kentucky pharmacists, 1282 pharmacists responded (response rate = 27.3%); the majority (n = 827) were community pharmacists. Community pharmacists were divided on willingness to provide clean needles/syringes, with 39.1% not willing (score 1 or 2 of 6) and 30% very willing (score 5 or 6 of 6). Few were willing to dispose of used needles/syringes, with only 18.7% willing. Community pharmacists who agreed that pharmacists could have significant public health impact by providing access to clean needles expressed 3.56 times more willingness to provide clean needles (95% CI 3.06-4.15), and 2.04 times more willingness to dispose of used needles (95% CI 1.77-2.35). Chain/supermarket pharmacists (n = 485, 58.6% of community pharmacies) were 39% less likely to express willingness to dispose of used needles (95% CI 0.43-0.87) when compared with independent community pharmacists (n = 342, 41.4% of community pharmacies). Independent pharmacists reported different barriers (workflow) than their chain/supermarket pharmacist colleagues (concerns of clientele)., Conclusions: Kentucky community pharmacists were more willing to provide clean needles than to dispose of used needles. Strategies to mitigate barriers to participation in syringe/needle exchange are warranted.

Objective: To collect formative information to design a tailored tobacco treatment intervention for women with newborns treated or evaluated for neonatal abstinence syndrome and to explore current tobacco use behaviors and facilitators and barriers to smoking cessation., Design: Qualitative descriptive study., Setting: An academic medical center in the southern United States., Participants: Mothers (N = 11) of newborns who were treated or evaluated for neonatal abstinence syndrome at birth within the preceding 3 months. Women recruited were older than 18 years and reported opioid dependence and smoking during pregnancy., Methods: Participants took part in semistructured individual interviews that lasted approximately 1 hour. Interviews were professionally transcribed and analyzed in MAXQDA using content analysis., Results: Five themes emerged from the data: Strategizing to Reduce Risk, Desire to Quit Smoking in the Future, Holding on to Smoking While Working Through Recovery, Feeling Judged by Nurses, and Feeling Supported and Empowered by Nurses. Participants reported that they to reduce risk to their newborns by avoiding second- and thirdhand smoke exposure. Participants wanted to stop smoking but reported many barriers, including multiple life stressors compounded by their newborns' extended stays in the hospital. However, most participants described overall positive experiences and the support of health care providers., Conclusion: Holistic tobacco treatment programs that incorporate stress relief and social support and are led by trusted health care providers have the potential to be effective to reduce smoking in new mothers with histories of opioid dependence disorders and smoking and whose newborns are in the NICU., (Copyright © 2017 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Purpose: To better understand policy/advocacy concepts and methodology utilized in all levels of nursing educational programs and develop clarity concerning structure of policy content and integration across all levels of education., Design and Methods: Cross-sectional analysis of data obtained from a survey sent to 19,043 nursing faculty in the United States; 598 total responses; 514 complete responses. Quantitative data points were analyzed using SPSS and qualitative data was grouped and analyzed by theme., Findings: Barriers and perceptions of student engagement and student learning outcomes along with institutional and faculty development barriers were explored in baccalaureate, masters, and doctoral level nursing programs. Thirty-six percent of respondents reported having experience in development and implementation of policy, ranging from local to international spheres and 21% reported active involvement in current state and federal policy development. Seventy percent of respondents have advocated for the nursing profession through professional organizations while 44% report current activity in legislative advocacy., Conclusions: The value of nursing policy education, advocacy, and analysis must be valued in higher education., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Lesbian, gay, and bisexual (LGB) individuals smoke at rates 1.5-2 times higher than the general population, but less is known about LGB consumption of other tobacco products (OTPs) and gender differences. OTP use among young adult LGB bar patrons and the relationship among past quit attempts, intention to quit, and binge drinking with OTP use was examined., Methods: A cross-sectional survey of young adults (aged 18-26) in bars/nightclubs in seven U.S. cities between 2012 and 2014 (N=8,010; 1,101 LGB participants) was analyzed in 2016. Logistic regressions examined current use of five OTPs (cigarillos, electronic cigarettes, hookah, chewing tobacco, and snus) and sexual minority status, adjusting for demographics and comparing LB women and GB men with their heterosexual counterparts., Results: LGB bar/nightclub patrons used all OTPs more than their heterosexual counterparts. LB women were more likely than heterosexual women to use cigarillos, electronic cigarettes, hookah, chew, and snus. GB men were more likely than heterosexual men to smoke cigarillos, electronic cigarettes, hookah, and use chew and snus. Past-year quit attempt was associated with increased odds of electronic cigarette use in men and women, and increased odds of dual use (cigarettes and OTPs) among men. Intention to quit was negatively associated with dual use among women. Binge drinking was associated with increased use of all OTPs across genders., Conclusions: LGB bar-going young adults are at higher risk for OTP use than their heterosexual counterparts. Bar-based interventions are needed to address all forms of tobacco use in this high-risk group., (Copyright © 2017. Published by Elsevier Inc.)

Objective: Tobacco-free policies are being rapidly adopted nationwide, yet compliance with these policies remains a challenge. This study explored college campus key informants' experiences with tobacco policies, and their perceived benefits, drawbacks, and outcomes., Participants: The sample for this study was 68 key informants representing 16 different California universities with varying tobacco policies (no smoking indoors and within 20 feet of entrances, designated smoking areas, 100% smoke-free, and 100% tobacco-free)., Methods: Qualitative, descriptive study. Semistructured interviews were transcribed verbatim and analyzed using content analysis., Results: Strategies to improve compliance ranged from a social approach to a heavy focus on punitive enforcement. Key informants from campuses using a social approach alone reported barriers to improving compliance, including a perceived lack of efficacy of the approach. However, these campuses found it challenging to incorporate enforcement through campus police or security., Conclusions: College campus decision makers should explore using a combined approach (social approach as well as formal enforcement), with enforcement primarily the responsibility of nonpolice university channels (eg, Student Affairs, employee supervisors).

Use of electronic cigarettes (e-cigs) is quickly growing in the United States, despite the unknown health implications and unregulated device contents. Although research is emerging around e-cigs in general, there continues to be a lack of scientific evidence regarding the safety and risks of e-cig use on maternal and fetal health, even though adverse health effects of nicotine on maternal and fetal outcomes are documented. This review summarizes existing perceptions of e-cig use in pregnancy, based on the limited number of publications available, and highlights the necessity of conducting additional research in this field of public health. Authors conducted a literature search of scientific peer-reviewed articles published from January 2006 to October 2016, comprising more than a decade of research. Search keywords include ‘tobacco use’, ‘electronic cigarette(s)’ and ‘pregnancy’. Fifty-seven publications were identified, narrowed to fifteen by screening title/abstract for potential relevance, with seven articles chosen for final inclusion. Of these seven studies, most participants not only believed e-cigs pose risks to maternal and child health but also perceived e-cigs as a safer and potentially healthier alternative to traditional cigarettes, and may assist with smoking cessation. Further research is needed to determine health implications and provide clinical guidelines for e-cig use in pregnancy.