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Introduction Electronic referral (e-referral) to quitlines helps connect tobacco-using patients to free, evidence-based cessation counseling. Little has been published about the real-world implementation of e-referrals across U.S. health systems, their maintenance over time, and the outcomes of e-referred patients. Aims and Methods Beginning in 2014, the University of California (UC)-wide project called UC Quits scaled up quitline e-referrals and related modifications to clinical workflows from one to five UC health systems. Implementation strategies were used to increase site readiness. Maintenance was supported through ongoing monitoring and quality improvement programs. Data on e-referred patients (n = 20 709) and quitline callers (n = 197 377) were collected from April 2014 to March 2021. Analyses of referral trends and cessation outcomes were conducted in 2021–2022. Results Of 20 709 patients referred, the quitline contacted 47.1%, 20.6% completed intake, 15.2% requested counseling, and 10.9% received it. In the 1.5-year implementation phase, 1813 patients were referred. In the 5.5-year maintenance phase, volume was sustained, with 3436 referrals annually on average. Among referred patients completing intake (n = 4264), 46.2% were nonwhite, 58.8% had Medicaid, 58.7% had a chronic disease, and 48.8% had a behavioral health condition. In a sample randomly selected for follow-up, e-referred patients were as likely as general quitline callers to attempt quitting (68.5% vs. 71.4%; p = .23), quit for 30 days (28.3% vs. 26.9%; p = .52), and quit for 6 months (13.6% vs. 13.9%; p = .88). Conclusions With a whole-systems approach, quitline e-referrals can be established and sustained across inpatient and outpatient settings with diverse patient populations. Cessation outcomes were similar to those of general quitline callers. Implications This study supports the broad implementation of tobacco quitline e-referrals in health care. To the best of our knowledge, no other paper has described the implementation of e-referrals across multiple U.S. health systems or how they were sustained over time. Modifying electronic health records systems and clinical workflows to enable and encourage e-referrals, if implemented and maintained appropriately, can be expected to improve patient care, make it easier for clinicians to support patients in quitting, increase the proportion of patients using evidence-based treatment, provide data to assess progress on quality goals, and help meet reporting requirements for tobacco screening and prevention.

Introduction Meta-analyses have shown an association between smoking and the risk of Coronavirus Disease 2019 (COVID-19) disease severity, but the risk of smoking and coronavirus infection is less clear. Aims and Methods We re-analyzed data from the British Cold Study, a 1986–1989 challenge study that exposed 399 healthy adults to 1 of 5 “common cold” viruses (including n = 55 for coronavirus 229E). Participants with cotinine levels below 15 ng/mL (noncurrent smokers) were compared with participants with higher cotinine levels or self-reported smoking (current smokers). We calculated overall and coronavirus-specific unadjusted and adjusted relative risks (RRs) for current smoking and each outcome (infection and illness), and tested whether each association was modified by the type of respiratory virus. Results Current smokers had a higher adjusted risk than noncurrent smokers for infection (adjusted RR [aRR] = 1.12, 95% CI: 1.01, 1.25) and illness (aRR = 1.48, 95% CI: 1.11, 1.96). Neither association was modified by an interaction term for smoking and type of virus (infection: p = .44, illness: p = .70). The adjusted RR estimates specific to coronavirus 229E for infection (aRR = 1.22, 95% CI: .91, 1.63) and illness (RR = 1.14, 95% CI: .62, 2.08) were not statistically significant. Conclusions These RRs provide estimates of the strength of associations between current smoking and infection and illness that can be used to guide tobacco control decisions. Implications Systematic reviews and meta-analyses have found an association between smoking and COVID-19 disease severity, but fewer studies have examined infection and illness. The British Cold Study, a high-quality challenge study that exposed healthy volunteers to respiratory viruses including a coronavirus, provides an opportunity to estimate the RR for current smoking and infection and illness from coronaviruses and other viruses to guide tobacco control decisions. Compared with noncurrent smokers, current smokers had a 12% increased risk of having a laboratory-confirmed infection and a 48% increased risk of a diagnosed illness, which was not modified by the type of respiratory virus including a coronavirus.

Introduction Proactive outreach offering tobacco treatment is a promising strategy outside of clinical settings, but little is known about factors for engagement. The study objective is to examine the impact of caller area code in a proactive, phone-based outreach strategy on consenting low-income smokers to a quitline e-referral. Aims and Methods This pragmatic randomized trial included unassisted adult smokers (n = 685), whose preferred language was English or Spanish, in a Los Angeles safety-net health system. Patients were randomized to receive a call from a local or generic toll-free area code. Log-binomial regression was used to examine the association between area code and consent to a quitline e-referral, adjusted for age, gender, language, and year. Results Overall, 52.1% of the patients were contacted and, among those contacted, 30% consented to a referral. The contact rate was higher for the local versus generic area code, although not statistically significant (55.6% vs. 48.7%, p = .07). The consent rate was higher in the local versus generic area code group (adjusted prevalence ratio 1.29, 95% CI 1.01–1.65) and also higher for patients under 61 years old than over (adjusted prevalence ratio 1.47, 95% CI 1.07–2.01), and Spanish-speaking than English-speaking patients (adjusted prevalence ratio 1.40, 95% CI 1.05–1.86). Conclusions Proactive phone-based outreach to unassisted smokers in a safety net health system increased consent to a quitline referral when local (vs. generic) area codes were used to contact patients. While contact rate did not differ by area code, proactive phone-based outreach was effective for engaging younger and Spanish-speaking smokers. Implications Population-based proactive phone-based outreach from a caller with a local area code to unassisted smokers in a safety net health system increases consent to an e-referral for quitline services. Findings suggest that a proactive phone-based outreach, a population-based strategy, is an effective strategy to build on the visit-based model and offer services to tobacco users, regardless of the motivational levels to quit.

To date, most genetic association analyses of smoking behaviors have been conducted in populations of European ancestry and many of these studies focused on the phenotype that measures smoking quantity, that is, cigarettes per day. Additional association studies in diverse populations with different linkage disequilibrium patterns and an alternate phenotype, such as total tobacco exposure which accounts for intermittent periods of smoking cessation within a larger smoking period as measured in large cardiovascular risk studies, can aid the search for variants relevant to smoking behavior. For these reasons, we undertook an association analysis by using a genotyping array that includes 2,100 genes to analyze smoking persistence in unrelated African American participants from the Atherosclerosis Risk in Communities study. A locus located approximately 4 kb downstream from the 3′-UTR of the brain-derived neurotrophic factor (BDNF) significantly influenced smoking persistence. In addition, independent variants rs12915366 and rs12914385 in the cluster of genes encoding nicotinic acetylcholine receptor subunits (CHRNA5–CHRNA3–CHRNB4) on 15q25.1 were also associated with the phenotype in this sample of African American subjects. To our knowledge, this is the first study to more extensively evaluate the genome in the African American population, as a limited number of previous studies of smoking behavior in this population included evaluations of only single genomic regions. Cancer Prev Res; 4(5); 729–34. ©2011 AACR.

Supplementary Figure and Table from Genetic Variability of Smoking Persistence in African Americans

ImportanceCalifornia’s tobacco control efforts have been associated with a decrease in cancer mortality, but these estimates are based on smoking prevalence of the general population. Patient-level tobacco use information allows for more precise estimates of the proportion of cancer deaths attributable to smoking.ObjectiveTo calculate the proportion (smoking-attributable fraction) and number (smoking-attributable cancer mortality) of cancer deaths attributable to tobacco use using patient-level data.Design, Setting, and ParticipantsThe smoking-attributable fraction and smoking-attributable cancer mortality were calculated for a retrospective cohort of patients whose cancer was diagnosed from 2014 to 2019 with at least 1 year of follow-up using relative risks from large US prospective studies and patient-level smoking information. Follow-up continued through April 2022. A population-based cohort was identified from the California Cancer Registry. Participants included adults aged 20 years and older with a diagnosis of 1 of the 12 tobacco-related cancers (oral cavity or pharynx, larynx, esophagus, lung, liver, stomach, pancreas, kidney, bladder, colon or rectum, cervix, and acute myeloid leukemia).ExposuresTobacco use defined as current, former, or never.Main Outcomes and MeasuresThe primary outcomes were the smoking-attributable fraction and smoking-attributable cancer mortality for each of the 12 tobacco-related cancers over 2 time periods (2014-2016 vs 2017-2019) and by sex.ResultsAmong 395 459 patients with a tobacco-related cancer, most (285 768 patients [72.3%]) were older than 60 years, the majority (228 054 patients [57.7%]) were non-Hispanic White, 229 188 patients were men (58.0%), and nearly one-half (184 415 patients [46.6%]) had lung or colorectal cancers. Nearly one-half of the deaths (93 764 patients [45.8%]) in the cohort were attributable to tobacco. More than one-half (227 660 patients [57.6%]) of patients had ever used tobacco, and 69 103 patients (17.5%) were current tobacco users, which was higher than the proportion in the general population (11.7%). The overall smoking-attributable fraction of cancer deaths decreased significantly from 47.7% (95% CI, 47.3%-48.0%) in 2014 to 2016 to 44.8% (95% CI, 44.5%-45.1%) in 2017 to 2019, and this decrease was seen for both men and women. The overall smoking-attributable cancer mortality decreased by 10.2%.Conclusions and RelevanceCalifornia still has a substantial burden of tobacco use and associated cancer. The proportion of cancer deaths associated with tobacco use was almost double what was previously estimated. There was a modest but significant decline in this proportion for overall tobacco-associated cancers, especially for women.

ObjectivesAs the social and legal acceptance of cannabis use grows, health professionals must understand and mitigate the impact of cannabis use in the perinatal period. Here we compare the prevalence of tobacco and cannabis use during and after pregnancy in California, a state that recently legalized cannabis use.MethodsMeasures of tobacco and cannabis use during and after pregnancy were obtained from California's Maternal and Infant Health Assessment, an annual population-based survey of California resident women with a live birth. To allow analysis of county-level variation, we pooled data from the 35 counties with the largest numbers of births from 2017 to 2019.ResultsCannabis use was more than twice as common as cigarette smoking among pregnant women (4.9% vs. 2.1%) in California. This difference was even more pronounced in some counties; for example, in Los Angeles, cannabis use was four times more prevalent than cigarette use. Either during or soon after birth, 7.3% of women in California reported cannabis use. Of those who smoked tobacco cigarettes prior to pregnancy, 73% quit before their third trimester of pregnancy, though 33.0% of these women reported a post-partum relapse in cigarette use.ConclusionsStates that have legalized cannabis must attend to the increasing prevalence of perinatal cannabis use, as well as concurrent use with tobacco and other substances. Efforts to support cannabis cessation should draw from successful public health approaches in tobacco control.

Background Lung cancer screening (LCS) for former and current smokers requires that current smokers are counseled on tobacco treatment. In the USA, over 4 million former smokers are estimated to be eligible for LCS based on self-report for “not smoking now.” Tobacco use and exposure can be measured with the biomarker cotinine, a nicotine metabolite reflecting recent exposure. Objective To examine predictors of tobacco use and exposure among self-reported former smokers eligible for LCS. Design Cross-sectional study using the 2013–2018 National Health and Nutrition Examination Survey. Participants Former smokers eligible for LCS (n = 472). Main Measures Recent tobacco use was defined as reported tobacco use in the past 5 days or a cotinine level above the race/ethnic cut points for tobacco use. Recent tobacco exposure was measured among former smokers without recent tobacco use and defined as having a cotinine level above 0.05 ng/mL. Key Results One in five former smokers eligible for LCS, totaling 1,416,485 adults, had recent tobacco use (21.4%, 95% confidence interval (CI) 15.8%, 27.0%), with about a third each using cigarettes, e-cigarettes, or other tobacco products. Among former smokers without recent tobacco use, over half (53.0%, 95% CI: 44.6%, 61.4%) had cotinine levels indicating recent tobacco exposure. Certain subgroups had higher percentages for tobacco use or exposure, especially those having quit within the past 3 years or living with a household smoker. Conclusions Former smokers eligible for LCS should be asked about recent tobacco use and exposure and considered for cotinine testing. Nearly 1.5 million “former smokers” eligible for LCS may be current tobacco users who have been missed for counseling. The high percentage of “passive smokers” is at least double that of the general nonsmoking population. Counseling about the harms of tobacco use and exposure and resources is needed.

People who smoke are at increased risk of serious COVID-19-related disease but have had reduced access to cessation treatment during the pandemic. This study tested 2 approaches to promoting quitline services to Medicaid members who smoke at high rates: using COVID-19-specific messaging and offering free nicotine patches. The hypotheses were that both would increase enrollment.A California Medicaid mailing from October 2020 to January 2021 (N=7,489,093) included 4 versions of a flyer following a 2 × 2 design comparing generic with COVID-19-specific messaging and a no-patch with free-patch offer. The main outcome measure was quitline enrollments. Quit outcomes (attempted quitting, quit ≥7 days, quit ≥30 days) were assessed at 2 months. A subsequent free-patch offer was sent to all members (N=7,577,198) from April 2021 to June 2021. Data were collected in 2020-2021 and analyzed in 2022.The first mailing generated 1,753 enrollments. Response rates were 0.023% and 0.024% for generic and COVID-19-specific messaging, respectively (p=0.538), and 0.006% and 0.041% for no-patch and free-patch offers, respectively, the latter being 6.7 times more effective than the former (p0.0001). Quit outcomes were comparable across conditions. The subsequent free-patch offer generated 3,546 enrollments at $40.28 per enrollee.In a Medicaid mailing during COVID-19, offering free patches generated more than 6 times as many quitline enrollments as offering generic help. COVID-19-specific messaging was no more effective than generic messaging. Offering free patches was highly cost-effective. Medicaid programs partnering with quitlines should consider using similar strategies, especially during a pandemic when regular health care is disrupted.

Introduction Flavored tobacco sales restrictions (FTSRs) are implemented to reduce access to flavored tobacco products. We examined the association between seven cities with local FTSRs implemented in 2018/2019 and e-cigarette use among high school students in the California Bay Area. Aims and Methods We analyzed data from the California Healthy Kids Survey using a difference-in-differences (D-I-D) strategy. We compared pre- and post-policy changes one year after implementation in current and ever e-cigarette use among students attending school in a city with a FTSR (exposed) (n = 20 832) versus without (unexposed) (n = 66 126). Other outcomes included ever marijuana use in an e-cigarette and ease of access to e-cigarettes. Results Pre- to post-policy, the adjusted odds of current and ever e-cigarette use did not significantly change among students exposed and unexposed to a FTSR. In the adjusted D-I-D analysis, the odds of current (aOR: 1.25, 95% CI: 0.95, 1.65) and ever e-cigarette use (aOR: 1.06, 95% CI: 0.89, 1.26) did not significantly change by exposure group. However, one year post-implementation, the odds of ease of access to e-cigarettes significantly increased among exposed (aOR: 1.57, 95% CI: 1.27, 1.95) and unexposed students (aOR: 1.54, 95% CI: 1.39, 1.70). Similarly, the odds of ever using marijuana in an e-cigarette significantly increased among exposed (aOR: 1.35, 95% CI: 1.19, 1.53) and unexposed students (aOR: 1.29, 95% CI: 1.20, 1.39). Conclusions Local FTSRs in the California Bay Area were not associated with a change in e-cigarette use one year post-implementation. Increased ease of access and marijuana use may be explanatory factors. Implications FTSRs were not associated with a decrease in current or ever e-cigarette use among high school students in the California Bay Area one-year post-implementation. Potential explanatory factors are that ease of access to e-cigarettes and using marijuana in an e-cigarette increased. More research is needed to understand the influence of these factors on youth access and behaviors. To address the youth e-cigarette epidemic, a comprehensive approach is needed, including policies, media campaigns, education programs, and cessation tools targeted to youth.

INTRODUCTION Asian male immigrants have high smoking rates. This article describes outreach approaches in the Medi-Cal Incentives to Quit Smoking project to incentivize California Medicaid (Medi-Cal) calls to the California Smokers' Helpline (Helpline) Asian-language lines. METHODS Outreach efforts adapted Medi-Cal Incentives to Quit Smoking materials for the Asian-language lines. Community-based efforts included outreach at ethnic supermarkets and distribution through community networks. Leveraging the Helpline's Asian print media campaign, three press releases promoted Medi-Cal Incentives to Quit Smoking with Lunar New Year or community physician messaging. Medi-Cal all-household mailings with tracking codes also included the Asian-language lines. Helpline caller characteristics and trends were examined for project period 2012-2015. Analyses were conducted in 2018. RESULTS Among 4,306 Asian American Pacific Islander Medi-Cal callers, there were 37% Asian-speaking Asian Americans (9.5% Chinese, 17.2% Vietnamese, and 10.5% Korean); 44% English-speaking Asian Americans; 9% Pacific Islanders; and 10% Asian American Pacific Islander not otherwise specified. Almost 10% of Asian-speaking Asian Americans were activated by the financial incentive and this was similar for all-household mailings, although this was lower than the other groups. Medi-Cal calls to the Asian-language lines increased, from an average of 18 calls/month to 47 calls/month (162% increase) in the first and last 12 project months respectively. Community outreach was limited by timing and sustainability. The 3-month call totals before and after the Asian-language press releases were significantly greater for Asian-speaking calls than for English-speaking calls (Cochran-Mantel-Haenszel p

Certain racial and ethnic minorities have lower utilization of tobacco cessation services, such as Helpline counseling and cessation medications. The goal of the California Medicaid (Medi-Cal) Incentives to Quit Smoking Program was to facilitate successful cessation by promoting modest financial and cessation medication-related incentives to increase engagement with the California Smokers' Helpline counseling services. Differences in the response to incentives and outreach on engagement with Helpline services among racial/ethnic groups within the Medi-Cal population were examined.Analysis of Helpline caller data.African American (n=18,656); English-speaking Latinx (n=12,792); Spanish-speaking Latinx (n=3,254); and white (n=45,907) Medi-Cal callers.The Medi-Cal Incentives to Quit Smoking team conducted statewide and community-based outreach and facilitated direct-to-member all-household mailings about the Medi-Cal Incentives to Quit Smoking program to engage with Medi-Cal callers and promote Helpline services between March 2012 and July 2015 (analyzed 2017/2018). Medi-Cal callers could ask for a $20 gift card incentive after having completed a counseling session; in September 2013, callers were offered free nicotine replacement therapy.Three behavioral outcomes are reported that reflect activated callers and callers who engaged in treatment that is proven to improve chances of quitting smoking: receipt of the $20 incentive, receipt of nicotine replacement therapy, and receipt of counseling.African Americans and English-speaking Latinx had higher engagement with the financial incentive than whites (African American APR=1.66, 95% CI=1.59, 1.73, English-speaking Latinx APR=1.29, 95% CI=1.22, 1.36). Spanish-speaking Latinx had lower initial engagement with the financial incentive (APR=0.75, 95% CI=0.66, 0.85), but higher engagement with Medi-Cal's all-household mailing (Spanish-speaking Latinx 30.6% vs whites 18.2%, p0.001). Although African Americans and English-speaking Latinx had similar rates of completing counseling and receiving nicotine replacement therapy as whites, Spanish-speaking Latinx had higher rates than whites.The promotion of modest financial and cessation medication incentives through multiple outreach channels increased callers' engagement with the Helpline and appeared to promote ethnic and linguistic equity with respect to the receipt of counseling and nicotine replacement therapy. Targeted community-based outreach may resonate particularly for African Americans, and language-concordant Medi-Cal insurance plan mailings may have reached newly covered Spanish-speaking Latinx.This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Lung cancer screening (LCS) for former and current smokers requires that current smokers are counseled on tobacco treatment. In the USA, over 4 million former smokers are estimated to be eligible for LCS based on self-report for "not smoking now." Tobacco use and exposure can be measured with the biomarker cotinine, a nicotine metabolite reflecting recent exposure.To examine predictors of tobacco use and exposure among self-reported former smokers eligible for LCS.Cross-sectional study using the 2013-2018 National Health and Nutrition Examination Survey.Former smokers eligible for LCS (n = 472).Recent tobacco use was defined as reported tobacco use in the past 5 days or a cotinine level above the race/ethnic cut points for tobacco use. Recent tobacco exposure was measured among former smokers without recent tobacco use and defined as having a cotinine level above 0.05 ng/mL.One in five former smokers eligible for LCS, totaling 1,416,485 adults, had recent tobacco use (21.4%, 95% confidence interval (CI) 15.8%, 27.0%), with about a third each using cigarettes, e-cigarettes, or other tobacco products. Among former smokers without recent tobacco use, over half (53.0%, 95% CI: 44.6%, 61.4%) had cotinine levels indicating recent tobacco exposure. Certain subgroups had higher percentages for tobacco use or exposure, especially those having quit within the past 3 years or living with a household smoker.Former smokers eligible for LCS should be asked about recent tobacco use and exposure and considered for cotinine testing. Nearly 1.5 million "former smokers" eligible for LCS may be current tobacco users who have been missed for counseling. The high percentage of "passive smokers" is at least double that of the general nonsmoking population. Counseling about the harms of tobacco use and exposure and resources is needed.

Background The Cancer Center Cessation Initiative (C3I) was launched in 2017 as a part of the NCI Cancer Moonshot program to assist NCI-designated cancer centers in developing tobacco treatment programs for oncology patients. Participating centers have implemented varied evidence-based programs that fit their institutional resources and needs, offering a wide range of services including in-person and telephone-based counseling, point of care, interactive voice response systems, referral to the quitline, text- and web-based services, and medications. Methods We used a mixed methods comparative case study design to evaluate system-level implementation costs across 15 C3I-funded cancer centers that reported for at least one 6-month period between July 2018 and June 2020. We analyzed operating costs by resource category (e.g., personnel, medications) concurrently with transcripts from semi-structured key-informant interviews conducted during site visits. Personnel salary costs were estimated using Bureau of Labor Statistics wage data adjusted for area and occupation, and non-wage benefits. Qualitative findings provided additional information on intangible resources and contextual factors related to implementation costs. Results Median total monthly operating costs across funded centers were $11,045 (range: $5129–$20,751). The largest median operating cost category was personnel ($10,307; range: $4122–$19,794), with the highest personnel costs attributable to the provision of in-person program services. Monthly (non-zero) cost ranges for other categories were medications ($17–$573), materials ($6–$435), training ($96–$516), technology ($171–$2759), and equipment ($10–$620). Median cost-per-participant was $466 (range: $70–$2093) and cost-per-quit was $2688 (range: $330–$9628), with sites offering different combinations of program components, ranging from individually-delivered in-person counseling only to one program that offered all components. Site interviews provided context for understanding variations in program components and their cost implications. Conclusions Among most centers that have progressed in tobacco treatment program implementation, cost-per-quit was modest relative to other prevention interventions. Although select centers have achieved similar average costs by offering program components of various levels of intensity, they have varied widely in program reach and effectiveness. Evaluating implementation costs of such programs alongside reach and effectiveness is necessary to provide decision makers in oncology settings with the important additional information needed to optimize resource allocation when establishing tobacco treatment programs.

Community colleges face challenges to becoming smoke-free and have higher smoking prevalence rates than four-year colleges. This case study examines how Sacramento Taking Action Against Nicotine De...

Introduction University community members are critical to the success of their smoke and tobacco free (STF) policies. The present study evaluates changes in social enforcement-related attitudes and behaviors following introduction of a new online Tobacco Tracker tool in two university settings. Methods Campus wide surveys were administered to current students, faculty, and staff at two California public universities with 100% STF policies before (November 2018; N = 5078) and after (December 2019–January 2020; N = 4853) introduction of Tobacco Tracker in February 2019. Prospective surveillance reports over 12 months from Tobacco Tracker, a GIS tool for the campus community to report tobacco use and related litter that displays crowdsourced maps of hotspots, were analyzed. Outcomes included awareness and self-reported use of a tobacco reporting tool, readiness for policy social enforcement, an Intellectual Social Affective (ISA) Engagement scale, and environmental surveillance reports from Tobacco Tracker. Results In campus surveys, awareness of a tobacco reporting tool doubled (8.0%–16.9%, p < .0001), use of an online reporting tool tripled (1.1%–3.2%, p < .0001), and readiness to enforce the policy increased (p = .0008). ISA engagement did not change (p = .72). In Tobacco Tracker campus reports (N = 1163), active tobacco use was reported more frequently than tobacco-related litter. Conclusions Tobacco Tracker is a promising tool for college communities to support STF policy. Introduction of Tobacco Tracker was associated with an increase in campus awareness and utilization of a reporting tool, readiness to enforce policy, and campus tobacco surveillance. Future research should determine how Tobacco Tracker may improve policy compliance. Implications Tobacco Tracker is a promising tool for college communities to support smoke and tobacco free (STF) policy through active surveillance of smoking, vaping, and related litter on campus. Introduction of Tobacco Tracker was associated with changes in social enforcement-related attitudes and behaviors critical to realizing the preventive potential of STF policies. A crowdsourcing-based tool for monitoring tobacco use on college campuses can address a major barrier to social enforcement: discomfort confronting tobacco users. Further, it provides an alternative to punitive enforcement approaches and promises a sustainable solution to an infrastructure issue faced by many universities lacking resources to collect data on campus tobacco use and related litter.

BACKGROUND College campuses in the United States have begun implementing smoke and tobacco–free policies to discourage the use of tobacco. Smoke and tobacco–free policies, however, are contingent upon effective policy enforcement. OBJECTIVE This study aimed to develop an empirically derived web-based tracking tool (Tracker) for crowdsourcing campus environmental reports of tobacco use and waste to support smoke and tobacco–free college policies. METHODS An exploratory sequential mixed methods approach was utilized to inform the development and evaluation of Tracker. In October 2018, three focus groups across 2 California universities were conducted and themes were analyzed, guiding Tracker development. After 1 year of implementation, users were asked in April 2020 to complete a survey about their experience. RESULTS In the focus groups, two major themes emerged: barriers and facilitators to tool utilization. Further Tracker development was guided by focus group input to address these barriers (eg, information, policing, and logistical concerns) and facilitators (eg, environmental motivators and positive reinforcement). Amongst 1163 Tracker reports, those who completed the user survey (n=316) reported that the top motivations for using the tool had been having a cleaner environment (212/316, 79%) and health concerns (185/316, 69%). CONCLUSIONS Environmental concerns, a motivator that emerged in focus groups, shaped Tracker’s development and was cited by the majority of users surveyed as a top motivator for utilization.

In June 2016, California implemented a Tobacco 21 (T21) policy that increased the minimum sale age of tobacco products from 18 to 21. This study examined the association between California's T21 policy and smoking behavior (ever, current, daily, and nondaily) in 18–20 year-olds using data from the 2012–2019 Behavioral Risk Factor Surveillance System (n = 15,863). The annual change in odds of smoking among 18–20 year-olds post-policy (July 2016–December 2019) was compared with the pre-policy period (January 2012 – June 2016) 1) within California and 2) compared with states without a T21 policy. As a sensitivity analysis, 21–23 year-olds in California were used as the referent. Difference-in-difference estimates (D-I-D) were calculated using adjusted logistic regression and compared the post to pre-policy change in trends in California to the referent groups. Before California's T21 policy, there was an 11% annual decrease in the odds of ever smoking among 18–20 year-olds in California and a 6% decrease in the referent states. After the policy, these trends did not change significantly. Results for current smoking were similar. For daily smoking, there was an 8% annual decrease before the policy and a 26% annual decrease after the policy among 18–20 year-olds in California; D-I-D estimates were 0.80 (95% CI: 0.57, 1.14) using referent states as the comparison and 0.62 (95% CI: 0.41, 0.95) using 21–23 year-olds in California as the comparison. There was an association between California's T21 policy and a decrease in daily smoking among 18–20 year-olds, compared with 21–23 year-olds, more than three years post-implementation.

Tobacco treatment is increasingly recognized as important to cancer care, but few cancer centers have implemented sustainable tobacco treatment programs. The University of California Davis Comprehensive Cancer Center (UCD CCC) was funded to integrate tobacco treatment into cancer care. Lessons learned from the UCD CCC are illustrated across a systems framework with the Cancer Care Continuum and by applying constructs from the Consolidated Framework for Implementation Research. Findings demonstrate different motivational drivers for the cancer center and the broader health system. Implementation readiness across the domains of the Cancer Care Continuum with clinical entities was more mature in the Prevention domain, but Screening, Diagnosis, Treatment, and Survivorship domains demonstrated less implementation readiness despite leadership engagement. Over a two-year implementation process, the UCD CCC focused on enhancing information and knowledge sharing within the treatment domain with the support of the cancer committee infrastructure, while identifying available resources and adapting workflows for various cancer care service lines. The UCD CCC findings, while it may not be generalizable to all cancer centers, demonstrate the application of conceptual frameworks to accelerate implementation for a sustainable tobacco treatment program. Key common elements that may be shared across oncology settings include a state quitline for an adaptable intervention, cancer committees for outer/inner setting infrastructure, tobacco quality metrics for data reporting, and non-physician staff for integrated services.

Introduction We explored the impact of a temporary tobacco-free public policy for the 2008 Summer Olympics on the smoking prevalence and secondhand smoke exposure among the population of a co-hosting city, Qingdao, China. Methods The Qingdao Diabetes Survey was analyzed for 2006 (n = 4599) and 2009 (n = 4680), which are survey years before and after the tobacco-free Olympics public policy period (July 2007 to January 2009). We analyzed the differences in self-reported smoking prevalence and exposure to secondhand smoke at home and/or workplace, and compared odds of smoking by survey year and of exposure to secondhand smoke among nonsmokers. Results From 2006 to 2009, the male smoking prevalence declined from 51.4% (95% confidence interval [CI] = 49.0% to 53.9%) to 42.6% (95% CI = 40.2% to 45.1%), and the proportion of lighter smokers decreased more. Among nonsmokers, the secondhand smoke exposure rate declined from 62.2% (95% CI = 60.5% to 63.9%) to 56.8% (95% CI = 55.1% to 58.6%). Regression analyses show 34% lower odds of men smoking after Olympics (OR = 0.66, 95% CI = 0.57% to 0.77%). Rural residents and individuals who are not retired were more likely to smoke. Female nonsmokers report 17% less exposure to secondhand smoke after Olympics (OR = 0.83, 95% CI = 0.70% to 0.98%). Urban nonsmokers were more likely to be exposed than their rural counterparts. Conclusions Smoking prevalence among men and secondhand smoke exposure among women significantly decreased in Qingdao, China, after the tobacco-free Olympics public policy period. As only the proportion of lighter smokers decreased, this may help explain why urban nonsmokers reported increased exposure. Unintended increased secondhand smoke exposure and cessation support need to be addressed in large-scale policy campaigns. Implications Hosting the Olympic Games can help to initiate large-scale tobacco-free public policies for hosting cities. Although previous studies have demonstrated reduction in nonsmoker exposure to secondhand smoke, the impact on the hosting city’s smoking prevalence or exposure rates is unclear. After the Olympic Games in Qingdao, China, smoking prevalence among men significantly decreased, mostly due to light smokers. Secondhand smoke exposure at home and/or workplace significantly decreased among female nonsmokers. Urban nonsmokers had an unintended consequence of increased secondhand smoke exposure after the tobacco-free Olympic policy period. Concurrent promotion of cessation support for heavier smokers may be needed.

Author(s): Tran, Mi T; Jeong, Matthew B; Nguyen, Vickie V; Sharp, Michael T; Yu, Edgar P; Yu, Filmer; Tong, Elisa K; Kagawa-Singer, Marjorie; Cuaresma, Charlene F; Sy, Angela U; Tsoh, Janice Y; Gildengorin, Ginny L; Stewart, Susan L; Nguyen, Tung T | Abstract: BACKGROUND:To the authors' knowledge, there are few studies to date regarding colorectal cancer (CRC) beliefs, knowledge, and screening among multiple Asian American populations, who are reported to have lower CRC screening rates compared with white individuals. The current study was performed to assess knowledge and beliefs regarding the causes of CRC, its prevention, and factors associated with CRC screening among 3 Asian American groups. METHODS:The authors conducted an in-language survey with Filipino (Honolulu, Hawaii), Hmong (Sacramento, California), and Korean (Los Angeles, California) Americans aged 50 to 75 years who were sampled through social networks. Bivariate and multivariable analyses were conducted to assess factors associated with CRC screening. RESULTS:The sample of 981 participants was 78.3% female and 73.8% reported limited proficiency in English. Few of the participants were aware that age (17.7%) or family history (36.3%) were risk factors for CRC; 6.2% believed fate caused CRC. Only 46.4% of participants knew that screening prevented CRC (74.3% of Filipino, 10.6% of Hmong, and 55.8% of Korean participants; Pl.001). Approximately two-thirds of participants reported ever having undergone CRC screening (76.0% of Filipino, 72.0% of Hmong, and 51.4% of Korean participants; Pl.001) and 48.6% were up to date for screening (62.2% of Filipino, 43.8% of Hmong, and 41.4% of Korean participants; Pl.001). Factors found to be significantly associated with ever screening were being Korean (compared with Filipino), having a family history of CRC, having health insurance or a regular source of health care, and knowing that a fatty diet caused CRC. Believing that fate caused CRC and that praying prevented it were found to be negatively associated with ever screening. Factors associated with being up to date for CRC screening included being born in the United States, having a family history of CRC, and having access to health care. CONCLUSIONS:Knowledge regarding the causes of CRC and its prevention among Filipino, Hmong, and Korean individuals is low. However, health care access, not knowledge or beliefs, was found to be a key determinant of CRC screening. Cancer 2018;124:1552-9. © 2018 American Cancer Society.

Author(s): Saw, Anne; Paterniti, Debora A; Fung, Lei-Chun; Tsoh, Janice Y; Tong, Elisa K | Abstract: BackgroundChinese men smoke at high rates, and this puts household members at risk for tobacco-related diseases. Culturally responsive interventions that provide education and support are needed to promote smokefree living and reduce smoke exposure, particularly for US immigrants who experience changes in smokefree social norms. This qualitative study examines perspectives of Chinese American smoker and nonsmoker household pairs in the Creating Smokefree Living Together program.MethodsFour focus groups were conducted with 30 Chinese American participants (15 smokers and 15 nonsmokers) who, in household pairs, completed smokefree education interventions of either brief or moderate intensity. Nearly three-quarters of the smokers continued to smoke after the intervention at the time of focus group participation. All smokers were male, and most household nonsmokers were female spouses. All participants had limited English proficiency. Focus group meetings were recorded, and the recordings were translated and transcribed. Transcripts and field notes were thematically analyzed.ResultsThe following themes, shared by smokers and nonsmokers across interventions, were identified: 1) there was a preference for dyadic and group interventions because of the support offered, 2) increased knowledge of the health harms of smoke exposure within a pair improved the nonsmoker's support for smokefree living, 3) learning communication strategies improved household relationships and assertiveness for smokefree environments, 4) biochemical feedback was useful but had short-term effects, and 5) project magnets provided cues to action.ConclusionsInvolving household partners is critical to smokefree interventions. Simple reminders at home appear to be more powerful than personal biochemical feedback of smoke exposure for sustaining motivation and engagement in ongoing behavioral changes within the household. Cancer 2018;124:1599-606. © 2018 American Cancer Society.

Author(s): Tsoh, Janice Y; Tong, Elisa K; Sy, Angela U; Stewart, Susan L; Gildengorin, Ginny L; Nguyen, Tung T | Abstract: BACKGROUND:Nonadherence to colorectal cancer (CRC) screening among Asian Americans is high but not well understood. This study examined correlates of screening intention among Filipino, Hmong, and Korean Americans who were nonadherent to CRC screening. METHODS:Using cross-sectional, preintervention survey data from 504 Asian Americans (115 Filipinos, 185 Hmong, and 204 Koreans) aged 50-75 years who were enrolled in a multisite cluster randomized controlled trial of lay health educator intervention, we analyzed correlates of self-reported CRC screening nonadherence, which was defined as not being up-to-date for fecal occult blood test, sigmoidoscopy, or colonoscopy. RESULTS:Only 26.8% of participants indicated intention to obtain screening within 6 months (Hmong: 12.4%; Korean: 30.8%; and Filipino: 42.6%; P l .001). Only one third of participants had undergone a prior screening, and a majority did not know that screening is a method of CRC prevention method (61.3%) or had any knowledge of CRC screening guidelines (53.4%). Multivariable analyses revealed that patient-provider ethnicity concordance, provider's recommendation of screening, participants' prior CRC screening, perceived severity and susceptibility of CRC, and knowledge of guidelines were positively associated with screening intention. Specifically, knowing one or more screening guidelines doubled the odds of screening intention (adjusted odds ratio, 2.38; 95% confidence interval, 1.32-4.28). Hmong were less likely to have screening intention than Filipinos, which was unexplained by socio-demographics, health care factors, perceived needs for CRC screening, or knowledge of screening guidelines. CONCLUSION:CRC screening intention among nonadherent Filipino, Hmong, and Korean Americans was low. Targeting knowledge of CRC screening guidelines may be effective strategies for increasing CRC screening intention among nonadherent Asian Americans. Cancer 2018;124:1560-7. © 2018 American Cancer Society.

Author(s): Sun, Angela; Tsoh, Janice Y; Tong, Elisa K; Cheng, Joyce; Chow, Edward A; Stewart, Susan L; Nguyen, Tung T | Abstract: BackgroundAmong Chinese American individuals, only approximately 42% of cases of colorectal cancer (CRC) are diagnosed at an early stage, possibly because these patients are less likely than non-Hispanic white individuals to undergo CRC screening.MethodsPrimary care physicians (PCPs) were recruited from a local independent practice association serving Chinese Americans and randomized into early-intervention and delayed-intervention groups. PCPs in the early-intervention group received continuing medical education (CME), and their patients received an intervention mailer, consisting of a letter with the PCP's recommendation, a bilingual educational booklet, and a fecal occult blood test (FOBT) kit in year 1. PCPs in the delayed-intervention group received no CME, and their patients received the mailers in year 2.ResultsA total of 20 PCPs were assigned to the early-intervention and 22 PCPs to the delayed-intervention group. A total of 3120 patients of these participating PCPs who had undergone CRC screening that was due during the study period were included. A total of 915 mailers were sent in year 1 and 830 mailers were sent in year 2. FOBT screening rates increased from 26.7% at baseline to 58.5% in year 1 in the early-intervention group versus 19.6% at baseline to 22.2% in year 1 in the delayed-intervention group (Pl.0001). The overall effect size of the mailer intervention with or without CME was estimated as a difference of 26.6 percentage points (95% confidence interval, 22.0-31.2 percentage points) from baseline compared with usual care. The intervention was found to have no impact on rates of colonoscopy or sigmoidoscopy.ConclusionsThe results of the current pilot study demonstrated that a mailer including educational materials and FOBT kits can increase CRC screening rates with or without CME for the PCPs. Cancer 2018;124:1568-75. © 2018 American Cancer Society.

Background Asian Indians (AIs) in the United States exhibit disproportionate burdens of oral cancer and cardiovascular disease, which are potentially linked to smokeless tobacco. However, little is known about the use of cultural smokeless tobacco (CST) products in this population. Methods California Asian Indian Tobacco Use Survey data from 2004 (n = 1618) were used to investigate CST prevalence among California's AIs. CST products included paan, paan masala, and gutka. A multivariable logistic regression was conducted to examine factors (socioeconomic status, acculturation measures, and religious affiliation) associated with current CST use versus never use. Results The current CST prevalence was 13.0% (14.0% for men and 11.8% for women). In contrast, the prevalence of current cigarette use was 5.5% (8.7% for men and 1.9% for women), and the prevalence was lower for cultural smoked tobacco (0.1% for bidis and 0.5% for hookahs). Factors associated with CST use included the following: being male, being 50 years old or older, being an immigrant, speaking an AI language at home, having a higher level of education (adjusted odds ratio [AOR] for high school/some college, 2.6; 95% confidence interval [CI], 1.1-6.5; AOR for college degree or higher, 4.0; 95% CI, 1.7-9.5), having a higher income (AOR for $75,000-$100,000, 2.5; 95% CI, 1.3-4.7; AOR for ≥$100,000, 2.6; 95% CI, 1.4-5.0), identifying as non-Sikh (AOR for Hinduism, 10.0; 95% CI, 6.0-16.5; AOR for other faiths, 10.2; 95% CI, 5.9-17.7), and disagreeing that spiritual beliefs are the foundation of life (AOR, 2.1; 95% CI, 1.2-3.5). Conclusions The current CST prevalence is relatively high among California's AIs in comparison with the prevalence of smoking, with narrower differences between sexes. The association with a higher socioeconomic status is contrary to typical cigarette smoking patterns. Acculturation and religious affiliation are important factors associated with current use. Health care providers and policymakers should consider such determinants for targeted interventions. Cancer 2018;124:1607-13. © 2018 American Cancer Society.

Author(s): Tong, Elisa K; Saw, Anne; Fung, Lei-Chun; Li, Chin-Shang; Liu, Yu; Tsoh, Janice Y | Abstract: BackgroundChinese American men smoke at a high rate, which puts household nonsmokers at risk. The objective of this study was to evaluate the effectiveness of a brief-intensity versus moderate-intensity smoke-free-living educational intervention for household pairs.MethodsThe authors conducted a randomized controlled trial of Cantonese-speaking Chinese American smoker and household nonsmoker pairs in San Francisco, California. Pairs were randomized to moderate-intensity or brief-intensity group sessions with their household partner. The moderate-intensity group received 2 group sessions, a laboratory report of their baseline smoke exposure, as measured by 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and 3 follow-up calls over 6 months. The brief-intensity group received 1 group session on tobacco-cessation resources. Primary outcomes were biochemically validated, past-month smoking abstinence and elimination of nonsmoker household exposure at 12 months.ResultsParticipant pairs (n = 203) were male smokers, one-half of whom did not intend to quit within 6 months, with mostly female spouses as household nonsmokers. Approximately three-quarters of nonsmokers in both groups already had smoke-free home rules. At 12 months, smokers in both groups had similar biochemically validated 30-day abstinence rates (moderate-intensity group, 0%-20.7%; brief-intensity group, 0%-20.0%; P = .002 over time). More smokers in the moderate-intensity group used subsequent cessation group classes (moderate-intensity group, 50%; brief-intensity group, 24%; P = .004). Household nonsmokers in both groups had similar biochemically validated rates of no home exposure (moderate-intensity group, 24.5%-42.2%; brief-intensity group, 24.8%-33.3%; P = .0001 over time).ConclusionsA moderate-intensity smoke-free-living educational intervention for Chinese-speaking household pairs was not more effective than a brief-intensity intervention for smoking abstinence and elimination of household nonsmoker exposure. Abstinence rates were similar to those achieved with standard group counseling. Cancer 2018;124:1590-8. © 2018 American Cancer Society.

Background Cancer is the leading cause of death for Asian Americans. The authors evaluated the status of cancer prevention for Chinese Americans in San Francisco, which has had years of cancer prevention efforts. Methods Through a community-based clinic serving Chinese Americans, a randomized, controlled trial (n = 395) was conducted among participants who attended either a cancer prevention seminar or biospecimen education seminar. Changes in knowledge, attitudes, and screening completion/intent were measured across and between seminar groups. Results Participants were mostly women who had low acculturation and education levels. Over two-thirds to almost all participants knew about modifiable risk factors for cancer and that screening tests were available, including for lung cancer. The majority of women had already completed mammography and Papanicolaou (Pap) tests. Approximately one-half reported having completed colorectal cancer screening, prostate screening, or hepatitis B screening. Most were nonsmokers, but about one-half "strongly agreed" that they would want a test for tobacco smoke exposure. After the cancer prevention seminar, significant increases within group were noted for knowledge (eating healthy foods, from 93.1% to 97.7% [P = .0002]; secondhand smoke causes cancer, from 66.3% to 74.8% [P = .04]) and for screening completion/intent (colorectal cancer, from 58.1% to 64.5% [P = .002] cervical cancer, from 72.9% to 75.5% [P = .04]) and there was a trend toward an increase for prostate cancer (from 50.0% to 61.1%; P = .10). There was a significant change between groups for eating healthy foods (P = .004). Conclusions The current reports documents the gains in cancer prevention among Cantonese-speaking Chinese Americans, fostered by academic, community, and public health efforts. A community-based seminar demonstrated improvement in some cancer knowledge or screening intent and opportunities for continued efforts. Cancer 2018;124:1622-30. © 2018 American Cancer Society.

Author(s): Cuaresma, Charlene F; Sy, Angela U; Nguyen, Tung T; Ho, Reginald CS; Gildengorin, Ginny L; Tsoh, Janice Y; Jo, Angela M; Tong, Elisa K; Kagawa-Singer, Marjorie; Stewart, Susan L | Abstract: BACKGROUND:Filipino colorectal cancer (CRC) screening rates fall below Healthy People 2020 goals. In this study, the authors explore whether a lay health educator (LHE) approach can increase CRC screening among Filipino Americans ages 50 to 75 years in Hawai'i. METHODS:A cluster randomized controlled trial from 2012 through 2015 compared an intervention, which consisted of LHEs delivering 2 education sessions and 2 telephone follow-up calls on CRC screening plus a CRC brochure versus an attention control, in which 2 lectures and 2 follow-up calls on nutrition and physical activity plus a CRC brochure were provided. The primary outcome was change in self-reported ever receipt of CRC screening at 6 months. RESULTS:Among 304 participants (77% women, 86% had g 10 years of residence in the United States), the proportion of participants who reported ever having received CRC screening increased significantly in the intervention group (from 80% to 89%; P = .0003), but not in the control group (from 73% to 74%; P = .60). After covariate adjustment, there was a significant intervention effect (odds ratio, 1.9; 95% confidence interval, 1.0-3.5). There was no intervention effect on up-to-date screening. CONCLUSIONS:This first randomized controlled trial for CRC screening among Hawai'i's Filipinos used an LHE intervention with mixed, but promising, results. Cancer 2018;124:1535-42. © 2018 American Cancer Society.

Background College campuses in the United States have begun implementing smoke and tobacco–free policies to discourage the use of tobacco. Smoke and tobacco–free policies, however, are contingent upon effective policy enforcement. Objective This study aimed to develop an empirically derived web-based tracking tool (Tracker) for crowdsourcing campus environmental reports of tobacco use and waste to support smoke and tobacco–free college policies. Methods An exploratory sequential mixed methods approach was utilized to inform the development and evaluation of Tracker. In October 2018, three focus groups across 2 California universities were conducted and themes were analyzed, guiding Tracker development. After 1 year of implementation, users were asked in April 2020 to complete a survey about their experience. Results In the focus groups, two major themes emerged: barriers and facilitators to tool utilization. Further Tracker development was guided by focus group input to address these barriers (eg, information, policing, and logistical concerns) and facilitators (eg, environmental motivators and positive reinforcement). Amongst 1163 Tracker reports, those who completed the user survey (n=316) reported that the top motivations for using the tool had been having a cleaner environment (212/316, 79%) and health concerns (185/316, 69%). Conclusions Environmental concerns, a motivator that emerged in focus groups, shaped Tracker’s development and was cited by the majority of users surveyed as a top motivator for utilization.

Introduction and Aims. Non-smokers' assertive behaviour towards smokers by asking them not to smoke is important in promoting smoke-free environments. Korean and Chinese Americans come from countries where most women are non-smokers and assertive behaviour may not be prevalent but may increase after migration because of social-ecological factors. This study assessed the extent to which Korean and Chinese American non-smokers ask someone not to smoke and associated factors. Design and Methods. The 2003 California Chinese American and Korean American Tobacco Use Surveys were analysed. Multivariate logistic regression analyses examined factors related to non-smoker self-reports that they asked someone not to smoke within the past year. Results. About 40% reported past-year assertive behaviour against smoking, with higher rates among Koreans than Chinese (60.4% vs. 34.5%), those living with smokers (63.5%), ever exposed with a smoke-free home rule (62.3%), recently exposed at work without a smoke-free work policy (67.6%) and regularly exposed at other locations (52.3%). In combined multivariate analyses of both ethnic groups, assertive behaviour was associated with individual factors (single vs. married; tobacco exposure knowledge), family factors (living with smokers, exposed at home despite a smoke-free rule), community factors (exposed at work with no smoke-free policy, exposed at other locations) and cultural factors (Korean vs. Chinese ethnicity; lower acculturation). Discussion and Conclusions. Chinese and Korean American non-smokers report assertive behaviour against smoking, which is associated with social-ecological factors. Results help identify target groups and strategies for future intervention, including the need to implement or enforce smoke-free environments and promote empowerment. [Saw A, Tang H, Tsoh JY, Chen MS Jr, Tong EK. Non-smoker assertive behaviour against smoke exposure: Chinese and Korean American non-smokers. Drug Alcohol Rev 2017;00:000–000]

BACKGROUND Colorectal cancer (CRC) is the second most commonly diagnosed cancer among Korean American men and women. Although CRC screening is effective in reducing the burden of this disease, studies have shown that Korean Americans have low screening rates. METHODS The authors conducted a 2-arm cluster randomized controlled trial comparing a brochure (print) with a brochure and lay health educator (LHE) outreach (print + LHE) in increasing CRC screening rates among Korean American individuals. Self-administered written surveys at baseline and at 6 months assessed knowledge of CRC and its screening, ever screening, and being up to date with screening. RESULTS A total of 28 LHEs recruited 348 participants aged 50 to 75 years from their social networks. Significant percentages of participants reported not having health insurance (29.3%) or a usual source of care (35.6%). At 6 months postintervention, the print + LHE participants had a greater increase in knowledge compared with those in the print arm (P = .0013). In multivariable analyses, both groups had significant increases in ever screening (print plus LHE: odds ratio [OR], 1.60 [95% confidence interval (95% CI), 1.26-2.03] and print: OR, 1.42 [95% CI, 1.10-1.82]) and being up to date with screening (print plus LHE: OR, 1.63 [95% CI, 1.23-2.16] and print: OR, 1.40 [95% CI, 1.04-1.89]). However, these increases did not differ significantly between the study arms. Having insurance and having seen a provider within the past year were found to be positively associated with screening. CONCLUSIONS Compared with a brochure, LHE outreach yielded greater increases in knowledge but resulted in similar increases in CRC screening in a Korean American population with barriers to health care access. More work is needed to appropriately address logistical and system barriers in this community. Cancer 2017. © 2017 American Cancer Society.

Background Proactive referrals through electronic orders (eReferrals) can increase patient connection with tobacco quitlines. More information is needed on “real-world” implementation of electronic health record tools to promote tobacco cessation while minimizing provider burden. Objectives This paper examines the health system implementation of an eReferral to a tobacco quitline without best practice alerts in primary care, specialty, and hospital settings in an academic health system. Methods This is a prospective implementation study of a health system tobacco eReferral to a state quitline that was completed with an approach to minimize provider cognitive burden. Data are drawn from electronic health record data at University of California, Davis Health Systems (March 2013–February 2016). Results Over 3 years, 16,083 encounters with smokers resulted in 1,137 eReferral orders (7.1%). Treatment reach was 1.6% for quitline services and 2.3% for outpatient group classes. While the group classes were offered to outpatient smokers, the eReferral order was included in an outpatient order set and eventually an automated inpatient discharge order set; no provider alerts were implemented. Referrals were sustained and doubled after inpatient order set implementation. Among all first time eReferral patients, 12.2% had a 6 to 12 month follow-up visit at which they were documented as nonsmoking. Conclusion This study demonstrates a quitline eReferral order can be successfully implemented and sustained with minimal promotion, without provider alerts and in conjunction with group classes. Reach and effectiveness were similar to previously described literature.

© 2018 Elsevier Ltd Introduction: Previous studies found that offering free nicotine patches significantly increases calls to quitlines, although most used pre–post designs and did not directly compare the effects of patches and other incentives. The current study with California Medicaid members used a 2 × 2 design to directly assess the effects of offering free patches and incentives on calls to a quitline. The hypotheses were that offering either would make members more likely to call, and that offering both would increase demand even further. Methods: Flyers were inserted into a mailing sent to 4,268,696 Medicaid households, with one of four offers: (1) free counseling; (2) counseling plus patches; (3) counseling plus a $20 gift card; and (4) counseling plus patches and gift card. Ninety percent received the first offer and 10% received one of the other three offers, in equal proportions. The mailers shipped late 2013 to early 2014. Data were collected 2013–2015 and analyzed 2018. Results: Response rates were 0.029% for counseling, 0.115% for counseling plus patches, 0.122% for counseling plus gift card, and 0.200% for counseling, patches, and gift card. Both patches and gift cards had statistically significant effects (both p

Introduction Little is known about how incentives may encourage low income smokers to call for quitline services. This study evaluates the impact of outreach through health channels on California Medicaid (Medi-Cal) quitline caller characteristics, trends, and reach. Study design Longitudinal study. Setting/participants Medi-Cal quitline callers. Intervention Statewide outreach was conducted with health providers, Medi-Cal plans (all-household mailings with tracking codes), and public health organizations (March 2012–July 2015). For incentives, Medi-Cal callers could ask for a $20 gift card; in September 2013, callers were offered free nicotine patches. Main outcome measures Caller characteristics were compared with chi-square analyses, joinpoint analysis of call trends was performed accounting for Medi-Cal population growth, referral source among Medi-Cal and non–Medi-Cal callers was documented, and the annual percentage of the population reached who called the Helpline was calculated. Analyses were conducted 2016–2018. Results Total Medi-Cal callers were 92,900, a 70% increase from prior annual averages: 12.4% asked for the financial incentive, 17.3% reported the mailing code, and 73.3% received nicotine patches while offered. Among the two thirds of callers who completed counseling, 15.5% asked for the financial incentive, and 13.6% reported the mailing code. A joinpoint analysis showed call trends increased 23% above expected for the Medi-Cal population growth after mailings to providers and members began, and decreased after outreach ended. Annual reach increased from 2.3% (95% CI=2.1, 2.6) in 2011 to peak at 4.5% (95% CI=3.6, 5.3) in 2014. Among subgroups with higher reach rates, some also had higher rates of asking for the financial incentive (African Americans, American Indian), reporting the tracking code (whites), or both (aged 45–64 years). Medi-Cal callers were more likely than non–Medi-Cal callers to report providers (32.3% vs 23.8%) and plans (19.7% vs 1.4%) as their referral source, and less likely to cite media (20.2% vs 44.4%, p Conclusions Statewide outreach through health channels incentivizing Medi-Cal members increased the utilization and reach of quitline services. Supplement information This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Introduction Most smokers abstain from smoking during hospitalization but relapse upon discharge. This study tests the effectiveness of two proven treatments (i.e., nicotine patches and telephone counseling) in helping these patients stay quit after discharge from the hospital, and assesses a model of hospital−quitline partnership. Study design This study had a 2×2 factorial design in which participants were stratified by recruitment site and smoking rate and randomly assigned to usual care, nicotine patches only, counseling only, or patches plus counseling. They were evaluated at 2 and 6 months post-randomization. Setting/participants A total of 1,270 hospitalized adult smokers were recruited from August 2011 to November 2013 from five hospitals within three healthcare systems. Intervention Participants in the patch condition were provided 8 weeks of nicotine patches at discharge (or were mailed them post-discharge). Quitline staff started proactively calling participants in the counseling condition 3 days post-discharge to provide standard quitline counseling. Main outcome measures The primary outcome measure was self-reported 30-day abstinence at 6 months using an intention-to-treat analysis. Data were analyzed from September 2015 to May 2016. Results The 30-day abstinence rate at 6 months was 22.8% for the nicotine patch condition and 18.3% for the no-patch condition ( p =0.051). Nearly all participants (99%) in the patch condition were provided nicotine patches, although 36% were sent post-discharge. The abstinence rates were 20.0% and 21.1% for counseling and no counseling conditions, respectively ( p =0.651). Fewer than half of the participants in the counseling condition (47%) received counseling (mean follow-up sessions, 3.6). Conclusions Provision of nicotine patches proved feasible, although their effectiveness in helping discharged patients stay quit was not significant. Telephone counseling was not effective, in large part because of low rates of engagement. Future interventions will need to be more immediate to be effective. Trial Registration This study is registered at www.clinicaltrials.gov NCT01289275.

BACKGROUND Asian Americans have lower colorectal cancer (CRC) screening rates than non-Hispanic white individuals. Hmong Americans have limited socioeconomic resources and literacy. The current randomized controlled trial was conducted to determine whether bilingual/bicultural lay health educator (LHE) education could increase CRC screening among Hmong Americans. METHODS A cluster randomized controlled trial was conducted among Hmong Americans in Sacramento, California. LHEs and recruited participants were randomized to intervention or control groups. The intervention group received CRC education over 3 months delivered by an LHE. The control group received education regarding nutrition and physical activity delivered by a health educator. The outcomes were changes in self-reported ever-screening and up-to-date CRC screening after 6 months. RESULTS All 329 participants were foreign-born with mostly no formal education, limited English proficiency, and no employment. The majority of the participants were insured and had a regular source of health care. The intervention group experienced greater changes after the intervention than the control group for ever-screening (P = .068) and being up-to-date with screening (P 4 times the odds of receiving screening, both ever-screening and up-to-date screening. A higher CRC knowledge score mediated the intervention effect for both screening outcomes. CONCLUSIONS A culturally and linguistically appropriate educational intervention delivered by trained LHEs was found to increase CRC screening in an immigrant population with low levels of education, employment, English proficiency, and literacy. Cancer 2016. © 2016 American Cancer Society.

242 Background: Tobacco treatment is an important component of cancer care, and pragmatic strategies are needed. The University of California Davis Comprehensive Cancer Center (UCD CCC) was selected to join the National Cancer Institute Cancer Center Cessation Initiative (NCI C3I) to integrate tobacco treatment with cancer care. As a matrix cancer center, UCD had tobacco treatment workflows established in primary care, with Health Management Education group classes and a quitline order, but less so in cancer care. Methods: We use the RE-AIM framework for our study evaluation. During the two-year study period (1/2018-12/2019) patient data were reported in 6-month periods to NCI C3I from core Cancer Center clinics including medical, surgical, and radiation oncology. Three strategies were implemented serially and in convergence. Strategy #1 involved cancer provider and staff education and training, Strategy #2 initiated the Ask-Advise-Connect workflow with medical assistants assessing and referring within the clinic encounter, and Strategy #3 conducted Closing Care Gaps outreach to contact “unassisted” smokers outside of the clinic encounter. Stakeholder perspectives for implementation readiness across units were engaged at least bi-monthly by multidisciplinary members of the Cancer Committee, led by the physician-in-chief. Implementation strategies were developed in partnership with clinic management and Health Management Education staff with monthly rapid feedback reports for referral orders. Results: Our project Reach improved tobacco assessment from 83.6% to 96.4% and tobacco treatment program orders and outreach by 6-fold (from 40 to 254) over the four NCI C3I 6-month reporting periods. For tobacco treatment program Effectiveness, among 118 patients who engaged in treatment (January 2018-June 2019), past-week abstinence at 6 months was 22.9% (missing data assumed to be smoking) Adoption and Implementation of tobacco treatment program referrals were highest in medical (5-10 fold) and surgical oncology (3-fold) annual increases. In contrast, radiation oncology referrals remained low due to a different clinic workflow and electronic health record module. Booster trainings have helped to Maintain referrals in the clinic. Conclusions: A matrix cancer center can rapidly adopt and implement tobacco treatment strategies that are internal and external to the clinic visit, with the goal of offering tobacco treatment and maximizing reach to all cancer patients who smoke.

The California Tobacco Control Program is the longest standing, publicly funded tobacco control program in the U.S. California's adult smoking rate declined from 23.7% (1989) to 11% (2016) but California still has more than 3 million smokers dispersed over 58 counties, requiring a coordinated approach to further tobacco control. Early California Tobacco Control Program success is rooted in public health policy strategies and a statewide media campaign that shifted social norms. In 2009, concepts for a coordinated approach were introduced by the California Tobacco Control Program in the state's first tobacco quit plan. The state quit plan called for public health's tobacco control programs to engage healthcare systems and insurers to work more directly with the California Smoker's Helpline (Helpline). With California's Medicaid (Medi-Cal) program expansion and the implementation of electronic medical record systems, health care plans and providers received additional support for system changes. Simultaneous with these changes, coordinated tobacco control efforts began, including California's Medi-Cal Incentives to Quit Smoking project (2012-2015). In the Medi-Cal Incentives to Quit Smoking project, safety-net providers and Medi-Cal plans were outreached and engaged to promote incentives for Medi-Cal members to utilize Helpline services. In another effort, UC Quits (2013-2015), the five University of California health systems used electronic medical record tools to promote tobacco treatments and electronic referrals to the Helpline. Now, as tobacco prevention is increasingly prioritized for quality improvement, California Tobacco Control Program is funding CA Quits, a statewide tobacco-cessation learning collaborative and technical assistance resource to promote integration of tobacco treatment services and quality improvement activities into safety-net health systems. CA Quits, in coordination with the Helpline, will connect public health departments, Medi-Cal plans, and safety-net providers to accelerate health systems change for tobacco-cessation treatment throughout the state. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Introduction In California, half of pregnant women and children are on California's Medicaid (Medi-Cal). The Medi-Cal Incentives to Quit Smoking program provided incentives to adults on Medi-Cal to call the California Smokers Helpline (Helpline) from March 2012 to July 2015. This analysis examined reach of the Medi-Cal Incentives to Quit Smoking program among pregnant and parenting women. Methods This study examined caller data from the Helpline from 2010 to 2015 among women of reproductive age (18–45 years) enrolled in Medi-Cal (n=32,691; analyzed in 2017/2018). The authors calculated the annual percentage of the target population reached who called the Helpline by pregnancy status and used adjusted prevalence ratios to examine the associations between Medi-Cal Incentives to Quit Smoking incentive period, pregnancy/parenting status, Medi-Cal Incentives to Quit Smoking incentives ($20 gift card and nicotine patch), and counseling. Results Over the study period, the percentage of the target population reached increased for women of reproductive age (2.1% in 2011 to 3.0% in 2014) and pregnant women (2.1% in 2011 to 3.3% in 2014). The percentage of women who asked for the $20 gift card (13.6%) was not substantially different by pregnancy status, and WIC and nonprofits were important referral sources. Pregnant women were less likely to receive nicotine patches, but there was a 3- to 4-fold increase during the Medi-Cal Incentives to Quit Smoking incentive period for both pregnant and nonpregnant women. Among nonpregnant women, counseling decreased 14% during the Medi-Cal Incentives to Quit Smoking incentive period. Conclusions Results suggest that the nicotine patch incentives motivated women to call the Helpline, even pregnant women who needed a physician's approval consistent with current American College of Obstetricians and Gynecologists cautions about the appropriateness of the patch during pregnancy. Supplement information This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

INTRODUCTION Nonsmoking pregnant women in China have significant exposure to secondhand smoke (SHS). Few interventions have focused on pregnant women reducing their SHS exposure. METHODS This clustered randomized controlled trial, conducted at eight hospitals in Sichuan, China, compared a prenatal health education intervention with usual clinical care as a control. The primary outcome was self-reported "no SHS exposure" before and 3 months after birth. The intervention consisted of three large group educational sessions, standardized clinician advice, brief monthly follow-up calls, and educational materials and resources. A random sample of participants was biochemically validated before birth with hair nicotine, a long-term biomarker of smoke exposure. RESULTS Overall, 1181 participants were randomized to intervention (n = 526) and control (n = 655) groups. More participants in the intervention group than the control group reported no SHS exposure 3 months after birth (Total: 77.9% vs. 52.6%, P < .001; Home: 81.2% vs. 53.3%, P < .001). The intervention group also had greater changes in improved smoke-free homes and SHS knowledge and attitudes. Controlling for covariates, the intervention group was less likely to report SHS exposure than the control group (Total: OR = 0.47, 95% CI = 0.31 to 0.71; Home: OR = 0.33, 95% CI = 0.21 to 0.53), and this effect was sustained 3 months after birth. The adjusted log concentration of hair nicotine for the intervention group decreased by 0.28 log µg/g more than the control group. CONCLUSIONS Our smoke-free health education intervention for nonsmoking pregnant women significantly reduced SHS exposure before and after birth. This intervention model can become part of a standard protocol for the care of pregnant women in hospital settings.

Author(s): Tong, Elisa K; Fagan, Pebbles; Cooper, Leslie; Canto, Maria; Carroll, William; Foster-Bey, John; Hebert, James R; Lopez-Class, Maria; Ma, Grace X; Nez Henderson, Patricia; Perez-Stable, Eliseo J; Santos, LorrieAnn; Smith, Justin H; Tan, Yin; Tsoh, Janice; Chu, Kenneth | Abstract: IntroductionIn 2005, the National Cancer Institute funded the Community Networks Program (CNP), which aimed to reduce cancer health disparities in minority racial/ethnic and underserved groups through community-based participatory research, education, and training. The purpose of this study was to describe the CNP model and their tobacco-related work in community-based research, education, and training using a tobacco disparities research framework.MethodsWe conducted a comprehensive review of the CNP tobacco-related activities including publications, published abstracts, research activities, trainee pilot studies, policy-related activities, educational outreach, and reports produced from 2005-2009. Two authors categorized the tobacco-related activities and publications within the framework.ResultsAlthough there was no mandate to address tobacco, the CNPs produced 103 tobacco-related peer-reviewed publications, which reflects the largest proportion (12%) of all CNP cancer-related publications. Selected publications and research activities were most numerous under the framework areas "Psychosocial Research," "Surveillance," "Epidemiology," and "Treatment of Nicotine Addiction." Thirteen CNPs participated in tobacco control policymaking in mainstream efforts that affected their local community and populations, and 24 CNPs conducted 1147 tobacco-related educational outreach activities. CNP activities that aimed to build research and infrastructure capacity included nine tobacco-related pilot projects representing 16% of all CNP cancer-related pilot projects, and 17 publications acknowledging leveraged partnerships with other organizations, a strategy encouraged by the CNP.ConclusionsThe CNP is a promising academic-community model for working to eliminate tobacco-related health disparities. Future efforts may address scientific gaps, consider collaboration across groups, assess the extent of operationalizing community-based participatory research, and improve common tracking measures.

Chinese American men smoke at a high rate, which puts household nonsmokers at risk. The objective of this study was to evaluate the effectiveness of a brief-intensity versus moderate-intensity smoke-free-living educational intervention for household pairs.The authors conducted a randomized controlled trial of Cantonese-speaking Chinese American smoker and household nonsmoker pairs in San Francisco, California. Pairs were randomized to moderate-intensity or brief-intensity group sessions with their household partner. The moderate-intensity group received 2 group sessions, a laboratory report of their baseline smoke exposure, as measured by 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and 3 follow-up calls over 6 months. The brief-intensity group received 1 group session on tobacco-cessation resources. Primary outcomes were biochemically validated, past-month smoking abstinence and elimination of nonsmoker household exposure at 12 months.Participant pairs (n = 203) were male smokers, one-half of whom did not intend to quit within 6 months, with mostly female spouses as household nonsmokers. Approximately three-quarters of nonsmokers in both groups already had smoke-free home rules. At 12 months, smokers in both groups had similar biochemically validated 30-day abstinence rates (moderate-intensity group, 0%-20.7%; brief-intensity group, 0%-20.0%; P = .002 over time). More smokers in the moderate-intensity group used subsequent cessation group classes (moderate-intensity group, 50%; brief-intensity group, 24%; P = .004). Household nonsmokers in both groups had similar biochemically validated rates of no home exposure (moderate-intensity group, 24.5%-42.2%; brief-intensity group, 24.8%-33.3%; P = .0001 over time).A moderate-intensity smoke-free-living educational intervention for Chinese-speaking household pairs was not more effective than a brief-intensity intervention for smoking abstinence and elimination of household nonsmoker exposure. Abstinence rates were similar to those achieved with standard group counseling. Cancer 2018;124:1590-8. © 2018 American Cancer Society.

Asian Indians (AIs) in the United States exhibit disproportionate burdens of oral cancer and cardiovascular disease, which are potentially linked to smokeless tobacco. However, little is known about the use of cultural smokeless tobacco (CST) products in this population.California Asian Indian Tobacco Use Survey data from 2004 (n = 1618) were used to investigate CST prevalence among California's AIs. CST products included paan, paan masala, and gutka. A multivariable logistic regression was conducted to examine factors (socioeconomic status, acculturation measures, and religious affiliation) associated with current CST use versus never use.The current CST prevalence was 13.0% (14.0% for men and 11.8% for women). In contrast, the prevalence of current cigarette use was 5.5% (8.7% for men and 1.9% for women), and the prevalence was lower for cultural smoked tobacco (0.1% for bidis and 0.5% for hookahs). Factors associated with CST use included the following: being male, being 50 years old or older, being an immigrant, speaking an AI language at home, having a higher level of education (adjusted odds ratio [AOR] for high school/some college, 2.6; 95% confidence interval [CI], 1.1-6.5; AOR for college degree or higher, 4.0; 95% CI, 1.7-9.5), having a higher income (AOR for $75,000-$100,000, 2.5; 95% CI, 1.3-4.7; AOR for ≥$100,000, 2.6; 95% CI, 1.4-5.0), identifying as non-Sikh (AOR for Hinduism, 10.0; 95% CI, 6.0-16.5; AOR for other faiths, 10.2; 95% CI, 5.9-17.7), and disagreeing that spiritual beliefs are the foundation of life (AOR, 2.1; 95% CI, 1.2-3.5).The current CST prevalence is relatively high among California's AIs in comparison with the prevalence of smoking, with narrower differences between sexes. The association with a higher socioeconomic status is contrary to typical cigarette smoking patterns. Acculturation and religious affiliation are important factors associated with current use. Health care providers and policymakers should consider such determinants for targeted interventions. Cancer 2018;124:1607-13. © 2018 American Cancer Society.

To the authors' knowledge, there are few studies to date regarding colorectal cancer (CRC) beliefs, knowledge, and screening among multiple Asian American populations, who are reported to have lower CRC screening rates compared with white individuals. The current study was performed to assess knowledge and beliefs regarding the causes of CRC, its prevention, and factors associated with CRC screening among 3 Asian American groups.The authors conducted an in-language survey with Filipino (Honolulu, Hawaii), Hmong (Sacramento, California), and Korean (Los Angeles, California) Americans aged 50 to 75 years who were sampled through social networks. Bivariate and multivariable analyses were conducted to assess factors associated with CRC screening.The sample of 981 participants was 78.3% female and 73.8% reported limited proficiency in English. Few of the participants were aware that age (17.7%) or family history (36.3%) were risk factors for CRC; 6.2% believed fate caused CRC. Only 46.4% of participants knew that screening prevented CRC (74.3% of Filipino, 10.6% of Hmong, and 55.8% of Korean participants; P.001). Approximately two-thirds of participants reported ever having undergone CRC screening (76.0% of Filipino, 72.0% of Hmong, and 51.4% of Korean participants; P.001) and 48.6% were up to date for screening (62.2% of Filipino, 43.8% of Hmong, and 41.4% of Korean participants; P.001). Factors found to be significantly associated with ever screening were being Korean (compared with Filipino), having a family history of CRC, having health insurance or a regular source of health care, and knowing that a fatty diet caused CRC. Believing that fate caused CRC and that praying prevented it were found to be negatively associated with ever screening. Factors associated with being up to date for CRC screening included being born in the United States, having a family history of CRC, and having access to health care.Knowledge regarding the causes of CRC and its prevention among Filipino, Hmong, and Korean individuals is low. However, health care access, not knowledge or beliefs, was found to be a key determinant of CRC screening. Cancer 2018;124:1552-9. © 2018 American Cancer Society.

Filipino colorectal cancer (CRC) screening rates fall below Healthy People 2020 goals. In this study, the authors explore whether a lay health educator (LHE) approach can increase CRC screening among Filipino Americans ages 50 to 75 years in Hawai'i.A cluster randomized controlled trial from 2012 through 2015 compared an intervention, which consisted of LHEs delivering 2 education sessions and 2 telephone follow-up calls on CRC screening plus a CRC brochure versus an attention control, in which 2 lectures and 2 follow-up calls on nutrition and physical activity plus a CRC brochure were provided. The primary outcome was change in self-reported ever receipt of CRC screening at 6 months.Among 304 participants (77% women, 86% had 10 years of residence in the United States), the proportion of participants who reported ever having received CRC screening increased significantly in the intervention group (from 80% to 89%; P = .0003), but not in the control group (from 73% to 74%; P = .60). After covariate adjustment, there was a significant intervention effect (odds ratio, 1.9; 95% confidence interval, 1.0-3.5). There was no intervention effect on up-to-date screening.This first randomized controlled trial for CRC screening among Hawai'i's Filipinos used an LHE intervention with mixed, but promising, results. Cancer 2018;124:1535-42. © 2018 American Cancer Society.

Cancer is the leading cause of death for Asian Americans. The authors evaluated the status of cancer prevention for Chinese Americans in San Francisco, which has had years of cancer prevention efforts.Through a community-based clinic serving Chinese Americans, a randomized, controlled trial (n = 395) was conducted among participants who attended either a cancer prevention seminar or biospecimen education seminar. Changes in knowledge, attitudes, and screening completion/intent were measured across and between seminar groups.Participants were mostly women who had low acculturation and education levels. Over two-thirds to almost all participants knew about modifiable risk factors for cancer and that screening tests were available, including for lung cancer. The majority of women had already completed mammography and Papanicolaou (Pap) tests. Approximately one-half reported having completed colorectal cancer screening, prostate screening, or hepatitis B screening. Most were nonsmokers, but about one-half "strongly agreed" that they would want a test for tobacco smoke exposure. After the cancer prevention seminar, significant increases within group were noted for knowledge (eating healthy foods, from 93.1% to 97.7% [P = .0002]; secondhand smoke causes cancer, from 66.3% to 74.8% [P = .04]) and for screening completion/intent (colorectal cancer, from 58.1% to 64.5% [P = .002] cervical cancer, from 72.9% to 75.5% [P = .04]) and there was a trend toward an increase for prostate cancer (from 50.0% to 61.1%; P = .10). There was a significant change between groups for eating healthy foods (P = .004).The current reports documents the gains in cancer prevention among Cantonese-speaking Chinese Americans, fostered by academic, community, and public health efforts. A community-based seminar demonstrated improvement in some cancer knowledge or screening intent and opportunities for continued efforts. Cancer 2018;124:1622-30. © 2018 American Cancer Society.

Two products indigenous to the Indian subcontinent and popular among South Asians globally - paan and paan masala - are inconsistently categorised as tobacco by researchers, clinicians, program planners and policymakers. This article calls for a universally standard classification of these smokeless carcinogenic products as tobacco products and thus, subject to the same public health and clinical protections applied to other forms of tobacco. This recommendation is guided by scientific evidence strongly indicating the common presence of tobacco in paan and paan masala. Inclusion of these two products in population-level surveillance, clinical screening, as well as public health program planning and policy interventions may have considerable impact on preventing and reducing tobacco-related disparities among South Asians around the world.

Background: Biospecimen collection from diverse populations can advance cancer disparities research, but is currently underrepresented. Methods: We partnered with a community-based clinic serving Cantonese-speaking Chinese Americans to develop and revise an educational seminar on biospecimen collection. Through a randomized controlled trial (n = 395), the intervention seminar was compared with a control seminar (cancer prevention) on change in willingness to donate biospecimens. Results: At baseline, many were willing to donate a biospecimen (saliva, urine, hair, toenails, blood, unused cancerous tissue) whether healthy or hypothetically had cancer. Also, many would donate because future generations would benefit, and few had concerns about donation. In logistic regression analyses, there was an intervention effect for willingness to donate: urine if had cancer [OR, 2.2; 95% confidence interval (CI), 1.3–3.7], toenails if healthy (OR, 2.1; 95% CI, 1.4–3.2) or had cancer (OR, 2.3; 95% CI, 2.0–2.7), hair if healthy (OR, 1.8; 95% CI, 1.3–2.5) or had cancer (OR, 2.8; 95% CI, 1.9–4.0), and unused cancerous tissue (OR, 1.8; 95% CI, 1.2–2.9). There was also an intervention effect for donating because future generations would benefit (OR, 2.0; 95% CI, 1.4–3.0), and this attitude was a strong independent predictor for willingness to donate all biospecimens, whether healthy or had cancer (OR, 2.9–4.2). Conclusion: Cantonese-speaking Chinese American participants of an educational seminar on biospecimen collection showed greater increases in willingness to donate biospecimens and donating for the benefit of future generations, than participants who attended a control seminar. Impact: Donating for the benefit of future generations is a theme that should be incorporated in messages that encourage biospecimen donation for Chinese Americans. See all articles in this CEBP Focus section, “Community Network Program Centers.” Cancer Epidemiol Biomarkers Prev; 23(3); 392–401. ©2014 AACR.

Background Tobacco biomarkers including serum cotinine and urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) have been used in research settings. Purpose The goal of the study was to examine the association of cotinine and NNAL with asthma outcomes in the U.S. adult population. Methods A cross-sectional design was used, using data from the National Health and Nutrition Examination Survey, 2007–2008, with participants aged >20 years with self-reported asthma (N=456). Past-year asthma exacerbations and emergency room/urgent care visits for asthma were examined. Analyses were conducted in 2013. Results Among adult asthmatics, 50.3% reported a past-year asthma attack (61.8% smokers, 46.6% nonsmokers, p =0.029). Among these, 24.7% reported a past-year emergency/urgent visit for asthma (34.7% smokers, 20.1% nonsmokers, p =0.034). Median concentrations of cotinine and creatinine-adjusted NNAL (NNAL/Cr) were significantly higher in those with a past-year asthma attack (0.43 ng/mL and 7.28 pg/mL) than in those without (0.06 ng/mL and 2.26 pg/mL), and highest in those with past-year emergency/urgent visits (0.93 ng/mL and 28.14 pg/mL). Among nonsmokers, increasing levels of log cotinine or log NNAL/Cr, adjusted for demographics, were significantly associated with past-year asthma exacerbation (log cotinine OR=1.46 [95% CI=1.1, 1.92]; log NNAL/Cr OR=1.42 [95% CI=1.07, 1.88]) and past-year emergency/urgent visit (log cotinine OR=1.95 [95% CI=1.32, 2.88]; log NNAL/Cr OR=1.58 [95% CI=1.23, 2.02]). Among smokers, increasing biomarker levels were not significantly associated with either outcome. Conclusions In a population-based cross-sectional analysis, increased cotinine and NNAL were found to be associated with asthma exacerbation and healthcare use in nonsmokers with asthma. If these findings are confirmed in prospective studies, these biomarkers might be candidates for clinical indicators of risk of asthma.

Recent studies reported that smoking cessation leads to higher short-term risk of type 2 diabetes than continuing to smoke. However, the duration of increased diabetes risk following smoking cessation needs further investigation. We followed 135,906 postmenopausal women aged 50–79 years enrolled in the Women's Health Initiative between September 1, 1993, and December 31, 1998, over an average of 11 years to examine the association between smoking cessation and risk of diabetes using Cox proportional hazard multivariable-adjusted regression models. Compared with that for never smokers, the risk for diabetes was significantly elevated in current smokers (hazard ratio = 1.28, 95% confidence interval: 1.20, 1.36) but was even higher in women who quit smoking during the first 3 years of follow-up (hazard ratio = 1.43, 95% confidence interval: 1.26, 1.63). Among former smokers, the risk of diabetes decreased significantly as the time since quitting increased and was equal to that of never smokers following a cessation period of 10 years. In new quitters with low cumulative exposure (