Search

The field of digital health is evolving rapidly and encompasses a wide range of complex and changing technologies used to support individual and population health. The COVID-19 pandemic has augmented digital health expansion and significantly changed how digital health technologies are used. To ensure that these technologies do not create or exacerbate existing health disparities, a multi-pronged and comprehensive research approach is needed. In this commentary, we outline five recommendations for behavioral and social science researchers that are critical to promoting digital health equity. These recommendations include: (i) centering equity in research teams and theoretical approaches, (ii) focusing on issues of digital health literacy and engagement, (iii) using methods that elevate perspectives and needs of underserved populations, (iv) ensuring ethical approaches for collecting and using digital health data, and (v) developing strategies for integrating digital health tools within and across systems and settings. Taken together, these recommendations can help advance the science of digital health equity and justice.The field of digital health is quickly growing and changing. Digital health technologies have the potential to increase access to health-related information and healthcare and improve wellbeing, but it is important that those technologies don’t widen existing health disparities or create new ones. Behavioral and social science researchers have a key role to play in centering equity in their research teams and theoretical approaches, focusing on key barriers to access, uptake, and usage, studying digital health in ways that elevate the voices and needs of historically underserved groups, being thoughtful about how digital health data are collected and used, and making sure that digital health tools are designed to be used in real-world settings.

OBJECTIVE: This pilot study tested the acceptability and short-term outcomes of a culturally specific mobile health (mHealth) intervention (Path2Quit) in a sample of economically disadvantaged African American adults. We hypothesized that Path2Quit would demonstrate greater acceptability, biochemically verified abstinence, and promote nicotine replacement therapy (NRT) use compared with a standard text-messaging program. METHOD: In a 2-arm pilot randomized trial, adults who sought to quit smoking (N=119) received either Path2Quit or the National Cancer Institute’s (NCI) SmokefreeTXT, both combined with a brief behavioral counseling session plus two weeks of NRT. Outcomes included acceptability (intervention evaluation and use), NRT utilization, 24-hour quit attempts, self-reported 7-day point prevalence abstinence (ppa), and biochemically-verified smoking abstinence at the 6-week follow-up. RESULTS: Participants were 52% female/48% male, mostly single (60%), completed ≥ 12 years of education (83%), middle-aged, and 63% reported a household income < $10k/year. Participants smoked 11 (SD=8.2) cigarettes/day for 25 (SD=16) years, and reported low nicotine dependence. There were no differences in intervention evaluations or use (ps>.05), yet Path2Quit led to significantly greater NRT utilization at follow-up (p.05). However, Path2Quit resulted in significantly greater carbon monoxide confirmed ppa (AOR=3.55; CI: 1.32–9.54) at the 6-week follow-up. CONCLUSIONS: A culturally specific mHealth intervention demonstrated positive effects on NRT use and short-term abstinence. Additional research in a larger sample, and with longer-term follow-up is warranted.

Background: Ensuring equitable access to smoking cessation services for cancer patients is necessary to avoid increasing disparities in tobacco use and cancer outcomes. In 2017, the Cancer Center Cessation Initiative (C3I) funded National Cancer Institute (NCI)-designated Cancer Centers to integrate evidence-based smoking cessation programs into cancer care. We describe the progress of C3I Cancer Centers in expanding the reach of cessation services across cancer populations. Methods: Cancer centers (n=17) reported on program characteristics and reach (the proportion of smokers receiving evidence-based cessation treatment) for two 6-month periods. Reach was calculated overall and by patient gender, race, ethnicity, and age. Results: Average reach increased from 18.5% to 25.6% over 1 year. Reach increased for all racial/ethnic groups, and in particular for American Indian/Alaska Native (6.6-24.7%), Asian/Native Hawaiian/Pacific Islander (7.3-19.4%), and black (18.8-25.9%) smokers. Smaller gains in reach were observed among Hispanic smokers (19.0-22.8%), but these were similar to gains among non-Hispanic smokers (18.9-23.9%). By age group, smokers aged 18-24 years (6.6-14.5%) and >65 years (16.1-24.5%) saw the greatest increases in reach. Conclusion: C3I Cancer Centers achieved gains in providing smoking cessation services to cancer patients who smoke, thereby reducing disparities that had existed across important subgroups. Taking a population-based approach to integrating tobacco treatment into cancer care has potential to increase reach equity. Implementation strategies including targeted and proactive outreach to patients and interventions to increase providers' adoption of evidence-based smoking cessation treatment may advance reach even further.

NIH has acknowledged and committed to ending structural racism. The framework for NIH's approach, summarized here, includes understanding barriers; developing robust health disparities/equity research; improving its internal culture; being transparent and accountable; and changing the extramural ecosystem so that diversity, equity, and inclusion are reflected in funded research and the biomedical workforce.

Racial/ethnic minority communities are experiencing an undue burden from coronavirus disease 2019 (COVID-19), and the availability of Food and Drug Administration (FDA) authorized vaccines is critical for improving population health. National surveys assessing vaccination willingness and reports of vaccination administration by race/ethnicity indicate at least two areas that warrant attention: elevated vaccine hesitancy among African American and Latino adults, and the need to ensure equitable access to vaccination. COVID-19 vaccine hesitancy is not uniform within racial/ethnic minority populations; yet, given the disproportionate impact, understandable distrust, and widespread misinformation, there is an imperative to overcome challenges associated with vaccination willingness and uptake, as well as implementation and access. This Perspective discusses the complexity of drivers for each of these areas, which include individual, community, and structural factors. It also highlights two initiatives at the National Institutes of Health. One is focused on addressing misinformation and distrust through academic-community partnerships, and the other on community-engaged behavioral interventions to address the population-specific reasons for COVID-19 vaccine hesitancy, support informed decision-making, and promote equitable access among populations with health disparities. For the foreseeable future, proactive and persistent efforts around COVID-19 mitigation strategies, including vaccination, will remain of paramount importance for health equity.

BACKGROUND: The objective of this study was to test the hypothesis that exercise would be more effective than a support group plus Fitbit (SG+Fitbit) program in improving functional outcomes in older breast cancer survivors (BCSs) and that race would moderate the exercise effect on outcomes. METHODS: Older African American (AA) and non-Hispanic White (NHW) BCSs were purposively recruited and enrolled into the 52-week randomized controlled trial. The interventions included 20 weeks of supervised moderate-intensity aerobic and resistance training followed by 32 weeks of unsupervised exercise called IMPROVE (n = 108) and a 20-week SG+Fitbit program followed by 32 weeks of unsupervised activity (n = 105). Study outcomes were assessed at 20 and 52 weeks. The primary outcome was the change in Short Physical Performance Battery (SPPB) scores 20 weeks from the baseline between arms. Secondary outcomes included change in the 6-Minute Walk Test (6MWT) in meters 20 weeks from the baseline between arms. General linear regression and multivariable logistic regression analyses were used. RESULTS: The mean age was 71.9 years (SD, 5.9 years), and 44% were AA. SPPB scores did not differ between arms (adjusted difference in mean change, 0.13; 95% CI, −0.28 to 0.55; P = .53). However, the exercise arm (vs the SG+Fitbit arm) improved on the 6MWT (21.6 m; 95% CI, 2.5-40.6 m; P = .03). Race moderated the exercise effect on the 6MWT (adjusted interaction effect, 43.3 m; 95% CI, 6.3-80.2 m; P = .02); this implied that the change in the adjusted mean for the 6MWT at 20 weeks from the baseline was 43.3 m higher in AA exercise participants versus NHW exercise participants. CONCLUSIONS: Combined aerobic and resistance exercise appears to improve physical performance in older BCSs, and the exercise effect might be moderated by race, with AAs appearing to derive larger benefits in comparison with NHWs. Larger studies are warranted to confirm the study findings.

Low-socioeconomic status (SES) individuals have higher rates of obesity. Social media platforms are used frequently by low-SES individuals and facilitate important weight loss program components including social support. Very few social media-based weight loss interventions, however, have enrolled or been tailored to low-SES participants. The purpose of this article is to examine the feasibility of a social media-based weight loss intervention among low-SES adults. We conducted a one-group pretest post-test pilot intervention study with two groups (group 1, n = 39, group 2, n = 16) of low-SES overweight/obese adults who were enrolled in a 12-week social media-based weight loss intervention including self-monitoring via Fitbits and participation in a private Facebook group. A moderator provided educational content and encouraged social support via Facebook. Descriptive statistics were used to assess intervention acceptability and engagement. Exploratory analyses were conducted to examine changes in study outcomes and engagement patterns. The study had good retention (86%). Among 55 total participants enrolled, there were 9,175 participant interactions within the Facebook group. Among completers (n = 47), 96% indicated they would recommend the intervention to a friend. Mean weight loss was 1.07 kg (SD = 3.96, p = .0498), and participants reported increases in positive dietary social support (mean = 2.47, SD = 5.09, p = .0007). Engagement in this social media-based pilot intervention was high and exceeded results from previous studies using similar formats. Participants evaluated the intervention favorably. Changes in weight loss and several theoretical mediators were in the desired direction. Overall, our results indicate social media groups as a platform for weight loss intervention delivery among low-SES adults are feasible and should be studied in larger randomized trials.

Objectives: This study investigated a) racial/ethnic differences in past-year discrimination experiences and b) associa­tions between discrimination and smoking abstinence. Design: Prospective, longitudinal analysis of smoking status. Perceived past-year discrimi­nation was assessed at baseline. ANCOVAs and intent-to-treat hierarchical logistic regressions were conducted. Setting: Dual-site (Tampa, FL and Miami, FL) randomized controlled trial testing the effects of a group cessation intervention plus pharmacotherapy. Participants: Treatment-seeking adult smokers (N=347; non-Hispanic White, non-Hispanic African American/Black, or Hispanic). Main Outcome Measures: Biochemically verified 7-day point prevalence abstinence (7-day ppa) was assessed immediately post-intervention and at 6-month follow-up. Results: After controlling for covari­ates, African Americans/Blacks reported greater perceived discrimination compared with non-Hispanic Whites (P=.02), and Hispanics (P=.06). Non-Hispanic Whites and Hispanics did not differ in perceived racial/ethnic discrimination experiences over the past year. Irrespective of race/ ethnicity, past-year perceived discrimina­tion was inversely associated with 7-day ppa, both post-intervention (AOR=.97, CI: .95-.99) and at 6-months (AOR=.98, CI: .96-.99). Among African Americans/Blacks, past-year perceived discrimination was inversely associated with 7-day ppa, both post-intervention (AOR=.95, CI: .92-.97) and at 6-months (AOR=.97, CI: .94-.99). Perceived discrimination was unrelated to 7-day ppa among Hispanics. Among non-Hispanic Whites, past-year perceived discrimination was inversely associated with post-intervention 7-day ppa (AOR=.95, CI: .91-.99), but not 6-months. Conclusions: Perceived racial/ethnic discrimination was greater among African American/Black smokers compared with non-Hispanic Whites. Perceived discrimina­tion was negatively associated with tobacco cessation in the full sample, and for African Americans at 6-months post-intervention. These data have implications for interven­tion delivery and health disparities. Ethn Dis. 2020;30(3):411-420; doi:10.18865/ed.30.3.411

INTRODUCTION: Despite the strong relationship between marijuana and tobacco use, especially among African American individuals and males, very few studies have examined the association between marijuana and menthol cigarette use. This study was designed to identify the prevalence of past month, past year and lifetime marijuana use and marijuana dependence among menthol and non-menthol cigarette smokers, as well as the association between marijuana and menthol cigarette use among African American female and male cigarette smokers. METHODS: Data were drawn from 1,173 African American adult cigarette smokers in the 2017 National Survey on Drug Use and Health. RESULTS: Overall, 8.8%, 13.9% and 44.7% of African American menthol and non-menthol cigarette smokers reported past month, past year and lifetime marijuana use, respectively. Weighted multivariable logistic regression models revealed a significant interaction between gender and past month marijuana use on menthol cigarette use (AOR = 1.49, 95% CI: 1.21–2.42, p < .05). Past month marijuana use was associated with an increased odds of past month menthol cigarette use (relative to non-menthol cigarette use) among females, but a decreased odds of past of past month menthol cigarette use among males. CONCLUSIONS: When stratified by gender, marijuana use is differentially related to menthol cigarette use among African American adults. Given the prevalence of menthol cigarette use among this population, it is important to examine factors such as marijuana use that could be targeted in prevention and treatment interventions for African Americans, especially females, who are at risk for smoking or are currently smoking menthol cigarettes. IMPLICATIONS: This study found that marijuana use was associated with an increased odds of menthol cigarette use among African American females, while marijuana use was associated with a decreased odds of menthol cigarette use among their male counterparts. The impact of marijuana use on menthol cigarette smoking differs among females and males, highlighting the need for gender-tailored interventions that target marijuana use among African American individuals, especially females, who are at risk for smoking or are currently smoking menthol cigarettes.

IntroductionCognitive-behavioral therapy (CBT) for tobacco cessation is an evidence-based, yet underutilized intervention. More research is needed to understand why some treatment-seekers are ‘no-shows’ for the initial visit.AimExamine factors associated with participant no-shows among smokers scheduled for group CBT.MethodsTobacco smokers (N = 115) were recruited from the community, screened, and if eligible, scheduled to begin group-based CBT plus nicotine replacement therapy. At the screening, participants reported their recruitment source, demographics, smoking history, and contact information. We computed the distance to the study site using the address provided. Regression analyses tested predictors of participant no-shows for the initial visit.ResultsEligible participants were mostly recruited via flyers (56%), female (58%), African American (61%), middle-aged (Mage = 49 years), averaged 16 cigarettes per day, and resided 8 miles away from the study site. The overall initial visit no-show rate was 56%. Bivariate analyses indicated that respondents who were recruited online, younger, and lived further away from the site were more likely to be no-shows. Younger age significantly predicted failure to attend in the multivariable model.ConclusionsFindings highlight potential barriers to participation in a group-based intervention, and have implications for pre-intervention engagement strategies and modifications that may increase reach and uptake.

The Youth Enjoy Science (YES) Program at the Case Comprehensive Cancer Center is a National Cancer Institute (NCI) R25- funded training grant, designed to increase the pipeline of underrepresented minor­ity (URM) students entering college and pursuing biomedical research and health care careers in the Cleveland Metropolitan and surrounding school districts. The three components of the program include: Learn to Beat Cancer, engaging middle school students and their families; Research to Beat Cancer, designed for high school students and college undergraduates; and Teach to Beat Cancer, focused on enhancing science, technology, engineering, and mathemat­ics (STEM) teaching capacity among high school teachers. This study focuses on Research to Beat Cancer, which, in 2018 enrolled 36 URM students as paid sum­mer scholars. Students were assigned to a faculty mentor, were taught laboratory safety, responsible conduct of research and the scientific method, and then immersed in full-time laboratory cancer research during an eight-week period. Twice each week, students participated in Lunch and Learn Seminars where faculty members provided combined motivational and scientific guidance lectures. In a capstone poster session at the end of the program, students presented their research to peers, medical and graduate students, family members, faculty, community members and leaders. Students’ perceptions of the program were reported using descriptive statistics and qualitative thematic analyses. Twenty-four of the 2018 YES students (67%) and 19 (53%) mentors completed the online post-program survey. Opportunity was a major qualitative theme from student and mentor responses. Future research will investigate the long-term impacts of YES, including college enrollment.Ethn Dis. 2020;30(1):15-24; doi:10.18865/ed.30.1.15

Medical distrust is both a psychosocial construct and an underappreciated individual social determinant of health with the potential to affect oncology care and clinical trial participation. A community-based participatory research effort, called the Forward Movement Project (FMP), identified multilevel factors affecting trust for healthcare and research in an underserved urban community. In FMP Phase II, we implemented a community-responsive approach to provide lay-oriented education and address misinformation, with the goal of beginning to remediate distrust for healthcare systems and biomedical research.Community residents (N = 154 adults, 64% male, M = 61.5 years old, 53% annual income$10,000, 83% African American/Black) engaged in participant-driven dialogues with oncology clinicians/clinical researchers and support services professionals. A program evaluation focused on trust for healthcare and biomedical research.Participants reported positive evaluations of both the program and the cancer center clinicians and staff, who were rated as trustworthy (80% strong agreement). However, trust for healthcare systems ("Strongly agree" = 58%) and medical researchers ("Strongly agree" = 50%) following the program was moderate. Over half of the sample (52%) strongly agreed they would participate in a clinical trial compared to before joining this study.Findings supported the user-generated program approach. The FMP is an example of a model for true community engaged research and has implications for rebuilding trust in healthcare and research.

Control of the COVID-19 pandemic relies heavily on behavioral mitigation strategies such as physical distancing, hand washing and mask wearing. Even with the availability of SARS-CoV-2 vaccines, the extraordinary effort to distribute the vaccines must be paired with continued adherence to behavioral recommendations as well as vaccine confidence. To facilitate rapid and equitable uptake of the vaccines, there is a need for responsive, trustworthy, and evidence-informed communication about vaccination, enhanced trust in science, and engaging populations disproportionately affected by the pandemic. Efforts to address vaccine hesitancy and increase vaccine confidence will address the emerging gaps between vaccine availability and actual vaccination. Although these gaps are attributable, in part, to challenges with logistics and access, social and behavioral drivers of vaccination decision making also have a significant role in vaccination uptake. As federal, state, and local health and public health agencies coordinate vaccine dissemination, there will be a continuous need to adapt to an evolving landscape of SARS-CoV-2 vaccines, new scientific information, and the spread of COVID-19- and vaccine-related misinformation. Facilitating widespread vaccination and maintaining a focus on equity requires thoughtful and compassionate approaches to reach and address the needs of those who are disproportionately affected by the pandemic such as underserved, vulnerable, and racial/ethnic minority populations. This commentary focuses on several National Institutes of Health initiatives that are supporting behavioral and social science research to address SARS-CoV-2 vaccine communication and increase the uptake of vaccination. We conclude with implications for future research.

Ethn Dis. 2021;31(Suppl 1):289-292;doi:10.18865/ed.31.S1.289

Objective: The exclusion criteria of tobacco cessation randomized clinical trials (RCTs) may have unintended consequences on inclusion and cessation disparities. We examined racial/ethnic differences in: a) ex­clusion from a group-based cessation RCT; and b) reasons for exclusion.Design: Quasi-experimental. Inclusion criteria were self-identification as African American/Black, non-Hispanic White, or Hispanic (any race), adults, minimum five cigarettes/day or carbon monoxide reading of ≥ 8 parts per million (ppm), interest in quitting, and spoke/read English. Data were obtained from a parent trial, which is ongo­ing and will be completed in 2019. Analyses for our present study on participant screen­ing and enrollment were conducted in 2018.Main Outcome Measures: Study ineligi­bility, and reasons for exclusion (contra­indications for nicotine patch use, serious mental illness [SMI, eg, bipolar disorder or schizophrenia], alcohol dependence or illicit drug use, current tobacco treatment, attendance barriers [eg, transportation], and other concerns [eg, aggressive, intoxicated, disruptive, visibly ill]).Results: Of 1,206 individuals screened, 36% were ineligible. The most frequent reasons were SMI (28%), alcohol depen­dence or drug use (10%), and attendance barriers (7%). Ineligibility was greater among African Americans (42%) and Hispan­ics (37%), compared with Whites (24%; P

Tobacco smoking is responsible for one out of every five deaths in the US, according to the Centers for Disease Control and Prevention (CDC). Recent advances in treatment delivery include technology-based mobile health approaches, which seek to deliver real-time feedback to smokers to aid quit attempts and mitigate lapses. With regard to the measurement of smoking, clinical trials rely on participant self-report and/or biochemical verification of smoking status to evaluate outcomes. Wearable sensors have the potential to improve current approaches by providing personalized feedback and objective verification of smoking status ( Burns, 2000 ). In this paper, we describe the development of a novel smoking cessation system that combines motion detection and an Android software application to monitor smoking in real-time. In this system, a personalized smoking cessation plan will be created based on the goal of complete cessation or smoking reduction. Once the plan is created, the mobile system will monitor the users׳ smoking activity and provide feedback. An LSTM algorithm has been computed to train and test the motion data, which was collected from two armbands, to detect smoking and non-smoking motions. The internet message service will be used to remind users to stick to their plan when the sensor detects current smoking. Related video links are pushed and pulled to the users via Short Message Service (SMS) to support smoking cessation. Findings have implications for tobacco cessation treatment delivery and assessment of smoking status.

The COVID-19 pandemic has been mitigated primarily using social and behavioral intervention strategies, and these strategies have social and economic impacts, as well as potential downstream health impacts that require further study. Digital and community-based interventions are being increasingly relied upon to address these health impacts and bridge the gap in health care access despite insufficient research of these interventions as a replacement for, not an adjunct to, in-person clinical care. As SARS-CoV-2 testing expands, research on encouraging uptake and appropriate interpretation of these test results is needed. All of these issues are disproportionately impacting underserved, vulnerable, and health disparities populations. This commentary describes the various initiatives of the National Institutes of Health to address these social, behavioral, economic, and health disparities impacts of the pandemic, the findings from which can improve our response to the current pandemic and prepare us better for future infectious disease outbreaks.

Background African Americans (AA) and socioeconomic status (SES) disadvantaged older breast cancer survivors (BCS) are more likely to experience poor functional and health outcomes. However, few studies have evaluated the putative beneficial effects of exercise on these outcomes in older racial minority and SES-disadvantaged BCS. Methods This is a mixed-methods study that includes a randomized-controlled trial, “IMPROVE”, to evaluate a group-based exercise intervention compared to a support group program in older BCS, followed by post-intervention semi-structured interviews to evaluate the intervention. The trial aims to recruit 220 BCS with 55 in each of four strata defined by race (AA versus Non-Hispanic Whites) and SES (disadvantaged vs. non-disadvantaged). Participants are ≥65 years old and within five years of treatment completion for stage I-III breast cancer. Participants are randomized to a 52-week, three sessions/week, one-hour/session, moderate intensity aerobic and resistance group exercise intervention, (n = 110) or a 52-week, one hour/week, support group intervention [attention-control arm], (n = 110). The first 20 weeks of both programs are supervised and the last 32 week s , unsupervised. The primary outcome is the change in Short Physical Performance Battery (SPPB) Scores at 20 weeks from baseline, between the two arms. Secondary outcomes include change in SPPB scores at 52 weeks, change in body composition and biomarkers, at 20 and 52 weeks from baseline, between arms. Discussion Results of the trial may contribute to a better understanding of factors associated with recruitment, and acceptability, and will inform future exercise programs to optimally improve health outcomes for older BCS.

INTRODUCTION: Recruiting racial/ethnic minorities in smoking cessation trials is a priority. This study described lessons learned from recruiting a diverse sample of African American, White, and Hispanic/Latinx smokers in a smoking cessation trial. METHODS: We implemented a 42-month recruitment campaign utilizing reactive (e.g., word-of-mouth, newspaper, radio, online ads, flyers, community partnerships) and proactive (e.g., direct invitations) strategies. We included 821 participants in the analysis. We described our recruitment strategies’ implementation, their enrollment yield and rate (number enrolled/number screened) by race/ethnicity, and direct cost-per-participant (CPP: total cost/number of enrolled) for paid strategies. RESULTS: Enrollment yields were higher using reactive strategies than proactive strategies (94.3% vs. 5.7%). The top source of enrollment was word-of-mouth among African Americans (36%) and Whites (44%), and flyers among Hispanics/Latinxs (34%). Proactive recruitment, word-of-mouth, and flyers were more successful among African Americans than other groups. Newspaper and online ads were more successful among Hispanics/Latinxs than other groups (P

Introduction Research has shown that African Americans gain more than average weight after smoking cessation. However, African Americans have been underrepresented in post-cessation weight gain research. The current study examined 1) the pattern of weight gain and 2) the association between smoking status and weight gain in a sample of African Americans seeking smoking cessation treatment. Methods Data were drawn from a randomized controlled trial testing the efficacy of a 4-week culturally specific smoking cessation cognitive behavioral therapy (CBT) intervention among African American smokers (N = 342). Weight was measured and self-reported smoking status was biochemically verified at baseline, end of counseling, 3-, 6-, and 12-month follow-ups. Random effects multilevel modeling was used to examine weight gain over twelve months post CBT, and a fully unconditional model tested the pattern of weight gain over time. Smoking status was included as a time-varying factor to examine its effect on weight gain, controlling for potential confounding variables. Results Weight significantly increased among those who remained abstinent over 12 months post CBT [average gain of seven lbs. (three kg)]. Controlling for covariates, abstinence was predictive of the rate of weight gain for those with high weight concern. Conclusions Weight gain among African American abstainers was comparable to the average post-cessation weight gain observed among the general population. It is possible that exposure to CBT (culturally specific or standard) may have mitigated excessive weight gain. Future research should assess predictors of weight gain in African American smokers to inform future smoking cessation interventions and help elucidate factors that contribute to tobacco- and obesity-related health disparities.

Tobacco is a risk factor of head and neck cancer (HNC) and smoking cessation alone may reduce HNC risk by 70%. Soluble CD44 (solCD44), a cell surface receptor linked to cell proliferation and migration, and total protein (TP) levels can detect early HNC. This study aims to determine whether salivary solCD44 and TP levels in oral rinses change following a smoking cessation program. 150 smokers provided oral rinse samples at baseline and at a 12-month follow-up after participation in a smoking cessation program. Assays to measure levels of solCD44, TP, and cotinine, a metabolite used as a biomarker of tobacco exposure, were completed. A paired-samples t-test was used to determine whether there was a statistically significant (p < 0.05) mean difference in biomarker levels before and after the program. Baseline and at 12-month follow-up data were available for 88 subjects, 21 of whom quit smoking entirely. Mean levels of solCD44 significantly decreased by 0.412 ng/mL from baseline to the 12-month follow-up, p = 0.010. There was no significant difference in mean TP levels, p = 0.975. Mean cotinine levels decreased significantly by 74.7 ng/mL, p = 0.035. This is the first work demonstrating an association between smoking cessation and decreased solCD44 levels in oral rinses. Decreased expression of the tumorigenic CD44 may be one mechanism by which smoking cessation lowers cancer risk.

Pharmacotherapies for tobacco cessation are efficacious and recommended during quit attempts. Racial/ethnic minorities in the United States are less likely to use medication-based aids for tobacco cessation, despite greater difficulty achieving long-term abstinence. The reasons for this include, among others, provider- and patient-level considerations. Primary care clinicians play an important role in encouraging racial/ethnic minority tobacco users to use cessation pharmacotherapy. To better understand pharmacotherapy use, we conducted a narrative review of patient-level factors that may determine uptake and adherence. This review indicates that social and cultural factors impact pharmacotherapy use, including health care experiences, beliefs, perceptions, and norms. The proportion of individuals using pharmacotherapy during quit attempts and adhering to the full course of treatment may be enhanced with greater attention to the ethnocultural concerns of these groups. Culturally appropriate assessment and brief advice delivered by primary care providers could yield significant benefits in population health. Recommendations for treating racial/ethnic tobacco users with pharmacotherapy for cessation are offered.

Tobacco cessation after cancer diagnosis leads to better patient outcomes. However, tobacco treatment services are frequently unavailable in cancer care settings, and multilevel implementation challenges can impede uptake of new programs. The National Cancer Institute (NCI) dedicated Cancer Moonshot funding through the Cancer Center Cessation Initiative (C3I) for NCI-Designated Cancer Centers to implement or enhance the implementation of tobacco treatment services. We examined a pragmatic application of the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance) to evaluate tobacco treatment programs implemented within Cancer Centers funded through C3I. Using three C3I-funded Centers as examples, we describe how each RE-AIM construct was operationalized to evaluate the implementation of a wide range of cessation services (e.g., tobacco use screening, counseling, Quitline referral, pharmacotherapy) in this heterogeneous group of cancer care settings. We discuss the practical challenges encountered in assessing RE-AIM constructs in real world situations, including using the electronic health record (EHR) to aid in assessment. Reach and effectiveness evaluation required that Centers define the setting(s) where cessation services were implemented (to determine the "denominator"), enumerate the patient population, report current patient tobacco use, patient engagement in tobacco treatment, and 6-month cessation outcomes. To reduce site heterogeneity, increase data accuracy, and reduce burden, reach was frequently captured via standardized EHR enhancements that improved the identification of current smokers and tobacco treatment referrals. Effectiveness was determined by cessation outcomes (30-day point prevalence abstinence at 6-months post-engagement) assessed through a variety of data collection approaches. Adoption was measured by the characteristics and proportion of targeted cancer care settings and clinicians engaged in cessation service delivery. Implementation was assessed by examining the delivery of tobacco screening assessments and intervention components across sites, and provider-level implementation consistency. Maintenance assessments identified whether tobacco treatment services continued in the setting after implementation and documented the sustainability plan and organizational commitment to continued delivery. In sum, this paper demonstrates a pragmatic approach to using RE-AIM as an evaluation framework that yields relevant outcomes on common implementation metrics across widely differing tobacco treatment approaches and settings.

Background: Community and patient engagement in the healthcare system and biomedical research are prerequisites for eliminating health disparities. We conducted a &ldquo, listening tour&rdquo, to enhance our understanding of multilevel factors associated with community trust. Methods: Using community-based participatory research (CBPR) methods, we conducted a phenomenological qualitative study. &ldquo, Town-hall&rdquo, style discussions were held at nine sites across an urban, Midwestern city. We recruited adults (N = 130) via community networks, social media, flyers, and word-of-mouth. Demographic assessments were self-administered and listening tour sessions were conducted by trained moderators. Themes were framed within the social ecological model (SEM, intrapersonal, interpersonal, institutional, community, and policy levels). Results: Participants were mostly female (68%), African American (80%), had health coverage (97%) and were diagnosed with a chronic health condition (71%). The overarching theme was sociodemographic differences in distrust, such that African Americans and deaf/hearing impaired participants perceived disparities in healthcare, a lower quality of care, and skepticism about biomedical research, relative to Whites. Conclusions: The depth of distrust for healthcare providers, systems, and researchers in underserved communities remains strong and complex. Findings highlight the need to understand the lived experiences of community members, and how distrust is maintained. Multilevel interventions to increase trust and the accrual of underrepresented populations into clinical trials are needed.

Introduction: Internet-based tobacco ces­sation programs have increased in use and popularity in recent years. To examine evi­dence for racial/ethnic digital inequality in web-only tobacco cessation services offered by US tobacco quitlines, we conducted an analysis of quitline enrollees in five states. We hypothesized that racial/ethnic minori­ties would demonstrate lower enrollment and utilization of a web-only tobacco cessa­tion program.Methods: The sample includes enrollees into five state quitlines whose service op­tions included a web-only program in 2015 (N=32,989). Outcomes included web-entry into the quitline, web-only enrollment, establishment of a web account, and the number of times users logged into the pro­gram. Regression models tested associations with race/ethnicity.Results: Compared with Whites, African Americans, Hispanics, American Indians/ Alaska Natives, and “others” were less likely to enter the quitline via the web (Ps

Stress is robustly associated with tobacco smoking and relapse. African Americans experience greater difficulty quitting compared to whites, yet no studies have examined race differences in physiological stress biomarkers during a quit attempt. This pilot study compared cortisol levels among treatment-seeking African American and white smokers, and relapse rates. Adult smokers (N = 115, n = 72 African American, n = 43 White) received eight sessions of group cognitive behavioral therapy plus transdermal nicotine patches. Assessments included demographics, salivary cortisol (collected at session 1, the end-of-therapy [EOT], and one-month post-therapy), and carbon monoxide-verified smoking relapse. Overall, cortisol levels declined over the course of the day at baseline, the EOT, and the one-month follow-up. African Americans exhibited lower cortisol levels compared to Whites at baseline and the EOT, but not at the one-month follow-up. In addition, African American smokers exhibited flatter slopes compared to Whites at each time point. Relapse rates were greater among African Americans at the EOT and one-month follow-up. The attenuated cortisol pattern observed in African Americans may indicate hypothalamic-pituitary-adrenal axis (HPA) exhaustion and aid our understanding of tobacco-related disparities. There is a need to focus on stress mechanisms and specific intervention approaches in order to eliminate racial/ethnic differences.

I am delighted to write the Foreword for this timely supplement to Ethnicity & Disease. The work of the Transdisciplinary Collaborative Center for Health Disparities Research at Morehouse School of Medicine exemplifies the mission and scope of the journal, which includes understanding and addressing social and racial/ethnic factors related to health care access and outcomes. This supplement moves the field forward in its collective efforts toward disparity reduction and health equity, with a focus on health policy. The articles in this special issue have a common theme – health equity advancement and potential targets for policy interventions to eliminate disparities.

Background Most value-based care educational interventions teach knowledge of cost but fail to recognize the interrelatedness of the Accreditation Council for Graduate Medical Education (ACGME) competencies of medical knowledge, patient care, practice-based learning and improvement, and systems-based practice. Objective We analyzed the impact on clinical decision-making of an educational curriculum that incorporated the spectrum of ACGME competencies. Methods Five didactic sessions for a gynecologic oncology fellowship were modified to incorporate cost- and value-based care considerations for each clinical topic addressed. After discussion, the group of fellows identified 1 high-value and 5 low-value practices to target for improvement. The fellows then undertook a chart audit of clinical decisions occurring for patients seen in the outpatient clinics. The frequency of low- and high-value practices was compared before and after the educational intervention. Results A total of 126 patients with a cervical cancer diagnosis were seen by participants in the outpatient setting during the entire observation period. After the intervention, the occurrence of 3 identified low-value practices was reduced by 13% to 33%, demonstrating modest effect sizes (effect size φ = 0.2–0.3). One high-value practice (smoking cessation counseling) increased 100% after a fellow-initiated quality improvement project was undertaken. Two low-value practices, including routine surveillance imaging, remained unchanged. Conclusions Overlaying value-based concepts in didactic conference teaching resulted in measurable changes in decision-making behavior. Engaging learners in a subsequent, focused quality practice review served as a vital part of their educational experience and allowed us to assess learner competency in its practical application.

Cigarette smoking is highly prevalent among persons living with the human immunodeficiency virus (HIV) (PLWH), with rates as high 50% as compared to 14% in the general U.S. population. Tobacco use causes morbidity and mortality in PLWH, and tobacco-related harm is substantially higher in PLWH than smokers in the general population, providing the scientific premise for developing effective tobacco cessation interventions in this population. To better address this issue, we conducted six focus group sessions with 45 African American smokers who are living with HIV to understand the barriers to smoking cessation and the strategies that would be helpful to overcome these barriers. We organized our findings by the Phase-Based Model of Smoking Treatment to understand the intervention components that are needed at each phase to help PLWH successfully quit smoking. Participants in our focus group sessions articulated key components for incorporation into tobacco cessation intervention for PLWH: a personalized plan for quitting, reminders about that plan, and a support system. Participants thought that their HIV and tobacco use were disassociated. Participants described barriers to the use of pharmacotherapy, including adverse side effects of the gum and patch and concerns about the negative health effects of some oral medications. Substance use was identified as a commonly co-occurring condition as well as a barrier to successfully ceasing to smoke tobacco products. In summary, these findings offer information on the components of a tobacco cessation intervention for PLWH, namely reminders, a support system, substance use treatment, and monitoring to prevent relapse.

Introduction Text-messaging programs for smoking cessation improve abstinence outcomes in the general population. However, little is known about engagement and abstinence outcomes among African Americans in text-messaging smoking cessation programs. The current study compares engagement and abstinence between Blacks and Whites in the National Cancer Institute’s SmokefreeTXT program. Method Data were from Blacks (n = 1333) and Whites (n = 7154) who enrolled in the 6-week SmokefreeTXT program between August 2017 and June 2018. We assessed the association between race and program initiation and completion; responses to weekly smoking cessation, mood, and craving assessments; and self-reported abstinence using multivariable logistic regression. Results Blacks and Whites initiated the program at a similar frequency, yet Blacks were more likely to complete the program (adjusted odds ratio [AOR] = 1.71, 95% confidence interval [CI] = 1.43 to 2.06). Blacks were less likely to respond to all seven abstinence, mood, and craving assessments (eg, AOR of quit day responses = 0.63, 95% CI = 0.51 to 0.77; 6-week AOR = 0.50, 95% CI = 0.34 to 0.72). Self-reported abstinence was lower among Blacks for all seven smoking assessments (eg, quit day abstinence AOR = 0.52, 95% CI = 0.41 to 0.68; 6-week abstinence AOR = 0.58, 95% CI = 0.38 to 0.89). Conclusion Although Blacks were more likely than Whites to complete the SmokefreeTXT program, they were less likely to engage with the program by responding to assessment questions and had lower abstinence rates. Qualitative research may reveal unique barriers to engagement among Blacks. Implications Black smokers enrolled in a nationwide mobile smoking cessation program at a rate comparable to White smokers. However, they were significantly less likely to engage with the program or quit smoking. This study highlights the need to examine barriers to cessation for Black smokers.

Cigarette smoking is the primary preventable cause of death and disease worldwide. Studies reveal that smoking is associated with psychiatric symptoms, sociodemographic characteristics, social stressors, and lack of social support. In general, smokers report poorer mental health and benefit from support to be able to quit smoking (Jorm et al., 1999). In this paper, a tailored smoking cessation system has been developed in which the counseling and support is delivered via video-messaging. The system engages users in adaptive motivating video access. Users can interact with the system and the system selects the best matching video for them by processing their messages using Natural Language Processing (NLP). We have tailored 77 videos for interactive contents that encompass important issues users might face during the process of smoking cessation. A novel application-based data driven approach has been taken for categorizing videos to push to participants. The approach is based on analyzing 750 messages of people in the cessation process. We observed that most of the messages’ contents were about smoking health effects, cravings, triggers, relapse, positive mood, low cessation self efficacy, medications, and culturally specific targeting inquiries. Considering these categories, videos are categorized to the corresponding groups by an intelligent approach. The information underlying the data driven categories allows for improving and facilitating smoking status assessment. The system has the potential for improving future smoking cessation decision-making adaptive interventions and health monitoring systems. The goal is to tailor the system to meet the needs of the users in real-time and maximize the potential impact.

Objective: E-cigarette use is increasing among adult cigarette smokers. With the availability and variety of appealing charac­teristics, including menthol flavor, e-ciga­rette use patterns may differ among menthol and non-menthol cigarette smokers. This study compared e-cigarette knowledge and use between current menthol and non-menthol smokers aged ≥18 years.Design: Current adult cigarette smokers (N=223; M=42.1 years; SD=12.2; 68% menthol smokers) recruited in South Florida completed an interviewer-administered sur­vey via telephone during June to November 2014.Main Outcome Measures: E-cigarette use (ever-use, past 30-day use, past 30-day flavored e-cigarette use, and past 30-day mentholated e-cigarette use), consideration of e-cigarette use for quitting/reduction of cigarettes, and knowledge assessments. Bivariate and multivariate analyses tested associations with menthol smoking.Results: Menthol smokers were more likely to be African American or Hispanic (PConclusions: Our findings suggest that, compared with current non-menthol smokers, current menthol smokers are more likely to consider using e-cigarettes to help quit/reduce smoking, and are more likely to use menthol flavored e-cigarettes. Further research is needed to better ex­amine low e-cigarette knowledge among menthol smokers, which may represent an important intervention target.Ethn Dis. 2018;28(3):153-160; doi:10.18865/ ed.28.3.153.

Introduction Previous research indicates that marijuana use may be interrelated with combustible tobacco use among U.S. adolescents and young adults. However, little is known about this relationship during older adulthood. The purpose of this study was: 1) examine the prevalence of past-month marijuana, cigarette and cigar use, and 2) assess the associations between demographic and tobaccouse variables with past-month marijuana use, among a nationally representative sample of U.S. adults 50 years and older. Material and Methods Data are from the public-use files of the 2013 National Survey on Drug Use and Health (NSDUH). The sample consisted of 6325 adults aged ≥50 years. Results Overall, 2.98% (N=216) of the sample reported past-month marijuana use; higher prevalence was noted for those who were past-month users of cigarettes (15.62%, N=1162) and lower prevalence was noted for those who were past-month users of cigars (2.68%, N=176). After accounting for covariables, past-month cigarette use was the strongest predictor of past-month marijuana use (adjusted odds ratio [AOR]=5.19, 95% CI, 3.51-7.66). Additionally, past-month cigar use showed a positive association with past-month marijuana use (AOR=2.41, 95% CI, 1.23-4.72). Conclusions Tobacco prevention, cessation, and control efforts that target older adults should be tailored effectively to address the use of marijuana and other combustible tobacco products.

Background African Americans suffer disproportionately from tobacco-related illness and have more difficulty quitting smoking than other racial/ethnic groups. Previous research indicates that African American treatment-seekers are high utilizers of tobacco quitlines, yet cessation rates via quitlines are lower relative to whites. The goal of the present study is to test the effectiveness of adding a culturally specific, video-based, adjunct to standard quitline care. It is hypothesized that the integration of an evidence-based intervention (Pathways to Freedom: Leading the Way to a Smoke-Free Community©; PTF) into quitline services will increase cessation and treatment engagement compared to control conditions, and that effects will be moderated by sociocultural factors (e.g., culturally specific intervention expectancies, acculturation, and ethnic identity). Methods This study is a 3-arm semi-pragmatic randomized controlled trial (RCT). Participants will be 1050 enrollees in the North Carolina State quitline (QuitlineNC) who self-identify as African American. Usual quitline care includes up to 4 proactive quit coaching calls, website access, and two-weeks of nicotine patch therapy. Eligible study participants will be randomized to receive (1) standard quitline services plus PTF (PTF); (2) quitline services plus a standard tobacco cessation DVD (attention control); or (3) quitline services alone (usual care). Assessments will be conducted at baseline, 3 and 6-months post-enrollment. The primary outcome will be biochemically verified 7 day ppa at 6-months. Generalized linear mixed models (GLMMs) and hierarchical logistic regression will be used to assess the effects of treatment group on cessation outcomes and to test potential moderators. Discussion This study will answer questions regarding the implementation and effectiveness of integrating a culturally specific video intervention into a real-world, population-level tobacco intervention. It will also aid our understanding of individual-difference variables that are associated with success. If an incremental benefit is found, this trial will have implications for increasing the responsiveness of tobacco quitlines for African Americans, reducing tobacco cessation disparities, and best practices for improving minority health. In addition, the PTF intervention has the potential for widespread disseminated through quitlines, which are available across the United States. Trial registration Clinicaltrials.gov NCT03064971 . Registered on February 22, 2017.

Objective: The urge to smoke is a predictor of smoking relapse. Little research has focused on the impact of acute urges during treatment among African Americans. This study examined the relationship between smoking urges and long-term abstinence among treatment seekers. Design: Longitudinal prospective investigation. Urges to smoke were assessed at the initial (session 1) and final (session 8) sessions among adult smokers (N=308) enrolled in a 4-week group intervention trial. Nicotine patch use was assessed over 30 days. Main Outcome Measures: Biochemically verified 7-day point prevalence abstinence (7-day ppa) was assessed immediately postintervention, and at 3-, 6-, and 12-month follow-ups. Hierarchical logistic regressions tested associations between session 1 and session 8 urges and 7-day ppa at each smoking status assessment. Results: There was a significant overall decrease in smoking urges (M=29, SD=15 at session 1; M=17, SD=11 at session 8). After controlling for covariates, urges to smoke at session 1 were unrelated to 7-day ppa at any of the assessment points. However, session 8 urges were inversely associated with 7-day ppa post-intervention (AOR=.94, CI:.92-.97), at 3-months (AOR=.93, CI: .89-.97), 6-months (AOR=.93, CI: .90-.97), and 12-months (AOR=.96, CI: .96-.99). Nicotine patch use was positively associated with 7-day ppa at each assessment. Conclusions: The most robust predictors of abstinence through 12-months postintervention were decreased urges over the 4-week, 8-session group intervention and the frequency of nicotine patch use. Interventions aimed at addressing the needs of African American smokers should address urges and encourage nicotine replacement adherence to increase abstinence rates.Ethn Dis. 2017;27(4):395-402; doi:10.18865/ ed.27.4.395.

The purpose of this study was to systematically review recent empirical literature on smoking cessation in racial/ethnic minority groups. Specifically, we focused on smoking cessation intervention trials and investigations of factors associated with cessation. Studies published between 2010 and September 2014 were considered. Nine smoking cessation intervention trials and 16 studies examining correlates of smoking behavior were published in within the past 3 years. Results demonstrated promise for varenicline in facilitating cessation among African Americans and Hispanics, and culturally specific behavioral counseling appears to be efficacious among Asian Americans. In trans-group comparisons, racial/ethnic minorities reported greater quit attempts compared to Whites; yet success may be reduced due to factors such as menthol smoking, low pharmacotherapy use, and lower readiness to quit. Recommendations for evidence-based interventions and future research are offered.

Introduction Despite smoker interest in e-cigarettes as a harm reduction or cessation aid, many smokers prematurely discontinue vaping after trying a product. This study explored the role of early subjective sensory experiences in vaping persistence and desistance. Methods African American menthol cigarette smokers aged ≥18 years (N = 15; M = 54.1 years; SD = 8.2), motivated to quit smoking, and interested in trying e-cigarettes were recruited in Washington, DC. Participants were followed for 3 weeks and provided menthol cigalike e-cigarettes after Week 1. Participants completed three interviews about their vaping experiences. Thematic analysis of responses was designed to understand the sensory aspects of vaping. Results During the first 2 weeks of vaping, four participants reported a positive vaping experience while 11 reported decreased satisfaction. Salient sensory attributes of dissatisfaction included poor taste, insufficient throat hit, difficulty pulling, and a lack of "whole body" satisfaction compared to their preferred cigarette brand. Conclusions The sensory experiences with a specific cigalike e-cigarette were related to vaping persistence and desistence. Although this was a small volunteer sample of African American menthol smokers motivated to quit smoking, 27% (N = 4) of participants with a positive vaping experience continued using the product, while 73% (N = 11) of participants' vaping experience was unsatisfactory across several experiential categories. In future research of e-cigarettes' efficacy as a smoking cessation or reduction aid, both device characteristics and smokers' expectations for these devices should be considered, so vapers do not expect the same taste sensations, throat sensations, and "whole body" satisfaction as they experienced with their menthol cigarettes. Implications The subjective sensory experiences associated with initial e-cigarette product use are associated with use patterns. Subjective sensory experiences may also help understand the differences in the appeal, satisfaction, and harm-reduction potential of the rapidly evolving diverse types of products emerging in the marketplace. How products meet the sensory needs of smokers wanting to switch or quit smoking may influence adherence and success rates.

Cigarette smoking has been implicated in causing many cancers and cancer deaths. There is mounting evidence indicating that smoking negatively impacts cancer treatment efficacy and overall survival. The NCCN Guidelines for Smoking Cessation have been created to emphasize the importance of smoking cessation and establish an evidence-based standard of care in all patients with cancer. These guidelines provide recommendations to address smoking in patients and outlines behavioral and pharmacologic interventions for smoking cessation throughout the continuum of oncology care.

Background: While smoking rates in the United States have decreased, some population subgroups have smoking rates that exceed national and state averages. These higher rates often are associated with higher incidence rates of tobacco-associated cancers. Over time, a decrease in smoking rates leads to lower cancer incidence.Methods: Using spatial modelling techniques, we identified an underserved geographic locale in South Florida with higher than expected incidence rates of tobacco-associated cancers. We then used a community-based participatory research (CBPR) design to conduct focus groups in 2011 to elicit information about the acceptability of a smoking cessation intervention delivered by trained former smokers from within peer networks.Results: A variety of smoking cessation strategies was presented and discussed in separate, gender-stratified focus groups comprised of former and current smokers (n = 39). Focus group findings consistently indicated that support groups were the preferred cessation mechanism in this community. Based on this finding, we changed our initially proposed cessation approach to one which employed support groups as a quit method.Conclusions: Currently, we are collecting pilot data to test this intervention and to reach smokers who might not otherwise be directly targeted with cessation messaging from larger tobacco control initiatives. If successful, this strategy can be adapted to effect other important changes in health behaviours in at-risk populations.

The prevalence of e-cigarette use is increasing, yet few studies have focused on its use in racial/ethnic minority populations. We examined associations between race/ethnicity and e-cigarette use, plans to continue using e-cigarettes, and reasons for use among current/former smokers. Participants (285 in total; 29% non-Hispanic White, 42% African American/Black, and 29% Hispanic) were recruited between June and November 2014. Telephone-administered surveys assessed demographics, cigarette smoking, e-cigarette use, plans to continue using, and reasons for use. Analyses of covariance (ANCOVAs) and multivariable logistic regressions were conducted. African Americans/Blacks were significantly less likely to report ever-use compared to Whites and Hispanics (50% vs. 71% and 71%, respectively; p < 0.001). However, African American/Black ever users were more likely to report plans to continue using e-cigarettes compared to Whites and Hispanics (72% vs. 53% and 47%, respectively, p = 0.01). African American/Black participants were more likely to use e-cigarettes as a cessation aid compared to both Whites (p = 0.03) and Hispanics (p = 0.48). White participants were more likely to use e-cigarettes to save money compared to Hispanics (p = 0.02). In conclusion, racial/ethnic differences in e-cigarette use, intentions, and reasons for use emerged in our study. African American ever users may be particularly vulnerable to maintaining their use, particularly to try to quit smoking. These findings have implications for cigarette smoking and e-cigarette dual use, continued e-cigarette use, and potentially for smoking-related disparities.