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The efficacy of tobacco treatment delivered by state quitlines in diverse populations is well-supported, yet little is known about associations between treatment dose and cessation outcomes following the implementation of Ask-Advise-Connect (AAC), an electronic health record-based systematic referral process that generates a high volume of proactive calls from the state quitline to smokers. The current study is a secondary analysis of a 34-month implementation trial evaluating ACC in 13 safety-net clinics in Houston, TX. Treatment was delivered by a quitline and comprised up to five proactive, telephone-delivered multi-component cognitive-behavioral treatment sessions. Associations between treatment dose and abstinence were examined. Abstinence was assessed by phone six months after treatment enrollment, and biochemically confirmed via mailed saliva cotinine. Among smokers who enrolled in treatment and agreed to follow-up (n = 3704), 29.2% completed no treatment sessions, 35.5% completed one session, 16.4% completed two sessions, and 19.0% completed ≥three sessions. Those who completed one (vs. no) sessions were no more likely to report abstinence (OR: 0.98). Those who completed two (vs. no) sessions were nearly twice as likely to report abstinence (OR: 1.83). Those who completed ≥three (vs. no) sessions were nearly four times as likely to report abstinence (OR: 3.70). Biochemically-confirmed cessation outcomes were similar. Most smokers received minimal or no treatment, and treatment dose had a large impact on abstinence. Results highlight the importance of improving engagement in evidence-based treatment protocols following enrollment. Given that motivation to quit fluctuates, systematically offering enrollment to all smokers at all visits is important. Keywords: Quitline, Telephone counseling, Ask-Advise-Connect, Electronic health record, Smoking cessation, Tobacco

Clinical guidelines endorse either a 30 or 20 pack-year smoking history threshold when determining eligibility for lung cancer screening (LCS). However, self-reported smoking history is subject to recall bias that can affect patient eligibility. We examined the reliability of smokers’ self-reported tobacco use and its impact on eligibility for LCS. Current or former smokers aged 55–77 years completed questionnaires requesting demographic information and smoking history. Data were collected between December 2014 and September 2015. Total pack-year smoking history was calculated for each participant based on their responses at baseline and one month later. One hundred and two participants completed the study (mean age = 63.6 years). The intraclass correlation coefficient for the pack-year estimate was 0.93. For the 30 pack-year threshold, eight (7.8%) participants were eligible at one but not both assessment periods. For the 20 pack-year threshold, twelve participants (11.8%) were eligible at one but not both assessment periods. Inconsistent reporting was higher among current compared to former smokers. Smokers’ self-reported tobacco use appears highly reliable over short time periods. Nevertheless, there is some inconsistent reporting. We recommend that clinicians carefully assess smoking history, probe patients’ recall of duration and quantity of smoking, and collect tobacco use information at every encounter. Keywords: Mass screening, Diagnostic screening programs, Early detection of cancer, Smoking, Self report, Patient reported outcomes

Abstract Background Although the Short Test of Functional Health Literacy in Adults (S-TOFHLA) is widely used, misidentification of individuals with low health literacy (HL) in specific HL dimensions, like numeracy, is a concern. We examined the degree to which individuals scored as “adequate” HL on the S-TOFHLA would be considered as having low HL by two additional numerical measures. Methods English-speaking adults aged 45–75 years were recruited from a large, urban academic medical center and a community foodbank in the United States. Participants completed the S-TOFHLA, the Subjective Numeracy Scale (SNS), and the Graphical Literacy Measure (GL), an objective measure of a person’s ability to interpret numeric information presented graphically. Established cut-points or a median split classified participants and having high and low numeracy. Results Participants (n = 187), on average were: aged 58 years; 63% female; 70% Black/African American; and 45% had a high school degree or less. Of those who scored “adequate” on the S-TOFHLA, 50% scored low on the SNS and 40% scored low on GL. Correlation between the S-TOFHLA and the SNS Total was moderate (r = 0.22, n = 186, p = 0.01), while correlation between the S-TOFHLA and the GL Total was large (r = 0.53, n = 187, p ≤ 0.01). Conclusions Findings suggest that the S-TOFHLA may not capture an individuals’ HL in the dimension of numeracy. Efforts are needed to develop more encompassing and practical strategies for identifying those with low HL for use in research and clinical practice. Trial registration NCT02151032 (retrospectively registered: May 30, 2014).

Introduction . Patient decision aid (PDA) certification standards recommend including the positive and negative features of each option of the decision. This review describes the inclusion of concepts related to overdiagnosis and overtreatment, negative features often ambiguously defined, in cancer screening PDAs. Methods . Our process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We reviewed 1) current systematic reviews of decision aids, 2) the Ottawa Hospital Research Institute Decision Aid Library Inventory, and 3) a web-based, gray literature search. Two independent reviewers identified and evaluated PDAs using content analysis. Reviewers coded whether overdiagnosis/overtreatment was described as 1) detecting cancer that would not lead to death, 2) detecting cancer that would not cause symptoms, and/or 3) a potential harm or consequence of screening. Coding discrepancies were resolved through consensus. Results . A total of 904 records (e.g., articles, PDAs) were reviewed and 85 PDAs were identified: prostate ( n = 36), breast ( n = 26), lung ( n = 10), colorectal ( n = 10), and other ( n = 3). Sixty-seven PDAs included concepts related to overdiagnosis/overtreatment; 57 (67.1%) used a term other than overdiagnosis/overtreatment, 23 (27.1%) used the specific term “overdiagnosis,” and 13 (15.3%) used “overtreatment.” PDAs described overdiagnosis/overtreatment as a potential harm or consequence of screening ( n = 62) and/or a detection of a cancer that would not cause symptoms (n = 49). Thirty-six described overdiagnosis as the detection of a cancer that would not result in death. Twenty PDAs described the probabilities associated with overdiagnosis/overtreatment. Conclusions . Over three quarters of cancer screening PDAs addressed concepts related to overdiagnosis/overtreatment, yet terminology was inconsistent and few included probability estimates. Consistent terminology and minimum standards to describe overdiagnosis/overtreatment would help guide the design and certification of cancer screening PDAs.