Search

PURPOSE: Multidisciplinary lung cancer care is assumed to improve care delivery by increasing transparency, objectivity, and shared decision making; however, there is a lack of high-level evidence demonstrating its benefits, especially in community-based health care systems. We used implementation and team science principles to establish a colocated multidisciplinary lung cancer clinic in a large community-based health care system and evaluated patient experience and outcomes within and outside this clinic. METHODS: We conducted a prospective frequency-matched comparative effectiveness study (ClinicalTrials.gov identifier: NCT02123797 ) evaluating the thoroughness of lung cancer staging, receipt of stage-appropriate treatment, and survival between patients receiving care in the multidisciplinary clinic and those receiving usual serial care. Target enrollment was 150 patients on the multidisciplinary arm and 300 on the serial care arm. We frequency-matched patients by clinical stage, performance status, insurance type, race, and age. RESULTS: A total of 526 patients were enrolled: 178 on the multidisciplinary arm and 348 on the serial care arm. After adjusting for other factors, multidisciplinary patients had significantly higher odds (odds ratio [OR]: 2.3 [95% CI, 1.5 to 3.4]) of trimodality staging compared with serial care. Patients on the multidisciplinary arm also had higher odds of receiving invasive stage confirmation (OR: 2.0 [95% CI, 1.4 to 3.1]) and mediastinal stage confirmation (OR: 1.9 [95% CI, 1.3 to 2.8]). Additionally, patients receiving multidisciplinary care were significantly more likely to receive stage-appropriate treatment (OR: 1.8 [95% CI, 1.1 to 3.0]). We found no significant difference in overall or progression-free survival between study arms. CONCLUSION: The multidisciplinary clinic delivered significant improvements in evidence-based quality care on multiple levels. Even in the absence of a demonstrable survival benefit, these findings provide a strong rationale for recommending this model of care.

Non-adherence to immunosuppressant therapy is a significant concern following a solid organ transplant, given its association with graft failure. Adherence to immunosuppressant therapy is a modifiable patient behaviour, and different approaches to increasing adherence have emerged, including multi-component interventions. There has been limited exploration of the effectiveness of interventions to increase adherence to immunosuppressant therapy.This review aimed to look at the benefits and harms of using interventions for increasing adherence to immunosuppressant therapies in solid organ transplant recipients, including adults and children with a heart, lung, kidney, liver and pancreas transplant.We searched the Cochrane Kidney and Transplant Register of Studies up to 14 October 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.All randomised controlled trials (RCTs), quasi-RCTs, and cluster RCTs examining interventions to increase immunosuppressant adherence following a solid organ transplant (heart, lung, kidney, liver, pancreas) were included. There were no restrictions on language or publication type.Two authors independently screened titles and abstracts of identified records, evaluated study quality and assessed the quality of the evidence using the GRADE approach. The risk of bias was assessed using the Cochrane tool. The ABC taxonomy for measuring medication adherence provided the analysis framework, and the primary outcomes were immunosuppressant medication initiation, implementation (taking adherence, dosing adherence, timing adherence, drug holidays) and persistence. Secondary outcomes were surrogate markers of adherence, including self-reported adherence, trough concentration levels of immunosuppressant medication, acute graft rejection, graft loss, death, hospital readmission and health-related quality of life (HRQoL). Meta-analysis was conducted where possible, and narrative synthesis was carried out for the remainder of the results.Forty studies involving 3896 randomised participants (3718 adults and 178 adolescents) were included. Studies were heterogeneous in terms of the type of intervention and outcomes assessed. The majority of studies (80%) were conducted in kidney transplant recipients. Two studies examined paediatric solid organ transplant recipients. The risk of bias was generally high or unclear, leading to lower certainty in the results. Initiation of immunosuppression was not measured by the included studies. There is uncertain evidence of an association between immunosuppressant medication adherence interventions and the proportion of participants classified as adherent to taking immunosuppressant medication (4 studies, 445 participants: RR 1.09, 95% CI 0.95 to 1.20; I² = 78%). There was very marked heterogeneity in treatment effects between the four studies evaluating taking adherence, which may have been due to the different types of interventions used. There was evidence of increasing dosing adherence in the intervention group (8 studies, 713 participants: RR 1.14, 95% CI 1.03 to 1.26, I² = 61%). There was very marked heterogeneity in treatment effects between the eight studies evaluating dosing adherence, which may have been due to the different types of interventions used. It was uncertain if an intervention to increase immunosuppressant adherence had an effect on timing adherence or drug holidays. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on persistence. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on secondary outcomes. For self-reported adherence, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants classified as medically adherent to immunosuppressant therapy (9 studies, 755 participants: RR 1.21, 95% CI 0.99 to 1.49; I² = 74%; very low certainty evidence). Similarly, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the mean adherence score on self-reported adherence measures (5 studies, 471 participants: SMD 0.65, 95% CI -0.31 to 1.60; I² = 96%; very low certainty evidence). For immunosuppressant trough concentration levels, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants who reach target immunosuppressant trough concentration levels (4 studies, 348 participants: RR 0.98, 95% CI 0.68 to 1.40; I² = 40%; very low certainty evidence). It is uncertain whether an intervention to increase adherence to immunosuppressant medication may reduce hospitalisations (5 studies, 460 participants: RR 0.67, 95% CI 0.44 to 1.02; I² = 64%; low certainty evidence). There were limited, low certainty effects on patient-reported health outcomes such as HRQoL. There was no clear evidence to determine the effect of interventions on secondary outcomes, including acute graft rejection, graft loss and death. No harms from intervention participation were reported.Interventions to increase taking and dosing adherence to immunosuppressant therapy may be effective; however, our findings suggest that current evidence in support of interventions to increase adherence to immunosuppressant therapy is overall of low methodological quality, attributable to small sample sizes, and heterogeneity identified for the types of interventions. Twenty-four studies are currently ongoing or awaiting assessment (3248 proposed participants); therefore, it is possible that findings may change with the inclusion of these large ongoing studies in future updates.

IntroductionBeginning in 2019, several U.S. states implemented temporary or permanent bans on the sale of flavored e-cigarettes. This study examined the impact of flavor bans on adult e-cigarette use in Washington, New Jersey, and New York.MethodsAdults who used e-cigarettes at least once a week before the flavor bans were recruited online. Respondents reported their e-cigarette use, primarily used flavor, and ways of obtaining ecigarettes before and after the bans. Descriptive statistics and multinomial logistic regression models were applied.ResultsAfter the ban, 8.1% of respondents (N=1624) quit using e-cigarettes, those primarily used banned menthol or other flavors declined from 74.4% to 50.8, those using tobacco-flavored declined from 20.1% to 15.6%, and those using non-flavored increased from 5.4% to 25.4%. More frequent e-cigarette use and smoking cigarettes were associated with being less likely to quit e-cigarettes and more likely to use banned flavors. Of those primarily using banned flavors, 45.1% obtained e-cigarettes from in-state stores, 31.2% from out-of-state stores, 32% from friends, family, or others, 25.5% from Internet/mail sellers, 5.2% from illegal sellers, 4.2% mixed flavored e-liquids themselves, and 6.9% stocked up on e-cigarettes before the ban.ConclusionsMost respondents continued to use e-cigarettes with banned flavors post-ban. Compliance of local retailers with the ban was not high, and many respondents obtained banned-flavor e-cigarettes through legal channels. However, the significant increase in the use of non-flavored e-cigarettes post-ban suggests that these may serve as a viable alternative among those who used previously used banned or tobacco flavors.ImplicationsThis study examined the impact on adult e-cigarette users from the recent e-cigarette-only flavor bans in Washington State, New Jersey, and New York. We found that most respondents continued to use e-cigarettes with banned flavors post-ban and obtain banned-flavor e-cigarettes through legal channels. Our findings indicate that non-flavored e-cigarettes may serve as an acceptable alternative to both non-tobacco and tobacco-flavored e-cigarettes and state e-cigarette flavor bans are unlikely to prompt a significant number of adult e-cigarette users to replace their e-cigarette use with new or increased smoking. Enforcing compliance of retailers to the policy is crucial to control e-cigarette use.

Introduction Waterpipe tobacco (WPT) smoking has increased among the young population in the United States. This study assessed the extent and predictors of WPT smoking initiation and progression among US adolescents (12–17 years) and young adults (18–24 years) longitudinally. Aims and Methods We analyzed data from 4 waves (2013–2018) of the Population Assessment of Tobacco and Health (PATH) study comprising 10 692 respondents (adolescents = 5428 and young adults = 5264). Kaplan–Meier survival method estimated probabilities of WPT initiation and progression. Cox proportional hazards regression models delineated predictors of the outcomes. Results Between 2013 and 2018, 4.8% of adolescents initiated and 10.6% progressed WPT smoking. Among young adults, 18.5% initiated and 14.1% progressed WPT smoking during the same time interval. Predictors among adolescents included, WPT initiation: Hispanic ethnicity (adjusted odds ratio (aHR) = 1.75, 95% confidence interval (CI) = 1.23–2.49), lower harm perception (aHR = 2.89, 95% CI = 2.10–3.98), and other tobacco products use (aHR = 3.97, 95% CI = 2.73–5.78); WPT progression: illicit drug use (aHR = 4.60, 95% CI = 1.99–10.67). Predictors among young adults included, WPT initiation: non-Hispanic Black (aHR = 2.31, 95% CI = 1.78–3.00), Hispanic (aHR = 1.77, 95% CI = 1.34–2.33), lower harm perception (aHR = 2.77, 95% CI = 2.19–3.50), and other tobacco products use (aHR = 3.14, 95% CI = 2.25–4.38); WPT progression: non-Hispanic Black (aHR = 1.51 95% CI = 1.09–2.10), lower harm perception (aHR = 1.80, 95% CI = 1.41–2.30), and alcohol use (aHR = 1.61, 95% CI = 1.13–2.30). Conclusions Results indicate a high prevalence of WPT initiation and progression among adolescents and young adults over time, with minority racial/ethnic groups being at greater risk for both. WPT-specific risk communication interventions (eg, educational campaigns and health warning labels) are warranted to limit WPT smoking among young people.

Banning flavors in e-cigarettes and other tobacco products may decrease their use. To examine how current users of flavored e-cigarettes might react to a ban on flavored e-cigarettes when: (i) menthol flavor is banned together with other flavors, or (ii) this ban on e-cigarettes is combined with a ban on menthol cigarettes and flavored cigars. A national cross-sectional survey of 2,347 current users of flavored e-cigarettes was conducted in May 2022. For each hypothetical ban scenario, respondents reported if they would quit all tobacco product use, continue to use e-cigarettes with no flavor or flavors that were not banned, or switch to alternative tobacco products. Multinomial logistic regressions were used to estimate the associations between responses and ban scenarios, adjusting for tobacco use and demographic variables. If e-cigarettes with any flavors except menthol and tobacco were banned, the majority of current e-cigarette users would keep using e-cigarettes with no flavor or tobacco and menthol flavor. When menthol flavor was added to a ban, a greater proportion of respondents would quit all tobacco use; however, more would also switch to cigarettes or cigars. When menthol cigarettes and flavored cigars were added to a ban, those who used menthol flavor only would be less likely to switch to cigarettes and cigars. Among current e-cigarette users, the harm reduction (i.e., from quitting all use) from a ban on flavored e-cigarettes, particularly if menthol is also banned, may be outweighed by the harm increases (i.e., switching to cigarettes or cigars, or other products that are more harmful than using e-cigarettes). A concurrent ban on menthol cigarettes and flavored cigars would secure more certain net reductions to public health harms from e-cigarette use and smoking.

Objective. The efficacy of individualized, community-based physical activity as an adjunctive smoking cessation treatment to enhance long-term smoking cessation rates was evaluated for the Lifestyle Enhancement Program (LEAP). Methods. The study was a two-arm, parallel-group, randomized controlled trial. All participants ( n = 392 ) received cessation counseling and a nicotine patch and were randomized to physical activity ( n = 199 ; YMCA membership and personalized exercise programming from a health coach) or an equal contact frequency wellness curriculum ( n = 193 ). Physical activity treatment was individualized and flexible (with each participant selecting types of activities and intensity levels and being encouraged to exercise at the YMCA and at home, as well as to use “lifestyle” activity). The primary outcome (biochemically verified prolonged abstinence at 7-weeks (end of treatment) and 6- and 12-months postcessation) and secondary outcomes (7-day point prevalent tobacco abstinence (PPA), total minutes per week of leisure time physical activity and strength training) were assessed at baseline, 7 weeks, 6 months, and 12 months. Results. Prolonged abstinence in the physical activity and wellness groups was 19.6% and 25.4%, respectively, at 7-weeks, 15.1% and 16.6% at 6-months, and 14.1% and 17.1% at 12 months (all between-group P values >0.18). Similarly, PPA rates did not differ significantly between groups at any follow-up. Change from baseline leisure-time activity plus strength training increased significantly in the physical activity group at 7 weeks ( P = 0.04 ). Across treatment groups, an increase in the number of minutes per week in strength training from baseline to 7 weeks predicted prolonged abstinence at 12 months ( P ≤ 0.001 ). Further analyses revealed that social support, fewer years smoked, and less temptation to smoke were associated with prolonged abstinence over 12 months in both groups. Conclusions. Community-based physical activity programming, delivered as adjunctive treatment with behavioral/pharmacological cessation treatment, did not improve long-term quit rates compared to adjunctive wellness counseling plus behavioral/pharmacological cessation treatment. This trial is registered with https://beta.clinicaltrials.gov/study/NCT00403312, registration no. NCT00403312.

Aims Heart failure (HF) is an ongoing epidemic and a serious clinical and public health issue. Currently, little is known about prospective associations between insomnia symptoms and HF incidence. We investigated the longitudinal associations between time-varying insomnia symptoms (difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening, non-restorative sleep) and incident HF. Methods and results Data were obtained from the Health and Retirement Study in the US for a population-representative sample of 12,761 middle-aged and older adults (age ≥ 50 years; mean [SD] age, 66.7 [9.4] years; 57.7% females) who were free from HF at baseline in 2002. Respondents were followed for 16 years for incident HF. We employed marginal structural discrete-time survival analyses to adjust for potential time-varying biological, psycho-cognitive, and behavioral factors and to account for bias due to differential loss to follow-up. At baseline, 38.4% of the respondents reported experiencing at least one insomnia symptom. During the 16-year follow-up, 1,730 respondents developed incident HF. Respondents experiencing one (hazard ratio [HR]=1.22; 95% CI: 1.08–1.38), two (HR=1.45; 95% CI: 1.21–1.72), three (HR=1.66; 95% CI: 1.37–2.02), or four (HR=1.80; 95% CI: 1.25–2.59) insomnia symptoms had a higher hazard of incident HF than asymptomatic respondents. Respondents that had trouble initiating sleep (HR=1.17; 95%CI: 1.01–1.36), maintaining sleep (HR=1.14; 95% CI: 1.01–1.28), early-morning awakening (HR=1.20; 95% CI: 1.02–1.43), or non-restorative sleep (HR=1.25; 95% CI: 1.06–1.46) had a higher hazard of incident HF than asymptomatic respondents. Conclusion Insomnia symptoms, both cumulatively and individually, are associated with incident HF. Public health awareness and screening for insomnia symptoms in at-risk populations should be encouraged to reduce HF incidence.

Job-related stress may affect smoking initiation, progression, and intensity, therefore, it is important to have a better understanding of these associations to design targeted and effective workpl...

IntroductionTo understand the impact of e-cigarette devices, flavours, nicotine levels and prices on adult e-cigarette users’ choices among closed-system and open-system e-cigarettes, cigarettes and heated tobacco products (HTPs).MethodsOnline discrete choice experiments were conducted among adult (≥18 years) e-cigarette users (n=2642) in August 2020. Conditional logit regressions were used to assess the relative impact of product attributes and the interactions between product attributes and user characteristics, with stratified analyses to examine differences by smoking status and primarily used e-cigarette device and flavour.ResultsOn average, participants preferred non-tobacco and non-menthol flavours most, preferred open-system over closed-system e-cigarettes and preferred regular nicotine level over low nicotine level. However, the preference varied by demographics, smoking status and the primarily used e-cigarette device and flavour. The differences in preference among products/devices were larger than the difference among flavours or nicotine levels. Participants who primarily used closed-system e-cigarettes exhibited similar preferences for closed-system and open-system e-cigarettes, but those who primarily used open-system e-cigarettes preferred much more open-system over closed-system e-cigarettes. HTP was the least preferred product, much lower than cigarettes in general, but participants living in states where IQOS is being sold had similar preferences to cigarettes and HTPs.ConclusionsPeople are unlikely to switch to another product/device because of the restriction of flavour or nicotine level. If non-tobacco and non-menthol flavours were banned from open-system e-cigarettes, users may switch to menthol flavour e-cigarettes. Intervention strategies should be tailored to specific groups.

Introduction Pregnancy creates a unique window of opportunity for smoking cessation. However, pregnant women from underserved groups can face personal, social, and environmental challenges that impede quitting. This study draws upon the socioecological framework to explore perspectives on smoking cessation among pregnant and postpartum women from low-income groups in the mid-South of the United States. Methods Semistructured interviews were conducted with 60 women who were pregnant or postpartum. Data were analyzed in Dedoose qualitative software using the directed content analysis approach. Results Findings reveal that at the individual level, motivations for smoking cessation included the fact of being pregnant, risks associated with the infant's health, and desire to breastfeed. However, some pregnant women perceived that slowing down on smoking during pregnancy was adequate to prevent harm to their fetuses. Individual-level factors that made smoking cessation difficult included nicotine addiction and habit, boredom, stressful life circumstances, fear of weight gain, and perceived lack of willpower. At the interpersonal level, living in a smoke-free environment where loved ones do not smoke and emotional and practical support from social network members including partners and family members were thought to facilitate smoking cessation. At the organizational level, access to nicotine replacement therapies and counseling aided in their abilities to quit smoking. At the policy level, pregnant women viewed increase in cigarette prices, warning labels on the cigarette pack, and the potential for a ban on cigarette sales as having some effect in helping them quit smoking. Discussion This study offers theoretical insights into factors that function as barriers or facilitators of smoking cessation among pregnant and postpartum women from low-income groups in the United States. Designing multilevel smoking cessation interventions while considering the interplay of individual, interpersonal, organizational, and policy level factors may lead to better cessation outcomes.

Decreasing COVID-19 vaccine hesitancy is an urgent challenge in the US. This study aimed to examine COVID-19 vaccine hesitancy among U.S. adults with a history of using tobacco products or marijuana. Data were collected online in 2020–2021 including respondents’ willingness to accept a COVID-19 vaccine, factors that may promote vaccine acceptance, and prior history of influenza vaccination. Logistic regression models were conducted to estimate the associations between vaccine hesitancy and demographic characteristics, substance use, the impact of the COVID-19 pandemic, and prior influenza vaccination. Among 387 respondents, 49.1% were willing to receive a COVID-19 vaccine, 26.0% were unwilling, and 24.9% were “not sure.” Blacks, suburban or rural residents, those who lived by themselves or with a family with five members or above, those who were not stressed because of the COVID-19 pandemic were more likely to say “no” to a COVID-19 vaccine. Respondents who never, only once, or during some years received an influenza vaccine were 7.0, 6.2, and 5.2 times more likely to say “no” to a COVID-19 vaccine than respondents who received an influenza vaccination every year or almost every year. The use of cigarettes, e-cigarettes, and marijuana, as well as heavy drinking of alcohol, were not associated with COVID-19 hesitancy. The associations between demographic factors and vaccine hesitancy were roughly similar for COVID-19 and influenza vaccines. Although various demographic groups have different levels of vaccine hesitancy and also have different factors to increase their acceptance, addressing misinformation related to COVID-19 vaccines, particularly concern about the safety of the vaccines is crucial in general.

Alharbi and colleagues' article, "Adoption of health mobile apps during the COVID-19 lockdown: a Health Belief Model approach", was interesting, well-written, and informative [...].

Oral cancer is prone to late-stage diagnosis, and subsequent low five-year survival rates. A small number of interventions or campaigns designed to enhance knowledge of risk factors and symptoms associated with oral cancer have been attempted in the UK, US, and some other countries. The purpose of this systematic review is to assess the effectiveness of interventions designed to improve oral cancer knowledge. We searched five databases to identify randomized controlled trials (RCTs) and non-randomized/quasi-experimental (NR/QE) studies targeting the general population or high-risk groups (tobacco users or alcohol consumers), aged ≥15 years, and reporting the outcomes of individual and/or community level interventions. Two co-authors independently identified relevant studies, extracted data, and assessed the risk of bias. Adhering to PRISMA guidelines, 27 (eight RCTs and 19 NR/QE studies) of the 551 studies identified from the five databases met the inclusion criteria. All RCTs and nine NR/QE studies used either printed materials, health education sessions, multimedia aids, or some combinations of these tools. The other ten NR/QE studies were community-based and used mass media campaigns to increase oral cancer awareness. Overall, the majority of studies significantly improved oral cancer knowledge; however, heterogeneity in study design and variation in measurement tools made it difficult to compare outcomes. Findings suggest that individual and/or community level interventions are generally effective in increasing knowledge of oral cancer risk factors, signs and symptoms, and/or its early diagnosis and prevention strategies among the general population or high-risk groups. However, the long-term benefits of these interventions are understudied.

Background U.S. Hispanic/Latino construction workers constitute a large and historically underserved group in terms of smoking cessation services. Using formative research, we developed a worksite smoking cessation intervention tailored to the life/work circumstances of these workers. Aims This study aims to examine the feasibility, acceptability, and potential efficacy of the developed intervention “Enhanced Care” (EC; one group behavioral counseling session provided around the food truck + fax referral to tobacco quitline [QL] + 8-week nicotine replacement treatment [NRT]) compared with “Standard Care” (SC; fax referral to tobacco QL + 8-week NRT) in a pilot, two-arm, cluster randomized controlled trial. Method In collaboration with construction site safety managers, a sample of 17 construction sites (EC: nine sites/65 smokers; SC: eight sites/69 smokers) was enrolled. Participants received two follow-ups at 3 and 6 months after enrollment. Feasibility outcomes were enrollment rate, adherence to treatment, and 6-month retention rates. The primary efficacy outcome was 6 months prolonged abstinence verified by expired carbon monoxide Results Enrollment rate was high (85.9%). Six-month follow-up rates were acceptable (EC = 76.9%, SC = 66.6%). Adherence to treatment was better in the EC group (received worksite intervention: EC = 93.8%, SC = 88.4%; contacted by QL: EC = 49.2%, SC = 40.6%). Abstinence rates were 27.7% for the EC and 20.3% for the SC ( p = .315). Discussion The developed intervention was feasible and acceptable, and it substantially improved abstinence among Hispanic/Latino workers. The involvement of safety managers was essential to the implementation of the intervention. Training safety managers to deliver the intervention has great potential to implement a sustainable smoking cessation service in the construction sector.

Objectives: Waterpipe tobacco smoking (WTS) is an emerging public health crisis, particularly among youth and young adults. Different from the use of other tobacco products and e-cigarettes, WTS tends to be a social activity occurring among friends or persons associated with social networks. In this paper, we review a potential strategy for WTS-related research. Methods: As a bottom-up computational model, agent-based modeling (ABM) can simulate the actions and interactions of agents, as well as the dynamic interactions between agents and their environments, to gain an understanding of the functioning of a system. ABM is particularly useful for incorporating the influence of social networks in WTS, and capturing people's space-time activity and the spatial distribution of WTS venues. Results: Comprehensive knowledge of WTS-related behaviors at the individual level is needed to take advantage of ABM and use it to examine policies such as the interaction between WTS and cigarette smoking and the effect of flavors used in waterpipe tobacco. Longitudinal and WTS-specific surveys and laboratory experiments are particularly helpful to understand WTS basic mechanisms and elicit individual preferences, respectively. Conclusions: We argue that the uniqueness of WTS makes ABM a promising tool to be used in WTS-related research, as well as understanding use of other tobacco products.

IntroductionThis study examines how current smokers using menthol cigarettes or flavoured cigars, and current users of flavoured e-cigarettes may respond to three hypothetical flavour-ban scenarios: (1) banning only menthol cigarettes and flavoured cigars; (2) also banning e-cigarettes with any non-tobacco flavours except menthol; and (3) also banning e-cigarettes with any non-tobacco flavours, including menthol.MethodsRecruited from mTurk, respondents were asked if they would quit all tobacco-nicotine use or continue or start using products that were still legally available. The patterns of responding to each ban scenario, for both flavoured smokers and users of non-tobacco flavoured e-cigarettes, were summarised. Multinomial logistic regressions were used to estimate associations between demographics, smoking or e-cigarette use status and reactions to a ban.ResultsA ban on menthol cigarettes and flavoured cigars would lead to 12%–20% of flavoured smokers trying to quit all tobacco use and 32%–52% switching to non-flavoured smoking, with the remaining switching to e-cigarettes or other products. Compared with a ban on only menthol cigarettes and flavoured cigars, also banning flavoured e-cigarettes would increase the likelihood of quitting all tobacco-nicotine use (OR=2.58) but also increase the likelihood of switching to non-flavoured smoking (OR=1.74).ConclusionsOur results indicate that a ban on menthol cigarettes and flavoured cigars would decrease smoking. However, it is unclear if adding a ban of menthol e-cigarettes would lead to additional benefits because without menthol e-cigarettes as an alternative, some smokers and e-cigarette users may switch to non-flavoured tobacco smoking, rather than quit all tobacco use.

Background Waterpipe (WP) use is rapidly increasing among young people worldwide due to the widespread misperception that it is safer than cigarette smoking. Health warning labels (HWLs) can effectively communicate tobacco-related health risks but have yet to be developed for WP. This study aimed to optimize and adapt a set of 16 pictorial WP-specific HWLs, developed by an international Delphi study, to the Tunisian context. HWLs were grouped into four themes: WP health risks, WP harm to others, WP-specific harms, and WP harm compared to cigarettes. Methods Using a mixed method approach, we conducted ten focus groups combined with a survey among young WP users and nonusers (N = 63; age 18–34 years). In the survey, participants rated the HWLs on several communication outcomes (e.g., reaction, harm perception, effectiveness) and were then instructed to view all HWLs in each theme and rank them in the order of overall perceived effectiveness, from the most to the least effective. Afterward, participants provided in-depth feedback on HWLs and avenues for improvement. Mean effectiveness rating scores and percentages of participants’ top-ranked HWLs were calculated. Discussions were audio-taped, transcribed verbatim, and analyzed thematically. Results The top-ranked HWLs were those showing oral cancers, orally transmitted diseases, and a sick child. Focus group discussion illustrated that these selections were based on participants’ reactions to the direct impact of WP on a person’s physical appearance and evoking guilt over children’s exposure to WP smoke. Suggestions for improvement highlighted the need to use the local dialect and more affirmative statements (e.g., avoiding "may" or "can"). Conclusions This study is the first in North Africa to attempt to advance HWLs policy as the World Health Organization recommended. The results of this study can be used as a basis for implementing WP-specific health messages in the Eastern Mediterranean Region.

Needs assessments have been successful in helping communities and congregations focus their health ministry efforts; however, most have used leader perceptions of congregational health needs. The purpose of this study was to examine and compare the self-reported needs of both church leaders and members to be addressed by their congregation. Church leaders (n = 369) and members (n = 459) from 92 congregations completed the 2019 Mid-South Congregational Health Survey. Frequencies and generalized linear mixed models (GLMM) were performed to examine the top 10 self-reported needs and associations by church role, respectively. Of the top 10 congregational needs, anxiety or depression, high blood pressure, stress, and healthy foods were ranked identically regardless of church role. Church leaders perceived obesity and diabetes to be important congregational health needs, whereas members perceived affordable health care and heart disease to be important congregational health needs. GLMM, controlling for within-church clustering and covariates, revealed church leaders were more likely than members to report obesity (odds ratio [OR]: 1.93, 95% confidence interval [CI] = [1.39, 2.67], p < .0001) and diabetes (OR: 1.73, 95% CI = [1.24, 2.41], p = .001) as congregational needs. Findings display similarities and differences in needs reported by church role. Including many perspectives when conducting congregational health needs assessments will assist the development of effective faith-based health promotion programs.

This prospective observational study examined the association of socioecological factors with quitting behavior among US adolescents who exclusively use electronic cigarettes (e-cigarettes).We used data from past 30-day adolescent exclusive e-cigarette users (n = 243) participating in Wave 3 of the Population Assessment of Tobacco and Health study, who were then followed-up with approximately 12 months later for Wave 4. Weighted unadjusted and adjusted multivariate logistic regression models and structural equation modeling were performed to analyze the data.Adolescents were significantly less likely to quit e-cigarettes if they perceived that nicotine in e-cigarettes was "slightly/somewhat harmful" to health (adjusted odds ratio [aOR] = 0.38; 95% confidence interval [CI]: 0.16-0.90, p = .02). Similarly, adolescents who reported that someone else in their home owned an e-cigarette (aOR = 0.43 [95% CI: 0.19-0.94], p = .03) or important people in their life used e-cigarettes (aOR = 0.45 [95% CI: 0.21-0.95], p = .03) were significantly less likely to quit e-cigarettes. The structural equation modeling showed a direct significant relationship of individual-level (b = 0.206, p = .02) and interpersonal-level factors (b = 0.170, p = .04) with e-cigarette quitting behavior.Our findings suggest that individual-level (harm perception) and interpersonal-level (e-cigarette use at home and by important people) factors may play a significant role in e-cigarette quitting behavior among US adolescents.

To date, there is no scientific consensus on whether insomnia symptoms increase mortality risk. We investigated longitudinal associations between time-varying insomnia symptoms (difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening, and nonrestorative sleep) and all-cause mortality among middle-aged and older adults during 14 years of follow-up. Data were obtained from 2004 through 2018 survey waves of the Health and Retirement Study in the United States for a population-representative sample of 15 511 respondents who were ≥50 years old in 2004. Respondents were interviewed biennially and followed through the end of the 2018 survey wave for the outcome. Marginal structural discrete-time survival analyses were employed to account for time-varying confounding and selection bias. Of the 15 511 cohort respondents (mean [±SD] age at baseline, 63.7 [±10.2] years; 56.0% females), 5878 (31.9%) died during follow-up. At baseline (2004), 41.6% reported experiencing at least one insomnia symptom. Respondents who experienced one (HR = 1.11; 95% CI: 1.03–1.20), two (HR = 1.12; 95% CI: 1.01–1.23), three (HR = 1.15; 95% CI: 1.05–1.27), or four (HR = 1.32; 95% CI: 1.12–1.56) insomnia symptoms had on average a higher hazard of all-cause mortality, compared to those who were symptom-free. For each insomnia symptom, respondents who experienced difficulty initiating sleep (HR = 1.12; 95% CI: 1.02–1.22), early-morning awakening (HR = 1.09; 95% CI: 1.01–1.18), and nonrestorative sleep (HR = 1.17; 95% CI: 1.09–1.26), had a higher hazard of all-cause mortality compared to those not experiencing the symptom. The findings demonstrate significant associations between insomnia symptoms and all-cause mortality, both on a cumulative scale and independently, except for difficulty maintaining sleep. Further research should investigate the underlying mechanisms linking insomnia symptoms and mortality.

BackgroundThe use of marijuana (MJ), combustible cigarettes (hereafter cigarettes), and electronic nicotine delivery systems (ENDS) is widespread among United States (US) adults and linked to worsening respiratory symptoms, especially among adults with asthma. This study examined state-specific prevalence and factors associated with MJ, ENDS, and cigarette use among US adults with asthma.MethodsWe analyzed data of 41 974 adults aged ≥18 years having self-reported current asthma from the 2018 Behavioral Risk Factor Surveillance System (BRFSS). We reported weighted prevalence to account for complex survey design and performed multivariable logistic regression models to examine factors associated with current use of MJ, ENDS, and cigarettes.ResultsOverall prevalence of current MJ, ENDS, and cigarette use among adults with asthma was 14.5%, 6.6%, and 27.2%, respectively. Our results showed the US states and territories with highest and lowest use prevalence for MJ (California: 23.6% vs Guam: 3.2%), ENDS (Indiana: 12.8% vs North Dakota: 4.0%), and cigarettes (West Virginia: 42.1% vs Guam: 12.3%). Both MJ and ENDS users were more likely to be male, younger, and live in an urban area, but MJ users were more likely and ENDS users less likely to be Non-Hispanic (NH) American Indian/Alaskan Native. Cigarette users were more likely to be older, have at least 1 health condition, and were less likely to be NH Black or Hispanic and college-educated.ConclusionMany US adults with asthma use MJ, ENDS, and cigarettes. Our findings provide insights for clinicians about the urgent need for effective interventions to reduce tobacco and MJ use among adults with asthma.

Introduction A ban on menthol cigarettes and flavored cigars may reduce smoking and tobacco-related disparities. Aims and Methods We aimed to examine the response of current smokers to a hypothetical ban on menthol cigarettes and flavored cigars. Current smokers were recruited online and reported the alternative products that they may switch to under a hypothetical ban, if they would try to obtain the banned products from illicit channels, and their support to the ban. Results 51% of current smokers would use nonflavored cigarettes and cigars as alternatives, 45% would switch to flavored heated tobacco products or e-cigarettes or quit smoking. 17% would try to obtain the banned flavored products from illicit markets. A majority of menthol only smokers opposed the ban. Daily smokers would be more likely to switch to nonflavored smoking, to try illicit market products, and were less supportive of the ban. Black smokers would be less likely to switch to nonflavored smoking and were more supportive of the ban. Smokers who used menthol cigarettes only would be more likely to switch to nonflavored smoking, less likely to try illicit market sellers, and were the least supportive of the ban. Conclusions In response to a ban of all added flavors for cigarettes or cigars, nearly half of the current smokers would quit smoking, largely by switching to nonsmoking products. However, smokers with more chronic use and those who used only menthol cigarettes would be more likely to switch to nonflavored smoking, diminishing the harm reduction potential. The ban may decrease the relatively higher prevalence of menthol cigarette smoking among Blacks compared with other groups. Implications A ban on the sale of menthol cigarettes and flavored cigars may decrease the prevalence of smoking because some current smokers may quit smoking and switch to nonsmoking products. However, smokers with more chronic use and those who used menthol cigarettes only were more likely to switch to nonflavored cigarettes or cigars, diminishing the harm reduction potential of the ban. Black smokers would be more likely to switch to products other than cigarettes and cigars thus decreasing their relatively higher prevalence of smoking compared with other groups.

Only a few studies investigated the link between tobacco smoking-related media and youth smoking in the Eastern Mediterranean Region (EMR). This study aimed to assess the influence of both promotional and control messages on cigarette smoking behavior among young Jordanian students. Generalized Linear Mixed Models were analyzed using data from the Irbid Longitudinal Smoking Study that followed a random sample of 2174 students (2008-2011). We examined the associations of media messaging with smoking behavior, as well as intention-to-quit smoking, and intention-to-start smoking, among young adolescents. At baseline, 12.2% and 43.7% of students were exposed to only pro-smoking or only anti-smoking messages, while 41.8% were equally exposed to both. Exposure to anti-smoking messages was associated with lower odds of ever smoking at baseline among girls (AOR = 0.4; 95% CI: 0.2, 0.8). Boys who were exposed to anti-smoking messages were more likely to report an intention to quit, with borderline significance (AOR = 2.0; 95% CI: 0.9, 4.1). The cumulative exposure to anti-smoking messages over time was associated with lower odds of intention to smoke among girls (AOR = 0.5; 95% CI: 0.3, 0.9) but with higher odds among boys (AOR = 1.8; 95% CI: 1.0, 3.1). In both sexes, media messaging was not associated with progression of the smoking habit. In conclusion, this comprehensive analysis of both pro- and anti-smoking messages advances our understanding of their role in influencing youths' smoking behaviors, and could guide the development of evidence-based interventions to address adolescent tobacco smoking in Jordan and the EMR.

The purpose of this study is to evaluate country adherence to the World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC) guidelines in terms of including quitline information on cigarette packaging. Data were gathered from the WHO’s Global Health Observatory database. The study included countries that were signatories to the FCTC, had a toll-free quitline, and required health warnings on cigarette packaging. Countries were then classified by income level according to the World Bank. From 2007 to 2018, the number of countries that established a quitline increased from 34 to 60. During the same timeframe among those countries, the number of countries that included information about the quitline on cigarette packaging increased from 5 to 37, with a larger proportion (79%) of high-income countries promoting their quitlines on cigarette packaging compared to middle-income (45%) countries. Although there was an increase in adherence to the WHO FCTC guidelines, there is still a need for several countries to include quitline information on cigarette packaging.

Introduction Waterpipe (WP) smoking is the leading tobacco use method among young adults in Lebanon. WP use is harmful, yet misperceptions about its safety exist. Implementing pictorial health warning labels (HWLs) on WP products is a promising strategy to correct this misperception. This study aimed to culturally adapt a set of 12 pictorial HWLs recently developed by an international expert panel to young adults in Lebanon. HWLs were grouped into four themes: WP health risks, WP harm to others, WP-specific harms, and WP harm compared to cigarettes. Aims and Methods We conducted nine focus groups among WP smokers and nonsmokers (N = 77; 52% females; age 18–34 years) to explore participants’ perceptions of the developed HWLs on attention, reaction (fear, avoidance), effectiveness (harm perception), and improvement (design/content, relatedness). Sessions were audio-taped, transcribed verbatim, and analyzed using directed qualitative content analysis. Results Emotionally provocative warnings were perceived as most effective, while symbolic and abstract warnings were found not believable. Warnings depicting visible bodily health effects and harm to babies seemed most promising. Participants were generally skeptical about Theme 4 because it might encourage switching to cigarettes. For cultural adaptation, participants recommended using shorter text with affirmative phrases, increasing the picture’s size and improving their quality, adding the WP device picture to enhance HWLs’ relatability, and develop testimonial messages that depict real people and stories. Conclusions Results will provide Lebanon and perhaps other countries in the Eastern Mediterranean Region with evidence-based HWLs that they can further develop, test, and implement within their specific culture. Implications Results provide Lebanon with evidence-based WP-specific pictorial HWLs that can be further developed and tested. HWLs provoking negative affect, with visible health consequences, and depicting harm to babies are promising. Participants recommended using definitive scientific claims presenting the health risks in numerical form. However, this needs to be balanced against protecting the credibility of HWLs scientifically and legally. Increasing the HWLs size and adding the WP device picture to the HWLs can enhance their relatability. Further research can help address some questions raised by this study, such as the potential of testimonial warnings that depict real people.

The efficacy of cognitive-behavioral therapy (CBT) is limited by clients’ failure to complete homework assignments. Widespread growth in smartphone use and application (app) software provides the potential to enhance the homework completion. In this pilot study, we examined the demographics of clients who declined to use an app to complete homework in CBT for gambling disorder. We also systematically collected information on what clients liked and disliked about an app to complete homework and compared their homework completion and treatment attendance with an archival, matched sample of 15 clients who completed homework using hardcopy. Clients who declined to use the app to complete homework were socioeconomically disadvantaged. Almost all clients who rated the app agreed or strongly agreed that they enjoyed using it. Clients who used the app to complete homework attended a similar number of treatment sessions but completed more homework than clients who used hardcopy. For individuals with access to smartphones, these results support the acceptability and feasibility of a smartphone app to complete therapeutic homework in CBT for gambling disorder and allow us to make several recommendations for future randomized controlled trials. These studies should allow clients to customize the frequency of homework reminders and to complete homework over multiple log-ins to the app. However, the implementation of smartphone-based healthcare interventions may not enhance the accessibility of care for individuals from socioeconomically disadvantaged backgrounds.

We explored the perceived strengths, barriers to implementation, and suggestions for sustainable implementation of a multidisciplinary model within a community-based hospital system from the physicians’ perspectives. We conducted 9 focus groups with 37 physicians involved in the care of lung cancer patients. Grounded theory methodology guided the identification of recurrent themes that emerged from the qualitative data analysis. The majority of study participants agreed that the multidisciplinary model could benefit patients by promoting high quality, efficient, and well-coordinated care. Co-location, financial disincentives, and time constraints were identified as major deterrents to full participation in a multidisciplinary clinic. Other perceived challenges were the integration of a multidisciplinary care model into the existing healthcare system, maintenance of referral streams, and designation of the physician primarily responsible for a patient’s care. Educating physicians about the availability of a multidisciplinary clinic, establishing efficient processes for initial consultations, implementing technology for virtual participation, and using a nurse navigator with reliable closed-loop communication were suggested to improve the implementation of the multidisciplinary model. Physicians generally agreed that the multidisciplinary model could improve lung cancer care, but they perceived significant personal, institutional, and system-level barriers that need to be addressed for its successful implementation in a community healthcare setting.