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Purpose: Although quitlines reach 1% to 2% of tobacco users annually, additional efforts are needed to increase their impact. We hypothesized that offering less intensive services would increase the rate of re-enrollment in any service, as well as re-enrollment in more intensive services. This study describes the enrollment patterns and identifies re-enrollment predictors for Oklahoma Tobacco Helpline (OTH) participants. Design: This study used a comparative observational design. Setting: The setting for this study was the OTH, a telephone-based cessation program funded by the Oklahoma Tobacco Settlement Endowment Trust. The OTH participants could select either a multicall telephone-based cessation program (MC) or one or more individual services (IS), including a 2-week nicotine replacement therapy (NRT) starter kit, e-mail or text-based support, and a printed quit guide. Participants: A total of 35 648 first-time adult OTH participants eligible for the multicall program from October 2015 through September 2018 were included. Measures: Demographic and tobacco use variables and initial quitline service selection were collected at intake. Additional service utilization was tracked for 6 months following initial registration. Analysis: Pearson chi-square and t tests were used to test for significant differences between groups. Multinomial logistic regression was used to examine predictors of re-enrollment. Results: Individual services were more frequently selected (n = 17 266) than MC (n = 14 326), despite all users being eligible for MC. A much higher proportion of IS registrants re-enrolled than MC registrants (16% vs 3%, P < .0001) Among the IS cohort, those who received an NRT follow-up call were 14.7 times more likely to re-enroll in IS, and 7.8 times more likely to re-enroll in MC, than those who were not reached by phone. Conclusions: Access to free NRT without a telephone-coaching requirement is a draw for tobacco users, especially those with lower income and the uninsured. The results suggest the value of increasing use of nonphone services in an effort to increase interest in quitting and reach.

This study aimed to assess how the relationship between youth assets and future no-tobacco use among youth might differ according to race/ethnicity, neighborhood factors and socio-economic status. Five waves of annual data were collected from 1111 youth/parent pairs living in Oklahoma, USA who were randomly selected to participate in the Youth Asset Study (YAS). A marginal logistic regression model using all five waves of no-tobacco use, demographics, and their interaction was used to compare the change in tobacco use over time. Among 1111 youth, (Mean age = 14.3; 53% female; 39% White, 28% Hispanic, 24% Black, and 9% other), the percentage of youth tobacco use increased significantly from baseline to wave 5 (4 years after baseline) for all racial/ethnic groups and all parental income groups. Assets were prospectively associated with no tobacco use in the past 30 days for Black, White and Hispanic youth and for youth in all income categories (adjusted odds ratio range = 1.9–2.7). There was one statistically significant association between the neighborhood environment and future no tobacco use. To conclude, the protective effects of youth assets in terms of prevention of tobacco use among youth do not differ by youth race/ethnicity or parental income in the presence of neighborhood environmental factors.

This cohort study evaluates the first 22 months of implementation of the Cherokee Nation Heath Services community-based program designed to eliminate hepatitis C virus (HCV) infection., Key Points Question Can a community-based tribal hepatitis C virus (HCV) elimination program be implemented successfully in a rural setting? Findings In this cohort study, first-time HCV screening coverage increased from 20.9% to 38.2% from 3 years before to 22 months into implementation of the Cherokee Nation Health Services HCV elimination program. Identification, treatment, and cure of newly identified current HCV infections increased. Meaning In this study, implementation of a community-based HCV elimination program was associated with an improved cascade of care; this information may serve other organizations planning to implement similar programs in large rural areas., Importance In 2019, hepatitis C virus (HCV) infection contributed to more deaths in the US than 60 other notifiable infectious diseases combined. The incidence of and mortality associated with HCV infection are highest among American Indian and Alaska Native individuals. Objective To evaluate the association of the Cherokee Nation (CN) HCV elimination program with each element of the cascade of care: HCV screening, linkage to care, treatment, and cure. Design, Setting, and Participants This cohort study used data from the CN Health Services (CNHS), which serves approximately 132 000 American Indian and Alaska Native individuals residing in the 14-county CN reservation in rural northeastern Oklahoma. Data from the first 22 months of implementation (November 1, 2015, to August 31, 2017) of an HCV elimination program were compared with those from the pre–elimination program period (October 1, 2012, to October 31, 2015). The analysis included American Indian and Alaska Native individuals aged 20 to 69 years who accessed care through the CNHS between October 1, 2012, and August 31, 2017. Cure data were recorded through April 15, 2018. Exposure The CN HCV elimination program. Main Outcomes and Measures The main outcomes were the proportions of the population screened for HCV, diagnosed with current HCV infection, linked to care, treated, and cured during the initial 22 months of the elimination program period and the pre–elimination program period. Data from electronic health records and an HCV treatment database were analyzed. The cumulative incidence of HCV infection in this population was estimated using bayesian analyses. Results Among the 74 039 eligible individuals accessing care during the elimination program period, the mean (SD) age was 36.0 (13.5) years and 55.9% were women. From the pre–elimination program period to the elimination program period, first-time HCV screening coverage increased from 20.9% to 38.2%, and identification of current HCV infection and treatment in newly screened individuals increased from a mean (SD) of 170 (40) per year to 244 (4) per year and a mean of 95 (133) per year to 215 (9) per year, respectively. During the implementation period, of the 793 individuals with current HCV infection accessing the CNHS, 664 were evaluated (83.7%), 394 (59.3%) initiated treatment, and 335 (85.0%) had documented cure. In less than 2 years, the 85% 3-year goal was reached for cure (85.0%), and the goal for linkage to care was nearly reached (83.7%), whereas screening (44.1%) and treatment initiation (59.3%) required more time and resources. Conclusions and Relevance This cohort study found that after 22 months of implementation, the CNHS community-based HCV elimination program was associated with an improved cascade of care. The facilitators and lessons learned in this program may be useful to other organizations planning similar programs.

Objectives This study's purpose was to determine if youth race/ethnicity, youth age and sex, parent income and education, household wealth, family poverty, and family structure were prospectively associated with youth assets in a community-based sample of racially/ethnically and economically-diverse youth and their parents. Methods Five waves of data were collected annually (2003 to 2008) from youth (N = 1111; Mean age = 14.4 years, SD = 1.6) and their parents using in-person, computer-assisted interviewing methods. Marginal logistic regression models and generalized estimating equations were conducted to assess prospective associations between the demographic factors and the number of assets the youth possessed (more than or less than the median number of 12 assets). Results Results indicated that 1-parent families (Odds Ratio = 0.62, 95% CIs = 0.50-0.76) lower parental education, (OR = 0.67, CI = 0.48-0.95 and OR = 0.77, CI = 0.61-0.97), and youth age (OR = 0.70, CI = 0.55-0.88 and OR = 0.59, CI = 0.45-0.77) were the only demographic factors that independently, prospectively, and significantly predicted which youth would possess less than the median number of assets. Conclusions Youth assets may be 1 mechanism that explains the negative effects of some demographic factors, particularly 1-parent families and low-parent education, on youth risk behaviors and health.

Background The prevalence of smokeless tobacco use in the U.S. is increasing and its use is a risk factor for a number of adverse health outcomes. Currently, there is limited evidence on the effectiveness of quitlines for tobacco cessation among smokeless tobacco users. Purpose To examine factors related to tobacco abstinence among exclusive smokeless tobacco users registering for services with the Oklahoma Tobacco Helpline. Methods Participants included 959 male exclusive smokeless tobacco users registering with the Helpline between 2004 and 2012; a total of 374 completed a follow-up survey 7 months post-registration. Data were collected between 2004 and 2013 and included baseline data at Helpline registration, services received, and 7-month follow-up for 30-day point-prevalence for tobacco abstinence. Univariate and multiple logistic regression examined associations between abstinence and participant characteristics, intensity of Helpline intervention, and behavioral factors. ORs and 95% CIs were reported. Analyses were completed in 2013. Results At the 7-month follow-up, 43% of the participants reported 30-day abstinence from tobacco. Each additional completed Helpline call increased the likelihood of tobacco cessation by 20% (OR=1.20, 95% CI=1.05, 1.38). Smokeless tobacco users with higher levels of motivation to quit at baseline were twice as likely to be abstinent than those with low or moderate levels of motivation (OR=2.05, 95% CI=1.25, 3.35). Use of nicotine replacement therapy was not associated with abstinence when adjusted for Helpline calls, income, and level of motivation. Conclusions Tobacco quitlines offer an effective intervention to increase smokeless tobacco abstinence.

Background The Oklahoma Communities of Excellence in Tobacco Control (CX) program was established in 2004. Thirty-three CX grants have been funded to implement comprehensive tobacco control programs in 50 counties and one tribal nation. Purpose To describe local tobacco policy gains within CX counties and short-term and intermediate outcomes such as Oklahoma Tobacco Helpline registration and awareness, quit attempts, and home smoking bans among adults. Methods A before-and-after study design examined outcomes within CX counties and among CX urban and rural counties. Comparisons were made with non-funded counties when possible. Local policy tracking databases were reviewed for the number of policies implemented from 2004 to 2013 in CX counties. Population-level tobacco indicators, using Helpline registration and 2004–2010 Behavioral Risk Factor Surveillance System data, quantified changes over time. Data were collected in 2003–2013 and analyzed in 2013. Results Eight hundred thirty-one legislated and voluntary policies were implemented in CX counties and high levels of Helpline registration were maintained. Statistically significant increases were observed in CX counties for the proportion of smokers making a quit attempt, Helpline awareness, and home smoking bans among smokers. These observed increases were greater in rural CX counties than urban. Non-CX counties only experienced a statistically significant increase in Helpline awareness. Conclusions Using community-based best practices in tobacco control while focusing on social norm change, CX counties experienced positive changes in smoking-related attitudes and behaviors. This study expands the evidence base for statewide tobacco control programming and underscores the value of community-based tobacco control programs.

The School Outcomes Measure (SOM) measures the outcomes of students who receive school-based occupational and physical therapies in the USA. This study examined the SOM’s discriminative ability and internal consistency. Descriptive data from a previous study of 73 students, classified by gross motor function classification (GMFCS) level of disability, was computed to determine the frequency of use of the SOM items and differences in subscale scores by students with various ages and levels of disability. There were no differences in mean subscale scores based on age; however students with less severe disabilities (GMFCS I–III) had higher mean scores in all subscales except expresses learning all students and behavior. Cronbach’s alpha coefficient was used to examine the internal consistency of items of the SOM. The correlations between many of the items within the subscales were high (.87–.99). Lower alpha coefficients were noted when the SOM was applied to students in GMFCS Levels II and III on two subscales when compared to GMFCS Levels I, IV, and V. On the basis of this evaluation, we revised the SOM to prepare it for a national field testing to measure its construct validity.

To increase the use of quitlines for treating tobacco use and dependence, quitline referral interventions are recommended for healthcare systems and providers. Research is limited as to whether fax-referred smokers have quit outcomes similar to those of traditional self-callers to quitlines.Oklahoma Tobacco Helpline registration data from March 2013 to October 2014 and 7-month follow-up data were used to compare hospital- and clinic-based fax-referred registrants (n=537) to self-callers (n=2,577). Contingency table chi-square tests and relative risks were used to identify differences in 30-day point prevalence abstinence at 7-month follow-up. Two-sided p-values0.05 were considered statistically significant. Analyses were conducted in 2015.Fax-referred registrants versus self-callers were significantly more likely to be older (49.4 vs 47.6 years), white (70.6% vs 59.1%), non-Hispanic (96.8% vs 94.2%), and to have smoked fewer than one pack of cigarettes per day (54.0% vs 44.9%). Self-callers versus fax-referred registrants were significantly more likely to be uninsured (36.5% vs 29.4%) and have received nicotine-replacement therapy from the Helpline (92.3% vs 79.9%). At 7-month follow-up, a similar proportion of fax-referred registrants reported not using tobacco in the past 30 days as compared to self-callers (29.3% vs 31.8%, p=0.2945).Although differences in sociodemographics, tobacco use behavior, and Helpline services were observed between fax-referred registrants and self-callers, quit outcomes at follow-up did not differ. This observational study has important implications for tobacco control initiatives as it shows patients fax-referred by hospitals and clinics to quitlines may be as successful as self-callers in quitting smoking.

Purpose. To evaluate the effectiveness of a cognitive behavioral treatment (CBT) addressing cessation-related weight concerns delivered via a tobacco quitline that does not address weight concerns. Design. Randomized controlled trial, blinded 6-month follow-up. Setting. The Oklahoma Tobacco Helpline (OKHL). Subjects. All 7998 smokers who called the OKHL were screened; 4240 were eligible; 2000 were randomized to the standard quitline (STD) or the brief version of the CBT weight concerns program (WCP). Intervention. Telephone counseling to help people quit smoking and address concerns about cessation-related weight gain. Measures. Demographics, weight, tobacco status, weight concerns, self-efficacy in quitting, and quitting without weight gain. Analysis. Descriptive statistics and logistic regression. Results. Of those randomized, 1002 participants completed the 6-month survey (response rates = 53.2% for STD, 47% for WCP). Compared with STD, WCP led to reduced weight concerns (p < .01) and less weight gain among quitters (1.8 vs. −3.4 pounds; p = .01). Although not significant, participants in the WCP were more likely to report 30-day abstinence (33.3% vs. 36.8%, p = .24; intent to treat = 17.7 vs. 17.3). Conclusion. The WCP was successfully delivered via a quitline and resulted in improved attitudes about weight and decreased cessation-related weight gain without harming quit rates. Promotion of a quitline focused on addressing weight in conjunction with quitline treatment for smoking cessation may improve cessation and weight outcomes. Study limitations include use of self-report and survey response.

Object The authors debate the optimal management for Chiari malformation Type I (CM-I) while sharing their experience with posterior fossa decompression and duraplasty (PFDD). Methods The charts of 48 consecutive pediatric patients surgically treated for CM-I were retrospectively reviewed. Results Patients ranged in age from 2 to 17 years with an average age of 9.8 years. The most common presentations were headache, affecting 34 patients (71%), and pain (neck, back, or extremities), affecting 21 patients (44%). Twenty-seven patients (56%) had a syrinx. All 48 patients underwent PFDD utilizing acellular tissue matrix. The average hospital stay overall was 3.56 days, whereas the average stay for patients with (29 [60%] of 48) or without (19 [40%] of 48) scoliosis and/or syringomyelia was 3.72 and 3.32 days, respectively. The odds of a patient having a hospital stay of 4 or more days was nearly 3 times greater in patients with scoliosis and/or syringomyelia as compared with patients without either condition (OR 2.73, 95% CI 0.74–10.11, p = 0.1330). The average hospital stay for patients 0–8 years of age was 3.29 days; and for those 9–17 years of age, 3.78 days. The odds of a patient having a hospital stay of 4 or more days was nearly 4 times greater in 9- to 17-year-olds as compared with 0- to 8-year-olds (OR 3.73, 95% CI 1.03–13.52, p = 0.0455). Forty patients (89%) experienced early improvement in their signs and symptoms following PFDD. There were 2 revision PFDDs (4%). Conclusions Posterior fossa decompression and duraplasty is a safe and effective surgical option in the management of pediatric CM-I.

ObjectiveExamine the association between energy intake and television (TV) viewing in Americans.DesignNationally representative, cross-sectional study of 2003–2006 National Health and Nutrition Examination Survey.SettingTotal energy intake was determined by two 24 h recalls. TV viewing was reported as low (≤1 h/d), middle (2–3 h/d), and high (≥4 h/d). Multivariate linear regression models were used to analyse TV viewing and energy intake, adjusted for BMI (percentile for children 2–18 years), age, ethnicity and physical activity.SubjectsPre-school children (2–5 years;n1369), school-age children (6–11 years;n1759), adolescents (12–18 years;n3233) and adults (≥19 years;n7850) in the USA.ResultsThere was a significant association between TV viewing and energy intake for adolescent girls (highv. low:β= 195·2,P= 0·03) and men (highv. low:β= −113·0,P= 0·02; middlev. low:β= −131·1,P= 0·0002). Mean adjusted energy intake for adolescent girls was 7801·0, 8088·5 and 8618·2 kJ/d for low, middle and high TV viewing, respectively. Mean adjusted energy intake for men was 9845·9, 9297·2 and 9372·8 kJ/d for low, middle and high TV viewing.ConclusionsTV viewing was associated with energy intake in US children and adults only in 12–18-year-old girls and men. For girls, the high TV viewing category consumed more energy daily (816·3 kJ (195 kcal)) than the low category. In men, the middle and high TV viewing categories consumed less energy daily (548·4 kJ (131 kcal) and 473·0 kJ (113 kcal), respectively) than the low category. Our findings support some, but not all previous research. Future research is needed to explore this complicated relationship with rigorous measures of energy intake and TV viewing.