Cathy L Melvin

Tobacco use among sexual minorities in the USA, 1987 to May 2007: a systematic review

Objectives: This paper examines the prevalence of tobacco use among sexual minorities in the US through a systematic review of literature from 1987 to May 2007. Methods: Seven databases were searched for peer-reviewed research (Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library via Wiley InterScience, Education Resources Information Center (ERIC), Health Source: Nursing/Academic, Institute for Scientific Information (ISI) Web of Science, PsycINFO via EBSCO Host and PubMed). No language restrictions were used. Abstracts were identified in the literature search (n = 734) and were independently read and coded for inclusion or exclusion by two reviewers. When agreement was not reached, a third reviewer acted as arbitrator. Abstracts were included if they presented data collected in the US from 1987 to May 2007 and reported prevalence or correlation of tobacco use with sexual minority status. Studies reporting data from HIV-positive samples were excluded. The identified articles (n = 46) were independently read by two reviewers who recorded key outcome measures, including prevalence and/or odds ratios of tobacco use, sample size and domain of sexuality (identity, behaviour, or desire). Factors relating to study design and methodology were used to assess study quality according to nine criteria. Results: In the 42 included studies, 119 measures of tobacco prevalence or association were reported. The available evidence points to disparities in smoking among sexual minorities that are significantly higher than among the general population. Conclusions: Ongoing, targeted interventions addressing smoking among sexual minorities are warranted in tobacco control programs.

Systematic Review: Smoking Cessation Intervention Strategies for Adults and Adults in Special Populations

Tobacco use is the leading cause of preventable illness and death in the United States. Once users are dependent on tobacco, quitting is difficult. Nicotine dependence resulting from tobacco use hampers efforts to sustain abstinence from tobacco for a prolonged period or a lifetime (1). Many users make multiple attempts to quit, often without the assistance that could double or even triple their chances of success (1). Proven individual cessation strategies include counseling and behavioral therapy and, except when contraindicated, first-line and second-line medications (1). These strategies may prove especially helpful for individuals motivated to quit smoking in response to pregnancy or hospitalization for a smoking-related condition. Populations with psychiatric conditions and substance abuse problems have higher rates of smoking and show a lack of responsiveness to smoking cessation treatments (2, 3). More sensitive or specialized strategies and services for smoking cessation may be needed to help patients with overlapping conditions, such as multiple addictions or psychiatric, cognitive, or medical conditions (2, 3). As background for a National Institutes of Health conference, our full systematic review (4) synthesized new evidence on individual-based strategies designed to increase the likelihood that adult tobacco users (with and without selected coexisting conditions) will quit. We also compared findings from new studies with those summarized in previous systematic reviews and meta-analyses. Methods We searched MEDLINE, the Cumulative Index to Nursing and Applied Health (CINAHL), the Cochrane Library, Cochrane Clinical Trials Register, Psychological Abstracts, and Sociological Abstracts from 1 January 1980 through 10 June 2005 using Medical Subject Headings (Appendix Table 1) as search terms or key words when appropriate. We also manually searched reference lists. A technical expert panel helped us to ensure that we included important literature in our search. Appendix Table 1. Medical Subject Headings and Text Words We limited our review to human studies conducted in developed countries and published in English (Appendix Table 2 gives specific inclusion and exclusion criteria). We considered studies with samples that consisted of participants who were age 13 years and older, that included both sexes, and that were racially and ethnically diverse. We limited studies to those with 6 months or greater follow-up periods and minimum sample sizes of 30 patients for randomized, controlled trials and 100 patients for other experimental or observational studies. We excluded articles that did not report outcomes related to quit rates; articles that did not provide the minimum information required; and all editorials, letters, and commentaries. Appendix Table 2. Smoking Cessation Strategies: Inclusion and Exclusion Criteria for New Studies All studies were dually reviewed. We assessed the quality of studies according to how well they met the criteria from the U.S. Preventive Services Task Force (5) and the National Health Service Centre for Reviews and Dissemination (6). We rated the strength of the evidence using the criteria from the Task Force on Community Preventive Services (7). To determine whether the strength of evidence for each study was strong, sufficient, or insufficient, we evaluated the study design, study execution, and the size and consistency of reported effects. For 4 of the 5 key questions in the evidence report (Appendix Table 3), we relied on several well-conducted systematic reviews. The Table documents the type, quality, treatment format, and outcome for each review. We included original research studies that 1) were published beyond the date range in the systematic reviews, 2) covered topics not covered by the reviews, and 3) provided sufficient detail about their methods and outcomes. Appendix Table 3. Key Questions for the Full Evidence Report prepared for the Agency for Healthcare Research and Quality Table. Summary of Review Article Outcomes This review was funded by a contract from the Agency for Healthcare Research and Quality. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or other clinical service. Data Synthesis Literature Reviewed Of 1288 abstracts, we examined 488 for full article review and retained 102 (Appendix Figure). Of 43 studies relevant to this article, 5 were of good quality (1620), 23 were fair (2143), and 15 were poor (not presented here) (4458). Appendix Figure. Tobacco use: prevention, cessation, and control article disposition. KQ = key question. *Two studies counted as one because they used the same sample. One study addressed both KQ2 and KQ5. One study used adolescents and was excluded from the review. We report on 28 new studies not included in previous reviews (Appendix Table 4). Twenty-one studies addressed strategies to improve success rates for cessation (16, 17, 21, 22, 2434, 36, 37, 39, 4143), including self-help, counseling, pharmaceutical agents, and combinations of pharmaceutical and counseling therapies. Seven studies examined interventions in patients with coexisting conditions and nicotine dependence, including psychiatric conditions and substance abuse problems (1820, 23, 35, 38, 40), and 5 studies overlapped both categories (24, 30, 31, 33, 39). We reviewed this new body of evidence both independently and within the context of previous reviews. Appendix Table 4. Smoking Cessation Intervention Strategies To Improve Success Rates for Quit Attempts Alternative Approaches to Smoking Cessation Self-Help Approaches Two studies examined a self-help approach to improving cessation rates (26, 33). One study involved patients recently discharged from intensive care units (ICUs) (33); the other included patients undergoing lung cancer screening (26). Patients discharged from intensive care received verbal encouragement to remain nonsmoking at ICU discharge, a self-help ICU rehabilitation manual, and instructions to the immediate family not to smoke near the patient. Patients undergoing lung cancer screening received either a handout listing 10 smoking cessationrelated Internet sites or 2 self-help booklets, 1 of which provided information on available pharmacotherapies for nicotine dependence (26). Patients receiving the ICU rehabilitation package were much less likely to return to smoking after discharge than were the control patients (relative risk, 0.11 [95% CI, 0.02 to 0.64]); the investigators could not determine whether just the smoking cessation advice or the whole package (including an exercise program) was responsible for the high quit rate (33). Seven-day point-prevalence quit rates did not differ significantly between patients in the intervention and control groups undergoing lung cancer screening, although at 1-year follow-up more patients in the intervention group reported an attempt to stop smoking (26). We found insufficient evidence of efficacy for self-help strategies, given the small number of new studies and discrepancies between studies for the same outcome. Counseling Five studies evaluated the effects of counseling2 studies in hospital settings (30, 39), 1 in both primary care clinics and hospitals (24), and 2 in private practices (21, 36). All interventions included nurse counseling, self-help materials, and follow-up contact either in person or by telephone; all were compared with usual care (brief advice to quit smoking, related self-help materials, or both). Although self-reported abstinence rates were higher in the more comprehensive treatment in 1 study (30), neither hospital-based intervention increased biochemically verified abstinence rates at 12 months after discharge (30, 39). At 6-month follow-up, diabetic patients seen in primary clinics and hospitals who received nurse-managed assistance in quitting were significantly more likely to quit smoking than controls (24). Biochemically validated quit rates were 17.0% for the intervention group compared with 2.3% for the control group (P= 0.001). Three different counseling interventions showed no significant differences in quit rates at 12-month follow-up (21, 36, 39). Two studies reported increased abstinence with counseling treatment (24, 30); only 1 study verified cessation biochemically (24). Although previous reviews showed that counseling was effective, these new studies show mixed results. Pharmaceutical Monotherapy Five studies examined the effect of a single pharmaceutical agent on smoking cessation (27, 28, 32, 37, 41): 3 of bupropion (27, 32, 41) and 1 each of nicotine gum (28) and transdermal nicotine and nicotine nasal spray (37). Two studies were based in hospitals (27, 41), and 3 were population-based (28, 32, 37). Two studies compared 7 weeks of sustained-release bupropion with placebo. In a 6-month study, health care workers motivated to quit smoking received behavioral counseling and sustained-release bupropion or placebo (27). Continuous smoking abstinence at week 7 was achieved by 43% of patients in the bupropion group and 18% of patients in the placebo group (P< 0.001). Side effects, although frequent, were reversible in both groups and generally consistent with those noted in previous studies. In the other study, all participants received 2 months of transdermal nicotine replacement therapy and 3 months of cognitive behavioral counseling and either sustained-release bupropion or placebo (41). The investigators observed a nonsignificant trend for abstinence at 3 months but not at 6 or 12 months among participants randomly assigned to bupropion; biochemical measures of smoking did not significantly differ between groups. Holt and colleagues (32) attempted to determine whether bupropion combined with smoking cessation counseling was effective for the indigenous Maori population of New Zealand. A

Recommended cessation counselling for pregnant women who smoke: a review of the evidence

OBJECTIVE To review the evidence base underlying recommended cessation counselling for pregnant women who smoke, as it applies to the steps identified in the Agency for Healthcare Research and Qualitys publication,Treating tobacco use and dependence: a clinical practice guideline. DATA SOURCES Secondary analysis of literature reviews and meta-analyses. DATA SYNTHESIS A brief cessation counselling session of 5–15 minutes, when delivered by a trained provider with the provision of pregnancy specific, self help materials, significantly increases rates of cessation among pregnant smokers. This low intensity intervention achieves a modest but clinically significant effect on cessation rates, with an average risk ratio of 1.7 (95% confidence interval 1.3 to 2.2). There are five components of the recommended method—“ask, advise, assess, assist, and arrange”. CONCLUSIONS We recommend these evidence based procedures be adopted by all prenatal care providers. The use of this evidence based intervention is feasible in most office or clinic settings offering prenatal care and can be implemented without inhibiting other important aspects of prenatal care or disrupting patient flow. If implemented widely, this approach has the potential to achieve an important reduction in a number of adverse maternal, infant, and pregnancy outcomes and to reduce associated, excess health care costs.

Treating nicotine use and dependence of pregnant and parenting smokers: An update

A growing volume of research since 1975 has demonstrated that clinically proven, effective interventions exist to produce long-term or even permanent abstinence from tobacco for all smokers. Achieving cessation is important for all smokers but especially for pregnant and parenting smokers because their smoking poses risks not only for themselves but also for their pregnancies and children. Treatments for smokers in general apply to parenting smokers, but special considerations regarding treatment need to be made for pregnant women. Due to the harms associated with exposure to environmental tobacco smoke, or second-hand smoke (SHS), parents and caregivers of young children should receive treatment to achieve cessation or counseling on how to eliminate exposure of children to SHS. Despite the availability of these treatments, surveys show that fewer than half of all obstetricians caring for pregnant women in the United States actually provide such treatment. We review the recommendations made in 2000 regarding treatment for pregnant and parenting smokers, summarize recent findings that may affect treatment protocols, and make recommendations regarding further research in treatment approaches for pregnant and parenting smokers. We summarize recommended changes in treatment approaches for clinicians based on this review and describe the factors affecting clinician adoption and use of proven treatments and systems supports found to increase the likelihood of clinician use of these treatments.

Medicaid reimbursement for prenatal smoking intervention influences quitting and cessation

Background: 40% of births in the USA are covered by Medicaid and smoking is prevalent among recipients. The objective of this study was to evaluate the association between levels of Medicaid coverage for prenatal smoking cessation interventions on quitting during pregnancy and maintaining cessation after delivery. Methods: Population based survey study of 7513 post-partum women from 15 states who: participated in Pregnancy Risk Assessment Monitoring System (PRAMS) during 1998–2000; smoked at the beginning of their pregnancy; and had Medicaid coverage. Participating states were categorised into three levels of Medicaid coverage for smoking cessation interventions during prenatal care: extensive (pharmacotherapies and counselling); some (pharmacotherapies or counselling); or none. Quit rates among women who smoked before pregnancy and rates of maintaining cessation were examined. Results: Higher levels of coverage during prenatal care for smoking cessation interventions were associated with higher quit rates; 51%, 43%, and 39% of women quit in states with extensive, some, and no coverage, respectively. Compared to women in states with no coverage, women in states with extensive coverage had 1.6 times the odds of quitting smoking (odds ratio (OR) 1.58, 95% confidence interval (CI) 1.00 to 2.49). Maintenance of cessation after delivery was associated with extensive levels of Medicaid coverage; 48% of women maintained cessation in states with extensive coverage compared to 37% of women in states with no coverage. Compared to women in states with no coverage, women with extensive coverage had 1.6 times the odds of maintaining cessation (OR 1.63, 95% CI 1.04 to 2.56). Conclusions: Prenatal Medicaid coverage for both pharmacotherapies and counselling is associated with higher rates of quitting and continued cessation. This suggests policymakers can promote cessation by broadening smoking cessation services in Medicaid prenatal coverage.

Dissemination research in cancer control: where are we and where should we go?

Dissemination of evidence-based programs and policies is a critical final step in reducing the burden of cancer in the general public. Yet, we have not been fully successful to date in improving clinical or public health practice by disseminating programs found to be effective in research. Therefore, research is needed into the dissemination process and outcomes to enable better efforts in the future. This paper explores the definitions and models used for dissemination, the designs of dissemination studies, and possible research questions in dissemination research, all focused on cancer prevention and control. We hope that this paper will encourage dissemination research in our field.

Measurement and definition for smoking cessation intervention research: the Smoke-Free Families experience

The measures, definitions, and processes used in the Smoke-Free Families clinical trials to assure consistent measurement and reporting of various aspects of the trials are described. Definitions of current smokers at different points in the pregnancy, levels of addiction, biological verification, cessation, stages of change, and intervention approaches are presented along with the rationale underlying their adoption and development.

Sociodemographic, insurance, and risk profiles of maternal smokers post the 1990s: how can we reach them?

Declines in prenatal smoking rates have changed the composition of maternal smokers while public policy during the 1990s has likely made it more difficult to reach them. Medicaid expansions during the 1980s/early 1990s insured more women some time during pregnancy, but the 1996 welfare reform unexpectedly reduced enrollment in Medicaid by eligible pregnant women; overall, insurance coverage has declined since 2000. As the public sector struggles with fewer resources, it is important to understand the sociodemographic characteristics of prenatal smokers, their patterns of care, and nonsmoking risk behaviors. Targeting scarce dollars to certain settings or sub-populations can strengthen the infrastructure for tobacco policy change. We provide more current information on maternal smokers in 2002 based on the Pregnancy Risk Assessment Monitoring System (PRAMS) for 21 states. Data on urban/rural location, insurance coverage, access patterns, and nonsmoking risk behaviors (e.g., abuse) among low-income (<16,000) and other maternal smokers are included. Low-income maternal smokers are the working poor living in predominately urban areas with fewer health care resources than low-income nonsmokers. Over 50% of low-income maternal smokers are uninsured pre-pregnancy and use a clinic as their usual source of care. Regardless of income, smokers exhibit rates of nonsmoking risks that are two to three times those of nonsmokers and high rates of unintended pregnancy (68%) of low-income smokers. These characteristics likely call for a bundle of social support services beyond cessation for smokers to quit and remain smoke-free postpartum.

Best practice smoking cessation intervention and resource needs of prenatal care providers.

OBJECTIVE: To describe smoking cessation interventions by prenatal care providers and to identify factors associated with best practice. METHODS: A mailed survey assessed implementation of the “5 As” of best practice (Ask about smoking; Advise patients to quit; Assess willingness to quit; Assist with a cessation plan; and Arrange follow-up), practice characteristics, intervention training, resources, barriers, and attitudes toward reimbursement. Each factor in association with provider type and best practice implementation was analyzed. RESULTS: Of 1,138 eligible North Carolina health professionals, 844 responded (74%); 549 were providing prenatal care and returned completed surveys. Most asked about smoking (98%) and advised cessation (100%). Across provider type, one third (31%) consistently implemented all “5 As” of best practice. Most providers (90%) had at least one material resource (eg, pamphlets), which correlated with nearly 10 times the adjusted odds of best practice (odds ratio [OR] 9.6, 95% confidence interval [CI] 1.3–72.9). Seventy percent had at least one counseling resource. Having a counseling resource (OR 2.5, 95% CI 1.4–4.4) and a written protocol to identify staff responsibilities (OR 2.5, 95% CI 1.5–4.3) were equally associated with best practice. More than one half of providers endorsed reimbursement as influential on best practice. CONCLUSION: Best practice is well-established to promote prenatal smoking cessation yet implemented by only one third of prenatal care providers in North Carolina. In this study, best practice was associated with resources, practice organization, and reimbursement. Augmented use of available resources (eg, toll-free hotlines) and adequate reimbursement may promote best practice implementation. LEVEL OF EVIDENCE: III

Up in smoke: vanishing evidence of tobacco disparities in the Institute of Medicine's report on sexual and gender minority health.

The Institute of Medicine (IOM) released a groundbreaking report on lesbian, gay, bisexual, and transgender (LGBT) health in 2011, finding limited evidence of tobacco disparities. We examined IOM search terms and used 2 systematic reviews to identify 71 articles on LGBT tobacco use. The IOM omitted standard tobacco-related search terms. The report also omitted references to studies on LGBT tobacco use (n = 56), some with rigorous designs. The IOM report may underestimate LGBT tobacco use compared with general population use.