Jack E. Burkhalter

Tobacco Use and Readiness to Quit Smoking in Low-Income HIV-Infected Persons

The study aim was to identify covariates of smoking status and readiness to quit that encompassed key sociodemographic and health status variables, health-related quality of life, drug use and unprotected sex, and tobacco use variables in a cohort of low-income persons living with HIV. We also examined the impact of HIV diagnosis on smoking cessation. The sample (N = 428) was mostly male (59%) and Black (53%) or Hispanic (30%), and had a high school education or less (87%). Mean age was 40 years. Two-thirds of participants were current smokers, 19% former smokers, and 16% never smokers. Current smokers smoked a mean of 16 cigarettes/day for 22 years; 42% were in the precontemplation stage of readiness to quit smoking, 40% were contemplators, and 18% were in preparation. Most current smokers (81%) reported receiving medical advice to quit smoking. Multivariate logistic regression analyses indicated that current smokers, compared with former smokers, were more likely to use illicit drugs, perceive a lower health risk for continued smoking, and report less pain. Current smokers, compared with nonsmokers (former and never smokers), were more likely to report greater illicit drug use in their lifetime, current illicit drug use, and less pain. A multiple linear regression indicated that greater current illicit drug use, greater emotional distress, and a lower number of quit attempts were associated with lower stage of readiness to quit smoking. These findings confirm a high prevalence of smoking among HIV-infected persons and suggest a complex interplay among drug use, pain, and emotional distress that impact smoking status and, among smokers, readiness to quit. Tobacco control programs for HIV-infected persons should build motivation to quit smoking and address salient barriers to cessation--such as comorbid drug use, emotional distress, pain, and access to and coverage for treatment--and should educate smokers regarding the HIV-specific health benefits of cessation.

Construct Validity of the Posttraumatic Stress Disorder Checklist in Cancer Survivors: Analyses Based on Two Samples.

The measurement of posttraumatic stress disorder (PTSD) is critically important for the identification and treatment of this disorder. The PTSD Checklist (PCL; F. W. Weathers and J. Ford, 1996) is a self-report measure that is increasingly used. In this study, the authors investigated the factorial validity of the PCL with data from 236 cancer survivors who received a bone marrow or stem cell transplantation. The authors examined the fit of these data with the clinical model of 3 symptom clusters for PTSD, as proposed in the Diagnostic and Statistical Manual of Mental Disorders, and alternative models tested in prior research. By using confirmatory factor analysis the authors found that a 4-first-order-factor model of PTSD provided the best fit. The relations of PTSD symptoms with sociodemographic and medical variables were also explored.

Randomized Clinical Trial of Telephone-Administered Cognitive-Behavioral Therapy to Reduce Post-Traumatic Stress Disorder and Distress Symptoms After Hematopoietic Stem-Cell Transplantation

PURPOSE A significant number of survivors of hematopoietic stem-cell transplantation (HSCT) report enduring adverse effects of treatment, including illness-related post-traumatic stress disorder (PTSD) symptoms and general distress. We report results of a randomized clinical trial that tested the effects of a 10-session, telephone-administered cognitive-behavioral therapy (CBT) intervention on PTSD, depression, and distress symptoms. METHODS Survivors who had undergone HSCT 1 to 3 years earlier (N = 408) were assessed for study eligibility. Those who met study eligibility criteria (n = 89) completed a baseline assessment that included a clinical interview and self-report measures of PTSD symptoms (the primary outcome) and depression and general distress (the secondary outcomes). Next, they were randomly assigned to CBT or an assessment-only condition. Survivors in the CBT group completed 10 individual telephone-based CBT sessions (T-CBT) that included strategies to reduce PTSD symptoms, depression, and general distress. Follow-up assessments occurred at 6, 9, and 12 months after the baseline assessment. RESULTS Linear mixed-model analyses revealed that, compared with HSCT survivors in the assessment-only condition, survivors who completed T-CBT reported fewer illness-related PTSD symptoms, including less avoidance (P < .001) and fewer intrusive thoughts (P < .05) as well as less general distress and fewer depressive symptoms (P < .05) even after controlling for potential demographic and medical covariates. These results were consistent across the three follow-up assessments. CONCLUSION A brief, telephone-administered CBT intervention developed for HSCT survivors is an efficacious treatment for reducing illness-related PTSD symptoms and general distress.

Fatigue and Functional Impairment in Early-Stage Non-Small Cell Lung Cancer Survivors

CONTEXT Fatigue is the most common sequela among non-small cell lung cancer (NSCLC) survivors one to six years post-treatment and is associated with functional limitations. OBJECTIVES This study examined the prevalence, severity, and correlates of fatigue among early stage NSCLC survivors. METHODS Three-hundred fifty individuals diagnosed and surgically treated for Stage IA or IB NSCLC completed a survey that included the Brief Fatigue Inventory (BFI) to assess the prevalence and severity of fatigue. The Karnofsky Self-Reported Performance Rating scale (SR-KPS) was used as a measure of functional status and was compared with the severity of fatigue through Chi-squared analyses. Demographic, psychological, and medical correlates of fatigue were examined using logistic regression. RESULTS The prevalence of fatigue was 57%. Forty-one percent (n=142) of participants had mild fatigue and 16.8% (n=59) had moderate or severe fatigue (BFI≥4). Among the individuals reporting moderate or severe fatigue, 23.7% (n=14) had significant functional impairment (SR-KPS≤70%) compared with 2.8% (n=8) with mild or no fatigue (χ(2)=58.1, P<0.001). In the multivariate analysis, NSCLC survivors with pulmonary disease (odds ratio [OR]=2.28), depressive symptoms (OR=6.99), and anxiety symptoms (OR=2.31) were more likely to report experiencing clinically significant fatigue, whereas those who met physical activity guidelines (OR=0.29) reported less fatigue. CONCLUSION Fatigue is highly prevalent among NSCLC survivors and associated with more functional impairment. A comprehensive approach to the treatment of fatigue includes the screening and management of anxious and depressive symptoms, and pulmonary disorders such as chronic obstructive pulmonary disease.

Effectiveness of Partner Social Support Predicts Enduring Psychological Distress after Hematopoietic Stem Cell Transplantation

OBJECTIVE Hematopoietic stem cell transplant (HSCT) survivors who are 1 to 3 years posttransplant are challenged by the need to resume valued social roles and activities--a task that may be complicated by enduring transplant-related psychological distress common in this patient population. The present study investigated whether transplant survivors who receive adequate social support from their spouse or intimate partner experience lower distress. METHOD Effects of receiving a greater quantity of partner support (a common approach to studying enacted support) were compared with effects of receiving more effective partner support (i.e., support that more closely matches their needs in terms of its quantity and quality). Men and women (N = 230) who were 1 to 3 years posttransplant completed measures of partner support quantity (Manne & Schnoll, 2001), partner social support effectiveness (Rini & Dunkel Schetter, 2010), and psychological distress (Brief Symptom Inventory; Derogatis & Spencer, 1982). Potential medical and sociodemographic confounds were controlled in analyses. RESULTS As hypothesized, survivors reported less distress when they received more effective partner support (p < .001). Quantity of partner support was not associated with distress (p = .23). An interaction revealed that when partner support was effective, the quantity of support survivors received was not associated with their distress (p = .90); however, when partner support was ineffective, receiving a greater quantity of partner support was associated with substantially elevated distress (p = .002). CONCLUSIONS Findings suggest that clinical approaches to addressing or preventing enduring distress after HSCT should target features of partner support related to its appraised effectiveness.

Intention to quit smoking among lesbian, gay, bisexual, and transgender smokers.

INTRODUCTION Smoking is highly prevalent among lesbian, gay men, bisexual, and transgender (LGBT) persons and contributes to health disparities. Guided by the theory of planned behavior (TPB), we identified beliefs related to attitudes, perceived behavioral control, and subjective norms, as well as LGBT-specific variables, to explain variance in intention to quit smoking in the next 6 months in LGBT smokers. METHODS Individual interviews (n = 19) identified beliefs about quitting smoking and LGBT-salient variables and aided in survey development. Surveys were sent to a random sample from an LGBT community centers mailing list and center attendees, with a 25.4% response rate. Bivariate and multivariate analyses were conducted with the final sample of 101 smokers. RESULTS No sociodemographic or LGBT-specific variables beyond the TPB constructs were related to intention to quit smoking. A multivariate TPB model explained 33.9% of the variance in quitting intention. More positive attitudes and specific beliefs that cessation would make smokers feel more like their ideal selves and improve health and longevity were related to greater intention to quit (p values < .05). Subjective norm and perceived behavioral control were marginally significant, with perceived approval of partners and others and beliefs that life goal achievement would make it easier to quit positively related to intention. Depression and stress levels were high. DISCUSSION This is among the first studies to examine theoretically grounded variables related to intention to quit smoking in LGBT smokers. We identified specific behavioral, normative, and control beliefs that can serve as intervention targets to reduce smoking in the LGBT community.

Changes in Cancer-Related Risk Perception and Smoking Across Time in Newly-Diagnosed Cancer Patients

We examine the bidirectional relationships between cancer risk perceptions and smoking behavior among newly diagnosed cancer patients (N=188) during hospitalization for surgical resection, and at three and 12 months subsequently. Those with higher perceptions of risk for developing another cancer at three months were most likely to abstain from smoking by twelve months. Patients were relatively accurate in their cancer risk perceptions, with relapsers and continuous smokers reporting higher levels of risk perceptions at twelve months. Finally, those who quit smoking by 12 months felt at lower risk for developing cancer by 12 months. None of these relationships were significant between baseline and three months. Results indicate that perceived risk of cancer recurrence may be clinically useful in motivating smoking cessation after the acute cancer treatment phase is over. This study justifies an expanded theoretical framework attending to the distinct, prospective influences of illness risk perceptions on health behavior, and of health behavior on illness risk perceptions.

Current Dyspnea Among Long-Term Survivors of Early-Stage Non-small Cell Lung Cancer

Introduction: Dyspnea is common among lung cancer patients. As most studies of dyspnea have reviewed patients with active cancer or immediately after treatment, its prevalence during the longer-term period once treatment has been completed is not well characterized. This study quantifies the prevalence of dyspnea among lung cancer survivors and identifies potential correlates that may be amenable to intervention. Methods: Cross-sectional survey of 342 patients with disease-free, stage I, non-small cell lung cancer, assessed 1 to 6 years after surgical resection. Dyspnea was quantified using the Baseline Dyspnea Index. Any moderate/strenuous physical activity was measured using the Godin Leisure-Time Exercise Questionnaire. Mood disorder symptoms were assessed using the Hospital Anxiety and Depression Scale. Multiple regression analyses were used to examine demographic, medical, and health-related correlates of dyspnea. Results: Mean age was 68.9 years. Average predicted preoperative forced expiratory volume in 1 second was 89.0%. Current dyspnea, defined by a Baseline Dyspnea Index score of 9 or less, existed among 205 (60%) individuals. For 133 (65%) of these patients, dyspnea was absent preoperatively. Multivariate correlates of current dyspnea included preoperative dyspnea (odds ratio [OR] = 5.31), preoperative diffusing capacity (OR = 0.98), lack of moderate/strenuous physical activity (OR = 0.41), and the presence of clinically significant depression symptoms (OR = 4.10). Conclusions: Dyspnea is common 1 to 6 years after lung cancer resection, and is associated with the presence of preoperative dyspnea, reduced diffusing capacity, clinically significant depression symptoms, and lack of physical activity. Further research is needed to test whether strategies that identify and treat patients with these conditions attenuate dyspnea among lung cancer survivors.

Family-oncologist communication in cancer patient care.

Ensuring effective communication in cancer care is a challenge made greater by economic pressures, an increasing number and complexity of treatments, a profusion of information available to patients and their families on cancer and its treatment via the media and Internet, and the growing cultural and ethnic diversity of the U.S. population. A growing body of research supports the importance of effective physician communication skills in patient satisfaction and health outcomes. In cancer, communication involves multiple contacts over the continuum of care: during the diagnostic work-up, ‘‘breaking bad news’’ about the diagnosis of cancer, discussing treatment options, formulating and collaborating on treatment plans, cancer recurrence, seeking informed consent, and navigating transitions, particularly the change from a curative treatment approach to palliative care. Because cancer is a life-threatening illness, effective communication is important for solving the range of problems facing the patient and family, in sustaining hope, promoting adherence to treatment, and in achieving other important patient health outcomes. Effective communication with patients and their family members may also enhance oncology providers’ satisfaction with their own work, provide a buffer against emotional burnout and stress, and reduce the potential for adversarial relationships and malpractice liability with those in their care. Cancer occurs in a social context of family, friends, coworkers, and community members, who participate to varying degrees in the care of the patient and in encounters with the oncologist. The concept of cancer as an illness of the family—not the patient alone—has gained currency in light of cancer’s documented impact on family functioning. Family members influence patient-coping responses to illness by providing emotional support and in supporting adherence to treatment and other health-promoting behaviors. The economic value of caregiving (primarily by families, across all medical conditions) is high, with an estimated 25 million Americans providing unpaid care worth nearly

Development and Alpha Testing of QuitIT: An Interactive Video Game to Enhance Skills for Coping With Smoking Urges

200 billion annually. The degree of family participation in cancer care medical visits is also high. Beisecker and Moore reported that 77% of patients brought