Margaret Reid

Enhancing the Electronic Health Record to Increase Counseling and Quit-Line Referral for Parents Who Smoke

OBJECTIVE To assess the impact of an electronic health record (EHR) modification and brief clinician training on tobacco smoke exposure (TSE) management in pediatric primary care. METHODS Within a teaching hospital-based, urban primary care setting, we modified the EHR to include TSE screening prompts, decision support, educational literature, and simplified referral to the state quit line (QuitWorks). A brief training was conducted for the 48 clinic physicians (34 residents and 14 attendings). We collected cross-sectional, independent, random samples of EHR data from well-child visits for children ≤12 years old seen 3 months before (2024 visits) and 3 months after (1895 visits) the intervention and pooled client data from QuitWorks to evaluate TSE screening, counseling, and quit-line referrals. A needs assessment questionnaire examined preintervention attitudes and practice around TSE management; follow-up questionnaires explored satisfaction and subjective changes in skills. RESULTS The baseline needs assessment revealed that although most clinicians agreed that it is appropriate for pediatricians to conduct TSE screening, counseling, and referral during well-child visits, only about half screened, 42% counseled, and 28% routinely offered to refer smoking parents. In pre-post analyses of 117 and 112 EHR-documented positive screens, the intervention was associated with a 16-fold greater likelihood of counseling among positive screens (adjusted odds ratio 16.12; 95% confidence interval 7.28, 35.68). Referrals to QuitWorks increased from 1 before to 31 after the intervention. CONCLUSIONS Implementation of EHR modifications and a brief training to support TSE management was associated with higher rates of counseling and quit-line referrals for parents who smoke.

Comparison of Indoor Air Quality in Smoke-Permitted and Smoke-Free Multiunit Housing: Findings From the Boston Housing Authority

INTRODUCTION Secondhand smoke remains a health concern for individuals living in multiunit housing, where smoke has been shown to easily transfer between units. Building-wide smoke-free policies are a logical step for minimizing smoke exposure in these settings. This evaluation sought to determine whether buildings with smoke-free policies have less secondhand smoke than similar buildings without such policies. Furthermore, this study assessed potential secondhand smoke transfer between apartments with and without resident smokers. METHODS Fine particulate matter (PM2.5), airborne nicotine, and self-reported smoking activity were recorded in 15 households with resident smokers and 17 households where no one smoked in 5 Boston Housing Authority developments. Of these, 4 apartment pairs were adjacent apartments with and without resident smokers. Halls between apartments and outdoor air were also monitored to capture potential smoke transfer and to provide background PM2.5 concentrations. RESULTS Households within buildings with smoke-free policies showed lower PM2.5 concentrations compared to buildings without these policies (median: 4.8 vs 8.1 µg/m(3)). Although the greatest difference in PM2.5 between smoking-permitted and smoke-free buildings was observed in households with resident smokers (14.3 vs 7.0 µg/m(3)), households without resident smokers also showed a significant difference (5.1 vs 4.0 µg/m(3)). Secondhand smoke transfer to smoke-free apartments was demonstrable with directly adjacent households. CONCLUSION This evaluation documented instances of secondhand smoke transfer between households as well as lower PM2.5 measurements in buildings with smoke-free policies. Building-wide smoke-free policies can limit secondhand smoke exposure for everyone living in multiunit housing.

Has Boston's 2011 cigar packaging and pricing regulation reduced availability of single-flavoured cigars popular with youth?

Objective We evaluated retailer compliance with a cigar packaging and pricing regulation in Boston, Massachusetts, enacted in February 2012, and the regulations impact on availability of single cigars. Methods Grape-flavoured Dutch Masters (DM) single-packaged cigars were examined as market indicator. At quarterly intervals from October 2011 to December 2014, availability and price of DM single cigars were observed through professional inspector visits to tobacco retailers in Boston (n=2232) and 10 comparison cities (n=3400). Differences in price and availability were examined between Boston and the comparison cities and across Boston neighbourhoods. Results The mean price of DM single cigars sold in Boston increased from under

Cross-Disciplinary Consultancy to Enhance Predictions of Asthma Exacerbation Risk in Boston

1.50 in 2011 to above

Promising Strategies to Remove Inexpensive Sweet Tobacco Products From Retail Stores

2.50 in 2014, consistent with regulation requirements. Rates of retailer compliance reached 100% within 15 months postpolicy enactment based on observed price, and 97% at 30 months postenactment based on final sale prices. There was a 34.5% net decrease in the percentage of Boston retailers selling single cigars from 2011 to 2014. The number of Boston neighbourhoods with 3 or more retailers selling single cigars per 100 youth residents decreased from 12 in 2011 to 3 in 2014. No change in price or per cent of retailers selling single cigars was observed in the comparison cities in the same period. Conclusions Retailers throughout Boston are in compliance with the regulation. The regulation has been effective in reducing levels and disparities in availability of flavoured single cigars popular with youth across Boston neighbourhoods, regardless of socioeconomic status and racial/ethnic composition.

Referral Strategies to a Tobacco Quitline and Racial and/or Ethnic Differences in Participation

This paper continues an initiative conducted by the International Society for Disease Surveillance with funding from the Defense Threat Reduction Agency to connect near-term analytical needs of public health practice with technical expertise from the global research community. The goal is to enhance investigation capabilities of day-to-day population health monitors. A prior paper described the formation of consultancies for requirements analysis and dialogue regarding costs and benefits of sustainable analytic tools. Each funded consultancy targets a use case of near-term concern to practitioners. The consultancy featured here focused on improving predictions of asthma exacerbation risk in demographic and geographic subdivisions of the city of Boston, Massachusetts, USA based on the combination of known risk factors for which evidence is routinely available. A cross-disciplinary group of 28 stakeholders attended the consultancy on March 30-31, 2016 at the Boston Public Health Commission. Known asthma exacerbation risk factors are upper respiratory virus transmission, particularly in school-age children, harsh or extreme weather conditions, and poor air quality. Meteorological subject matter experts described availability and usage of data sources representing these risk factors. Modelers presented multiple analytic approaches including mechanistic models, machine learning approaches, simulation techniques, and hybrids. Health department staff and local partners discussed surveillance operations, constraints, and operational system requirements. Attendees valued the direct exchange of information among public health practitioners, system designers, and modelers. Discussion finalized design of an 8-year de-identified dataset of Boston ED patient records for modeling partners who sign a standard data use agreement.

Housing Quality and Mental Health: the Association between Pest Infestation and Depressive Symptoms among Public Housing Residents

Restricting access to tobacco products is critical to controlling tobacco use among young people. A 2012 report by the US Surgeon General found that exposure to tobacco marketing in stores, coupled with price discounting, increases smoking among young people. One study found that two-thirds of teenagers visited a convenience store or other neighborhood retailer at least once per week. According to the Federal Trade Commission, the tobacco industry spent >94% of its total marketing budget in convenience stores, gas stations, and other retail outlets in 2011. In 2009, the Family Smoking Prevention and Tobacco Control Act granted the US Food and Drug Administration (FDA) the authority to regulate the manufacture, distribution, and marketing of tobacco products. The FDA began by banning candy-, fruit-, and similarly sweet-flavored cigarettes because they were intentionally created for and marketed to young people. After the ban, however, the industry quickly pivoted and began producing inexpensive flavored cigars that resemble and are inhaled like cigarettes. In 2015, an estimated 10.3% of high school students in the country had smoked cigars, cigarillos, or little cigars at least once in the previous 30 days. A study published in 2015 found that >95% of adolescent cigar users smoked flavored cigars. Effective strategies are needed to remove low-cost flavored tobacco products from retail stores. To address public concerns about cigar use among young people, the City of Boston, Massachusetts, created, passed, and implemented its first cigar-packaging regulation in 2012 to reduce young people’s access to inexpensive flavored cigars. The regulation went into effect on January 31, 2012. It has produced promising results, as evidenced by increases in mean sale price, substantial decreases in the number of retailers selling single cigars, and reductions in disparities (by neighborhood, race, and income) in young people’s access to cigars in neighborhood retail stores. This brief article reviews the regulation and its effects. The Boston Cigar-Packaging Regulation

Evaluation of the Environmental Scoring System in Multiple Child Asthma Intervention Programs in Boston, Massachusetts

In this evaluation, we describe the success of a program that was designed strategically to connect vulnerable smokers of color to Massachusetts quitline services. BACKGROUND: Tobacco use inflicts a disproportionate burden of disease on people of color. We evaluated the reach among African American and Hispanic smokers in Boston of 2 referral strategies to the Massachusetts quitline: (1) a provider-referred strategy based in pediatric and dental clinics and (2) a targeted media campaign to promote self-referral to the quitline. METHODS: Selected demographic characteristics of Boston quitline participants during the study period (2010–2012) were compared between strategies. Self-referred smoker characteristics were also compared in the years before and after the media campaign. Finally, the characteristics of quitline participants were compared with smokers in the 2010 Boston Behavioral Risk Factor Surveillance Survey. RESULTS: During the study period, 4066 smokers received cessation services from the quitline; 3722 (91.5%) were self-referred, and 344 (8.5%) were referred by pediatric and dental providers. The proportion of black (31.6%) and Hispanic (20.3%) participants referred by providers was higher than among self-referred participants (18.3% and 7.8%, respectively; P <.001). Overall, provider-referred participants were less likely to be white (17.9%) than to be people of color. Self-referred smokers were more likely to be white (68.0%) than the estimated population of Boston smokers overall (62.9%; P <.001). CONCLUSIONS: The large-scale media campaign, which promoted self-referral, was associated with higher quitline participation overall, but the provider-referred strategy based in community health centers yielded participation from a greater proportion of smokers of color. The 2 strategies reached different subpopulations of smokers, and their combined reach enhanced access to cessation services among smokers from different racial and ethnic backgrounds.

Subsidized Housing and Adult Asthma in Boston, 2010–2015

Housing quality, which includes structural and environmental risks, has been associated with multiple physical health outcomes including injury and asthma. Cockroach and mouse infestations can be prime manifestations of diminished housing quality. While the respiratory health effects of pest infestation are well documented, little is known about the association between infestation and mental health outcomes. To address this gap in knowledge and given the potential to intervene to reduce pest infestation, we assessed the association between household pest infestation and symptoms of depression among public housing residents. We conducted a cross-sectional study in 16 Boston Housing Authority (BHA) developments from 2012 to 2014 in Boston, Massachusetts. Household units were randomly selected and one adult (n = 461) from each unit was surveyed about depressive symptoms using the Center for Epidemiologic Study-Depression (CES-D) Scale, and about pest infestation and management practices. In addition, a home inspection for pests was performed. General linear models were used to model the association between pest infestation and high depressive symptoms. After adjusting for important covariates, individuals who lived in homes with current cockroach infestation had almost three times the odds of experiencing high depressive symptoms (adjusted OR = 2.9, 95% CI 1.9–4.4) than those without infestation. Dual infestation (cockroach and mouse) was associated with over five times the odds (adjusted odds = 5.1, 95% CI 3.0–8.5) of experiencing high depressive symptoms. Using a robust measure of cockroach and mouse infestation, and a validated depression screener, we identified associations between current infestation and depressive symptoms. Although the temporal directionality of this association remains uncertain, these findings suggest that the health impact of poor housing conditions extend beyond physical health to include mental health. The study adds important information to the growing body of evidence that housing contributes to population health and improvements in population health may not be possible without addressing deficiencies in the housing infrastructure.

Role of Landlords in Creating Healthy Homes: Section 8 Landlord Perspectives on Healthy Housing Practices

Objectives To test the applicability of the Environmental Scoring System, a quick and simple approach for quantitatively measuring environmental triggers collected during home visits, and to evaluate its contribution to improving asthma outcomes among various child asthma programs. Methods We pooled and analyzed data from multiple child asthma programs in the Greater Boston Area, Massachusetts, collected in 2011 to 2016, to examine the association of environmental scores (ES) with measures of asthma outcomes and compare the results across programs. Results Our analysis showed that demographics were important contributors to variability in asthma outcomes and total ES, and largely explained the differences among programs at baseline. Among all programs in general, we found that asthma outcomes were significantly improved and total ES significantly reduced over visits, with the total Asthma Control Test score negatively associated with total ES. Conclusions Our study demonstrated that the Environmental Scoring System is a useful tool for measuring home asthma triggers and can be applied regardless of program and survey designs, and that demographics of the target population may influence the improvement in asthma outcomes.