Steven S. Fu

Why do providers contribute to disparities and what can be done about it

This paper applies social cognition research to understanding and ameliorating the provider contribution to racial/ethnic disparities in health care. We discuss how fundamental cognitive mechanisms such as automatic, unconscious processes (e.g., stereotyping) can help explain provider bias. Even well-intentioned providers who are motivated to be nonprejudiced may stereotype racial/ethnic minority members, particularly under conditions of that diminish cognitive capacity. These conditions—time pressure, fatigue, and information overload—are frequently found in health care settings. We conclude with implications of the social-cognitive perspective for developing interventions to reduce provider bias.

Post-traumatic stress disorder and smoking: a systematic review.

We conducted a systematic review of what is known about the relationship between post-traumatic stress disorder (PTSD) and smoking to guide research on underlying mechanisms and to facilitate the development of evidence-based tobacco treatments for this population of smokers. We searched Medline, PsychINFO, and the Cochrane Central Register of Controlled Trials and identified 45 studies for review that presented primary data on PTSD and smoking. Smoking rates were high among clinical samples with PTSD (40%-86%) as well as nonclinical populations with PTSD (34%-61%). Most studies showed a positive relationship between PTSD and smoking and nicotine dependence, with odds ratios ranging between 2.04 and 4.52. Findings also suggest that PTSD, rather than trauma exposure itself, is more influential for increasing risk of smoking. A small but growing literature has examined psychological factors related to smoking initiation and maintenance and the overlapping neurobiology of PTSD and nicotine dependence. Observational studies indicate that smokers with PTSD have lower quit rates than do smokers without PTSD. Yet a few tobacco cessation treatment trials in smokers with PTSD have achieved quit rates comparable with controlled trials of smokers without mental disorders. In conclusion, the evidence points to a causal relationship between PTSD and smoking that may be bidirectional. Specific PTSD symptoms may contribute to smoking and disrupt cessation attempts. Intervention studies that test behavioral and pharmacological interventions designed specifically for use in patients with PTSD are needed to reduce morbidity and mortality in this population.

Racial/Ethnic Disparities in the Use of Nicotine Replacement Therapy and Quit Ratios in Lifetime Smokers Ages 25 to 44 Years

We examined racial/ethnic variations in the use of nicotine replacement therapy (NRT) and quit ratios among Caucasian, African American, Asian, and Latino lifetime smokers ages 25 to 44 years. We conducted cross-sectional analyses using data from individuals (n = 27,031) screened for enrollment in the Collaborative Study of the Genetics of Nicotine Dependence. Participants were randomly sampled from three Midwestern metropolitan areas using Health Maintenance Organization membership lists in Detroit, MI and Minneapolis, MN and a driver’s license registry in St. Louis, MO from March 2003 to August 2005. A telephone survey collected information on smoking history, previous quit attempts, and sociodemographic characteristics. Among lifetime smokers (n = 9,216), univariate analysis indicated that African Americans (22%) and Latinos (22%) were significantly less likely to report having ever used NRT for smoking cessation than Caucasians (31%). Asians (22%) also reported lower rates of using NRT than Caucasians, but this difference was marginally significant (P = 0.06). These disparities persisted in multivariate analysis for African Americans [adjusted odds ratio (OR), 0.76; 95% confidence interval (95% CI), 0.63-0.91; P < 0.01] but not for Latinos (adjusted OR, 0.76; 95% CI, 0.54-1.06; P = 0.11) or Asians (adjusted OR, 0.98; 95% CI, 0.60-1.60; P = 0.95). As measured by the quit ratio, African Americans (35%) were less likely to have quit smoking than Caucasians (52%). This disparity persisted in multivariate logistic regression (adjusted OR, 0.66; 95% CI, 0.56-0.78; P < 0.001). Asian and Latino smokers were as likely as Caucasians to report smoking cessation. Future prospective studies are needed to assess whether lower utilization of cessation treatments such as NRT contribute to the observed disparity in quit ratios for African Americans. (Cancer Epidemiol Biomarkers Prev 2008;17(7):1640–7)

Ethnic Disparities in the Use of Nicotine Replacement Therapy for Smoking Cessation in an Equal Access Health Care System

Purpose. To examine ethnic variations in the use of nicotine replacement therapy (NRT) in an equal access health care system. Design. Cross-sectional survey. Setting. Eighteen Veterans Affairs medical and ambulatory care centers. Subjects. A cohort of male current smokers (n = 1606). Measures. Use of NRT (nicotine patch or nicotine gum), ethnicity, sociodemographics, health status, smoking-related history, and facility prescribing policy. Results. Overall, only 34% of African-American and 26% of Hispanic smokers have ever used NRT as a cessation aid compared with 50% of white smokers. In the past year, African-American smokers were most likely to have attempted quitting. During a serious past-year quit attempt, however, African-American and Hispanic smokers reported lower rates of NRT use than white smokers (20% vs. 22% vs. 34%, respectively, p = .001). In multivariate analyses, ethnicity was independently associated with NRT use during a past-year quit attempt. Compared with white smokers, African-American (adjusted odds ratio, .53; 95% confidence interval, .34–.83) and Hispanic (adjusted odds ratio, .55; 95% confidence interval, .28–1.08) smokers were less likely to use NRT. Conclusions. Assessment of variations in use of NRT demonstrates that African-American and Hispanic smokers are less likely to use NRT during quit attempts. Future research is needed on the relative contributions of patient, physician, and system features to gaps in guideline implementation to provide treatment for ethnic minority smokers.

Racial/ethnic differences in menthol cigarette smoking, population quit ratios and utilization of evidence‐based tobacco cessation treatments

AIMS This study examines the relationship between menthol cigarette smoking and the population quit ratio and whether menthol smokers differ in utilization of evidence-based smoking cessation aids among a nationally representative sample of US adult smokers. DESIGN, SETTING AND PARTICIPANTS Secondary data analysis of cross-sectional data from the 2005 National Health Interview Survey (NHIS) Cancer Control Supplement. The NHIS is a nationally representative survey of US households conducted annually. MEASUREMENTS The main outcome variables of interest were (1) the population quit ratio and (2) use of smoking quit aids. All analyses were conducted using SAS version 9.2 with SUDAAN, which corrects for the complex sampling design of the study. Univariate analyses were used to determine variables that differed significantly by menthol status and utilization of types of quit aids. Multiple logistic regression analysis modeled the relationship between menthol smoking status, demographic characteristics and smoking-related characteristics on the population quit ratio and utilization of quit aids. FINDINGS We observed significant differences in the population quit ratio for menthol versus non-menthol among African American smokers (34% versus 49%, P < 0.001), but not among whites (52% versus 50%). In multiple logistic regression analysis, there was a significant interaction between race and menthol smoking status. African American menthol smokers were significantly less likely than white non-menthol smokers to have quit smoking (adjusted odds ratio: 0.72, 95% confidence interval: 0.53, 0.97) after controlling for age group, sex, marital status, region and average number of cigarettes smoked per day. Menthol smoking status was not associated with differences in utilization of quit aids. CONCLUSIONS African Americans have the highest rates of menthol cigarette smoking of all racial and ethnic groups in the United States. Menthol cigarette smoking is associated negatively with successful smoking cessation among African Americans.

Chronic Disease Management for Tobacco Dependence: A Randomized, Controlled Trial

BACKGROUND Tobacco dependence disorder is a chronic relapsing condition, yet treatment is delivered in discrete episodes of care that yield disappointing long-term quit rates. METHODS We conducted a randomized controlled trial from June 1, 2004, through May 31, 2009, to compare telephone-based chronic disease management (1 year; longitudinal care [LC]) with evidence-based treatment (8 weeks; usual care [UC]) for tobacco dependence. A total of 443 smokers each received 5 telephone counseling calls and nicotine replacement therapy by mail for 4 weeks. They were then randomized to UC (2 additional calls) or LC (continued counseling and nicotine replacement therapy for an additional 48 weeks). Longitudinal care targeted repeat quit attempts and interim smoking reduction for relapsers. The primary outcome was 6 months of prolonged abstinence measured at 18 months of follow-up. RESULTS At 18 months, 30.2% of LC participants reported 6 months of abstinence from smoking, compared with 23.5% in UC (unadjusted, P = .13). Multivariate analysis showed that LC (adjusted odds ratio, 1.74; 95% CI, 1.08-2.80), quit attempts in past year (1.75; 1.06-2.89), baseline cigarettes per day (0.95; 0.92-0.99), and smoking in the 14- to 21-day interval post-quit (0.23; 0.14-0.38) predicted prolonged abstinence at 18 months. The LC participants who did not quit reduced smoking more than UC participants (significant only at 12 months). The LC participants received more counseling calls than UC participants (mean, 16.5 vs 5.8 calls; P < .001), longer total duration of counseling (283 vs 117 minutes; P < .001), and more nicotine replacement therapy (4.7 vs 2.4 boxes of patches; P < .001). CONCLUSION A chronic disease management approach increases both short- and long-term abstinence from smoking. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00309296.

Potential Unintended Consequences of Tobacco-Control Policies on Mothers Who Smoke: A Review of the Literature

BACKGROUND Secondhand smoke poses risks to children, particularly those from low socioeconomic backgrounds. Recently, there has been an increase in tobacco-control policies designed to reduce childrens exposure to secondhand smoke, including interventions to change parental smoking behaviors. However, little attention has been paid to understanding potential unintended consequences of such initiatives on mothers who smoke. As such, the objectives of this paper are to explore the potential consequences of tobacco-control policies designed to reduce childrens exposure to secondhand smoke on socially disadvantaged mothers who smoke and to provide recommendations for research, policy, and practice. EVIDENCE ACQUISITION A theory-guided, qualitative narrative review of the perceived discrimination, stigma, and stress and coping literature was conducted. MEDLINE and PsycINFO were searched to identify relevant articles from 1980 to October 2008 for review. EVIDENCE SYNTHESIS There is evidence that strategies designed to reduce secondhand smoke have contributed to smoking stigmatization. However, there is little research on the consequences of these initiatives or how they affect low-income mothers who smoke. Stigmatization research suggests that such policies may have unanticipated outcomes for socially disadvantaged mothers who smoke, such as decreased mental health; increased use of cigarettes or alcohol; avoidance or delay in seeking medical care; and poorer treatment by healthcare professionals. Recommendations for researchers, practitioners, and policymakers are presented. CONCLUSIONS Further research is needed to understand how initiatives to reduce childrens exposure to secondhand smoke, as well as broader tobacco-control initiatives, can be designed to minimize potential harm to mothers who smoke.

Menthol Cigarettes and Smoking Cessation During an Aided Quit Attempt

Menthol may make cigarettes more addictive and rates of menthol cigarette smoking are disproportionately higher among Black. However, few studies have examined the association between menthol cigarette smoking and cessation, and the studies to date have produced conflicting findings. The present study examines the effect of menthol cigarette smoking on cessation among a multi-ethnic sample of smokers making a pharmacotherapy-aided quit attempt. We hypothesized that menthol cigarette smoking would be associated with lower smoking abstinence rates and conducted a secondary analysis of data from a multi-site randomized controlled trial of an intervention designed to facilitate repeat tobacco cessation treatment (N = 1,343). The intervention consisted of a patient phone call and a computerized provider prompt. The primary outcome for this analysis was 7-day point prevalence smoking abstinence. The average age of the sample was 56 years old. Overall, 25% of the sample smoked menthol cigarettes: 19% of Whites, 62% of Blacks, and 25% of other ethnicity (p<.001). We observed no significant effects for menthol cigarette smoking or ethnicity on smoking abstinence rates. In conclusion, combined with findings from previous research, this study suggests that smoking menthol cigarettes does not decrease smoking cessation among older smokers during a quit attempt aided with pharmacotherapy.

Cigarette smoking among Chinese Americans and the influence of linguistic acculturation.

Less acculturated Chinese Americans experience cultural and language barriers. The present study assessed the relationship between linguistic aspects of acculturation and cigarette smoking among Chinese Americans. A cross-sectional, self-administered survey was administered to a consecutive sample of 541 Chinese American adults (aged 18 years or older) attending four pediatric, medical, or dental practices located in Philadelphias Chinatown from November 2000 to February 2001. Linguistic acculturation was measured by adapting a reliable and valid acculturation scale developed for Southeast Asians. English and Chinese language proficiency subscales were utilized to analyze the association between language proficiency and current smoking. Whereas 25% of Chinese American men reported current smoking, only 3% of Chinese American women reported current smoking. Chinese American men with lower English proficiency reported significantly higher rates of current smoking compared with Chinese American men with a higher level of English proficiency (33% vs. 18%, p<.01). Less English-proficient Chinese American male smokers were less likely to have received advice from a physician to quit smoking (50% vs. 85%, p=.01). In multivariate analysis, increased English proficiency was associated with decreased odds of current smoking (OR=0.38, 95% CI=0.16-0.89) among Chinese American men after controlling for confounding variables. In conclusion, higher English proficiency was associated with decreased current smoking among Chinese American men. Chinese American men with limited English proficiency should especially be targeted for tobacco control interventions. Further research is needed to assess whether acculturation is associated with smoking among Chinese American women and with use of smoking cessation treatments and services by Chinese American smokers.

Proactive tobacco treatment and population-level cessation a pragmatic randomized clinical trial

IMPORTANCE Current tobacco use treatment approaches require smokers to request treatment or depend on the provider to initiate smoking cessation care and are therefore reactive. Most smokers do not receive evidence-based treatments for tobacco use that include both behavioral counseling and pharmacotherapy. OBJECTIVE To assess the effect of a proactive, population-based tobacco cessation care model on use of evidence-based tobacco cessation treatments and on population-level smoking cessation rates (ie, abstinence among all smokers including those who use and do not use treatment) compared with usual care among a diverse population of current smokers. DESIGN, SETTING, AND PARTICIPANTS The Veterans Victory Over Tobacco Study, a pragmatic randomized clinical trial involving a population-based registry of current smokers aged 18 to 80 years. A total of 6400 current smokers, identified using the Department of Veterans Affairs (VA) electronic medical record, were randomized prior to contact to evaluate both the reach and effectiveness of the proactive care intervention. INTERVENTIONS Current smokers were randomized to usual care or proactive care. Proactive care combined (1) proactive outreach and (2) offer of choice of smoking cessation services (telephone or in-person). Proactive outreach included mailed invitations followed by telephone outreach to motivate smokers to seek treatment with choice of services. MAIN OUTCOMES AND MEASURES The primary outcome was 6-month prolonged smoking abstinence at 1 year and was assessed by a follow-up survey among all current smokers regardless of interest in quitting or treatment utilization. RESULTS A total of 5123 participants were included in the primary analysis. The follow-up survey response rate was 66%. The population-level, 6-month prolonged smoking abstinence rate at 1 year was 13.5% for proactive care compared with 10.9% for usual care (P = .02). Logistic regression mixed model analysis showed a significant effect of the proactive care intervention on 6-month prolonged abstinence (odds ratio [OR], 1.27 [95% CI, 1.03-1.57]). In analyses accounting for nonresponse using likelihood-based not-missing-at-random models, the effect of proactive care on 6-month prolonged abstinence persisted (OR, 1.33 [95% CI, 1.17-1.51]). CONCLUSIONS AND RELEVANCE Proactive, population-based tobacco cessation care using proactive outreach to connect smokers to evidence-based telephone or in-person smoking cessation services is effective for increasing long-term population-level cessation rates. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00608426.