Effectiveness of Two Community Health Worker Models of Tobacco Dependence Treatment Among Community Residents of Ohio Appalachia

Correlates related to follow-up in a community engagement program in North Central Florida

AIMS

This analysis identifies the correlates of 60- and 120-day telephone-based study follow-ups among community-dwelling adults in North Central Florida.

METHODS

Six thousand three hundred and forty participants were recruited by Community Health Workers from the University of Florida's community engagement program with a face-to-face baseline and two phone follow-ups assessing indicators of health.

RESULTS

Physical disability versus none (adjusted odds ratio [aOR], 1.5; 95% confidence interval [CI], 1.2─1.9), high trust in research versus none (aOR, 1.5; 95% CI, 1.1─2.1), history of research participation versus none (aOR, 1.6; 95% CI, 1.3─2.0), having health insurance versus none (aOR, 1.4; 95% CI, 1.1─1.7), interest in research participation versus none (aOR, 1.8; 95% CI, 1.3─2.7), and no drug use versus drug use (aOR, 0.5; 95% CI, 0.3─0.9) significantly predicted completion of follow-up.

CONCLUSIONS

Health and social factors such as disability, insurance, history of and interest in research, trust and no drug use significantly predicted completing two follow-ups. These findings can facilitate efforts to minimize attrition in the research enterprise.

Effectiveness of Village Health Worker-Delivered Smoking Cessation Counseling in Vietnam

INTRODUCTION

Smoking prevalence is high in Vietnam, yet tobacco dependence treatment (TDT) is not widely available.

METHODS

We conducted a quasiexperimental study that compared the effectiveness of health care provider advice and assistance (ARM 1) versus ARM 1 plus village health worker (VHW) counseling (ARM 2) on abstinence at 6-month follow-up. This study was embedded in a larger two-arm cluster randomized controlled trial conducted in 26 community health centers (CHCs) in Vietnam. Subjects (N = 1318) were adult patients who visited any participating CHC during the parent randomized controlled trial intervention period and were self-identified as current tobacco users (cigarettes and/or water pipe).

RESULTS

At 6-month follow-up, abstinences rates in ARM 2 were significantly higher than those in ARM 1 (25.7% vs. 10.5%; p < .001). In multivariate analyses, smokers in ARM 2 were almost three times more likely to quit compared with those in ARM 1 (adjusted odds ratio [AOR] = 2.96, 95% confidence interval [CI] = 1.78% to 4.92%). Compared to cigarette-only smokers, water pipe-only smokers (AOR = 0.4, 95% CI = 0.26% to 0.62%) and dual users (AOR = 0.62, 95% CI = 0.45% to 0.86%) were less likely to achieve abstinence; however, the addition of VHW counseling (ARM 2) was associated with higher quit rates compared with ARM 1 alone for all smoker types.

CONCLUSION

A team approach in TDT programs that offer a referral system for health care providers to refer smokers to VHW-led cessation counseling is a promising and potentially scalable model for increasing access to evidence-based TDT and increasing quit rates in low middle-income countries (LMICs). TDT programs may need to adapt interventions to improve outcomes for water pipe users.

IMPLICATIONS

The study fills literature gaps on effective models for TDT in LMICs. The addition of VHW-led cessation counseling, available through a referral from primary care providers in CHCs in Vietnam, to health care provider's brief cessation advice, increased 6-month biochemically validated abstinence rates compared to provider advice alone. The study also demonstrated the potential effectiveness of VHW counseling on reducing water pipe use. For LMICs, TDT programs in primary care settings with a referral system to VHW-led cessation counseling might be a promising and potentially scalable model for increasing access to evidence-based treatment.

Correlation between air quality and lung cancer incidence: A county by county analysis

BACKGROUND

Poor air quality has previously been associated with lung cancer development, but the risks associated with regional differences in air quality are poorly understood. We investigated the association of air quality indices with development of lung cancer in all Texas counties.

METHODS

Lung cancer incidence, air quality indicators (particulate matter <2.5 μm, radon levels, oil well density), and known risk factors were obtained using data from the Texas Commission on Environmental Quality and the Texas Cancer Registry. Linear regression models were constructed to correlate air quality indicators with lung cancer incidence and advanced stage at diagnosis (stage III or IV), while controlling for other patient characteristics.

RESULTS

Lung cancer incidence ranged from 27.6 to 103.4 cases per 100,000 people. In the study, 2.5 μm was associated with increased lung cancer incidence (β = 4.38, P < .0001), but not radon levels (β = -2.70, P = .41). Air quality indicators were not significantly associated with an advanced cancer diagnosis.

CONCLUSION

There are wide differences in the incidence of lung cancer across Texas. These differences seem to be related to air quality. Identifying high-risk areas may help to guide strategies such as implementation of targeted lung cancer screening programs.

Smoking cessation interventions for potential use in the lung cancer screening setting: A systematic review and meta-analysis

OBJECTIVES

Current guidelines recommend delivery of smoking cessation interventions with lung cancer screening (LCS). Unfortunately, there are limited data to guide clinicians and policy-makers in choosing cessation interventions in this setting. Several trials are underway to fill this evidence gap, but results are not expected for several years.

METHODS AND MATERIALS

We conducted a systematic review and meta-analysis of current literature on the efficacy of smoking cessation interventions among populations eligible for LCS. We searched PubMed, Medline, and PsycINFO for randomized controlled trials of smoking cessation interventions published from 2010-2017. Trials were eligible for inclusion if they sampled individuals likely to be eligible for LCS based on age and smoking history, had sample sizes >100, follow-up of 6- or 12-months, and were based in North America, Western Europe, Australia, or New Zealand.

RESULTS

Three investigators independently screened 3,813 abstracts and identified 332 for full-text review. Of these, 85 trials were included and grouped into categories based on the primary intervention: electronic/web-based, in-person counseling, pharmacotherapy, and telephone counseling. At 6-month follow-up, electronic/web-based (odds ratio [OR] 1.14, 95% CI 1.03-1.25), in-person counseling (OR 1.46, 95% CI 1.25-1.70), and pharmacotherapy (OR 1.53, 95% CI 1.33-1.77) interventions significantly increased the odds of abstinence. Telephone counseling increased the odds but did not reach statistical significance (OR 1.21, 95% CI 0.98-1.50). At 12-months, in-person counseling (OR 1.28 95% CI 1.10-1.50) and pharmacotherapy (OR 1.46, 95% CI 1.17-1.84) remained efficacious, although the decrement in efficacy was of similar magnitude across all intervention categories.

CONCLUSIONS

Several categories of cessation interventions are promising for implementation in the LCS setting.

Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation

BACKGROUND

Pharmacotherapies for smoking cessation increase the likelihood of achieving abstinence in a quit attempt. It is plausible that providing support, or, if support is offered, offering more intensive support or support including particular components may increase abstinence further.

OBJECTIVES

To evaluate the effect of adding or increasing the intensity of behavioural support for people using smoking cessation medications, and to assess whether there are different effects depending on the type of pharmacotherapy, or the amount of support in each condition. We also looked at studies which directly compare behavioural interventions matched for contact time, where pharmacotherapy is provided to both groups (e.g. tests of different components or approaches to behavioural support as an adjunct to pharmacotherapy).

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP in June 2018 for records with any mention of pharmacotherapy, including any type of nicotine replacement therapy (NRT), bupropion, nortriptyline or varenicline, that evaluated the addition of personal support or compared two or more intensities of behavioural support.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in which all participants received pharmacotherapy for smoking cessation and conditions differed by the amount or type of behavioural support. The intervention condition had to involve person-to-person contact (defined as face-to-face or telephone). The control condition could receive less intensive personal contact, a different type of personal contact, written information, or no behavioural support at all. We excluded trials recruiting only pregnant women and trials which did not set out to assess smoking cessation at six months or longer.

DATA COLLECTION AND ANALYSIS

For this update, screening and data extraction followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates, if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a random-effects model.

MAIN RESULTS

Eighty-three studies, 36 of which were new to this update, met the inclusion criteria, representing 29,536 participants. Overall, we judged 16 studies to be at low risk of bias and 21 studies to be at high risk of bias. All other studies were judged to be at unclear risk of bias. Results were not sensitive to the exclusion of studies at high risk of bias. We pooled all studies comparing more versus less support in the main analysis. Findings demonstrated a benefit of behavioural support in addition to pharmacotherapy. When all studies of additional behavioural therapy were pooled, there was evidence of a statistically significant benefit from additional support (RR 1.15, 95% CI 1.08 to 1.22, I² = 8%, 65 studies, n = 23,331) for abstinence at longest follow-up, and this effect was not different when we compared subgroups by type of pharmacotherapy or intensity of contact. This effect was similar in the subgroup of eight studies in which the control group received no behavioural support (RR 1.20, 95% CI 1.02 to 1.43, I² = 20%, n = 4,018). Seventeen studies compared interventions matched for contact time but that differed in terms of the behavioural components or approaches employed. Of the 15 comparisons, all had small numbers of participants and events. Only one detected a statistically significant effect, favouring a health education approach (which the authors described as standard counselling containing information and advice) over motivational interviewing approach (RR 0.56, 95% CI 0.33 to 0.94, n = 378).

AUTHORS' CONCLUSIONS

There is high-certainty evidence that providing behavioural support in person or via telephone for people using pharmacotherapy to stop smoking increases quit rates. Increasing the amount of behavioural support is likely to increase the chance of success by about 10% to 20%, based on a pooled estimate from 65 trials. Subgroup analysis suggests that the incremental benefit from more support is similar over a range of levels of baseline support. More research is needed to assess the effectiveness of specific components that comprise behavioural support.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of telephone support to help smokers quit, including proactive or reactive counselling, or the provision of other information to smokers calling a helpline.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2018.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which offered proactive or reactive telephone counselling to smokers to assist smoking cessation.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We pooled studies using a random-effects model and assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I² statistic. In trials including smokers who did not call a quitline, we used meta-regression to investigate moderation of the effect of telephone counselling by the planned number of calls in the intervention, trial selection of participants that were motivated to quit, and the baseline support provided together with telephone counselling (either self-help only, brief face-to-face intervention, pharmacotherapy, or financial incentives).

MAIN RESULTS

We identified 104 trials including 111,653 participants that met the inclusion criteria. Participants were mostly adult smokers from the general population, but some studies included teenagers, pregnant women, and people with long-term or mental health conditions. Most trials (58.7%) were at high risk of bias, while 30.8% were at unclear risk, and only 11.5% were at low risk of bias for all domains assessed. Most studies (100/104) assessed proactive telephone counselling, as opposed to reactive forms.Among trials including smokers who contacted helplines (32,484 participants), quit rates were higher for smokers receiving multiple sessions of proactive counselling (risk ratio (RR) 1.38, 95% confidence interval (CI) 1.19 to 1.61; 14 trials, 32,484 participants; I² = 72%) compared with a control condition providing self-help materials or brief counselling in a single call. Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate.In studies that recruited smokers who did not call a helpline, the provision of telephone counselling increased quit rates (RR 1.25, 95% CI 1.15 to 1.35; 65 trials, 41,233 participants; I² = 52%). Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate. In subgroup analysis, we found no evidence that the effect of telephone counselling depended upon whether or not other interventions were provided (P = 0.21), no evidence that more intensive support was more effective than less intensive (P = 0.43), or that the effect of telephone support depended upon whether or not people were actively trying to quit smoking (P = 0.32). However, in meta-regression, telephone counselling was associated with greater effectiveness when provided as an adjunct to self-help written support (P < 0.01), or to a brief intervention from a health professional (P = 0.02); telephone counselling was less effective when provided as an adjunct to more intensive counselling. Further, telephone support was more effective for people who were motivated to try to quit smoking (P = 0.02). The findings from three additional trials of smokers who had not proactively called a helpline but were offered telephone counselling, found quit rates were higher in those offered three to five telephone calls compared to those offered just one call (RR 1.27, 95% CI 1.12 to 1.44; 2602 participants; I² = 0%).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that proactive telephone counselling aids smokers who seek help from quitlines, and moderate-certainty evidence that proactive telephone counselling increases quit rates in smokers in other settings. There is currently insufficient evidence to assess potential variations in effect from differences in the number of contacts, type or timing of telephone counselling, or when telephone counselling is provided as an adjunct to other smoking cessation therapies. Evidence was inconclusive on the effect of reactive telephone counselling, due to a limited number studies, which reflects the difficulty of studying this intervention.

Smoking prevalence and trends among a U.S. national sample of women of reproductive age in rural versus urban settings

U.S. smoking prevalence is declining at a slower rate in rural than urban settings and contributing to regional health disparities. Cigarette smoking among women of reproductive age is particularly concerning due to the potential for serious maternal and infant adverse health effects should a smoker become pregnant. The aim of the present study was to examine whether this rural-urban disparity impacts women of reproductive age (ages 15-44) including pregnant women. Data came from the ten most recent years of the U.S. National Survey on Drug Use and Health (2007-2016). We estimated prevalence of current smoking and nicotine dependence among women categorized by rural-urban residence, pregnancy status, and trends using chi-square testing and multivariable modeling while adjusting for common risk factors for smoking. Despite overall decreasing trends in smoking prevalence, prevalence was higher among rural than urban women of reproductive age overall (χ2(1) = 579.33, p < .0001) and among non-pregnant (χ2(1) = 578.0, p < .0001) and pregnant (χ2(1) = 79.69, p < .0001) women examined separately. An interaction between residence and pregnancy status showed adjusted odds of smoking among urban pregnant compared to non-pregnant women (AOR = .58, [.53 -.63]) were lower than those among rural pregnant compared to non-pregnant women (AOR = 0.75, [.62 -.92]), consistent with greater pregnancy-related smoking cessation among urban pregnant women. Prevalence of nicotine dependence was also higher in rural than urban smokers overall (χ2(2) = 790.42, p < .0001) and among non-pregnant (χ2(2) = 790.58, p < .0001) and pregnant women examined separately (χ2(2) = 63.69, p < .0001), with no significant changes over time. Associations involving residence and pregnancy status remained significant in models adjusting for covariates (ps < 0.05). Results document greater prevalence of smoking and nicotine dependence and suggest less pregnancy-related quitting among rural compared to urban women, disparities that have potential for direct, multi-generational adverse health impacts.

Barriers and Facilitators of Engaging Community Health Workers in Non-Communicable Disease (NCD) Prevention and Control in China: A Systematic Review (2006⁻2016)

Background: Non-communicable diseases (NCDs) have become a dominant disease burden in China. Although China has a prevention-centered NCD strategy, the implementation effect in the community has been subjected to manpower and financial difficulties. Engaging community health workers (CHWs) in community-based interventions may be a cost-effective approach to relieve the resource shortage and improve health. This review aimed to synthesize evidence on types of NCD-related care that was provided by CHWs in China, and to identify relevant barriers and facilitators. Methods: A literature search was conducted in Medline, PubMed, ProQuest, and Google Scholar databases for English-written, peer-reviewed articles published from 1996 to 2016 that reported findings from NCD-related interventions delivered by CHWs in China. Each article was extracted independently by two researchers. Results: Twenty distinct studies met the inclusion criteria. The two most common types of CHW-led NCD-related care were diabetes and hypertension management (n = 7) and mental health care (n = 7). Thirteen studies discussed the barriers and 16 studies reported facilitators. The most common barriers included lack of support (n = 6), lack of resources (n = 4), and heavy reliance on technology (n = 4). The common facilitators included an integrated health system (n = 9), community and patient trust (n = 5), high quality training (n = 5), and CHWs’ capacity (n = 5). Fourteen studies mentioned training content, while only eight described detailed procedures and duration. Conclusions: This review suggests that trained and supervised Chinese CHWs had the capacity to provide grassroots NCDs preventive interventions. In order to increase the generalizability and sustainability of such programs, studies with robust designs are needed to explore the effectiveness of CHW-led programs, and the intervention strategies to improve the practice of CHWs in various settings.

A Descriptive Report of Electronic Cigarette Use After Participation in a Community-Based Tobacco Cessation Trial

Introduction

Smokers are using electronic cigarettes, also known as e-cigarettes, as a cessation aid, despite uncertainty about their efficacy. This report describes the association between use of e-cigarettes before and after cessation treatment and tobacco abstinence at 12 months. It also presents characteristics of e-cigarette users and reasons for use.

Methods

A longitudinal observational secondary analysis of self-reported e-cigarette use was conducted among adult Appalachian smokers enrolled in a community-based tobacco dependence treatment trial (n = 217). Data were collected at baseline, 3, 6, and 12 months following treatment. The primary outcome measure was biochemically-confirmed 7-day point prevalence tobacco abstinence at 12 months post-treatment.

Results

One in five participants reported using e-cigarettes post-treatment. Baseline sociodemographic and tobacco-related characteristics did not differ by e-cigarette use. Primary reasons for e-cigarette use included help in quitting, help in cutting down on cigarettes, and not as bad for health. At the 12 month follow-up, tobacco abstinence was significantly lower among post-treatment e-cigarette users (4.7%) than nonusers (19.0%); (OR = 0.21 95% CI: 0.05-0.91, p = .021). Baseline use was not associated with 12-month abstinence.

Conclusions

Among adult Appalachian smokers enrolled in community-based tobacco cessation treatment, use of e-cigarettes post-treatment was associated with lower abstinence rates at 12 months.

Implications

This descriptive report of electronic cigarette use after participation in a community-based group randomized tobacco dependence treatment trial adds to the body of science examining e-cigarette use and cessation. Post-treatment e-cigarette use was associated with less success in achieving abstinence at 12 months, as compared to nonuse. At 3 months post-treatment, the majority of those who reported use of e-cigarettes did so to assist with cessation.

The relationship between type of telephone service and smoking cessation among rural smokers enrolled in quitline tobacco dependence treatment

Quitlines are successful tools for smoking cessation, but no known study has examined whether type of phone service (cell phone only (CPO) vs. landline (LL)) impacts quitline utilization, quit attempts, and sustained cessation. This report details an observational study examining the association between phone service and quitline utilization and cessation among Ohio Appalachian adults willing to quit smoking and enrolled in a cessation trial from 2010 to 2014. A secondary analysis was conducted with data obtained from smokers enrolled in the Ohio Tobacco Quitline arm of a group randomized trial (n = 345). The intermediate outcome variables included number of calls, cumulative total call length, average call length, verified shipments of NRT, and 24-hour quit attempt. The primary outcome measure was biologically confirmed 7-day point prevalence abstinence from tobacco at 3, 6, and 12 months post treatment. Participants with LL service, on average, made almost one more call to the quitline and spoke 17.2 min longer over the course of treatment than those with CPO service. Those with LL service were more likely to receive a second 4-week supply of NRT. Phone service status was not associated with average quitline call length, receiving at least one NRT shipment, having made one quit attempt at the end of treatment, or biochemically confirmed abstinence at 3, 6, or 12-month follow-up. Participants with LL services completed more counseling calls, accrued a longer cumulative length, and received more NRT when compared with CPO service participants. However, type of phone service did not deter abstinence outcomes.

•

More calls for those with landline (LL) compared to cell only (CPO) phone access

•

Cumulative treatment call time higher for those with LL compared to CPO access

•

Receipt of 2nd 4-wk NRT supply more likely for those with LL compared to CPO access

•

Average quitline call length was not related to LL vs. CPO phone service access.

•

Abstinence 3, 6, and 12 months post-baseline were similar by LL vs. CPO phone access.

A growing geographic disparity: Rural and urban cigarette smoking trends in the United States

Rural areas of the United States have a higher smoking prevalence than urban areas. However, no recent studies have rigorously examined potential changes in this disparity over time or whether the disparity can be explained by demographic or psychosocial characteristics associated with smoking. The present study used yearly cross sectional data from the National Survey on Drug Use and Health from 2007 through 2014 to examine cigarette smoking trends in rural versus urban areas of the United States. The analytic sample included 303,311 respondents. Two regression models were built to examine (a) unadjusted rural and urban trends in prevalence of current smoking and (b) whether differences remained after adjusting for demographic and psychosocial characteristics. Results of the unadjusted model showed disparate and diverging cigarette use trends during the 8-year time period. The adjusted model also showed diverging trends, initially with no or small differences that became more pronounced across the 8-year period. We conclude that differences reported in earlier studies may be explained by differences in rural versus urban demographic and psychosocial risk factors, while more recent and growing disparities appear to be related to other factors. These emergent differences may be attributable to policy-level tobacco control and regulatory factors that disproportionately benefit urban areas such as enforcement of regulations around the sale and marketing of tobacco products and treatment availability. Strong federal policies and targeted or tailored interventions may be important to expanding tobacco control and regulatory benefits to vulnerable populations including rural Americans.

Tobacco cessation in Vietnam: Exploring the role of village health workers

The purpose of this study was to explore current tobacco use treatment (TUT) practice patterns, and attitudes and beliefs among Village Health Workers (VHWs) about expanding their role to include delivering smoking cessation interventions and the perceived barriers. We conducted a survey of 449 VHWs from 26 communes in Thai Nguyen province, Vietnam. We assessed TUT practice patterns including asking about tobacco use, advising smokers to quit, offering assistance (3As) and attitudes, self-efficacy, and norms related to TUT. Seventy two per cent of VHWs reported asking patients if they use tobacco, 78.6% offered advice to quit, and 41.4% offered cessation assistance to few or more patients in the past month. Self-efficacy was low, with 53.2% agreeing that they did not have the skills to counsel patients about smoking cessation. The most commonly reported barriers to offering TUT were a lack of training and perceived lack of patient interest. Greater awareness of their commune health centre's smoke-free policy and higher levels of self-efficacy were associated with screening and offering cessation assistance. VHWs support an expanded role in tobacco cessation, but require additional resources and training to increase their self-efficacy and skills to provide effective treatment.

Substance Use in Rural Central Appalachia: Current Status and Treatment Considerations

The burden of substance use and especially the unmatched rates of overdoses in rural Central Appalachia highlight the need for innovative approaches to curb the initiation to drug misuse and to address current substance use disorders. Effective substance use interventions involve a thorough understanding of the region. In Central Appalachia, many of the barriers to treatment are shared with other rural and impoverished areas, including a lack of access to health care and lack of health care providers with specialized training. Parts of Appalachia also present their own considerations, including the challenges of fostering trust and encouraging treatment-seeking in communities with dense, long-term, place-based social and family networks. Current policies and interventions for substance use have been largely inadequate in the region, as evidenced by continued increases in substance use and substance-related deaths, especially related to nonmedical prescription drug use and increasing heroin use. The authors discuss ways in which rural life, poverty, identity, and values in Appalachia have influenced substance use and treatment and propose strategies and interventions to improve outcomes.