Disparities in the Receipt of Tobacco Treatment Counseling within the US Context of the Affordable Care Act and Meaningful Use Implementation

Factors Associated with Smoking Cessation and the Receipt of Cessation Services in a Public, Safety-Net Primary Care System

BACKGROUND

Prevalence of smoking is high among patients receiving care in safety-net settings, and there is a need to better understand patient factors associated with smoking cessation and receipt of cessation services.

OBJECTIVE

To identify patient factors associated with smoking cessation attempts and receipt of cessation counseling and pharmacotherapy in a large safety-net health system.

DESIGN

We conducted a retrospective cohort analysis using EHR data in a safety-net system in San Francisco, CA.

PARTICIPANTS

We included 7384 adult current smokers who had at least three unique primary care encounters with documented smoking status between August 2019 and April 2022.

MAIN MEASURES

We assessed four outcomes using multivariate generalized estimating equation models: (1) any cessation attempt, indicating a transition in smoking status from "current smoker" to "former smoker"; (2) sustained cessation, defined as transition in smoking status from current smoker to former smokers for two or more consecutive visits; (3) receipt of smoking cessation counseling from healthcare providers; and (4) receipt of pharmacotherapy.

KEY RESULTS

Of 7384 current adult smokers, 17.6% had made any cessation attempt, and of those 66.5% had sustained cessation. Most patients (81.1%) received counseling and 41.8% received pharmacotherapy. Factors associated with lower odds of any cessation attempt included being aged 45-64, non-Hispanic black, and experiencing homelessness. The factor associated with lower odds of sustained cessation was being male. Factors associated with lower odds of receiving counseling were being insured by Medicaid or being uninsured. Factors associated with lower odds of receiving pharmacotherapy included speaking languages other than English, being male, and identifying as racial and ethnic minorities.

CONCLUSIONS

Health system interventions could close the gap in access to smoking cessation services for unhoused and racial/ethnic minority patients in safety-net settings, thereby increasing cessation among these populations.

The effect of neighborhood socioeconomic disadvantage on smoking status, quit attempts, and receipt of cessation support among adults with cancer: Results from nine ECOG-ACRIN Cancer Research Group trials

BACKGROUND

Tobacco use is associated with adverse outcomes among patients diagnosed with cancer. Socioeconomic determinants influence access and utilization of tobacco treatment; little is known about the relationship between neighborhood socioeconomic disadvantage (NSD) and tobacco assessment, assistance, and cessation among patients diagnosed with cancer.

METHODS

A modified Cancer Patient Tobacco Use Questionnaire (C-TUQ) was administered to patients enrolled in nine ECOG-ACRIN clinical trials. We examined associations of NSD with (1) smoking status, (2) receiving tobacco cessation assessment and support, and (3) cessation behaviors. NSD was classified by tertiles of the Area Deprivation Index. Associations between NSD and tobacco variables were evaluated using logistic regression.

RESULTS

A total of 740 patients completing the C-TUQ were 70% male, 94% White, 3% Hispanic, mean age 58.8 years. Cancer diagnoses included leukemia 263 (36%), lymphoma 141 (19%), prostate 131 (18%), breast 79 (11%), melanoma 69 (9%), myeloma 53 (7%), and head and neck 4 (0.5%). A total of 402 (54%) never smoked, 257 (35%) had formerly smoked, and 81 (11%) were currently smoking. Patients in high disadvantaged neighborhoods were approximately four times more likely to report current smoking (odds ratio [OR], 3.57; 95% CI, 1.69-7.54; p = .0009), and more likely to report being asked about smoking (OR, 4.24; 95% CI, 1.64-10.98; p = .0029), but less likely to report receiving counseling (OR, 0.11; 95% CI, 0.02-0.58; p = .0086) versus those in the least disadvantaged neighborhoods.

CONCLUSIONS

Greater neighborhood socioeconomic disadvantage was associated with smoking but less cessation support. Increased cessation support in cancer care is needed, particularly for patients from disadvantaged neighborhoods.

Trends in cigarette use and health insurance coverage among US adults with mental health and substance use disorders

AIMS

To estimate recent trends in cigarette use and health insurance coverage for United States adults with and without mental health and substance use disorders (MH/SUD).

DESIGN

Event study analysis of smoking and insurance coverage trends among US adults with and without MH/SUD using 2008-19 public use data from the National Survey on Drug Use and Health, an annual, cross-sectional survey.

SETTING

USA.

PARTICIPANTS

A nationally representative sample of non-institutionalized respondents aged 18-64 years (n = 448 762).

MEASUREMENTS

Outcome variables were three measures of recent cigarette use and one measure of past-year health insurance coverage. We compared outcomes between people with and without MH/SUD (MH disorder: past-year mental illness, predicted from Kessler-6 and the World Health Organization-Disability Assessment Schedule impairment scale; SUD: met survey-based DSM-IV criteria for past-year alcohol, cannabis, cocaine or heroin use disorder) and over time.

FINDINGS

Comparing pooled data from 2008 to 2009 and from 2018 to 2019, current smoking rates of adults with MH/SUD decreased from 37.9 to 27.9% while current smoking rates of adults without MH/SUD decreased from 21.4 to 16.3%, a significant difference in decrease of 4.9 percentage points (pts) [95% confidence interval (CI) = 3.3-6.6 pts]. Daily smoking followed similar patterns (difference in decrease of 3.9 pts (95% CI = 2.3-5.4 pts). Recent smoking abstinence rates for adults with MH/SUD increased from 7.4 to 10.9%, while recent smoking abstinence rates for adults without MH/SUD increased from 9.6 to 12.0%, a difference in increase of 1.0 pts (95% CI = -3.0 to 0.9 pts). In 2018-19, 11% of net reductions in current smoking, 12% of net reductions in daily smoking and 12% of net increases in recent smoking abstinence coincided with greater gains in insurance coverage for adults with MH/SUD compared to those without MH/SUD.

CONCLUSIONS

Improvements in smoking and abstinence outcomes for US adults with mental health and substance use disorders appear to be associated with increases in health insurance coverage.

System Interventions to Reduce Disparities in Covid-19 Vaccine Offer Rates

The Covid-19 pandemic has exposed stark disparities in health outcomes among communities of color. Black patients are at higher risk of being infected with and dying from Covid-19 but are less likely to be vaccinated relative to the overall population. At the San Francisco Health Network in March 2021, the vaccination rate for primary care patients aged 65 and older was 69.8% overall versus just 61.5% for Black patients. In this article, the authors share data that Black patients had lower documented offer rates for the Covid-19 vaccine in their primary care network. The network iterated a series of interventions to address the disparity in vaccine offer rate documentation and used process measure data and stakeholder engagement to understand this disparity. They observed a 7–percentage-point gap in March 2021, which briefly narrowed to a 4-point difference but increased to 5 to 6 points for most of 2021. By March 2022, the disparity had decreased to 2 points, and the offer rates for all patients reached 95% and for Black patients, 93%. This improvement journey generated conversations about implicit bias and burnout and ultimately led to reduced disparities in both the documented offer rate and the vaccination rate for Black patients in the network. In navigating conversations about implicit bias, the network found it most effective to focus on actionable system-level changes rather than on blaming individual behaviors.

Can inpatient pharmacists move the needle on smoking cessation? Evaluating reach and representativeness of a pharmacist-led opt-out smoking cessation intervention protocol for hospital settings

PURPOSE

Hospitalization affords an opportunity to reduce smoking, but fewer than half of patients who smoke receive evidence-based cessation treatment during inpatient stays. This study evaluated a pharmacist-led, electronic health record (EHR)-facilitated opt-out smoking cessation intervention designed to address this need.

METHODS

Analyses of EHR records for adult patients who smoked in the past 30 days admitted to an academic medical center in the upper Midwest were conducted using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. The reach of a pharmacist-led, EHR-facilitated protocol for smoking cessation treatment was assessed by comparing patients' receipt of nicotine replacement therapy (NRT) and tobacco quitline referral before and after implementation. χ2 tests, t tests, and multiple logistic regression models were used to compare reach across patient demographic groups to assess treatment disparities and the representativeness of reach. Adoption of the program by hospital services was also assessed.

RESULTS

Of the 70 hospital services invited to implement the program, 88.6% adopted it and 78.6% had eligible admissions. Treatment reach increased as rates of delivering NRT rose from 43.6% of eligible patients before implementation to 50.4% after implementation (P < 0.0001) and quitline referral rates rose from 0.9% to 11.9% (P < 0.0001). Representativeness of reach by sex and ethnicity improved after implementation, although disparities by race and age persisted after adjustment for demographics, insurance, and primary diagnosis. Pharmacists addressed tobacco use for eligible patients in 62.5% of cases after protocol implementation.

CONCLUSION

Smoking cessation treatment reach and representativeness of reach improved after implementation of a proactive, pharmacist-led, EHR-facilitated opt-out smoking cessation treatment protocol in adult inpatient services.

Disparities in Receipt of Smoking Cessation Assistance Within the US

This cross-sectional study analyzes sociodemographic variations in receiving smoking cessation assistance from health professionals by individuals who reported smoking, or quitting, within the past year.

Community Health Centers' Performance in Cancer Screening and Prevention

INTRODUCTION

Little is known about what clinic-level factors differentiate community health centers that achieve high performance on cancer-preventive care metrics. This study aims to describe the longitudinal trends in the delivery of 3 cancer-preventive care metrics (cervical and colorectal cancer screenings and tobacco-cessation intervention) and define and compare community health centers with high cancer-preventive care performance with those with low cancer-preventive care performance.

METHODS

This observational study used 2012-2019 community health center data (N=933) from the Uniform Data System. High/low performance was based on Healthy People 2020 targets and sample distribution. For each cancer-preventive care metric, the percentage of community health centers that met high (≥70.5% at cervical or colorectal cancer screening or >80% tobacco-cessation intervention) and low thresholds at 1, 2, and all the 3 screenings was estimated. Multivariable generalized estimating equations logistic regression modeling was used to assess the community health center‒level factors associated with screening performance.

RESULTS

The community health centers' performance for tobacco-cessation intervention remained at ≥80%, with a small increase over time. Performance for cervical cancer screening remained unchanged with about 50% of patients screened. Colorectal cancer screening performance increased from around 30% in 2012 to 44% in 2019. Very few community health centers reached high performance (3%) in all the 3 indicators, and 13% of community health centers were high in any 2 of the outcomes in 2019. Higher patient volume, a greater proportion of Hispanic patients, fewer uninsured patients, and community health centers located in the Northeast region were associated with high performance in 2019.

CONCLUSIONS

Very few community health centers meet all Healthy People 2020 goals in cancer screenings and may struggle to achieve the 2030 goals. Very few indicators differentiated high performers from low performers.

Tobacco Cessation Counseling and Medications Provided by Physicians to Tobacco Users During Primary Care Visits

INTRODUCTION

The established guidelines for treating tobacco use and dependency is brief provider intervention to assist those willing to quit by providing access to medication and/or behavioral counseling. The purpose of the study is to determine the extent of cessation treatment offered by providers during primary care visits by patients who are current tobacco users, and to examine associations between patient factors and treatment received.

METHODS

Using data from the 2015 to 2018 National Ambulatory Medical Care Survey (NAMCS), we examined tobacco cessation counseling and medications from 4590 visits by patients with current tobacco use. Separate multivariate logistic regressions were used to assess whether the odds of receiving tobacco cessation treatment varied by age, gender, race/ethnicity, and payment source.

RESULTS

Of visits by current tobacco users, 18.4% included cessation counseling, 5.5% included cessation medication, and 22.1% included at least 1 type of treatment. Visits by patients with Medicare had 44% greater odds of including counseling (CI = 1%-205%) and treatment (OR = 1.44; 95% CI = 1.01-2.06). Visits classified as "other payment type" had 73% greater odds of including counseling (OR = 1.73; 95% CI = 1.05-2.84). Visits by women had 86% greater odds of including medication (CI = 17%-294%).

CONCLUSIONS

Tobacco cessation treatment is underutilized by providers during primary care visits. Further research is necessary to understand and address barriers to providing routine cessation assistance.

Examining the role of healthcare access in racial/ethnic disparities in receipt of provider-patient discussions about smoking: A latent class analysis

Using insurance as a single indicator of healthcare access in examining the association between race/ethnicity and healthcare encounter-based interventions for smoking may not be adequate. In this study, we assessed the role of healthcare access using multifactorial measures in accounting for racial/ethnic disparities in the receipt of provider-patient discussions, defined as either being asked about smoking or advised to quit smoking by providers. We identified adult current smokers from the 2015 National Health Interview Survey. We first conducted a latent class analysis (LCA) to identify the underlying patterns of healthcare access measured by 13 indicators of healthcare access and utilization. We then used a propensity score - based weighting approach to examine racial/ethnic disparities in receiving provider-patient discussions about smoking or quitting in stratified groups by the distinct healthcare access clusters. Out of the 4134 adult current smokers who visited a doctor or a healthcare provider during the past 12 months, 3265 (79.90%) participants were classified as having high healthcare access and 869 (20.10%) participants as having low healthcare access. Compared to non-Hispanic whites, Hispanics had significantly lower odds of being asked about smoking (OR 0.46, 95% CI (0.27-0.77)) and being advised to quit (OR 0.57, 95% CI (0.34-0.97)) in the low access group, but neither association was significant in the high access group. In addition to increasing health insurance coverage, reducing other healthcare access barriers for Hispanics will likely facilitate provider-patient discussion and promote tobacco cessation among Hispanic smokers.

The Influence of Increasing Levels of Provider-Patient Discussion on Quit Behavior: An Instrumental Variable Analysis of a National Survey

Objective: We aimed to examine the influence of increasing levels of discussion (both asked and advised, either asked or advised but not both, and neither asked nor advised) on quit behavior. Methods: We included 4133 adult current smokers from the 2015 National Health Interview Survey. The primary outcomes were quit intent and quit attempt, and the secondary outcomes were methods used for quitting. We used an instrumental variable analysis, as well as propensity score weighted and multivariable logistic regressions. Results: Compared to no discussion, having both or only one discussion, respectively, increased quit intent (OR = 1.65, 95% CI = 1.63–1.66 and OR = 1.02, 95% CI = 0.99–1.05), quit attempt (OR = 1.76, 95% CI = 1.75–1.77 and OR = 1.60, 95% CI = 1.57–1.63). Among those who attempted to quit (n = 1536), having both or only one discussion increased the use of pharmacologic (OR = 1.99, 95% CI = 1.97–2.02 and OR = 1.56, 95% CI = 1.49–1.63) or behavioral (OR = 2.01, 95% CI = 1.94–2.08 and OR = 2.91, 95% CI = 2.74–3.08) quit methods. Conclusions: Increasing levels of provider–patient discussion encourages quit behavior, and should be an integral part of reducing the health and economic burden of smoking. Strategies that promote the adherence and compliance of providers to communicate with patients may help increase the success of smoking cessation.

Past-year discrimination and cigarette smoking among sexual minority women: investigating racial/ethnic and sexual identity differences

Although findings are mixed, discrimination has been identified as a risk factor for smoking in sexual minority women (SMW; e.g., lesbian and bisexual). We examined associations between past-year discrimination and cigarette smoking among SMW. Using regression analyses we examined associations of past-year discrimination including count of types of discriminatory experiences and attributions of the main reason for discrimination (i.e., sexual orientation, race/ethnicity, gender) with smoking outcomes (e.g., current smoking, nicotine dependence, smoking more cigarettes now than 12 months ago). We conducted exploratory analyses to examine whether race/ethnicity and sexual identity moderated the associations of past-year discrimination with smoking outcomes. The sample included 619 SMW. Most identified as lesbian (74.3%) and non-White (61.1%). SMW who reported a higher count of types of discriminatory experiences (AOR 1.54, 95% CI 1.12-2.12) and any gender-based discrimination in the past year (AOR 4.79, 95% CI 1.39-16.45) reported smoking more cigarettes now than 12 months ago. Associations of other past-year discrimination measures with other smoking outcomes were not significant. Compared to White SMW, any discrimination [B (SD) = 2.56 (0.83)] and a higher count of types of discriminatory experiences in the past year [B (SD) = 0.88 (0.31)] were associated with higher nicotine dependence scores in Black/African American SMW. Past-year discrimination are associated with smoking outcomes in SMW. Black/African American race moderated the associations of any past-year discrimination and a higher count of types of discriminatory experiences with nicotine dependence scores in SMW. Targeted interventions to mitigate the influence of discrimination on smoking among SMW are needed.

Association of dual and poly tobacco use with depressive symptoms and use of antidepressants

BACKGROUND

There is an established link between depression and tobacco use among adults; however, to date, research has not explored the association of use of dual/poly tobacco products with symptoms and use of medication for depression.

METHODS

Data were derived from a 2018 Texas population health assessment survey (n = 2034). Multivariable logistic and multinomial regressions were used to examine for associations between self-reported symptoms of depression and use of prescription medications for depression with use of dual/poly tobacco products.

RESULTS

About 20% of adults used one tobacco product, while 9.7% used two or more products. Compared to those without depressive symptoms, those with depressive symptoms had greater odds of single (aOR: 1.66, 95% CI; 1.21 - 2.29) or dual/poly (aOR: 3.09, 95% CI; 1.92 - 4.96) tobacco product use relative to non-users; and relative to single product use, those with depressive symptoms had greater odds of dual/poly tobacco product use (aOR: 2.07; 95% CI, 1.30 - 3.32). Compared to those not using medication for depression, use of medication for depression was associated with a 1.80 (95% CI: 1.15 - 2.84) greater odds of dual/poly tobacco product use relative to non-users; and a 1.91 (95% CI: 1.14 - 3.19) greater odds of dual/poly product use relative to single product users.

CONCLUSIONS

Study findings call for primary care providers and psychiatrists to expand screening of individuals experiencing depressive symptoms and using medication for depression, to include assessment for dual/poly tobacco product use.

Factors associated with receipt of the 5As model of brief intervention for smoking cessation among hospitalized patients

BACKGROUND AND AIMS

Guidelines recommend the 5As model of brief intervention for providing smoking cessation support in clinical settings. This study assessed patient and hospital characteristics associated with self-reported receipt of the 5As (ask, advise, assess, assist and arrange).

DESIGN

Multi-center cross-sectional study.

SETTING AND PARTICIPANTS

Adult inpatients (n = 1047) were randomly selected from 13 hospitals in the Barcelona province of Spain in 2014-2015.

MEASUREMENTS

We explored participants' receipt of the 5As through a questionnaire. Given the progressiveness of the 5As, we recoded the fulfillment of the intervention as: A₀ : no intervention; A₁ : ask; A₂ : ask and advise; A₃ : A₂ and assess; A₄ : A₃ and assist; and A₅ : A₄ and arrange a follow-up. We explored patient (e.g. age, sex, comorbidities) and hospital (e.g. type of hospital, unit) characteristics. We adjusted multi-level robust Poisson regression models to estimate the adjusted prevalence ratios (aPR) of the association between the recoded 5As intervention received.

FINDINGS

A total of 60.4% (n = 624) of patients had been asked (A₁ ) about their smoking status. Among smokers, 46.5% (n = 90) were advised (A₂ ), 26.6% (n = 48) assessed (A₃ ) and 4.6% (n = 10) received all the components of the 5As (A₅ ). Middle-aged smokers [aPR = 3.63; 95% confidence interval (CI) = 1.69-7.79] with a respiratory disease (aPR = 2.19; 95% CI = 1.11-4.34) were most likely to have been asked, advised and assessed (A₃ ). The cessation intervention was most frequently performed by physicians.

CONCLUSIONS

In the Barcelona province of Spain, it appears that fewer than half of hospitalized patients who smoke were advised to quit and few received the full 'five As' brief intervention for smoking cessation.

Tobacco-Related Counseling and Documentation in Adolescent Primary Care Practice: Challenges and Opportunities

INTRODUCTION

Primary care visits present an opportunity to reduce tobacco use and tobacco smoke exposure (TSE) among adolescents. To date, few studies have examined tobacco-related electronic health record (EHR) documentation in adolescent visits. The purpose of this study was to (1) describe tobacco-related EHR documentation practices in adolescent care clinics, including whether alternative tobacco products, parental use, and TSE were addressed; and (2) identify aspects of adolescent tobacco use that may inform EHR updates and counseling and documentation practices.

METHODS

Following a convergent mixed-methods design, we conducted an EHR review of 508 adolescent well-child visits, performed focus groups with pediatric providers and staff, and conducted in-depth interviews with adolescent patients. Record review data and interview transcripts were analyzed and interpreted concurrently.

RESULTS

In the EHR review, cigarette screening was documented in 92.3% of visits, smokeless tobacco screening in 51.4%, parental tobacco use in 23.2%, and home TSE in 33.1% of visits. Smoking status options were not mutually exclusive and did not include noncigarette products. No records documented assessment of e-cigarette use, despite nearly half of adolescent interview respondents citing these as the most popular products among adolescents. In interviews, adolescents discussed their experiences with alternative tobacco/nicotine products more than cigarettes.

CONCLUSIONS

Tobacco use status prompts should be revised for clarity and include noncigarette tobacco products and TSE. Provider education on noncigarette products and TSE assessment is needed. Improvements in EHR systems, resources, and tools can lead to better tobacco screening, prevention, and treatment practices among primary care providers.

IMPLICATIONS

Clinical guidelines call for pediatricians to assess and treat adolescent and parental tobacco use during primary care visits. The use of electronic health records (EHRs) can improve screening and counseling practices; however, few studies have examined tobacco-related EHR documentation practices in adolescent care settings. This mixed-methods study found low rates of EHR documentation related to noncigarette nicotine/tobacco products, parental tobacco use, and tobacco smoke exposure. These results demonstrate the need for increased provider training and EHR modifications to facilitate comprehensive tobacco control efforts in the adolescent population.

Trends and correlates of self-reported alcohol and nicotine use among women before and during pregnancy, 2009-2017

OBJECTIVE

To examine trends and correlates of frequency of self-reported alcohol and nicotine use among pregnant women.

METHODS

Cross-sectional study of 363,240 pregnancies from 2009 to 2017 screened for self-reported substance use at their first prenatal visit in Kaiser Permanente Northern California. Poisson regression with a log link function was used to estimate the annual prevalences of self-reported daily, weekly, and ≤ monthly alcohol and nicotine use, adjusting for socio-demographics. Generalized estimating equation models were used to estimate the adjusted odds ratios (aOR) of any self-reported prenatal alcohol or nicotine use among those who self-reported use in the year prior to pregnancy, by frequency of pre-pregnancy substance use and socio-demographics.

RESULTS

The sample was 64 % non-White [mean (SD) age = 30.1 (5.6)]. From 2009-2017, alcohol use before pregnancy increased from 63.4%-65.9% (trend p-value = .008), and prenatal alcohol use decreased from 11.6%-8.8% (trend p-value<.0001). Nicotine use before pregnancy decreased from 12.7 % to 7.7 % (trend p-value<.0001), and prenatal use decreased from 4.3 % to 2.0 % (trend p-value<.0001). Trends by use frequency were similar to overall trends. The odds of continued use of alcohol and nicotine during pregnancy were higher among those who used daily or weekly (versus monthly or less) in the year before pregnancy and varied with socio-demographics.

DISCUSSION

Prenatal alcohol and nicotine use decreased from 2009 to 2017. More frequent pre-pregnancy use predicted higher odds of prenatal use. Results suggest that interventions and education about the harms of prenatal substance use for frequent users prior to conception may reduce substance use during pregnancy.

Smoking and cessation treatment among persons with and without HIV in a U.S. integrated health system

BACKGROUND

Persons with HIV (PWH) are more likely to smoke and are more susceptible to the harmful effects of smoking than persons without HIV. We examined smoking patterns and use of cessation treatment among PWH and persons without HIV in a U.S. integrated health system.

METHODS

We identified adults (≥18 years) with HIV and demographically-matched persons without HIV between July 2013 and December 2017. Smoking status and cessation treatment were ascertained from health records. We calculated age-standardized annual prevalence of smoking and evaluated trends using Cochran-Armitage tests and Poisson regression. Factors associated with cessation treatment during the study period, and smoking in the last year of the study, were evaluated by HIV status using multivariable Poisson models.

RESULTS

The study included 11,235 PWH and 227,320 persons without HIV. Smoking prevalence was higher among PWH across all years but declined for both groups (from 16.6% to 14.6% in PWH and 11.6% to 10.5% in persons without HIV). Among smokers, PWH were more likely to initiate cessation treatment compared to persons without HIV (17.9% vs. 13.3%, covariate-adjusted prevalence ratio of 1.31, 95% CI = 1.15-1.50), with few differences in cessation treatment across subgroups of PWH. In 2017, smoking prevalence remained higher in PWH, especially among those who were younger or who had diagnoses of depression or substance use disorder.

CONCLUSION

In a setting with access to cessation resources, smoking prevalence decreased both in PWH and persons without HIV. PWH had greater uptake of cessation treatment, which is encouraging for smoking reduction and improved health.

Smoking Is Associated with Higher Intraocular Pressure Regardless of Glaucoma: A Retrospective Study of 12.5 Million Patients Using the Intelligent Research in Sight (IRIS®) Registry

PURPOSE

To compare the average intraocular pressure (IOP) among smokers, past smokers, and never smokers using the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry.

DESIGN

Retrospective database study of the IRIS® Registry data.

PARTICIPANTS

Intelligent Research in Sight Registry patients who were seen by an eye care provider during 2017.

METHODS

Patients were divided into current smoker, past smoker, and never smoker categories. The IOP was based on an average measurement, and separate analyses were performed in patients with and without a glaucoma diagnosis based on International Classification of Diseases (Ninth Edition and Tenth Edition) codes. Stratified, descriptive statistics by glaucoma status were determined, and the relationship between smoking and IOP was assessed with a multivariate linear regression model.

MAIN OUTCOME MEASURES

Mean IOP.

RESULTS

A total of 12 535 013 patients were included. Compared with never smokers, current and past smokers showed a statistically significantly higher IOP by 0.92 mmHg (95% confidence interval [CI], 0.88-0.95 mmHg) and 0.77 mmHg (95% CI, 0.75-0.79 mmHg), respectively, after adjusting for age, gender, glaucoma, age-related macular degeneration, diabetic retinopathy, cataract, glaucoma surgery, cataract surgery, and first-order interactions. In addition, the difference in IOP between current and never smokers was the highest in the fourth decade, regardless of the glaucoma status (glaucoma group, 1.14 mmHg [95% CI, 1.00-1.29 mmHg]; without glaucoma group, 0.68 mmHg [95% CI, 0.65-0.71 mmHg]).

CONCLUSIONS

Current smokers and past smokers have higher IOP than patients who never smoked. This difference is higher in patients with an underlying glaucoma diagnosis.

Commentary: Educational and Clinical Training for Addressing Tobacco-Related Cancer Health Disparities

In the United States, tobacco use is a leading contributor to inequities in cancer health among individuals for many ethnic, racial, sexual minority, and other minority groups as well as individuals in lower socioeconomic groups and other underserved populations. Despite remarkable decreases in tobacco use prevalence rates in the United States over the past 50 years, the benefits of tobacco control efforts are not equitably distributed. Tobacco-related disparities include higher prevalence rates of smoking, lower rates of quitting, less robust responses to standard evidence-based treatments, substandard tobacco treatment delivery by health care providers, and an increased burden of tobacco-related cancers and other diseases. Among the multiple critical barriers to achieving progress in reducing tobacco treatment-related disparities, there are several educational barriers including a unidimensional or essentialist conceptualizations of the disparities; a tobacco treatment workforce unprepared to address the needs of tobacco users from underserved groups; and known research-to-practice gaps in understanding, assessing, and treating tobacco use among underserved groups. We propose the development of competency-based curricula that: 1) use intersectionality as an organizing framework for relevant knowledge; 2) teach interpersonal skills, such as expressing sociocultural respect, a lack of cultural superiority, and empathy as well as skills for developing other-oriented therapeutic relations; and 3) are grounded in the science of the evidence-based treatments for tobacco dependence. These curricula could be disseminated nationally in multiple venues and would represent significant progress toward addressing tobacco-related disparities.

Disparities in knowledge and use of tobacco treatment among smokers in California following healthcare reform

The Affordable Care Act (ACA) promised to narrow smoking disparities by expanding access to healthcare and mandating comprehensive coverage for tobacco treatment starting in 2014. We examined whether two years after ACA implementation disparities in receiving clinician advice to quit and smokers' knowledge and use of treatment resources remained. We conducted telephone interviews in 2016 with a stratified random sample of self-reported smokers newly enrolled in the Kaiser Permanente Northern California's (KPNC) integrated healthcare delivery system in 2014 (N = 491; 50% female; 53% non-white; 6% Spanish language). We used Poisson regression with robust standard errors to test whether sociodemographics, insurance type, comorbidities, smoking status in 2016 (former, light/nondaily [<5 cigarettes per day], daily), and preferred language (English or Spanish) were associated with receiving clinician advice to quit and knowledge and use of tobacco treatment. We included an interaction between smoking status and language to test whether the relation between smoking status and key outcomes varied with preferred language. Overall, 80% of respondents received clinician advice to quit, 84% knew that KPNC offers cessation counseling, 54% knew that cessation pharmacotherapy is free, 54% used pharmacotherapy, and 6% used counseling. In multivariate models, Spanish-speaking light/nondaily smokers had significantly lower rates of all outcomes, while there was no association with other demographic and clinical characteristics. Following ACA implementation, most smokers newly enrolled in KPNC received clinician advice to quit and over half used pharmacotherapy, yet counseling utilization was low. Spanish-language outreach efforts and treatment services are recommended, particularly for adults who are light/nondaily smokers.

Disparities in Smoking Cessation Assistance in US Primary Care Clinics

OBJECTIVES

To examine associations between patient factors and smoking cessation assistance in US safety-net clinics.

METHODS

Using electronic health record data from the OCHIN network, we identified adults with at least 1 primary care visit to a study clinic (n = 143 clinics in 12 states) with at least 1 documented "current smoker" status during 2014 to 2016 (n = 136 314; 29.8%). We estimated odds ratios (ORs) of smoking cessation assistance receipt (none [reference], counseling, medication, or both) by patient covariates.

RESULTS

For all cessation assistance categories, odds of assistance were higher among women, those with more visits, those assessed and ready to quit, and patients with asthma or chronic obstructive pulmonary disease and hyperlipidemia. Odds of receiving both counseling and medication were lower among uninsured patients (OR = 0.56; 95% confidence interval [CI] = 0.48, 0.64), those of a race/ethnicity other than non-Hispanic White (OR range = 0.65-0.82), and those with diabetes (OR = 0.85; 95% CI = 0.79, 0.92), and higher among older patients and those with a comorbidity, with few exceptions.

CONCLUSIONS

Disparities in smoking cessation assistance receipt exist in safety-net settings, in particular by health insurance coverage and across race/ethnicity, even after control for other socioeconomic and demographic factors.