Management and Point-of-Care for Tobacco Dependence (PROMPT): a feasibility mixed methods community-based participatory action research project in Ottawa, Canada

Integrating Social Determinants of Health With Tobacco Treatment for Individuals With Opioid Use Disorder: Feasibility and Acceptability Study of Delivery Through Text Messaging

Background

Individuals with opioid use disorder (OUD) have a high prevalence of smoking and frequently experience unmet social determinants of health (SDOH), which may be barriers to smoking cessation. Hospitalization is an opportunity to encourage smoking cessation. Unfortunately, many clinicians do not provide tobacco treatment to support the maintenance of cessation achieved during hospitalization. Interventions are required to support these high-risk individuals after hospital discharge.

Objective

This study aimed to test the feasibility and acceptability of a 28-day SMS text messaging program tailored to individuals with OUD, which provides smoking cessation support and addresses unmet SDOH needs.

Methods

From July to December 2019, we enrolled 25 individuals who were hospitalized with tobacco dependence and OUD at our large safety net hospital. The SMS text messaging program was initiated during hospitalization and continued for 28 days. Participants were enrolled in either the ready to quit within 30 days or the not ready to quit within 30 days program based on their readiness to quit. Automated SMS text messages were sent twice daily for 4 weeks. The topics included health and cost benefits of quitting, both general and opioid specific (16 messages); managing mood and stress (8 messages); motivation, coping strategies, and encouragement (18 messages); addressing medication misconceptions (5 messages); links to resources to address substance use (2 messages providing links to the Massachusetts Substance Use Helpline and Boston Medical Center resources), tobacco dependence (1 message providing a link to the Massachusetts Quitline), and unmet SDOH needs (6 messages assessing SDOH needs with links to resources if unmet SDOH needs were identified). Questionnaires and interviews were conducted at baseline and at 2 and 4 weeks after enrollment.

Results

The participants were 56% (14/25) female, 36% (9/25) African American, 92% (23/25) unemployed, and 96% (24/25) Medicaid insured. Approximately 84% (21/25) activated the program, and none of the participants unsubscribed. Approximately 57% (12/21) completed either the 2- or 4-week questionnaires. Program satisfaction was high (overall mean 6.7, SD 0.8, range 1-7). Many perceived that the SMS text messaging program provided social support, companionship, and motivation to stop smoking. Messages about the health benefits of quitting were well received, whereas messages on how quitting cigarettes may prevent relapse from other substances had mixed views, highlighting the importance of tailoring interventions to patient preferences.

Conclusions

SMS text messaging to promote smoking cessation and address SDOH needs may be an effective tool for improving quit rates and health outcomes in individuals with tobacco dependence and OUD. Our study adds to the growing body of evidence that SMS text messaging approaches are feasible and acceptable for providing tobacco treatment to all individuals who smoke, even among low-income populations who have OUD and are not ready to quit.

Personalised multicomponent interventions for tobacco dependence management in low socioeconomic populations: a systematic review and meta-analysis

BACKGROUND

There remains a disproportionally high tobacco smoking rate in low-income populations. Multicomponent tobacco dependence interventions in theory are effective. However, which intervention components are necessary to include for low socioeconomic status (SES) populations is still unknown.

OBJECTIVE

To assess the effectiveness of multicomponent tobacco dependence interventions for low SES and create a checklist tool examining multicomponent interventions.

METHODS

EMBASE and MEDLINE databases were searched to identify randomised controlled trials (RCTs) published with the primary outcome of tobacco smoking cessation measured at 6 months or post intervention. RCTs that evaluated tobacco dependence management interventions (for reduction or cessation) in low SES (experience of housing insecurity, poverty, low income, unemployment, mental health challenges, illicit substance use and/or food insecurity) were included. Two authors independently abstracted data. Random effects meta-analysis and post hoc sensitivity analysis were performed.

RESULTS

Of the 33 included studies, the number of intervention components ranged from 1 to 6, with smoking quit rates varying between 1% and 36.6%. Meta-analysis revealed that both the 6-month and 12-month outcome timepoints, multicomponent interventions were successful in achieving higher smoking quit rates than the control (OR 1.64, 95% Cl 1.41 to 1.91; OR 1.74, 95% Cl 1.30 to 2.33). Evidence of low heterogeneity in the effect size was observed at 6-month (I2=26%) and moderate heterogeneity at 12-month (I2=56%) outcomes.

CONCLUSION

Multicomponent tobacco dependence interventions should focus on inclusion of social support, frequency and duration of components. Employing community-based participatory-action research approach is essential to addressing underlying psychosocioeconomic-structural factors, in addition to the proven combination pharmacotherapies.

PROSPERO REGISTRATION NUMBER

CRD42017076650.

Text-messaging to promote smoking cessation among individuals with opioid use disorder: quantitative and qualitative evaluation

INTRODUCTION

Individuals with opioid use disorder (OUD) who smoke cigarettes have high tobacco-related comorbidities, lack of access to tobacco treatment, lack of inclusion in smoking cessation trials, and remain understudied in the mobile health field. The purpose of this study was to understand patients' with OUD perceptions of 1) text message programs to promote smoking cessation, 2) content and features to include in such a program, and 3) how message content should be framed.

METHODS

From December 2018 to February 2019, we recruited 20 hospitalized individuals with a concurrent diagnosis of OUD and tobacco dependence at Boston Medical Center (BMC), the largest safety-net hospital in New England. We surveyed participants' cell phone use, their interest in a text message program to promote smoking cessation, and their reactions to and ratings of a series of 26 prototype texts. We then conducted open-ended interviews to elicit content and suggestions on how text message interventions can improve motivation to increase smoking cessation among individuals with OUD. The interviews also included open-ended inquiries exploring message ratings and message content, inquiries about preferences for message duration, frequency, and personalization.

RESULTS

Quantitative analysis of questionnaire data indicated that the majority of participants owned a cell phone (95%, 19/20). Most participants (60%, 12/20) reported that they would be interested or very interested in receiving text messages about smoking cessation. Text messages about the health benefits of quitting were rated the highest among various categories of text messages. Qualitative analysis showed that almost every participant felt that text messages would help motivate smoking cessation given the support it would provide.

CONCLUSIONS

This study demonstrates that individuals with OUD who smoke cigarettes perceive that a text message program designed to promote smoking cessation would motivate and support smoking cessation efforts. Our findings demonstrate that such a program is feasible as participants own cell phones, frequently send and receive text messages, and have unlimited text message plans. Findings from this study provide valuable insight into content and features to include when developing text message programs to address barriers to smoking cessation in individuals who have OUD and smoke cigarettes.

Nurse-led intervention to decrease drug use among LTBI positive homeless adults

BACKGROUND

People experiencing homelessness (PEH) are disproportionately diagnosed with active tuberculosis. While promoting latent tuberculosis infection (LTBI) treatment has been a call to action, PEH engaging in substance use often experience challenges in completing LTBI treatment.

METHODS

In this non-randomized single arm study, we tested an innovative, community-based, nurse-led community health worker (RN-CHW) model, on reducing drug use among 50 PEH, residing in homeless shelters or living on the streets in Los Angeles. Follow-up was at 3- and 6- months.

RESULTS

Findings revealed significant and ongoing decrease in any drug use (odds ratio [OR] = 0.30; 95% confidence interval [CI] = 0.14-0.68); p = .004), amphetamine use (OR = 0.14; 95% CI = 0.02-0.81; p = .029), cannabis use (OR = 0.26; 95% CI = 0.12-0.57; p = .001) and methamphetamine use (OR = 0.30; 95% CI = 0.10-0.90; p = .031) at 6-month follow-up.

CONCLUSIONS

To our knowledge, this pilot study is the first to evaluate the impact a RN-CHW delivered intervention on reduction in drug use among PEH enrolled in a LTBI intervention. LTBI interventions may serve as an entryway into reduction in drug use among this underserved population.

Pain Agreements and Time-to-Event Analysis of Substance Misuse in a Primary Care Chronic Pain Program

BACKGROUND

Types and correlates of pain medication agreement (PMA) violations in the primary care setting have not been analyzed.

METHODS

A retrospective analysis was completed to examine patient characteristics and correlates of PMA violations, a proxy for substance misuse, over a 15-year period in an outpatient General Medicine Pain Service within the Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill. Patients who signed the PMA were managed for chronic pain from 2002 through 2017 (N = 1,210). The incidence of PMA violations was measured over a 15-year span. Substance misuse was defined a priori in the study as urine toxicology screen positive for illicit or nonprescribed controlled substances, patient engagement in prescription alteration, doctor-shopping, or diversion.

RESULTS

Most patients received a prescription for a controlled substance (77.4%). During enrollment, 488 (40.3%) patients had one or more violations of their PMA. One-third (33.4%) of pain service patients had a violation within 365 days of signing the agreement. Active tobacco smokers had double the incidence of agreement violation within the first 30 days of enrollment. Almost one-half (49.8%) of violations were due to inconsistent use of controlled substances. Patients with any prior DWI/DUI or drug-related offense had a significantly increased rate of substance misuse (P < 0.0001).

CONCLUSIONS

PMA violations were common among a population of patients managed for chronic nonmalignant pain. Universal opioid prescribing precautions, including PMAs, require further investigation to assess their roles in mitigating the potential patient and societal harms associated with opioid prescribing.

Provision of peer support at the intersection of homelessness and problem substance use services: a systematic 'state of the art' review

Background

Peer support refers to a process whereby individuals with lived experience of a particular phenomenon provide support to others by explicitly drawing on their personal experience. It has been adopted in a variety of service contexts including homelessness, substance use, mental and physical health. Those who experience homelessness have some of the most complex intersecting health and social challenges. This ‘state of the art’ review provides a systematic search and synthesis of literature examining use of peer support models within services for people impacted by homelessness and problem substance use.

Methods

A systematic search using six databases (CINAHL, SocINDEX, PsycINFO, MEDLINE, Scopus and Web of Knowledge) was conducted in August 2019 and identified 2248 papers published in English after the year 2000. After de-duplication and scanning titles/abstracts, 61 papers were deemed relevant. Three more papers (including one grey literature report) were identified via references, but two papers were later excluded due to relevance. The final 62 papers included studies conducted in five countries. A thematic analysis approach was used to compare and contrast the study findings and provide a synthesis of the main learning points.

Results

In recent years there has been a substantial increase in research examining the utility of peer support yet there is significant variation across this field. Alongside profiling the range of settings, aims, populations, and main outcomes of these studies, this paper also provides an overview of overarching themes: the overall effectiveness and impact of peer-staffed or peer-led interventions; and challenges commonly faced in these roles. Five themes relating to the challenges faced by peers were identified: vulnerability, authenticity, boundaries, stigma, and lack of recognition.

Conclusions

While our findings provide support for current efforts to involve individuals with lived experience in providing peer support to those experiencing concurrent problem substance use and homelessness, they also urge caution because of common pitfalls that can leave those providing the support vulnerable. We conclude that peers should be respected, valued, supported, and compensated for their work which is often profoundly challenging. Suggested guidelines for the implementation of peer involvement in research studies and service delivery are presented.

Perceived barriers to quitting cigarettes among hospitalized smokers with substance use disorders: A mixed methods study

AIMS

Smoking cessation may promote long-term recovery in patients with substance use disorders (SUD). Yet smoking rates remain alarmingly high in this population. Using a sequential explanatory mixed methods approach, we examined smoking rates among hospitalized patients with SUD at a large safety-net hospital, and then characterized factors associated with smoking behaviors both quantitatively and qualitatively.

METHOD

We abstracted data from all hospital admissions (7/2016-6/2017) and determined demographics, substance use type, and other characteristics associated with cigarette use among those with SUD. We then conducted semi-structured qualitative interviews with 20 hospitalized SUD smokers. We analyzed transcripts to characterize factors that affect patients' smoking habits, focusing on the constructs of the Health Belief Model.

RESULTS

The prevalence of cigarette smoking among hospitalized smokers with SUD was three times higher than those without SUD. Qualitative analyses showed that patients perceived that smoking cigarettes was a less serious concern than other substances. Some patients feared that quitting cigarettes could negatively impact their recovery and perceived that clinicians do not prioritize treating tobacco dependence. Almost all patients with heroin use disorder described how cigarette use potentiated their heroin high. Many SUD patients are turning to vaping and e-cigarettes to quit smoking.

CONCLUSION

Hospitalized patients with SUD have disproportionately high smoking rates and perceive multiple barriers to quitting cigarettes. When designing and implementing smoking cessation interventions for hospitalized patients with SUD, policymakers should understand and take into account how patients with SUD perceive smoking-related health risks and how that influences their decision to quit smoking.

Assessing community (peer) researcher's experiences with conducting spirometry and being engaged in the 'Participatory Research in Ottawa: Management and Point-of-care for Tobacco-dependence' (PROMPT) project

PLAIN SUMMARY

This article examines the overall experiences of community researchers in their involvement with the 'PROMPT' project for smoking cessation, which targeted community members who were homeless or at-risk for homelessness. More specifically, four community members, representing the study population were involved in the project as researchers. They were asked to complete surveys at both the beginning and end of each research training session to better understand their learning as it related to using a key instrument for this project, a spirometer, to measure project participants' lung function. Spirometry is typically performed by trained healthcare providers. Community researchers were also interviewed to explore what their experiences were like working as a researcher with their own at-risk community. Although the researchers felt that the training was sufficient, more research is needed to evaluate training effectiveness among community researchers in delivering acceptable quality lung function testing using a spirometer. Upon analyzing the small group discussion and survey results, we found that the community researchers had an overall positive experience with both the project, and the training that was provided to equip them with the knowledge, tools, and resources they needed to successfully work in a research project of this kind. They also faced challenges that are common in such community-based projects, such as the power differential between the researchers with a healthcare background and themselves who have lived experience with the issue at hand.

ABSTRACT

Background The Ottawa Citizen Engagement and Action Model (OCEAM) used a Community Based Participatory Action Research (CBPAR) approach by involving the most at-risk urban population. Community (peer) researchers participated in every step of the study despite the multiple challenges. Objective To assess the community researchers' training and experiences in a CBPAR project, PROMPT: Participatory Research in Ottawa: Management and Point-of-care for Tobacco Dependence. Method Four community researchers were recruited, representative of the PROMPT project's target population with current or past poly-substance use; smoking tobacco; and/or being homeless or at-risk for homelessness. The community researchers participated in all phases of PROMPT, including study design, development of questionnaires, participant recruitment, administering consent forms and questionnaires, as well as hand-held spirometry after rigorous training. To assess their knowledge and comfort level with spirometry testing after standardized training, questionnaires were administered pre- and post-training. In turn, to assess their overall experience, interviews were conducted at the end of study completion. Results All community researchers underwent small-group training sessions including presentations, discussions and hands-on practice adapted from standardized training material prepared for health care professionals. Spirometry training was included in all sessions. Self-perceived knowledge and confidence in administering spirometry, as well as skill-testing score averages improved between the pre- and post-training questionnaires. Overall, all the community researchers had a fulfilling experience participating in the project. Conclusion Despite challenges, involving community researchers with lived experience is feasible, satisfying and productive even in the most marginalized populations. Standardized spirometry training of community researchers' representative of the PROMPT target population, with no healthcare educational background, was feasible and effective in improving knowledge, confidence and readiness to administer spirometry.