Pandemic Action Plan: Phase 3-Lessons Learned from Implementation. "What Did We Learn?"

The COVID-19 pandemic created critical challenges for hospitals and health care providers. Suddenly clinics were forced to close; elective procedures were delayed; scheduled visits were canceled; emergency rooms were overcrowded; hospital beds, equipment, and personal protective equipment (PPE) were in short supply; and staff were faced with rapidly changing circumstances, care protocols, trauma, and personal risk. To better address challenges of the ongoing COVID-19 pandemic and prepare for future pandemics, the National Telemedicine Technology Assessment Resource Center (TTAC) was asked to develop a Pandemic Response Action Plan that would allow its users to address critical issues with available telemedicine and related technologies. The project was constructed in 3 phases. Phase 1-Develop a Pandemic Response Action Plan and a Pandemic Response Action Plan Policy and Regulatory Summary, which identifies the regulatory challenges as well as policy recommendations. Phase 2-Publish the Action Plan and the Policy and Regulatory Summary. Phase 3-Look at health care providers who used the approaches, tools, and technology in the Pandemic Action Plan and document the results. This document represents Phase 3. This document is Phase 3. In this report we look back at health care providers who used the approaches in the Phase 1 Pandemic Response Action Plan as published in Phase 2. In this document we report on the challenges and results of implementing parts of the Pandemic Action Plan. It records the findings, conclusions, and recommendations resulting from the experience of health care providers and the professional experiences of the team and their organizations in implementing parts or all of the plan. Methods: The same multidisciplinary team that constructed Phase 1 and Phase 2 were engaged to develop this Phase 3 report. The members of the team represent leadership expertise and key stakeholders in health care delivery during a pandemic (administration, infection control, physicians, nurses, public health, contingency planning, disaster response, and information technology) as well as a facilitator. For Phase 3, the group used structured brainstorming to define the findings, issues, and results of their own organizations' digital health response to the pandemic. In addition, eight health care providers (hospitals) identified by the Telemedicine Resource Centers' (TRCs) organizations, who used the Pandemic response Plan (created in Phases 1 and 2), were interviewed. All interviews were conducted by the same facilitator with leaders (CEO, and leaders of the telemedicine programs) in each of the eight programs, using a standard questionnaire created by the team. Current literature references are included in this report to illustrate when findings are known to have broader applicability. Conclusions: The impact of the COVID-19 Pandemic was severe and identified multiple critical challenges and weaknesses. Applying the approaches, tools, and technology outlined in the Pandemic Response Action Plan proved to be effective in addressing critical provider challenges. However, implementing these tools during a crisis was difficult unless the organization had experience with the tools and necessary workflows in advance. Implementing these tools as part of standard workflows and everyday operations increased the capabilities and resilience of these organizations in the provision of care during this and for future pandemics.

Access to perinatal doula services in Medicaid: a case analysis of 2 states.

Doula services support maternal and child health, but few Medicaid programs reimburse for them. Through qualitative interviews with key policy informants (n = 20), this study explored facilitators and barriers to Medicaid reimbursement through perceptions of doula-related policies in 2 states: Oregon, where doula care is reimbursed, and Massachusetts, where reimbursement is pending. Five themes characterize the inclusion of doula services in Medicaid. In Theme 1, stakeholders recognized an imperative to expand access to doula services. Subsequent themes represent complications in accomplishing that imperative. In Theme 2, perceptions that doula services were not valued by health care providers resulted in conflict between doulas and the health care system. In Theme 3, complex billing processes created friction and impeded reimbursement. In Theme 4, internal conflict presented barriers to policymaking. In Theme 5, structural fragmentation between state government and doula communities was prominent in Massachusetts, presenting tensions during policymaking. Informants reported on problems demanding resolution to establish equitable and robust doula care policies. Medicaid coverage of doula services requires ongoing collaboration with doulas, providers, and health care advocates.

Criteria for Deployment of the United States National Guard to Domestic Sudden-Onset Natural Disasters: A Scoping Review.

INTRODUCTION: This study is a scoping review to identify literature pertinent to the question: "What are the criteria for deployment of the United States National Guard (USNG) to domestic sudden-onset natural disasters (SODs)?" As this question relies on factors across many disciplines-legal, medical, technical, cultural-and as there is no foundational body of academic literature or unified governmental or USNG policy addressing this question, a scoping review was designed to identify the body of literature on which further research and policy decisions surrounding this question may be based. MATERIALS AND METHODS: On January 23, 2023 a modified PRISMA-ScR search was performed using an online search engine of the following databases: Academic Search Premier, Google Scholar, JSTOR, PubMed, Web of Science, and WorldCat. The inclusion criteria included the involvement of the USNG response to U.S. domestic SOD. Non-SOD results were excluded. Results from all years and of any type of literature were considered and were limited to the English language. First, titles and abstracts were screened by 2 independent reviewers. Then, a full-text review was performed by 2 independent reviewers. Finally, data were extracted from included texts by 2 independent reviewers. A third reviewer resolved any discrepancies at each stage. This study did not require approval of an institutional review board. RESULTS: Out of the 886 results identified by the original search, after the complete review process, 34 sources were relevant to the research question. Fifteen criteria for the deployment of the USNG to SODs were identified. Overwhelmed local responders, utility failure, the need for the provision of security, and the need for logistical coordination were the most commonly identified criteria. Hurricanes were the most common SOD addressed in the included literature, and most results were event reports. CONCLUSIONS: This modified PRISMA-ScR identified a foundation on which elected officials, USNG leadership, and the larger disaster response community may develop policies and disaster response plans to optimize available resources through the activation of the USNG when responding to SODs.

Design and conduct of a randomized controlled feeding trial in a residential setting with mitigation for COVID-19.

BACKGROUND: Evaluating effects of different macronutrient diets in randomized trials requires well defined infrastructure and rigorous methods to ensure intervention fidelity and adherence. METHODS: This controlled feeding study comprised two phases. During a Run-in phase (14-15 weeks), study participants (18-50 years, BMI, ≥27 kg/m2) consumed a very-low-carbohydrate (VLC) diet, with home delivery of prepared meals, at an energy level to promote 15 ± 3% weight loss. During a Residential phase (13 weeks), participants resided at a conference center. They received a eucaloric VLC diet for three weeks and then were randomized to isocaloric test diets for 10 weeks: VLC (5% energy from carbohydrate, 77% from fat), high-carbohydrate (HC)-Starch (57%, 25%; including 20% energy from refined grains), or HC-Sugar (57%, 25%; including 20% sugar). Outcomes included measures of body composition and energy expenditure, chronic disease risk factors, and variables pertaining to physiological mechanisms. Six cores provided infrastructure for implementing standardized protocols: Recruitment, Diet and Meal Production, Participant Support, Assessments, Regulatory Affairs and Data Management, and Statistics. The first participants were enrolled in May 2018. Participants residing at the conference center at the start of the COVID-19 pandemic completed the study, with each core implementing mitigation plans. RESULTS: Before early shutdown, 77 participants were randomized, and 70 completed the trial (65% of planned completion). Process measures indicated integrity to protocols for weighing menu items, within narrow tolerance limits, and participant adherence, assessed by direct observation and continuous glucose monitoring. CONCLUSION: Available data will inform future research, albeit with less statistical power than originally planned.

A Cost-Effectiveness Analysis of Population-Level Dental Caries Prevention Strategies in US Children.

OBJECTIVE: To improve oral health disparities and outcomes among US children impacted by dental caries, there is a need to understand the cost-effectiveness of a targeted, risk-based versus universal-based approach for caries prevention. METHODS: Health and economic outcomes were simulated in a cohort of 50,000 US children aged 1-18 years, comparing current practice (CP) to risk-based-prevention (RBP) and prevention-for-all (PFA) strategies using health care sector and limited societal perspectives. Prevention included biannual oral health exams and fluoride varnish application, and one-time dental sealant placement. The primary outcome is the cost-effectiveness ratio (ICER), defined as the additional cost per quality-adjusted life year (QALY) gained when comparing each strategy to the next least costly one. RESULTS: For RBP compared to CP, the ICER was US$83,000/QALY from the health care sector perspective; for PFA compared to RBP the ICER was US$154,000/QALY. Using a limited societal perspective that includes caregiver time spent attending dental or medical setting visits, RBP compared to CP yielded a ratio of $119,000/QALY and PFA compared to RBP was $235,000/QALY. Results were most sensitive to changes in the probability of pain from an episode of dental caries, costs for prevention and restoration, and the loss in health-related quality of life due to dental caries pain. Scenario analyses evaluating a reduced intensity of prevention services yielded lower ICERs. CONCLUSION: Using a risk-based approach that identifies and targets children at increased risk for dental caries to guide the delivery of prevention services represents an economic value similar to other pediatric prevention programs.

Sugar-sweetened or artificially-sweetened beverage consumption, physical activity, and risk of cardiovascular disease in adults: a prospective cohort study.

BACKGROUND: Whether physical activity could mitigate the adverse impacts of sugar-sweetened beverages (SSBs) or artificially sweetened beverages (ASBs) on incident cardiovascular disease (CVD) remains uncertain. OBJECTIVES: This study aimed to examine the independent and joint associations between SSB or ASB consumption and physical activity and risk of CVD, defined as fatal and nonfatal coronary artery disease and stroke, in adults from 2 United States-based prospective cohort studies. METHODS: Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% CIs between SSB or ASB intake and physical activity with incident CVD among 65,730 females in the Nurses' Health Study (1980-2016) and 39,418 males in the Health Professional's Follow-up Study (1986-2016), who were free from chronic diseases at baseline. SSBs and ASBs were assessed every 4-y and physical activity biannually. RESULTS: A total of 13,269 CVD events were ascertained during 3,001,213 person-years of follow-up. Compared with those who never/rarely consumed SSBs or ASBs, the HR for CVD for participants consuming ≥2 servings/d was 1.21 (95% CI: 1.12, 1.32; P-trend < 0.001) for SSBs and 1.03 (95% CI: 0.97, 1.09; P-trend = 0.06) for those consuming ≥2 servings/d of ASBs. The HR for CVD per 1 serving increment of SSB per day was 1.18 (95% CI: 1.10, 1.26) and 1.12 (95% CI: 1.04, 1.20) for participants meeting and not meeting physical activity guidelines (≥7.5 compared with <7.5 MET h/wk), respectively. Compared with participants who met physical activity guidelines and never/rarely consumed SSBs, the HR for CVD was 1.47 (95% CI: 1.37, 1.57) for participants not meeting physical activity guidelines and consuming ≥2 servings/wk of SSBs. No significant associations were observed for ASB when stratified by physical activity. CONCLUSIONS: Higher SSB intake was associated with CVD risk regardless of physical activity levels. These results support current recommendations to limit the intake of SSBs even for physically active individuals.

A Qualitative Study of Hospitals and Payers Implementing Community Doula Support.

INTRODUCTION: The impact of doula care on birth outcomes is well-established; however, doula support remains underutilized. Identifying barriers and facilitators to implementation is integral as the demand for doula care increases. The primary objective of this study was to examine doula program implementation across hospitals and payers at varying stages of implementation. METHODS: Representatives from 4 hospitals and 2 payers participated in focus group discussions. The doula programs were categorized as anticipated, initial, and advanced implementation statuses. Coding and thematic analysis were conducted using a deductive application of the Consolidated Framework for Implementation Research. RESULTS: There were 20 participants across 5 focus group discussions. Participants were mostly female, and nearly all had worked at their organization for at least 2 years. Salient themes shared across participants included valuing internal outcome data or peer-reviewed literature to support doula care as well as anecdotal stories; the reality of the resource-intensive nature of doula care implementation that goes beyond funding for doulas; and both the need for individual champions for change, such as midwives, and a supportive organizational culture that values health equity. DISCUSSION: The findings of this study highlight 3 contextual aspects that should be considered when implementing doula programs. These recommendations include: (1) use of a combination of research evidence and anecdotes when eliciting stakeholder support; (2) consideration of resources beyond funding such as program implementation support; (3) critical evaluation of organizational culture as a primary driver influencing the implementation of doula care. The future of the doula workforce in United States hospitals rests on the crux of intentional buy-in from hospital administration and clinical providers as well as the availability of requisite resources.

Assessing community pharmacy services in health professional shortage areas across Wisconsin.

BACKGROUND: Primary care health professional shortage areas (HPSAs) lack sufficient primary care providers to meet their health care needs, which contributes to worse health outcomes within underserved populations. Community pharmacies are commonly located in HPSAs and provide nondispensing services that can help address unmet health care needs. However, there is limited data on the nature, scope, and reimbursement for community pharmacy services. OBJECTIVES: Using survey data from the state of Wisconsin, this study compares the prevalence of and reimbursement for services provided by community pharmacies in primary care HPSAs and non-HPSAs and describes barriers to pharmacy service implementation. METHODS: A survey tool on pharmacy services, reimbursement, and barriers to service implementation was developed, pilot tested, and administered to every community pharmacy in Wisconsin. Data were collected via mail and online over two waves of survey administration from November 2021 to May 2022. Pearson's chi-squared and t tests were used to compare the prevalence of and reimbursement for services between HPSA and non-HPSA pharmacies. Content analysis was used to identify themes that described barriers to pharmacy service implementation. RESULTS: Responses were received from 287 of 774 eligible community pharmacies (37.1%). HPSA pharmacies were significantly more likely to be in rural areas. Regardless of pharmacy location, community pharmacies reported commonly providing a variety of services, but reimbursement for these services was considerably less frequent. The prevalence of reimbursement was <50% for two-thirds of services. Pharmacy staffing, time, and financial issues were the most commonly reported barriers to service implementation. CONCLUSIONS: Community pharmacies provide a diverse set of services to meet the health care needs of their patients, but often do so with inadequate staffing or reimbursement. Action is needed to support community pharmacies in meeting the health care needs of their communities and to ensure patient access to medications and pharmacy services.

The Breast-Imaging Operations, Practices and Systems Inventory: A framework to examine mammography facility effects on screening in rural communities.

PURPOSE: Develop and test a measurement framework of mammogram facility resources, policies, and practices in Appalachia. METHODS: Survey items describing 7 domains of imaging facility qualities were developed and tested in the Appalachian regions of Kentucky, Ohio, Pennsylvania, Virginia, and West Virginia. Medicare claims data (2016-2018) were obtained on catchment area mammogram services. Construct validity was examined from associations with facility affiliation, community characteristics, mammogram screening uptake, and market reach. Analyses were performed with t-tests and ANOVA. RESULTS: A total of 192 (of 377) sites completed the survey. Five factors were initially selected in exploratory factor analysis (FA) and refined in confirmatory FA: capacity, outreach & marketing, operational support, radiology review (NNFI = .94, GFI = 0.93), and diagnostic services (NNFI = 1.00, GFI = 0.99). Imaging capacity and diagnostic services were associated with screening uptake, with capacity strongly associated with catchment area demographic and economic characteristics. Imaging facilities in economically affluent versus poorer areas belong to larger health systems and have significantly more resources (P < .001). Facilities in economically distressed locations in Appalachia rely more heavily on outreach activities (P < .001). Higher facility capacity was significantly associated (P < .05) with larger catchment area size (median split: 48.5 vs 51.6), mammogram market share (47.4 vs 52.7), and screening uptake (47.6 vs 52.4). CONCLUSIONS: A set of 18 items assessing breast imaging services and facility characteristics was obtained, representing policies and practices related to a facility's catchment area size, market share, and mammogram screening uptake.

Physiologic Adaptation to Macronutrient Change Distorts Findings from Short Dietary Trials: Reanalysis of a Metabolic Ward Study.

An influential 2-wk cross-over feeding trial without a washout period purported to show advantages of a low-fat diet (LFD) compared with a low-carbohydrate diet (LCD) for weight control. In contrast to several other macronutrient trials, the diet order effect was originally reported as not significant. In light of a new analysis by the original investigative group identifying an order effect, we aimed to examine, in a reanalysis of publicly available data (16 of 20 original participants; 7 female; mean BMI, 27.8 kg/m2), the validity of the original results and the claims that trial data oppose the carbohydrate-insulin model of obesity (CIM). We found that energy intake on the LCD was much lower when this diet was consumed first compared with second (a difference of -1164 kcal/d, P = 3.6 × 10-13); the opposite pattern was observed for the LFD (924 kcal/d, P = 2.0 × 10-16). This carry-over effect was significant (P interaction = 0.0004) whereas the net dietary effect was not (P = 0.4). Likewise, the between-arm difference (LCD - LFD) was -320 kcal/d in the first period and +1771 kcal/d in the second. Body fat decreased with consumption of the LCD first and increased with consumption of this diet second (-0.69 ± 0.33 compared with 0.57 ± 0.32 kg, P = 0.007). LCD-first participants had higher ß-hydroxybutyrate levels while consuming the LCD and lower respiratory quotients while consuming LFD when compared with LFD-first participants on their respective diets. Change in insulin secretion as assessed by C-peptide in the first diet period predicted higher energy intake and less fat loss in the second period. These findings, which tend to support rather than oppose the CIM, suggest that differential (unequal) carry-over effects and short duration, with no washout period, preclude causal inferences regarding chronic macronutrient effects from this trial.

Medicaid Reimbursement for Doula Care: Policy Considerations From a Scoping Review.

Evidence suggests that perinatal doula care can support maternal health and reduce racial inequities among low-income pregnant and postpartum people, prompting growing interest by state Medicaid agencies to reimburse for doula services. Emerging peer-reviewed and gray literature document factors facilitating or impeding that reimbursement. We conducted a scoping review of that literature (2012-2022) to distill key policy considerations for policymakers and advocates in the inclusion of doula care as a Medicaid-covered benefit. Fifty-three reports met the inclusion criteria. Most (53%) were published in 2021 or 2022. Their stated objectives were advocating for expanded access to doula care (17%), describing barriers to policy implementation, and/or offering recommendations to overcome the barriers (17%). A primary policy consideration among states was prioritizing partnership with doulas and doula advocates to inform robust and equitable policymaking to sustain the doula profession.

Drivers of decision-making regarding infant sleep practices among mothers with opioid use disorder.

OBJECTIVE: To understand the perspectives and perceived facilitators of and barriers to following safe infant sleeping practices among mothers with opioid use disorder (OUD). STUDY DESIGN: Using the Theory of Planned Behavior (TPB) framework, we conducted qualitative interviews with mothers with OUD regarding infant sleep practices. We created codes and generated themes, concluding data collection upon achieving thematic saturation. RESULTS: Twenty-three mothers with infants 1-7 months of age were interviewed from 08/2020 to 10/2021. Mothers chose sleeping practices they perceived made their infants safer, more comfortable, and minimized infant withdrawal symptoms. Mothers in residential treatment facilities were influenced by facility infant sleep rules. Hospital sleep modeling and varied advice by providers, friends and family influenced maternal decisions. CONCLUSIONS: Mothers reported factors unique to their experience with OUD that influenced their decisions about infant sleep that should be considered when developing tailored interventions to promote safe infant sleep in this population.

Siphophage 0105phi7-2 of Bacillus thuringiensis: Novel Propagation, DNA, and Genome-Implied Assembly.

Diversity of phage propagation, physical properties, and assembly promotes the use of phages in ecological studies and biomedicine. However, observed phage diversity is incomplete. Bacillus thuringiensis siphophage, 0105phi-7-2, first described here, significantly expands known phage diversity, as seen via in-plaque propagation, electron microscopy, whole genome sequencing/annotation, protein mass spectrometry, and native gel electrophoresis (AGE). Average plaque diameter vs. plaque-supporting agarose gel concentration plots reveal unusually steep conversion to large plaques as agarose concentration decreases below 0.2%. These large plaques sometimes have small satellites and are made larger by orthovanadate, an ATPase inhibitor. Phage head-host-cell binding is observed by electron microscopy. We hypothesize that this binding causes plaque size-increase via biofilm evolved, ATP stimulated ride-hitching on motile host cells by temporarily inactive phages. Phage 0105phi7-2 does not propagate in liquid culture. Genomic sequencing/annotation reveals history as temperate phage and distant similarity, in a virion-assembly gene cluster, to prototypical siphophage SPP1 of Bacillus subtilis. Phage 0105phi7-2 is distinct in (1) absence of head-assembly scaffolding via either separate protein or classically sized, head protein-embedded peptide, (2) producing partially condensed, head-expelled DNA, and (3) having a surface relatively poor in AGE-detected net negative charges, which is possibly correlated with observed low murine blood persistence.

Sugar- or artificially-sweetened beverage consumption, physical activity, and risk of cardiovascular disease in US adults.

Background: The extent to which physical activity attenuates the detrimental effects of sugar (SSBs)- or artificially-sweetened beverages (ASBs) on the risk of cardiovascular disease is unknown. Methods: We used Cox proportional-hazards models to calculate hazard ratios and 95% confidence interval [HR (CI)] between SSB or ASB intake and physical activity with cardiovascular disease risk among 65,730 women in the Nurses' Health Study (1980-2016) and 39,418 men in the Health Professional's Follow-up Study (1986-2016), who were free from chronic diseases at baseline. SSBs and ASBs were assessed every 4-years and physical activity biannually. Results: A total of 13,269 cardiovascular events were ascertained during 3,001,213 person-years of follow-up. Compared with those that never/rarely consumed SSBs or ASBs, HR and 95% CI for cardiovascular disease for participants consuming ≥2 servings/day were 1.21 (95% CI,1.12 to 1.32; P-trend<0.001) and 1.03 (95% CI, 0.97 to 1.09; P-trend=0.06), respectively. In the joint analyses, for participants meeting and not meeting physical activity guidelines (<7.5 vs ≥7.5 MET-h/week) as well as consuming ≥2 servings/day of SSBs or ASBs, the HRs for cardiovascular disease were 1.15 (95% CI, 1.08 to 1.23) and 0.96 (95% CI, 0.91 to 1.02), and 1.47 (95% CI, 1.37 to 1.57) and 1.29 (95% CI, 1.22 to 1.37) respectively, compared with participants who met physical activity guidelines and never/rarely consumed these beverages. Similar patterns were observed when coronary heart disease and stroke were analyzed. Conclusions: Our findings suggest that among physically active participants, higher SSB intake, but not ASBs, is associated with a higher cardiovascular risk. Our results support current recommendations to limit the intake of SSB and maintain adequate physical activity levels.

Dual-energy CT iodine overlay improves efficiency of oral contrast leak assessment.

BACKGROUND: Evaluation for gastrointestinal leak is a frequent imaging indication, and dual-energy computed tomography (DECT) with oral or rectally administered contrast can be used to improve efficiency and diagnostic confidence. PURPOSE: To assess the value of the DECT iodine overlay (IO) reconstruction as a stand-alone image set compared to routine CT in assessing oral or rectal contrast leak from the gastrointestinal system. MATERIAL AND METHODS: A blinded, retrospective audit study was performed by three readers who each interpreted 50 studies performed for assessment of oral or rectal contrast leak that were acquired using DECT. Each reader independently assessed both the routine CT images and the images of the reconstructed IO for contrast leak in random order with a six-week "wash-out period" between readings. Clinical follow-up provided the reference standard. Readers recorded the presence/absence of a leak, diagnostic confidence, image quality score, and interpretation time for each image set. RESULTS: Pooled data for overall accuracy in identification of a leak increased from 0.81 (95% confidence interval [CI]=0.74-0.87) for routine CT to 0.91 (95% CI=0.85-0.95) with IO, and the area under the curve (AUC) was significantly higher for IO than routine CT (P = 0.015). Readers required significantly less time to interpret IO than routine CT (median improvement of 12.5 s per image using pooled data; P < 0.001) while maintaining diagnostic confidence and perceived image quality. CONCLUSION: Use of DECT IO reconstructions for identification of oral or rectal contrast leak requires less time to interpret than routine CT with improved accuracy and maintained diagnostic confidence and perceived image quality.

Understanding cigarette smoking among mothers with opioid use disorder.

BACKGROUND: Cigarette smoking is highly prevalent among mothers with opioid use disorder (OUD). Organizations such as the American College of Obstetrics and Gynecology recommend cessation of cigarettes during the pre- and postnatal periods. Factors that inform decisions to continue or stop smoking cigarettes among pregnant and postpartum mothers with OUD are unclear. AIMS: This study aimed to understand (1) the lived experience of mothers with OUD regarding cigarette smoking and (2) barriers and facilitators to reduction of cigarette smoking during the pre- and postnatal periods. METHODS: Guided by the Theory of Planned Behavior (TPB) framework, we completed semi-structured, in-depth interviews with mothers with OUD with infants 2-7 months of age. We used an iterative approach to analysis by conducting interviews and developing and revising codes and themes until we reached thematic saturation. RESULTS: Fifteen of 23 mothers reported smoking cigarettes prenatally and postnatally, 6 of 23 smoked cigarettes during the prenatal period only, and 2 mothers were non-smokers. We found that mothers: 1) believed that smoke exposure had negative health consequences and may exacerbate withdrawal symptoms for their infants; 2) implemented risk mitigation practices, which were dictated both by themselves and by outside rules, to reduce the harmful effects of smoke around infants; 3) were motivated to quit or cut-down on smoking because of the desire to optimize the health and well-being of their infants; 4) continued to smoke because they felt that the stress related to caregiving and their own recovery were a higher priority than quitting smoking; and 5) were influenced by exposure to smokers with whom they lived, as well as by the varied advice of medical providers, family, and friends. CONCLUSION: While mothers with OUD acknowledged the negative health impact of cigarette smoke exposure to their infants, many experienced stressors related to recovery and caregiving unique to those with OUD that impacted their cigarette smoking behaviors.