Association of COVID-19 and the prevalence of in-person vs telehealth primary care visits and subsequent impacts on tobacco use assessment and referral for cessation assistance.

INTRODUCTION: The COVID-19 pandemic dramatically altered patterns of health care delivery. Smoking remains an important risk factor for multiple chronic conditions and may exacerbate more severe symptoms of COVID-19. Thus, it is important to understand how pandemic-induced changes in primary care practice patterns affected smoking assessment and cessation assistance. METHODS: Electronic health record (EHR) data from 8 community health centers were examined from March 1, 2019 to February 28, 2022. Data include both telehealth (phone and video) and in-person office visits and represent 310,388 visits by adult patients. Rates of smoking assessment, provision of referral to counseling and orders for smoking cessation medications were calculated. Comparisons by visit mode and time period were examined using generalized estimating equations and logistic regression. RESULTS: The proportion of telehealth visits was <0.1% one year prior to COVID-19 onset and, 54.5% and 34.1% 1 and 2 years after. The odds of asking about smoking status and offering a referral to smoking cessation counseling were significantly higher during in-person vs. telehealth visits; AOR (95% CI) = 15.0 (14.7 -15.4) and AOR (95% CI)= 6.5 (3.0 - 13.9), respectively. The interaction effect of visit type * time period was significant for ordering smoking cessation medications. CONCLUSION: Telehealth visits were significantly less likely to include smoking status assessment and referral to smoking cessation counseling compared to in-person visits. Given that smoking assessment and cessation assistance do not require face-to-face interactions with health care providers, continued efforts are needed to ensure provision at all visits, regardless of modality. IMPLICATIONS: The COVID-19 pandemic dramatically altered patterns of health care seeking and delivery with a considerable rise in telehealth visits. This study examined one year prior to the onset of COVID-19 and two years after to evaluate the assessment of tobacco use and assistance with tobacco cessation and differences during in-person vs telehealth visits. Tobacco assessment was 15 times more likely during in-person vs. telehealth visits in the two years post onset of COVID-19. Given that telehealth visits are likely to continue, ensuring that patients are regularly assessed for tobacco regardless of visit modality is an important concern for health systems.

Assessing exogenous carbohydrate intake needed to optimize human endurance performance across sex: insights from modeling runners pursuing a sub-2-h marathon.

Carbohydrate (CHO) availability sustains high metabolic demands during prolonged exercise. The adequacy of current CHO intake recommendations, 30-90 g·h-1 dependent on CHO mixture and tolerability, to support elite marathon performance is unclear. We sought to scrutinize the current upper limit recommendation for exogenous CHO intake to support modeled sub-2-h marathon (S2M) attempts across elite male and female runners. Male and female runners (n = 120 each) were modeled from published literature with reference characteristics necessary to complete a S2M (e.g., body mass and running economy). Completion of a S2M was considered across a range of respiratory exchange rates, with maximal starting skeletal muscle and liver glycogen content predicted for elite male and female runners. Modeled exogenous CHO bioavailability needed for male and female runners were 93 ± 26 and 108 ± 22 g·h-1, respectively (P < 0.0001, d = 0.61). Without exogenous CHO, males were modeled to deplete glycogen in 84 ± 7 min, females in 71 ± 5 min (P < 0.0001, d = 2.21) despite higher estimated CHO oxidation rates in males (5.1 ± 0.5 g·h-1) than females (4.4 ± 0.5 g·h-1; P < 0.0001, d = 1.47). Exogenous CHO intakes ≤ 90 g·h-1 are insufficient for 65% of modeled runners attempting a S2M. Current recommendations to support marathon performance appear inadequate for elite marathon runners but may be more suitable for male runners in pursuit of a S2M (56 of 120) than female runners (28 of 120).NEW & NOTEWORTHY This study scrutinizes the upper limit of exogenous carbohydrate (CHO) recommendations for elite male and female marathoners by modeling sex-specific needs across an extreme metabolic challenge lasting ∼2 h, a sub-2-h marathon. Contemporary nutritional guidelines to optimize marathon performance appear inadequate for most elite marathon runners but appear more appropriate for males over their female counterparts. Future research examining possible benefits of exogenous CHO intakes > 90 g·h-1 should prioritize female athlete study inclusion.

Sustained Effects of a Systems-Based Strategy for Tobacco Cessation Assistance.

INTRODUCTION: Primary care settings that serve lower-income patients are critical for reducing tobacco-related disparities; however, tobacco-related care in these settings remains low. This study examined whether processes for the provision of tobacco cessation care are sustained 18 and 24 months after implementing a health system-level intervention consisting of electronic health record functionality changes and expansion of rooming staff roles. METHODS: This nonrandomized stepped-wedge study included electronic health record data from adults with ≥1 primary care visit to 1 of 8 community-based clinics between August 2016 and September 2019. Generalized estimating equations methods were used to compute ORs of asking about tobacco use and among those who use tobacco, providing brief advice to quit and assessing readiness to quit, contrasting 18 and 24 months after implementation to both preimplementation (baseline) and 12 months after implementation. Using a 2-level model of patients clustered in clinics, outcomes were examined over time by clinic site. Analyses were conducted in 2022. RESULTS: A total of 305,665 patient visits were evaluated. Significantly higher odds of all 3 outcomes were observed at 18 and 24 months than at baseline. The odds of asking about tobacco use increased, whereas the odds of advising to quit were similar at 18 and 24 months to those at 12 months. Odds of assessing readiness to quit decreased at 18 months (OR=0.71; 95% CI=0.63, 0.80) and 24 months (OR=0.46; 95% CI=0.40, 0.52). Performance varied significantly by clinical site. CONCLUSIONS: Health system changes can have a sustained impact on tobacco assessment and the provision of brief advice among lower-income patients. Strategies to sustain assessment of readiness to quit are warranted.

Measuring Nicotine Dependence Among Adolescent and Young Adult Cigarillo Users.

INTRODUCTION: Current measures of nicotine dependence (ND) were developed and validated for cigarette smokers only, limiting their utility for other combustible tobacco users. This study evaluates the psychometric properties of a pool of new and adapted items to measure ND among cigarillo and multiple tobacco product users. AIMS AND METHODS: Items were drawn from the PROMIS Nicotine Dependence Item Bank which were adapted to be product neutral and new items were developed from a qualitative study of 60 adolescent and young adult cigarillo smokers. A total of 42 ND items were included in a web-based survey. Eligible participants were 14-28 year olds who smoked a minimum of 2 cigarillos per week. Analyses included confirmatory factor analysis, item response theory analysis, analysis of differential item functioning, and reliability. Ordinary least square regression was used to test the association of ND score with deciles of nicotine consumption. RESULTS: Among the 1089 participants, the median number of cigarillos smoked per week was 20; 54% of participants also smoked cigarettes. All PROMIS items and 8 of 10 new items met the item response theory fit criteria. Two PROMIS items had nonignorable differential item functioning. The pool of 40 items had good score reliability for a range of 2 SDs. Twenty-, eight-, and four-item short forms showed similarly good measurement properties; each was positively associated with decile of nicotine consumption, p < .001; R2 = 0.33. CONCLUSIONS: This adapted bank of ND items is psychometrically sound and includes items that are product neutral, making it suitable for assessing ND among cigarillo and polytobacco users. IMPLICATIONS: This study rigorously evaluates adapted items to measure ND among cigarillo and polytobacco users and reports the reliability initial evidence of validity of short form scores.

"I got a little addiction": Adolescent and young adult cigarillo users' self-perceptions of addiction.

BACKGROUND: While prior research has informed how cigarette smokers understand and apply the term addiction, little is known about how this term is used by cigarillo smokers. This is an important area of study given the decline in cigarette use and increase in cigar product consumption. PURPOSE/OBJECTIVES: This paper examines how cigarillo smokers self-identify in terms of addiction and the association of this identification with tobacco use, quitting experiences, and level of nicotine dependence. METHODS: Transcripts from semi-structured interviews conducted in 2015-2016 with 57 participants (aged 14-28) about cigarillo use and beliefs were analyzed using a phenomenological approach to examine themes around addiction and cessation experiences. Analyses were limited to participants endorsing having a habit. Quantitative analyses were conducted to assess associations with demographics, tobacco use, addiction, cessation, and nicotine dependence for two groups: participants endorsing having an addiction to cigarillos and those who did not. RESULTS: All participants described the term addiction similarly. Participants with an addiction had significantly higher nicotine dependence and self-rating of addiction than those without an addiction. Although most quitting experiences did not differ between the two groups, participants who did not identify as addicted felt that they could quit smoking cigarillos at any time. CONCLUSIONS: Variations in identification with addiction are not associated with differences in definitions, use and quit experiences. Understanding self-perceptions of addiction can inform targeted communication to encourage cessation and the use of cessation resources.

Characteristics of Patients Engaging in Quitline Counseling After an Electronic Referral.

INTRODUCTION: Proactive, electronic referral of primary care patients to quitlines has great potential to provide evidence-based tobacco-cessation assistance to tobacco users. However, the quitline contact rates and engagement of individuals beyond 1 counseling call are poor. This study examines the characteristics of electronically referred patients who engage with the quitline. METHODS: This cross-sectional study included 2,407 primary care patients who reported using tobacco and accepted an electronic referral to the quitline. Outcomes included contact, enrollment, and receipt of ≥2 counseling sessions from the quitline. All measures were assessed from the electronic health record. The association of patient characteristics and outcomes was evaluated using logistic regression modeling with generalized estimating equation methods. Data were collected in 2016‒2018 and were analyzed in 2020. RESULTS: Among 2,407 referred patients, 794 (33.0%) were contacted; of those, 571 enrolled (71.9%); and of those, 240 (42.0%) engaged in ≥2 quitline counseling sessions. In multivariable analyses, older adults (aged 50-64 and ≥65 years) were significantly more likely to be contacted (OR=2.32, 95% CI=1.6, 3.4) and to receive ≥2 counseling sessions (OR=2.34, 95% CI=1.2, 4.7) than those aged 18-34 years. Those with both Medicare and Medicaid insurance coverage were more likely than those with Medicaid only to be contacted (OR=1.71, 95% CI=1.4, 2.2), to enroll (OR=1.84, 95% CI=1.2, 2.9), and to receive ≥2 counseling sessions (OR=1.83, 95% CI=1.2, 2.9). CONCLUSIONS: The current quitline phone-based approach is less likely to engage younger adults and those with Medicaid coverage; however, there is a need to improve quitline engagement across all patients. Identification and testing of alternative engagement approaches are needed.

A cluster randomized trial evaluating a teachable moment communication process for tobacco cessation support.

INTRODUCTION: This study examines the uptake of a clinician-focused teachable moment communication process (TMCP) and its impact on patient receipt of tobacco cessation support. The TMCP is a counseling method that uses patient concerns to help clinicians guide behavior change discussions about tobacco. We evaluate the added value of the TMCP training in a health system that implemented an Ask-Advise-Connect (AAC) systems-based approach. METHODS: A stepped wedge cluster randomized trial included eight community health centers. Training involved a web module and onsite skill development with standardized patients and coaching. Main outcome measures included contact and enrollment in cessation services among patients referred for counseling, prescription of cessation medications and quit attempts. RESULTS: Forty-four of 60 eligible clinicians received the TMCP training. Among TMCP-trained clinicians 68% used a TMCP approach (documented by flowsheet use) one or more times, with the median number of uses being 15 (IQR 2-33). Overall, the TMCP was used in 661 out of 8198 visits by smokers (8%). There was no improvement in any of the tobacco cessation assistance outcomes for the AAC + TMCP vs. the AAC only period. Visits where clinicians used the TMCP approach were associated with increased ordering of tobacco cessation medications, (OR = 2.6; 95% CI = 1.9, 3.5) and providing advice to quit OR 3.2 (95% CI 2.2, 4.7). CONCLUSIONS: Despite high fidelity to the training, uptake of the TMCP approach in routine practice was poor, making it difficult to evaluate the impact on patient outcomes. When the TMCP approach was used, ordering tobacco cessation medications increased. IMPLICATIONS: Tobacco cessation strategies in primary care have the potential to reach a large portion of the population and deliver advice tailored to the patient. The poor uptake of the approach despite high training fidelity suggests that additional implementation support strategies, are needed to increase sustainable adoption of the TMCP approach. TRIAL REGISTRATION: clinicaltrials.gov #NCT02764385 , registration date 06/05/2016.

Cigarillo and multiple tobacco product use and nicotine dependence in adolescents and young adults.

INTRODUCTION: Multiple tobacco product (MTP) use is a growing public health concern, particularly among adolescents and young adults. This study identifies subgroups of MTP use among cigarillo users and examines associations with nicotine dependence (ND). METHODS: 1089 youth (ages 14-28) who currently smoke cigarillos completed a web-based survey regarding their current use of cigarillos, little cigars, traditional cigars, cigarettes, e-cigarettes, and waterpipe/hookah. Latent class analysis (LCA) was used to identify patterns of product use by type and amount. The LCA also assessed the relationship between the latent classes and a 38-item measure of ND, controlling for relevant demographics. RESULTS: Most participants (88.2%) reported using two or more tobacco products in the past 30 days. The best-fitting LCA solution revealed 7 classes: (1) Mixed-Light tipped cigarillo and light cigarette users, 28.9%; (2) Light tipped cigarillo users, 15.8%; (3) Light untipped cigarillo users, 14.3%; (4) Heavy tipped cigarillo users, 13.4%; (5) E-cigarette and waterpipe users, 11.9%; (6) Heavy users of tipped and untipped cigarillos and light users of cigarettes, 9.8%; and (7) Dabblers who primarily used traditional cigars, but were also likely to use a variety of other products, 6.1%. Classes comprised of those using multiple products-particularly those that included cigarettes-had significantly higher levels of ND than other classes (Tukey's HSD P < .05). CONCLUSIONS: Distinct patterns of MTP use are evident among young cigarillo smokers. Smoking multiple products, particularly smoking cigarillos in combination with cigarettes, is associated with higher ND compared to other product use patterns.

Quitting the quitline: a qualitative study of patient experience of electronic referrals to quitlines.

BACKGROUND: The use of electronic referrals (eReferrals) to state quitlines (QLs) for tobacco-using patients is a promising approach for addressing smoking cessation on a large scale. However, QL contact, enrollment, and completion rates are low. The purpose of this study was to examine the eReferral to QL process from the patient's perspective in order to inform strategies for improving QL engagement. METHODS: We conducted interviews with 55 patients who agreed to an eReferral at a primary care visit to 1 of 8 safety-net community health centers in Cuyahoga County, Ohio (September 2017-August 2018). Interviews were designed to explore the experiences of three subgroups of patients who subsequently: 1) declined participation in the QL; 2) were unreachable by the QL; or 3) were enrolled in or had completed the QL program. Analysis was guided by a phenomenological approach designed to identify emergent themes. RESULTS: Reasons for QL program non-completion included changing life circumstances and events making cessation unviable; misunderstandings about the QL; discomfort with telephonic counseling; perceived lack of time for counseling; cell phone barriers; and having already quit smoking. We found that some individuals who were no longer engaged with the QL still desired continued support from the QL. CONCLUSIONS: Participants intentionally and unintentionally disengage from the QL for a wide variety of reasons, several of which are mediated by low socioeconomic status. Integrating QL care with community-based resources that address these mediators could be a promising strategy.

12-Month Evaluation of an EHR-Supported Staff Role Change for Provision of Tobacco Cessation Care in 8 Primary Care Safety-Net Clinics.

SIGNIFICANCE: Guidelines urge primary care practices to routinely provide tobacco cessation care (i.e., assess tobacco use, provide brief cessation advice, and refer to cessation support). This study evaluates the impact of a systems-based strategy to provide tobacco cessation care in eight primary care clinics serving low-income patients. METHODS: A non-randomized stepped wedge study design was used to implement an intervention consisting of (1) changes to the electronic health record (EHR) referral functionality and (2) expansion of staff roles to provide brief advice to quit; assess readiness to quit; offer a referral to tobacco cessation counseling; and sign the referral order. Outcomes assessed from the EHR include performance of tobacco cessation care tasks, referral contact, and enrollment rates for the quitline (QL) and in-house Freedom from Smoking (FFS) program. Generalized estimating equations (GEE) methods were used to compute odds ratios contrasting the pre-implementation vs. 1-, 3-, 6-, and 12-month post-implementation periods. RESULTS: Of the 176,061 visits, 26.1% were by identified tobacco users. All indicators significantly increased at each time period evaluated post-implementation. In comparison with the pre-intervention period, assessing smoking status (26.6% vs. 55.7%; OR = 3.7, CI = 3.6-3.9), providing advice (44.8% vs. 88.7%; OR = 7.8, CI = 6.6-9.1), assessing readiness to quit (15.8% vs. 55.0%; OR = 6.2, CI = 5.4-7.0), and acceptance of a referral to tobacco cessation counseling (0.5% vs. 30.9%; OR = 81.0, CI = 11.4-575.8) remained significantly higher 12 months post-intervention. For the QL and FFS, respectively, there were 1223 and 532 referrals; 324 (31.1%) and 103 (24.7%) were contacted; 241 (74.4%) and 72 (69.6%) enrolled; and 195 (80.9%) and 14 (19.4%) received at least one counseling session. CONCLUSIONS: This system change intervention that includes an EHR-supported role expansion substantially increased the provision of tobacco cessation care and improvements were sustained beyond 1 year. This approach has the potential to greatly increase the number of individuals referred for tobacco cessation counseling.

Effectiveness of Social Media Approaches to Recruiting Young Adult Cigarillo Smokers: Cross-Sectional Study.

BACKGROUND: The prevalence of social media use among youth and young adults suggests it is an appropriate platform for study recruitment from this population. Previous studies have examined the use of social media for recruitment, but few have compared platforms, and none, to our knowledge, have attempted to recruit cigarillo users. OBJECTIVE: The purpose of this study was to examine the effectiveness of different social media platforms and advertisement images for recruiting cigarillo users aged 14-28 years to complete a cigarillo use survey. METHODS: We obtained objective data for advertisement impressions for a 39-week social media recruitment campaign. Advertisements were targeted to users based on their age, geography, and interests. Effectiveness was defined as the percentage of approved surveys per advertising impression. Chi-square tests were performed to compare the effectiveness of different advertisement images and platforms. RESULTS: Valid survey completers (n=1089) were predominately older (25-28 years old, n=839, 77%). Of the 1089 survey completers, 568 (52%) identified as male, 335 (31%) as African American, and 196 (18%) as Hispanic. Advertisements delivered via Facebook/Instagram were more effective than Twitter; 311/1,027,738 (0.03%) vs 661/2,998,715 (0.02%); χ21=21.45, N=4,026,453); P<.001. Across platforms, ads featuring exclusively an image of cigarillos were more effective (397/682,994, 0.06%) than ads with images of individuals smoking (254/1,308,675, 0.02%), individuals not smoking (239/1,393,134, .02%), and groups not smoking (82/641,650, 0.01%); χ23133.73, N=4,026,453; P<.001. CONCLUSIONS: The campaign was effective in recruiting a diverse sample representative of relevant racial/ethnic categories. Advertisements on Facebook were more effective than Twitter. Advertisements that featured an image of a cigarillo were consistently the most effective and should be considered by others recruiting cigarillo users via social media.

Designing for Sustainability: An Approach to Integrating Staff Role Changes and Electronic Health Record Functionality Within Safety-Net Clinics to Address Provision of Tobacco Cessation Care.

BACKGROUND: Guidelines urge primary care practices to routinely provide tobacco cessation care, but quality indicators for the provision of advice and assistance to quit smoking lag. This study evaluated the implementation of a systems-based strategy to improve performance of tobacco cessation care in primary care clinics. METHODS: Changes to the electronic health record (EHR) facilitated staff to document when they ask about tobacco use, advise the patient to quit, offer to connect the patient to a quitline (QL) counselor, and refer interested patients to receive a call from a QL. Medical assistants (MAs) were trained to use the new sections of the EHR, and their roles were expanded to include the provision of brief cessation advice and activation of the QL referral. Primary outcomes were change in tobacco cessation processes preimplementation vs. one, three, and six months postimplementation of the strategy. RESULTS: The increase in performance of tobacco cessation care was significant and sustained at six months postimplementation for assessing smoking status (50.9% vs. 76.3%; odds ratio [OR] = 3.04; 95% confidence interval [CI] = 2.80-3.31), providing advice (15.1% vs. 92.7%; OR = 69.3; 95% CI = 51.88-92.60), assessing readiness to quit (22.8% vs. 76.6%; OR = 10.80; 95% CI = 8.92-13.08), and accepting a referral to the QL (1.3% vs. 21.7%; OR = 20.31; 95% CI = 4.91-84.05). CONCLUSION: Key stakeholder engagement informed a system change intervention that includes an EHR-supported role expansion of MAs for QL referrals; these changes substantially increased the provision of tobacco cessation care.

Evidence-Based Treatments for Borderline Personality Disorder: Implementation, Integration, and Stepped Care.

LEARNING OBJECTIVE: After participating in this activity, learners should be better able to:• Evaluate evidence-based therapies for borderline personality disorder ABSTRACT: Several manualized psychotherapies for treating borderline personality disorder (BPD) have been validated in randomized, controlled trials. Most of these approaches are highly specialized, offering different formulation of BPD and different mechanisms by which recovery is made possible. Mental health clinicians are challenged by the degree of specialization and clinical resources that these approaches require in their empirically validated adherent forms. While these effective treatments have renewed optimism for the treatment of BPD, clinicians may feel limited in their ability to offer any of them or may integrate an eclectic assortment of features from the different treatments. This article will evaluate four major evidence-based treatments for BPD-dialectical behavioral therapy, mentalization-based treatment, transference-focused psychotherapy, and General Psychiatric Management-and possible modes of implementation in adherent and integrative forms. Models of implementing these diverse treatment approaches will be evaluated, and the potential advantages of combining evidence-based treatments will be discussed, along with some cautionary notes. A proposal for providing stepwise care through assessment of clinical severity will be presented as a means of achieving system-wide changes and greater access to care.

Inhibition of apoptosis in neuronal cells infected with Chlamydophila (Chlamydia) pneumoniae.

BACKGROUND: Chlamydophila (Chlamydia) pneumoniae is an intracellular bacterium that has been identified within cells in areas of neuropathology found in Alzheimer disease (AD), including endothelia, glia, and neurons. Depending on the cell type of the host, infection by C. pneumoniae has been shown to influence apoptotic pathways in both pro- and anti-apoptotic fashions. We have hypothesized that persistent chlamydial infection of neurons may be an important mediator of the characteristic neuropathology observed in AD brains. Chronic and/or persistent infection of neuronal cells with C. pneumoniae in the AD brain may affect apoptosis in cells containing chlamydial inclusions. RESULTS: SK-N-MC neuroblastoma cells were infected with the respiratory strain of C. pneumoniae, AR39 at an MOI of 1. Following infection, the cells were either untreated or treated with staurosporine and then examined for apoptosis by labeling for nuclear fragmentation, caspase activity, and membrane inversion as indicated by annexin V staining. C. pneumoniae infection was maintained through 10 days post-infection. At 3 and 10 days post-infection, the infected cell cultures appeared to inhibit or were resistant to the apoptotic process when induced by staurosporine. This inhibition was demonstrated quantitatively by nuclear profile counts and caspase 3/7 activity measurements. CONCLUSION: These data suggest that C. pneumoniae can sustain a chronic infection in neuronal cells by interfering with apoptosis, which may contribute to chronic inflammation in the AD brain.

Current practices in depression care.

Despite improved awareness among the medical community concerning common mental health disorders, the high prevalence of depression in the United States remains unchanged and has been compounded by increasing evidence of gaps in mental health care for ethnic and racial minorities. Thus, there is a strong need for the timely creation of comprehensive educational initiatives aimed at improving the quality of care provided by mental health professionals and primary care physicians. Fundamental to this process is the examination of current treatment standards, as well as identification of practices that require improved physician education. Consistent use of appropriate screening tools, diagnostic accuracy and timeliness, continual assessment of illness severity, adherence to practice guidelines, and individualized patient care need heightened attention to improve outcomes. This article describes the most prevalent types of depression and summarizes current practices in depression care, with an emphasis on treatment standards and opportunities for improved performance.