Medical School Clinical Trials Educational Intervention: Impact on Knowledge and Attitudes.

Medical student knowledge and opinions of clinical research have important ramifications for how likely they will be to refer patients into clinical trials as practicing physicians. This study examined students understanding, knowledge, and attitudes about clinical trials at the start of medical school and after completion of a multi-faceted intervention designed to increase medical students' confidence in understanding and explaining clinical trials during the pre-clinical and clinical years. Medical students were surveyed about their knowledge of and attitudes toward clinical trials in their first (N = 724) and third (N = 191) years of medical school. During the intervening years, students attend a lecture delivered by University of Hawai 'i Cancer Center faculty, were provided a resource manual from National Cancer Institute, participated in two problem-based learning clinical scenarios, and completed an optional practicum. After completing the comprehensive clinical trials education, there were significant increases in student understanding and knowledge and a decrease in student perception that clinical trials exploit participants. Most students agreed or strongly agreed that inclusion of clinical trials in the curriculum was important and would influence their future practice. Integration of clinical trials education into the medical school curriculum improved students' understanding of clinical research, their ability to communicate the clinical trials process, and confidence in conducting, referring to, and locating clinical trials. Medical students appreciate the importance of clinical trials in advancing medicine and medical education. Further integration of clinical trials education and opportunities to engage in research during medical school are warranted to address students' uncertainty about the benefits of participation for patients.

Neurologist Attitudes on Practicing in Hawai'i.

There is a shortage of neurologists nationwide, and the demand for neurologists is expected to increase in the upcoming years while the pool of practicing neurologists dwindles. Per Hawai'i Neurological Society, there were 44 practicing neurologists in the state of Hawai'i in 2019, representing a shortage of approximately 28 neurologists. Considering that Hawai'i is geographically, demographically, and culturally distinct compared to other states, a concern is that practicing neurology in Hawai'i poses unique challenges that may contribute to the low numbers of neurologists. An anonymous online survey was sent via email to all members of the Hawai'i Neurological Society from February 2019 to June 2019, inquiring about aspects of their practice they considered unique to Hawai'i. Twenty-three neurologists completed the survey, representing 52% of Hawai'i's neurology workforce. One neurologist completed a portion of the survey. Twenty-five percent of participants were born and raised or completed their medical education in Hawai'i. Self-reported reasons for practicing in Hawai'i included family, lifestyle, and patient population despite financial challenges and limited resources and opportunities. Participants suggested introducing a mandatory neurology rotation for Hawai'i medical students and creating an instate neurology residency program to combat the growing neurologist shortfall in Hawai'i. This survey identified local strengths and challenges in the field of neurology, potential ways to improve the practice environment in Hawai'i, and neurologists' perspectives on ways to address the neurology shortage.

Treating tobacco dependence to aid re-employment among job-seekers: A randomized controlled trial.

INTRODUCTION: U.S. reductions in smoking have not been experienced equally. Smoking prevalence is greater among persons of lower education, lower income, and unemployed. We evaluated whether a cessation intervention for job-seekers would result in significantly fewer cigarettes smoked per day and a greater likelihood of tobacco abstinence and re-employment, compared to the control condition at 6-months follow-up. METHODS: Unemployed, job-seekers who smoked daily were recruited from five employment development departments in the San Francisco Bay Area, October 2015 to February 2018. Intention to quit smoking was not required. Participants were randomized to a brief motivationally-tailored, computer-assisted counseling intervention or referred to a toll-free quitline. Midstudy, 8-weeks of combination nicotine replacement was added to the intervention. Expired carbon monoxide and cotinine testing verified abstinence. Data were analyzed fall 2019. RESULTS: Participants (N = 360; 70% men; 43% African American, 27% non-Hispanic Caucasian; 19% unhoused) averaged 12 cigarettes/day (SD = 6), 67% smoked within 30 min of wakening; 27% were in preparation stage to quit. During the 6-month study period, intervention participants were more likely to make a quit attempt (71% vs. 58%, p = .021) and reported significantly greater reduction in cigarettes/day than control participants (median reduction: 6.9 vs. 5.0, p = .038); however, bioconfirmed abstinence (3%) and re-employment (36%) did not differ by treatment group. CONCLUSIONS: In a diverse sample with economic hardships, quit attempts and smoking reduction were greater in the intervention group; however, few achieved abstinence, and neither abstinence nor re-employment differed by condition. A priority group, further research is needed on smoking and re-employment.

Natural American Spirit Brand Preference among Smokers with Mental Illness.

INTRODUCTION: Despite steady declines in the US smoking prevalence over the past 50 years, Natural American Spirit cigarettes (NAS), marketed as natural and organic, have seen a 400% rise in sales. In a sample of smokers with mental illness, based on previous research, we hypothesized that preference for NAS would be associated with younger age, higher education, and a stronger health-orientation. METHODS: Adult smokers were interviewed during acute psychiatric hospitalization in California between 2009-2013, reporting their preferred top 3 brands of cigarettes, smoking behaviors, self-rated health, and dietary and physical activity behaviors. The sample (N=956; M age=38.7, SD=13.5; 48.7% women) identified as 14.5% Hispanic ethnicity and 49.6% White, 23.7% African American, and 23.8% other race. RESULTS: NAS was identified as a top preferred brand by 15.2% of participants and was the fourth most popular brand for the sample overall. In a multivariate logistic regression, preference for NAS was significantly greater among participants who were younger (OR=0.97), had some college education or more (OR=2.64 to 4.31), ate a low-fat diet (OR=1.56) and reported better overall health (OR=1.26), p's<.05. Identifying as Hispanic ethnicity (OR=1.80) and White race (OR=3.00) also predicted NAS preference, p's<.05. NAS preference did not differ by gender or psychiatric diagnosis. CONCLUSIONS: Study findings indicate greater NAS brand appeal among smokers living with mental illness who are younger, more highly educated, and have a stronger orientation to health, perhaps because they perceive NAS to be a healthier cigarette to smoke. Marketing language that obscures the harms of smoking ought to be prohibited.

Likelihood of Unemployed Smokers vs Nonsmokers Attaining Reemployment in a One-Year Observational Study.

IMPORTANCE: Studies in the United States and Europe have found higher smoking prevalence among unemployed job seekers relative to employed workers. While consistent, the extant epidemiologic investigations of smoking and work status have been cross-sectional, leaving it underdetermined whether tobacco use is a cause or effect of unemployment. OBJECTIVE: To examine differences in reemployment by smoking status in a 12-month period. DESIGN, SETTING, AND PARTICIPANTS: An observational 2-group study was conducted from September 10, 2013, to August 15, 2015, in employment service settings in the San Francisco Bay Area (California). Participants were 131 daily smokers and 120 nonsmokers, all of whom were unemployed job seekers. Owing to the study's observational design, a propensity score analysis was conducted using inverse probability weighting with trimmed observations. Including covariates of time out of work, age, education, race/ethnicity, and perceived health status as predictors of smoking status. MAIN OUTCOMES AND MEASURES: Reemployment at 12-month follow-up. RESULTS: Of the 251 study participants, 165 (65.7) were men, with a mean (SD) age of 48 (11) years; 96 participants were white (38.2%), 90 were black (35.9%), 24 were Hispanic (9.6%), 18 were Asian (7.2%), and 23 were multiracial or other race (9.2%); 78 had a college degree (31.1%), 99 were unstably housed (39.4%), 70 lacked reliable transportation (27.9%), 52 had a criminal history (20.7%), and 72 had received prior treatment for alcohol or drug use (28.7%). Smokers consumed a mean (SD) of 13.5 (8.2) cigarettes per day at baseline. At 12-month follow-up (217 participants retained [86.5%]), 60 of 108 nonsmokers (55.6%) were reemployed compared with 29 of 109 smokers (26.6%) (unadjusted risk difference, 0.29; 95% CI, 0.15-0.42). With 6% of analysis sample observations trimmed, the estimated risk difference indicated that nonsmokers were 30% (95% CI, 12%-48%) more likely on average to be reemployed at 1 year relative to smokers. Results of a sensitivity analysis with additional covariates of sex, stable housing, reliable transportation, criminal history, and prior treatment for alcohol or drug use (25.3% of observations trimmed) reduced the difference in employment attributed to smoking status to 24% (95% CI, 7%-39%), which was still a significant difference. Among those reemployed at 1 year, the average hourly wage for smokers was significantly lower (mean [SD], $15.10 [$4.68]) than for nonsmokers (mean [SD], $20.27 [$10.54]; F(1,86) = 6.50, P = .01). CONCLUSIONS AND RELEVANCE: To our knowledge, this is the first study to prospectively track reemployment success by smoking status. Smokers had a lower likelihood of reemployment at 1 year and were paid significantly less than nonsmokers when reemployed. Treatment of tobacco use in unemployment service settings is worth testing for increasing reemployment success and financial well-being.

Correlates of nicotine withdrawal severity in smokers during a smoke-free psychiatric hospitalization.

Psychiatric hospitals are increasingly adopting smoke-free policies. Tobacco use is common among persons with mental illness, and nicotine withdrawal (NW), which includes symptoms of depression, anxiety, anger/irritability, and sleep disturbance, may confound psychiatric assessment and treatment in the inpatient setting. This study aimed to characterize NW and correlates of NW severity in a sample of smokers hospitalized for treatment of mental illness in California. Participants (N=754) were enrolled between 2009 and 2013, and averaged 17 (SD=10) cigarettes/day prior to hospitalization. Though most (70%) received nicotine replacement therapy (NRT) during hospitalization, a majority (65%) reported experiencing moderate to severe NW. In a general linear regression model, NW symptoms were more severe for women, African American patients, and polysubstance abusers. Though invariant by psychiatric diagnostic category, greater NW was associated with more severe overall psychopathology and greater cigarette dependence. The full model explained 46% of the total variation in NW symptom severity (F [19, 470]=23.03 p<0.001). A minority of participants (13%) refused NRT during hospitalization. Those who refused NRT reported milder cigarette dependence and stated no prior use of NRT. Among smokers hospitalized for mental illness, NW severity appears multidetermined, related to cigarette dependence, demographic variables, psychiatric symptom severity, and other substance use. Assessment and treatment of NW in the psychiatric hospital is clinically warranted and with extra attention to groups that may be more vulnerable or naïve to cessation pharmacotherapy.