Patterns of digital health access and use among US adults: A latent class analysis.

Background Digital technologies allow users to engage in health-related behaviors associated with positive outcomes. We aimed to identify classes of US adults with distinct digital technologies access and health use patterns and characterize class composition. Data came from Health Information National Trends Survey Wave 5 Cycles 1-4, a nationally representative cross-sectional survey of US adults ( N = 13,993). We used latent class analysis to identify digital technologies access and health use patterns based on 32 behaviors and access to requisite technologies and platforms that include the internet, internet-enabled devices, health monitors, and electronic health records (EHRs). We ran a multinomial logistic regression to identify sociodemographic and health correlates of class membership ( n = 10,734). Results Ten classes captured patterns of digital technology access and health use among US adults. This included a digitally isolated, a mobile-dependent, and a super user class, which made up 8.9%, 7.8%, and 13.6% of US adults, respectively, and captured access patterns from only basic cellphones and health monitors to near complete access to web-, mobile-, and EHR-based platforms. Half of US adults belonged to classes that lacked access to EHRs and relied on alternative web-based tools typical of patient portals. The proportion of class members who used digital technologies for health purposes varied from small to large. Older and less educated adults had lower odds of belonging to classes characterized by access or engagement in health behaviors. Hispanic and Asian adults had higher odds of belonging to the mobile-dependent class. Individuals without a regular healthcare provider and those who had not visited a provider in the past year were more likely to belong to classes with limited digital technologies access or health use. Discussion Only one third of US adults belonged to classes that had near complete access to digital technologies and whose members engaged in almost all health behaviors examined. Sex, age, and education were associated with membership in classes that lacked access to 1 + digital technologies or exhibited none to limited health uses of such technologies. Results can guide efforts to improve access and health use of digital technologies to maximize associated health benefits and minimize disparities.

Noncigarette Tobacco Product Use Among Smoking-Susceptible and Nonsusceptible Adolescent Never Smokers, 2009-2021.

PURPOSE: Examine trends in noncigarette tobacco use among smoking susceptible and nonsusceptible adolescents from 2009-2021. METHODS: Data came from cross-sectional samples of the National Youth Tobacco Survey (N = 183,198). Using Pierce's smoking susceptibility scale, participants were classified as either susceptible or nonsusceptible to cigarette smoking. Their use of noncigarette tobacco products was classified into four mutually exclusive categories: nonuse, noncigarette combustibles use, noncombustibles use, and noncigarette combustibles and noncombustibles dual use. We produced covariate-adjusted predicted marginal proportions of noncigarette tobacco use for 12 National Youth Tobacco Survey years, which were entered into Joinpoint trend analysis software to determine (a) trends in noncigarette tobacco use from 2009-2021 using the average annual percent changes (AAPCs) and (b) changes in each time segment using the average percent change. Models were fitted by smoking susceptibility, sex, and race/ethnicity. RESULTS: Nonuse was lower among susceptible (vs. nonsusceptible) adolescents whereas noncigarette tobacco use was higher. Trends show significant declines in nonuse (nonsusceptible: AAPC = -0.3%) and noncigarette combustibles use (susceptible: AAPC = -12%) between 2009-2021, increases in noncombustibles use (susceptible: AAPC = 18%, nonsusceptible: AAPC = 19%) between 2009 and 2019, and steadiness in dual use. Parallel trends were observed when stratified by sex and race/ethnicity with notable increases in noncombustibles use among females and Latinos. DISCUSSION: Noncigarette tobacco use differed by smoking susceptibility. Observed trends, especially when stratified by sex and race/ethnicity, raise concerns about tobacco use disparities among females and Latinos. Smoking susceptibility can help identify at-risk adolescents for current or future tobacco use.

Intervention targeting and retention, engagement and abstinence outcomes among Latino and White users of Smokefree.gov text messaging programmes: a cross-sectional study.

Background: We examined retention, engagement, and abstinence among Latino users of SmokefreeTXT en Español (SFTXTesp), a Latino-targeted text messaging smoking cessation intervention, and Latino and White users of SmokefreeTXT (SFTXT), a non-targeted intervention. Methods: Data came from 12281 users (1562 Latino SFTXTesp users and 2301 Latino and 8418 White SFTXT users). We conducted time-to-dropout analyses by race/ethnicity. Using logistic regression, we examined associations between intervention targeting, race/ethnicity, and responses to smoking status prompts, an engagement metric, and self-reported abstinence on quit day, intervention end, and one-month follow-up. Age, gender, census region, smoking frequency, cigarettes smoked per day, prequit time, and number of quit attempts were covariates. Results: Latinos in SFTXTesp (aOR 0.63) and SFTXT (0.88) were less likely to drop out of the intervention than Whites. SFTXTesp Latino users had higher response rates to smoking prompts than SFTXT Latinos users (aORs 1.35, quit day; 1.84, intervention end; 1.82, one-month follow-up). However, SFTXTesp and SFTXT Latino users had lower response rates than Whites (aORs 0.68, 0.45, quit day; 0.60, 0.30, intervention end; 0.64, 0.33, one-month follow-up). Abstinence was equivalent among Latinos in SFTXTesp and SFTXT interventions, but Latinos using SFTXTesp and SFTXT were less likely to be abstinent than Whites (aORs 0.42, 0.41, quit day; 0.45, 0.37, intervention end; and 0.53, 0.35, one-month follow-up). Conclusion: Linguistic intervention targeting improved retention and engagement among Latinos, but not abstinence. Latinos had higher retention but lower engagement and abstinence rates than Whites. Cultural targeting may engage Latinos in smoking cessation interventions and improve abstinence.

A prospective natural history study of post acute sequalae of COVID-19 using digital wearables: Study protocol.

Background: Post-acute sequelae of COVID-19 (PASC) is characterized by having 1 + persistent, recurrent, or emergent symptoms post the infection's acute phase. The duration and symptom manifestation of PASC remain understudied in nonhospitalized patients. Literature on PASC is primarily based on data from hospitalized patients where clinical indicators such as respiratory rate, heart rate, and oxygen saturation have been predictive of disease trajectories. Digital wearables allow for a continuous collection of such physiological parameters. This protocol outlines the design, aim, and procedures of a natural history study of PASC using digital wearables. Methods: This is a single-arm, prospective, natural history study of a cohort of 550 patients, ages 18 to 65 years old, males or females who own a smartphone and/or a tablet that meets pre-determined Bluetooth version and operating system requirements, speak English, and provide documentation of a positive COVID-19 test issued by a healthcare professional or organization within 5 days before enrollment. The study aims to identify wearables collected physiological parameters that are associated with PASC in patients with a positive diagnosis. The primary endpoint is long COVID-19, defined as ≥ 1 symptom at 3 weeks beyond first symptom onset or positive diagnosis, whichever comes first. The secondary endpoint is chronic COVID-19, defined as ≥ 1 symptom at 12 weeks beyond first symptom onset or positive diagnosis. We hypothesize that physiological parameters collected via wearables are associated with self-reported PASC. Participants must be willing and able to consent to participate in the study and adhere to study procedures for six months. Discussion: This is a fully decentralized study investigating PASC using wearable devices to collect physiological parameters and patient-reported outcomes. Given evidence on key demographics and risk profiles associated with PASC, the study will shed light on the duration and symptom manifestation of PASC in nonhospitalized patient subgroups and is an exemplar of use of wearables as population-level monitoring health tools for communicable diseases. Trial registration: ClinicalTrials.gov NCT04927442.

Telehealth access, willingness, and barriers during the COVID-19 pandemic among a nationally representative diverse sample of U.S. adults with and without chronic health conditions.

INTRODUCTION: During the COVID-19 pandemic, telehealth services represented a critical tool in maintaining continuity and access to care for adults in the USA. However, despite improvements in access and utilization during the pandemic, disparities in telehealth utilization have persisted. It is unclear what role access and willingness to use telehealth play in telehealth disparities. METHODS: We used data from the nationally representative COVID-19's Unequal Racial Burden (CURB) survey, an online survey conducted between December 2020 and February 2021, n = 5500. Multivariable Poisson regression was used to estimate the prevalence of perceived telehealth access and willingness to use telehealth services among adults with and without chronic conditions. RESULTS: Overall, 60.1% of adults with and 38.7% of adults without chronic conditions reported having access to telehealth. After adjustment, adults with chronic conditions were more likely to report telehealth access (adjusted prevalence ratio [aPR] = 1.35, 95% confidence interval [CI] = 1.21-1.50). Most adults with and without chronic conditions reported being willing to use telehealth services (85.1% and 79.8%, respectively), and no significant differences in willingness were observed across chronic condition status (aPR = 1.03, 95% CI = 0.95-1.13). Perceived telehealth access appeared to be a predictor of telehealth willingness in both groups (chronic conditions: aPR = 1.22, 95% CI = 0.97-1.54; no chronic conditions: aPR = 1.37, 95% CI = 1.22-1.54). The prevalence of perceived barriers to telehealth was low, with the majority reporting no barriers (chronic conditions = 51.4%; no chronic conditions = 61.4%). DISCUSSION: Perceived access to telehealth was associated with telehealth willingness. Investing in approaches that increase telehealth accessibility and awareness is needed to improve access to telehealth for adults with and without chronic conditions.

Decision Trade-Offs in Ecological Momentary Assessments and Digital Wearables Uptake: Protocol for a Discrete Choice Experiment.

BACKGROUND: Ecological momentary assessments (EMAs) and digital wearables (DW) are commonly used remote monitoring technologies that capture real-time data in people's natural environments. Real-time data are core to personalized medical care and intensively adaptive health interventions. The utility of such personalized care is contingent on user uptake and continued use of EMA and DW. Consequently, it is critical to understand user preferences that may increase the uptake of EMA and DW. OBJECTIVE: The study aims to quantify users' preferences of EMA and DW, examine variations in users' preferences across demographic and behavioral subgroups, and assess the association between users' preferences and intentions to use EMA and DW. METHODS: We will administer 2 discrete choice experiments (DCEs) paired with self-report surveys on the internet to a total of 3260 US adults through Qualtrics. The first DCE will assess participants' EMA preferences using a choice-based conjoint design that will ask participants to compare the relative importance of prompt frequency, number of questions per prompt, prompt type, health topic, and assessment duration. The second DCE will measure participants' DW preferences using a maximum difference scaling design that will quantify the relative importance of device characteristics, effort expectancy, social influence, and facilitating technical, health care, and market factors. Hierarchical Bayesian multinomial logistic regression models will be used to generate subject-specific preference utilities. Preference utilities will be compared across demographic (ie, sex, age, race, and ethnicity) and behavioral (ie, substance use, physical activity, dietary behavior, and sleep duration) subgroups. Regression models will determine whether specific utilities are associated with attitudes toward or intentions to use EMA and DW. Mixture models will determine the associations of attitudes toward and intentions to use EMA and DW with latent profiles of user preferences. RESULTS: The institutional review board approved the study on December 19, 2022. Data collection started on January 20, 2023, and concluded on May 4, 2023. Data analysis is currently underway. CONCLUSIONS: The study will provide evidence on users' preferences of EMA and DW features that can improve initial uptake and potentially continued use of these remote monitoring tools. The sample size and composition allow for subgroup analysis by demographics and health behaviors and will provide evidence on associations between users' preferences and intentions to uptake EMA and DW. Limitations include the cross-sectional nature of the study, which limits our ability to measure direct behavior. Rather, we capture behavioral intentions for EMA and DW uptake. The nonprobability sample limits the generalizability of the results and introduces self-selection bias related to the demographic and behavioral characteristics of participants who belong to web-based survey panels. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/47567.

Disparities in telehealth access, not willingness to use services, likely explain rural telehealth disparities.

PURPOSE: Although telehealth access and utilization have increased during the pandemic, rural and low-income disparities persist. We sought to assess whether access or willingness to use telehealth differed between rural and non-rural and low-income and non-low-income adults and measure the prevalence of perceived barriers. METHODS: We conducted a cross-sectional study using COVID-19's Unequal Racial Burden (CURB) online survey (December 17, 2020-February 17, 2021), which included 2 nationally representative cohorts of rural and low-income Black/African American, Latino, and White adults. Non-rural and non-low-income participants from the main, nationally representative sample were matched for rural versus non-rural and low-income versus non-low-income comparisons. We measured perceived telehealth access, willingness to use telehealth, and perceived telehealth barriers. FINDINGS: Rural (38.6% vs 44.9%) and low-income adults (42.0% vs 47.4%) were less likely to report telehealth access, compared to non-rural and non-low-income counterparts. After adjustment, rural adults were still less likely to report telehealth access (adjusted prevalence ratio [aPR] = 0.89, 95% CI = 0.79-0.99); no differences were seen between low-income and non-low-income adults (aPR = 1.02, 95% CI = 0.88-1.17). The majority of adults reported willingness to use telehealth (rural = 78.4%; low-income = 79.0%), with no differences between rural and non-rural (aPR = 0.99, 95% CI = 0.92-1.08) or low-income versus non-low-income (aPR = 1.01, 95% CI = 0.91-1.13). No racial/ethnic differences were observed in willingness to use telehealth. The prevalence of perceived telehealth barriers was low, with the majority reporting no barriers (rural = 57.4%; low-income = 56.9%). CONCLUSIONS: Lack of access (and awareness of access) is likely a primary driver of disparities in rural telehealth use. Race/ethnicity was not associated with telehealth willingness, suggesting that equal utilization is possible once granted access.

Novel Implementation Strategy to Electronically Screen and Signpost Patients to Health Behavior Apps: Mixed Methods Implementation Study (OptiMine Study).

BACKGROUND: Behavior change apps have the potential to provide individual support on a population scale at low cost, but they face numerous barriers to implementation. Electronic health records (EHRs) in acute care hospitals provide a valuable resource for identifying patients at risk, who may benefit from behavior change apps. A novel, emerging implementation strategy is to use digital technologies not only for providing support to help-seeking individuals but also for signposting patients at risk to support services (also called proactive referral in the United States). OBJECTIVE: The OptiMine study aimed to increase the reach of behavior change apps by implementing electronic signposting for smoking cessation and alcohol reduction in a large, at-risk population that was identified through an acute care hospital EHR. METHODS: This 3-phase, mixed methods implementation study assessed the acceptability, feasibility, and reach of electronic signposting to behavior change apps by using a hospital's EHR system to identify patients who are at risk. Phase 1 explored the acceptability of the implementation strategy among the patients and staff through focus groups. Phase 2 investigated the feasibility of using the hospital EHR to identify patients with target risk behaviors and contact them via SMS text message, email, or patient portal. Phase 3 assessed the impact of SMS text messages sent to patients who were identified as smokers or risky drinkers, which signposted them to behavior change apps. The primary outcome was the proportion of participants who clicked on the embedded link in the SMS text message to access information about the apps. The acceptability of the SMS text messages among the patients who had received them was also explored in a web-based survey. RESULTS: Our electronic signposting strategy-using SMS text messages to promote health behavior change apps to patients at risk-was found to be acceptable and feasible and had good reach. The hospital sent 1526 SMS text messages, signposting patients to either the National Health Service Smokefree or Drink Free Days apps. A total of 13.56% (207/1526) of the patients clicked on the embedded link to the apps, which exceeded our 5% a priori success criterion. Patients and staff contributed to the SMS text message content and delivery approach, which were perceived as acceptable before and after the delivery of the SMS text messages. The feasibility of the SMS text message format was determined and the target population was identified by mining the EHR. CONCLUSIONS: The OptiMine study demonstrated the proof of concept for this novel implementation strategy, which used SMS text messages to signpost at-risk individuals to behavior change apps at scale. The level of reach exceeded our a priori success criterion in a non-help-seeking population of patients receiving unsolicited SMS text messages, disconnected from hospital visits. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/23669.

Current state of unhealthy living characteristics in Black/African American and Latino populations: Tobacco use.

Over the past six decades, the United States has significantly improved tobacco-related health outcomes through mass efforts in policies, research, and behavioral and clinical interventions. Disparities persist, however, among communities of color who continue to suffer disproportionate rates of cardiovascular disease and other tobacco-related morbidity and mortality. In this review, we synthesize and discuss the tobacco use lifecycle across the lifespan, with special attention paid to socioecological determinants of tobacco-use behavior among Blacks and Latinos. This review summarizes the permeability of tobacco use and tobacco-related determinants across multiple levels of influence, from the individual to the societal, and highlights gaps in the tobacco control and prevention landscape. Given its continued evolution and impact on socially disadvantaged communities, we conclude with recommendations for improving current tobacco research and treatment and prevention efforts.

Smoking Susceptibility and Tobacco Media Engagement Among Youth Never Smokers.

BACKGROUND: Susceptibility to future smoking among youth never smokers has not changed in the past 20 years, although experimental cigarette smoking has decreased. We assessed how smoking susceptibility and tobacco industry-related marketing influenced smoking initiation. METHODS: Four waves (2013-2018) of the Population Assessment of Tobacco and Health Study data were analyzed among youth aged 12 to 17 years at wave 1 who completed wave 4. Susceptibility was assessed by 4 items (openness to curiosity, try soon, try in the next year, and if your best friend offered) and categorized into 4 levels (0 = definitely no to all; 1 = yes to 1; 2 = yes to 2; and 3 + 4 = yes to 3 or 4 susceptibility items). Multivariable logistic regression evaluated how susceptibility levels, electronic cigarette use, and tobacco-related media activity predicted future experimental (≥1 puff), current (past 30 days), or established (≥100 cigarettes) smoking. RESULTS: Among 8899 never smokers at wave 1, 16.4% became experimental smokers, 7.6% current smokers, and 1.8% established smokers at wave 4. Black and Latino/a youth were less likely to experiment. Youth who endorsed 3 or 4 susceptibility items at wave 1 were more likely to be experimental (adjusted odds ratio [aOR] = 6.0; confidence interval [CI] = 4.8-7.4), current (aOR = 4.2; CI = 3.2-5.4), or established (aOR = 4.4; CI = 2.4-7.9) smokers at wave 4. Exposure to tobacco marketing, using tobacco-related apps, seeing social media content posted about tobacco, and ever use of electronic cigarettes also predicted experimental smoking. CONCLUSIONS: Smoking susceptibility and exposure to tobacco industry-related marketing were predictive of cigarette smoking. Clinicians should consider screening adolescents for smoking susceptibility and tobacco-related media exposure.

Insights From the SmokeFree.gov Initiative Regarding the Use of Smoking Cessation Digital Platforms During the COVID-19 Pandemic: Cross-sectional Trends Analysis Study.

BACKGROUND: Smoking is a plausible risk factor for COVID-19 progression and complications. Smoking cessation digital platforms transcend pandemic-driven social distancing and lockdown measures in terms of assisting smokers in their quit attempts. OBJECTIVE: This study aims to examine trends in the number of visitors, followers, and subscribers on smoking cessation digital platforms from January to April 2020 and to compare these traffic data to those observed during the same 4-month period in 2019. The examination of prepandemic and postpandemic trends in smoking cessation digital platform traffic can reveal whether interest in smoking cessation among smokers is attributable to the COVID-19 pandemic. METHODS: We obtained cross-sectional data from daily visitors on the SmokeFree website; the followers of six SmokeFree social media accounts; and subscribers to the SmokeFree SMS text messaging and mobile app interventions of the National Cancer Institute's SmokeFree.gov initiative platforms, which are publicly available to US smokers. Average daily percentage changes (ADPCs) were used to measure trends for the entire 2020 and 2019 study periods, whereas daily percentage changes (DPCs) were used to measure trends for each time segment of change within each 4-month period. Data analysis was conducted in May and June 2020. RESULTS: The number of new daily visitors on the SmokeFree website (between days 39 and 44: DPC=18.79%; 95% CI 5.16% to 34.19%) and subscribers to the adult-focused interventions QuitGuide (between days 11 and 62: DPC=1.11%; 95% CI 0.80% to 1.43%) and SmokeFreeTXT (between days 11 and 89: DPC=0.23%; 95% CI 0.004% to 0.47%) increased, but this was followed by declines in traffic. No comparable peaks were observed in 2019. The number of new daily subscribers to quitSTART (ie, the teen-focused intervention) trended downward in 2020 (ADPC=-1.02%; 95% CI -1.88% to -0.15%), whereas the overall trend in the number of subscribers in 2019 was insignificant (P=.07). The number of SmokeFree social media account followers steadily increased by <0.1% over the 4-month study periods in 2019 and 2020. CONCLUSIONS: Peaks in traffic on the SmokeFree website and adult-focused intervention platforms in 2020 could be attributed to an increased interest in smoking cessation among smokers during the COVID-19 pandemic. Coordinated campaigns, especially those for adolescents, should emphasize the importance of smoking cessation as a preventive measure against SARS-CoV-2 infection and raise awareness of digital smoking cessation platforms to capitalize on smokers' heightened interest during the pandemic.

Guidelines for the design and conduct of human clinical trials on ingestion-time differences - chronopharmacology and chronotherapy - of hypertension medications.

Current hypertension guidelines fail to provide a recommendation on when-to-treat, thus disregarding relevant circadian rhythms that regulate blood pressure (BP) level and 24 h patterning and medication pharmacokinetics and pharmacodynamics. The ideal purpose of ingestion-time (chronopharmacology, i.e. biological rhythm-dependent effects on the kinetics and dynamics of medications, and chronotherapy, i.e. the timing of pharmaceutical and other treatments to optimize efficacy and safety) trials should be to explore the potential impact of endogenous circadian rhythms on the effects of medications. Such investigations and outcome trials mandate adherence to the basic standards of human chronobiology research. In-depth review of the more than 150 human hypertension pharmacology and therapeutic trials published since 1974 that address the differential impact of upon-waking/morning versus at-bedtime/evening schedule of treatment reveals diverse protocols of sometimes suboptimal or defective design and conduct. Many have been "time-of-day," i.e. morning versus evening, rather than circadian-time-based, and some relied on wake-time office BP rather than around-the-clock ambulatory BP measurements (ABPM). Additionally, most past studies have been of too small sample size and thus statistically underpowered. As of yet, there has been no consensual agreement on the proper design, methods and conduct of such trials. This Position Statement recommends ingestion-time hypertension trials to follow minimum guidelines: (i) Recruitment of participants should be restricted to hypertensive individuals diagnosed according to ABPM diagnostic thresholds and of a comparable activity/sleep routine. (ii) Tested treatment-times should be selected according to internal biological time, expressed by the awakening and bed times of the sleep/wake cycle. (iii) ABPM should be the primary or sole method of BP assessment. (iv) The minimum-required features for analysis of the ABPM-determined 24 h BP pattern ought to be the asleep (not "nighttime") BP mean and sleep-time relative BP decline, calculated in reference to the activity/rest cycle per individual. (v) ABPM-obtained BP means should be derived by the so-called adjusted calculation procedure, not by inaccurate arithmetic averages. (vi) ABPM should be performed with validated and calibrated devices at least hourly throughout two or more consecutive 24 h periods (48 h in total) to achieve the highest reproducibility of mean wake-time, sleep-time and 48 h BP values plus the reliable classification of dipping status. (vii) Calculation of minimum required sample size in adherence with proper statistical methods must be provided. (viii) Hypertension chronopharmacology and chronotherapy trials should preferably be randomized double-blind, randomized open-label with blinded-endpoint, or crossover in design, the latter with sufficient washout period between tested treatment-time regimens.

Dropout, response, and abstinence outcomes of a national text-messaging smoking cessation intervention for teens, SmokeFreeTeen.

Although text-messaging interventions are effective for smoking cessation, few target teens in the USA and little is known about their effectiveness. The purpose of this manuscript is to examine correlates of dropout, response to smoking status prompts, and abstinence rates among subscribers of SmokeFreeTeen, a free, publicly available text-messaging smoking cessation intervention sponsored by the National Cancer Institute's SmokeFree.Gov initiative, on quit day through 1 month follow-up. In a sample of teens (N = 2,685), aged 13-19, we examined demographics, smoking frequency, cigarettes smoked per day, prequit intervention time (i.e., maximum of 14 days of prequit day preparation), and number of quit attempts as correlates of response and abstinence rates among program initiators (i.e., participants who reached quit day but dropped out on or before intervention end) and completers (i.e., participants who reached quit day and completed the intervention). We also conducted Cox regression analysis of time from quit day to dropout by daily and nondaily smoking status. Two-thirds (n = 1,733, 64.54%) dropped out before the intervention ended, with dropout rates peaking on quit day (n = 289, 13.10%). Response rate to smoking status prompts remained below 30% throughout the intervention. At intervention end and 1 month follow-up, abstinence was 2.63% and 2.55% among program initiators, whereas abstinence was 6.09% and 6.01% among program completers. Dropout, response, and abstinence rates did not consistently differ by subscriber characteristics. Prequit time was associated with decreased likelihood of dropping out (adjusted hazards ratio: 0.94, confidence interval [CI]: 0.93-0.95), responding to smoking status prompts (adjusted odds ratio [aOR]: 0.94, CI: 0.92-0.96), and being abstinent (aOR: 0.96, CI: 0.93-0.99) on quit day. Two or more quit attempts were associated with increased response (aOR: 1.61, CI: 1.16-2.23) and abstinence (aOR: 1.91, CI: 1.25-2.92) rates on Day 7. In a first assessment of SmokeFreeTeen outcomes, we document high dropouts and low response and abstinence rates. SmokeFreeTeen produced abstinence rates lower than comparable text-messaging interventions targeting teens and young adults. Improving SmokeFreeTeen's reach, engagement, and effectiveness is needed.

Mining Electronic Health Records to Promote the Reach of Digital Interventions for Cancer Prevention Through Proactive Electronic Outreach: Protocol for the Mixed Methods OptiMine Study.

BACKGROUND: Digital behavior change interventions have demonstrated effectiveness for smoking cessation and reducing alcohol intake, which ultimately reduce cancer risk. Leveraging electronic health records (EHR) to identify at-risk patients and increasing the reach of digital interventions through proactive electronic outreach provide a novel approach that may increase the number of individuals who engage with evidence-based treatment. OBJECTIVE: This study aims to increase the reach of digital behavior change interventions by implementing a proactive electronic message system for smoking cessation and alcohol reduction among a large, at-risk population identified through an acute hospital EHR. METHODS: This protocol describes a 3-phase, mixed-methods implementation study to assess the acceptability, feasibility, and reach of a proactive electronic message system to digital interventions using a hospital's EHR system to identify eligible patients. In Phase 1, we will conduct focus group discussions with patients and hospital staff to assess the overall acceptability of the electronic message system. In Phase 2, we will conduct a descriptive analysis of the patient population in the hospital EHR regarding target risk behaviors and other person-level characteristics to determine the project's feasibility and potential reach. In Phase 3, we will send proactive messages to patients identified as smokers or risky drinkers. Messages will encourage and provide access to behavior change mobile apps via an embedded link; the primary outcome will be the proportion of participants who click on the link to access information about the apps. RESULTS: At the time of initial protocol submission, data collection was complete, but analysis had not begun. This study was funded by Cancer Research UK from April 2019 to March 2020. Health Research Authority approval was granted in June 2019. CONCLUSIONS: Increasing the reach of digital behavior change interventions can improve population health by reducing the burden of preventable death and disease. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/23669.

Barriers to Patient Portal Access and Use: Evidence from the Health Information National Trends Survey.

BACKGROUND: Patient access to their medical records through patient portals (PPs) facilitates information exchange and provision of quality health care. Understanding factors that characterize patients with limited access to and use of PPs is needed. METHODS: Data were from the 2017-2018 Health Information National Trends Survey 5, Cycles 1 and 2, a nationally representative survey of US adults ≥ 18 years old (n = 6789). Weighted multivariate logistic regressions modeled the associations between patient characteristics and access to, facilitators of use, and use of PPs and their functions. RESULTS: Individuals without (vs with) a regular doctor (adjusted odds ratio [aOR], 0.4; CI, 0.3-0.5) or health insurance (aOR, 0.4; CI, 0.2-0.7), those with high school (aOR 0.4; CI, 0.3-0.5) or with vocational/some college (aOR, 0.5; CI, 04.-0.7) education (vs college/postgraduate), or those with limited English proficiency (vs those who speak English very well) (aOR, 0.7; CI, 0.5-0.9) were less likely to report accessing their personal medical records. Women (vs men) were more likely to report accessing their medical records (aOR, 1.5; CI, 1.2-1.8). Similar patterns were found for PPs access and facilitators of use. Less consistent associations emerged between patient characteristics and use of PP functionalities. CONCLUSIONS: PP access and use are low. Having a primary care clinician, patient's educational attainment, and being a woman were factors associated with PP access and use, but not race/ethnicity. Once access was achieved, use of PP functionalities was generally uniform across demographic segments. Facilitating PP access and use among all patient populations is warranted.

Time to listen: a mixed-method study examining community-based views of mobile technology for interventions to promote physical activity.

INTRODUCTION: A mixed-method, co-design approach to studying the adoption of mobile health (mHealth) technology among African-American (AA) women has not been fully explored. Qualitative data may contextualise existing knowledge surrounding perceptions of mHealth among AA women as part of formative work for designing a physical activity application (app). METHODS: A convenience sample of 16 AA women completed an informatics survey prior to participating in focus groups exploring their use of mobile technology and health apps. Survey responses provided frequency data, while iterative transcript analysis of focus groups identified themes. RESULTS: The majority of participants (mean age=62.1 years, SD=6.6) felt comfortable using a tablet/smartphone (75.0%). Most (68.8%) reported using health-related apps, primarily focused on physical activity and nutrition. Focus groups revealed four overarching concepts, including (1) user attachment, (2) technology adoption, (3) potential facilitators and (4) potential barriers. Important features which may serve as facilitators or barriers to future adoption of a mobile app for an mHealth intervention include individual app tailoring and software concerns, respectively. DISCUSSION: Thematic analysis revealed high user attachment to smartphones and described participants' process for adopting new mHealth technology. CONCLUSION: Early engagement of target end users as a part of a broader co-design and community-based participatory research process for developing mHealth technologies may be useful for sustained adoption of these tools in future mHealth behavioural interventions.

Adolescent Smoking Susceptibility: Gender-Stratified Racial and Ethnic Differences, 1999-2018.

INTRODUCTION: Susceptibility, or openness to smoking, is a predictor of future smoking. This study examines within-gender racial/ethnic differences in smoking susceptibility over historical time (1999-2018) and developmental age (11-18 years). METHODS: Data were obtained from 205,056 adolescent never smokers in 14 waves of the National Youth Tobacco Survey. Weighted time-varying effect models were used to estimate nonlinear trends in smoking susceptibility among minority (versus white) adolescents. Analyses were conducted in 2019. RESULTS: Compared with whites, Latino/a adolescents were consistently more susceptible to smoking, whereas black and Asian adolescents fluctuated between being less and equally susceptible over time. American Indian, Alaska Native, Native Hawaiian, and Pacific Islander adolescents were more susceptible from 2014 to 2017, with differences being larger for girls. Susceptibility peaked at age 14 years. Compared with whites, Latino/a adolescents were more susceptible throughout adolescence. Black adolescents were more susceptible in early adolescence, whereas Asian adolescents were less or equally susceptible to smoking in early to mid-adolescence. American Indian, Alaska Native, Native Hawaiian, and Pacific Islander girls were more susceptible in early and mid-adolescence, but boys were more susceptible in early adolescence only. American Indian, Alaska Native, Native Hawaiian, and Pacific Islander girls were less susceptible than white girls aged 18 years. CONCLUSIONS: Twenty-year racial/ethnic differences in smoking susceptibility were evident, particularly among girls, but were mostly equivalent between genders over developmental age. Targeting susceptible adolescents with gender-, race/ethnic-, and age-tailored prevention efforts may prevent or delay adolescents' transition to tobacco use and reduce tobacco-related disparities.

Engagement and Short-term Abstinence Outcomes Among Blacks and Whites in the National Cancer Institute's SmokefreeTXT Program.

INTRODUCTION: Text-messaging programs for smoking cessation improve abstinence outcomes in the general population. However, little is known about engagement and abstinence outcomes among African Americans in text-messaging smoking cessation programs. The current study compares engagement and abstinence between Blacks and Whites in the National Cancer Institute's SmokefreeTXT program. METHOD: Data were from Blacks (n = 1333) and Whites (n = 7154) who enrolled in the 6-week SmokefreeTXT program between August 2017 and June 2018. We assessed the association between race and program initiation and completion; responses to weekly smoking cessation, mood, and craving assessments; and self-reported abstinence using multivariable logistic regression. RESULTS: Blacks and Whites initiated the program at a similar frequency, yet Blacks were more likely to complete the program (adjusted odds ratio [AOR] = 1.71, 95% confidence interval [CI] = 1.43 to 2.06). Blacks were less likely to respond to all seven abstinence, mood, and craving assessments (eg, AOR of quit day responses = 0.63, 95% CI = 0.51 to 0.77; 6-week AOR = 0.50, 95% CI = 0.34 to 0.72). Self-reported abstinence was lower among Blacks for all seven smoking assessments (eg, quit day abstinence AOR = 0.52, 95% CI = 0.41 to 0.68; 6-week abstinence AOR = 0.58, 95% CI = 0.38 to 0.89). CONCLUSION: Although Blacks were more likely than Whites to complete the SmokefreeTXT program, they were less likely to engage with the program by responding to assessment questions and had lower abstinence rates. Qualitative research may reveal unique barriers to engagement among Blacks. IMPLICATIONS: Black smokers enrolled in a nationwide mobile smoking cessation program at a rate comparable to White smokers. However, they were significantly less likely to engage with the program or quit smoking. This study highlights the need to examine barriers to cessation for Black smokers.

Dropout and Abstinence Outcomes in a National Text Messaging Smoking Cessation Intervention for Pregnant Women, SmokefreeMOM: Observational Study.

BACKGROUND: Population-level text messaging smoking cessation interventions may reduce racial and ethnic differences in smoking among pregnant women. OBJECTIVE: Our objective was to examine racial and ethnic differences in dropout, response, and abstinence rates among users of a US national, publicly available text messaging cessation intervention targeting pregnant women, SmokefreeMOM. METHODS: Participants were online subscribers to SmokefreeMOM who set a prospective quit date within the 9 months before their due date. We examined demographics, smoking frequency, number of cigarettes smoked per day, and prequit time (up to 14 days of preparation time before quit date) as correlates of response rate and abstinence at 8 time points: quit date, day 7, day 14, day 21, day 28, day 35, day 42 (intervention end), and day 72 (1-month follow-up). We conducted survival analysis of time from quit date to dropout by race and ethnicity. RESULTS: The mean age of the analytic sample of 1288 users was 29.46 (SD 7.11) years. Of these, 65.81% (848/1288) were white, 16.04% (207/1288) were black, 8.86% (114/1288) were Latina, and 9.29% (120/1288) were multiracial, American Indian/Alaska Native, Native Hawaiian Pacific Islander, or other; 82.68% (1065/1288) had some college education or less. Point-prevalence abstinence was 14.51% (157/1082) on quit day, 3.51% (38/1082) at intervention end, and 1.99% (21/1053) at 1-month follow-up. Black users (hazard ratio 0.68, 95% CI 0.51-0.91) and those with a high school degree or less (hazard ratio 0.66, 95% CI 0.49-0.89) or some college education (hazard ratio 0.75, 95% CI 0.57-0.99) were less likely to drop out than whites or users with a bachelor's degree or higher. Response and abstinence rates were similar across race, ethnicity, and education. CONCLUSIONS: Enrollment was low among racial and ethnic minority women but high among less-educated women. Abstinence at intervention end and 1-month follow-up was lower than that in controlled trials of text messaging cessation interventions for pregnant women (range 7%-20%). Increasing the reach, engagement, and effectiveness of SmokefreeMOM, especially among women with high rates of smoking during pregnancy, must be prioritized.

Parental Defensiveness about Multifactorial Genomic and Environmental Causes of Children's Obesity Risk.

Background: Future integration of genomics into weight management may target children with overweight given prospects for prevention. Meanwhile, parents learn about weight-related genomics primarily through the media, and little is known about parental reactions to complex genomic and environmental causes underlying children's obesity risk. Methods: Three hundred twenty-four parents with overweight who have a child 3-13 years of age were recruited through Amazon Mechanical Turk. Parents were randomized to read an article highlighting one of three causes of obesity risk: genetics only, family environment only, gene-family environment interactions (G × FE), or read a control article. Results: Parents who perceived their child to be overweight exhibited increased risk perception and guilt over parents of lean children overall, but exhibited decreased worry in response to the G × FE message. Furthermore, parents of children with overweight who received the G × FE message did not exhibit heightened risk perception or guilt, reported that the message was less relevant, and that they paid less attention to it. Conclusions: Multifactorial causal information about children's obesity risk elicits unintended consequences among parents whose children are most at-risk for obesity in adulthood. As these messages are most accurate, it is crucial to investigate effective ways to communicate the holistic nature of obesity risk to parents.