Tobacco Dependence Treatment Program Research Articles

Using information technology to integrate tobacco use treatment in routine oncology care: Lessons learned from the U.S. Cancer Center Cessation Initiative Cancer Centers.

Cancer patients who receive evidence-based tobacco-dependence treatment are more likely to quit and remain abstinent, but tobacco treatment programs (TTPs) are not consistently offered. In 2017, the U.S. National Cancer Institute, through the Cancer Moonshot, funded the Cancer Center Cessation Initiative (C3I). C3I supports 52 cancer centers to implement and expand evidence-based tobacco treatment in routine oncology care. Integration into routine care involves the use of health information technology (IT), including modifying electronic health records and clinical workflows. Here, we examine C3I cancer centers' IT leadership involvement and experiences in tobacco-dependence treatment implementation. This qualitative study of C3I-funded cancer centers integrated data from online surveys and in-person, semistructured interviews with IT leaders. We calculated descriptive statistics of survey data and applied content analysis to interview transcripts. Themes regarding IT personnel included suggestions to involve IT early, communicate regularly, understand the roles and influence of the IT team, and match program design with IT funding and resources. Themes regarding electronic health record (EHR) modifications included beginning modifications early to account for long lead time to make changes, working with IT to identify and adapt existing EHR tools for TTP or designing tools that will support a desired workflow developed with end-users, and working with IT personnel to make sure TTPs comply with system and state policies (e.g., privacy laws). The experiences of C3I cancer centers regarding the use of health IT to enhance tobacco-dependence treatment program implementation can guide cancer centers and community oncology practices to potentially enhance TTP implementation and patient outcomes.

Enrollments in a Tobacco Dependence Treatment Program during the Covid-19 Pandemic: A Case Study

During the pandemic, Covid-19 mortality rates were higher in those who smoke. Smokers reported relapse to tobacco use during the pandemic and /or an increase in the numbers of cigarettes smoked. Individuals reported working from home with more opportunity to smoke without restrictions, increased stress, anxiety, boredom, and isolation as their reasons for relapse or increased cigarette consumption. A health system tobacco cessation program was offered remotely with individual telephone or telehealth sessions and weekly virtual support groups. There was a significant increase in program enrollments and quit rates during the pandemic compared to the previous year. As individuals return to in-person work, tobacco control measures, such as tobacco-free indoor and outdoor environments as well as tobacco cessation programs will be important factors in reducing smoking and encouraging cessation.

An evaluation of the feasibility of implementing a novel tobacco dependence treatment program for high-risk individuals into clinical practice within a community mental health center

BackgroundIndividuals with serious mental illnesses experience deaths related to smoking at a higher prevalence than individuals without a psychotic-spectrum disorders. Traditional smoking cessation programs are often not effective among individuals with chronic mental disorders. Little is known about how to implement a tobacco cessation treatment program for this at-risk population within a community health center. The current study used qualitative methods to examine the factors that may enhance or impede the delivery of a novel tobacco cessation treatment for smokers with a psychotic-spectrum disorder diagnosis in an integrated care community health center.MethodsUsing a case study design, we conducted 22 semi-structured interviews with primary care providers, mental health providers, addiction counselors, case managers, intake specialists, schedulers, pharmacists, and administrative staff employed at the organization. Interviews were transcribed and themes were identified through a rich coding process.ResultsWe identified environmental factors, organizational factors, provider factors and patient factors which describe the potential factors that may enhance or impede the implementation of a smoking cessation program at the integrated care community health center. Most notably, we identified that community mental health centers looking to implement a smoking cessation program for individuals with chronic mental health disorders should ensure the incentives for providers to participate align with the program’s objectives. Additionally, organizations should invest in educating providers to address stigma related to smoking cessation and nicotine use.ConclusionsThe findings of our study provide valuable insight for administrators to consider when implementing a smoking cessation program in an integrated care community health center. Our findings provide public health practitioners with potential considerations that should be discussed when designing and implementing a smoking cessation program for individuals with chronic mental disorders.

Tobacco Dependence Treatment: Examining Cessation Effectiveness in Oncology Settings

The Wilmot Cancer Institute launched the Tobacco Dependence Treatment Program in 2015. Formal program evaluation consisted of 324 patients who presented for at least one visit to assess quit rates. The secondary aim was to ascertain the effectiveness of guideline recommendations that four or more visits would be beneficial in an outpatient oncology tobacco treatment program to promote success in smoking cessation. The first 32 months of program data revealed that there were significantly improved quit rates for those who were seen for four or more visits compared to those seen for three or fewer visits.

How has the COVID-19 pandemic affected tobacco users in India: Lessons from an ongoing tobacco cessation program.

INTRODUCTIONTobacco use is detrimental at any time. However, it is proving to be more dangerous during the COVID-19 pandemic. Tobacco use may increase the risk of being infected, increases the chances of complications, and also increases the probability of its spread. We assessed the awareness about this association and the impact of the lockdown on tobacco use among tobacco users registered before the lockdown for LifeFirst, a tobacco dependence treatment program.METHODS1016 tobacco users were under active follow-up in their course of the 6-month counselling program. From 14 to 28 May 2020, 650 (64%) of these registered users were contacted by counsellors for follow-up sessions over the telephone. Semi-structured questionnaires were filled in during the calls.RESULTSTwo-thirds (67%) of tobacco users were unaware of the association between tobacco and COVID-19. Only 30% of the users felt that the current situation had affected their tobacco use, the commonest impacts being unavailability and increased prices of tobacco products. While this was seen as an opportunity to quit by some users, some reported increased tobacco use due to increased stress. Of the 219 (34%) tobacco users who quit tobacco during the lockdown, 51% quit because of the lockdown and their concern over COVID-19. Abstinence among those who were aware of the association between the coronavirus and tobacco was twice that among those who were not aware.CONCLUSIONSAwareness activities about the harmful effects of tobacco during the coronavirus pandemic have to be strengthened. Measures to motivate and support tobacco users to quit have to be provided through cessation services.

Cost-Effectiveness of Community-Based Tobacco Dependence Treatment Interventions: Initial Findings of a Systematic Review.

IntroductionScientific literature evaluating the cost-effectiveness of tobacco dependence treatment programs delivered in community-based settings is scant, which limits evidence-based tobacco control decisions. The aim of this review was to systematically assess the cost-effectiveness and quality of the economic evaluations of community-based tobacco dependence treatment interventions conducted as randomized controlled trials in the United States.MethodsWe searched 8 electronic databases and gray literature from their beginning to February 2018. Inclusion criteria were economic evaluations of community-based tobacco dependence treatments conducted as randomized controlled trials in the United States. Two independent researchers extracted data on study design and outcomes. Study quality was assessed by using Drummond and Jefferson’s economic evaluations checklist. Nine of 3,840 publications were eligible for inclusion. Heterogeneity precluded formal meta-analyses. We synthesized a qualitative narrative of outcomes.ResultsAll 9 studies used cost-effectiveness analysis and a payer/provider/program perspective, but several study components, such as abstinence measures, were heterogeneous. Study participants were predominantly English speaking, middle aged, white, motivated to quit, and highly nicotine dependent. Overall, the economic evaluations met most of Drummond and Jefferson’s recommendations; however, some studies provided limited details. All studies had a cost per quit at or below $2,040 or an incremental cost-effectiveness ratio (ICER) at or below $3,781. When we considered biochemical verification, sensitivity analysis, and subgroups, the costs per quit were less than $2,050 or the ICERs were less than $6,800.ConclusionAll community-based interventions included in this review were cost-effective. When economic evaluation results are extrapolated to future savings, the low cost per quit or ICER indicates that the cost-effectiveness of community-based tobacco dependence treatments is similar to the cost-effectiveness of clinic-based programs and that community-based interventions are a valuable approach to tobacco control. Additional research that more fully characterizes the cost-effectiveness of community-based tobacco dependence treatments is needed to inform future decisions in tobacco control policy.

ES20.04 Tobacco Control Integration in Cancer Care: The Jordan Experience

Tobacco Control Integration in Cancer Care: The Jordan Experience Tobacco control is an integral component of any action plan that aims to reduce cancer incidence and mortality. Efforts at King Hussein Cancer Center, the only comprehensive cancer center in Jordan and the region, started 10 years ago. We sought to address the tobacco epidemic in Jordan on multiple fronts. In Jordan, tobacco prevalence exceeds 60%. About 50% of patients presenting with a cancer diagnosis are smokers. Integrating tobacco control in general and tobacco dependence treatment in patients suffering from cancer is pivotal. Smoking in patients with cancer has been shown to impact cancer treatment, increase complications from cancer treatment, increase cancer recurrence, increase the odds of development of secondary malignancies and eventually decrease overall long-term survival. Throughout the last 10 years our tobacco dependence treatment program grew in services and scope. The program addressed three major components required for tobacco control in cancer patients: First, patient-centered clinical tobacco dependence treatment service. Second, tobacco dependence treatment training and education for health-care providers. Third, research that addresses tobacco dependence in cancer patients. Our program provides 6 smoking cessation clinics every week dedicated mainly to our cancer patients. We have managed to address training needs for our staff by establishing a tobacco treatment specialist training program, the first ever to be accredited by The Council for Tobacco Treatment Training Programs outside the USA. We studied outcomes of our treatment program and developed means to improve referral to smoking cessation clinics as well as improve the abstinence of our patients. In addition, we studied knowledge, attitude and perception of our health care providers working at our institution; a step especially important in a country where significant numbers of health care providers are smokers. Finally, we studied the impact of our tobacco dependence treatment program on the survival of our patients. Understanding the impact of smoking cessation on short-term survival of patients with cancer (2 years) highlights the importance of integrating such programs as part of the acute treatment phase of these patients. Cancer registry and smoking cessation clinic data for cancer patients diagnosed between 2012 and 2016 were analyzed. Approximately 19% of cancer patients were seen at the smoking cessation clinic. In a sub-sample of 2,387 patients, a significant two-year survival advantage was observed for smokers who had visited the smoking cessation clinic and confirmed that they had not smoked on at least two of their 3, 6 or 12-month follow-up visits (HR 2.8, 95% confidence interval [CI] = 1.7–4.5) relative to those who never went to the smoking cessation clinic. Those at the smoking cessation clinic who were abstinent at only one follow-up point also exhibited a survival advantage (non-abstainers at the smoking cessation had comparable survival to those who were not seen at the clinic). In conclusion, tobacco control in patients with cancer has an important role in the outcome and survival of these patients and must be integrated in their short and long-term plan of care. Cessation, cancer, Tobacco

Enrollee Characteristics in an Intensive Tobacco Dependence Treatment Program: The Relationship of Race and Sex to Demographic Factors and Tobacco Use Patterns.

Intensive tobacco treatment programs offer many advantages relative to other treatment options, particularly for more complex patients, e.g., highly nicotine dependent, or those with medical and psychiatric symptoms and disorders. Efforts to better understand those who choose to enroll in these programs, particularly regarding the characteristics they possess known to mediate outcomes, are important considerations in tailoring available services. In this study, we examined how participants differed on key descriptive and tobacco use variables within race (i.e., African-American, Caucasian) and sex subgroups. Baseline characteristics from a large group of consecutive program enrollees were examined across targeted subgroups. Strong racial effects and some sex effects were noted for marital status, education, employment and health insurance status, alcohol consumption, presence of medical and psychiatric disorders, as well as participant tobacco use patterns and tobacco use rates of family, friends and coworkers. The differences in participant tobacco use measures across race and sex factors remained significant after adjusting for the confounding effects of all other covariates. These findings have implications for characterizing key patient subgroups who present at tobacco treatment clinics. Such information may contribute to options for tailoring treatment regimens.

Effectiveness of Village Health Worker-Delivered Smoking Cessation Counseling in Vietnam.

Smoking prevalence is high in Vietnam, yet tobacco dependence treatment (TDT) is not widely available. We conducted a quasiexperimental study that compared the effectiveness of health care provider advice and assistance (ARM 1) versus ARM 1 plus village health worker (VHW) counseling (ARM 2) on abstinence at 6-month follow-up. This study was embedded in a larger two-arm cluster randomized controlled trial conducted in 26 community health centers (CHCs) in Vietnam. Subjects (N = 1318) were adult patients who visited any participating CHC during the parent randomized controlled trial intervention period and were self-identified as current tobacco users (cigarettes and/or water pipe). At 6-month follow-up, abstinences rates in ARM 2 were significantly higher than those in ARM 1 (25.7% vs. 10.5%; p < .001). In multivariate analyses, smokers in ARM 2 were almost three times more likely to quit compared with those in ARM 1 (adjusted odds ratio [AOR] = 2.96, 95% confidence interval [CI] = 1.78% to 4.92%). Compared to cigarette-only smokers, water pipe-only smokers (AOR = 0.4, 95% CI = 0.26% to 0.62%) and dual users (AOR = 0.62, 95% CI = 0.45% to 0.86%) were less likely to achieve abstinence; however, the addition of VHW counseling (ARM 2) was associated with higher quit rates compared with ARM 1 alone for all smoker types. A team approach in TDT programs that offer a referral system for health care providers to refer smokers to VHW-led cessation counseling is a promising and potentially scalable model for increasing access to evidence-based TDT and increasing quit rates in low middle-income countries (LMICs). TDT programs may need to adapt interventions to improve outcomes for water pipe users. The study fills literature gaps on effective models for TDT in LMICs. The addition of VHW-led cessation counseling, available through a referral from primary care providers in CHCs in Vietnam, to health care provider's brief cessation advice, increased 6-month biochemically validated abstinence rates compared to provider advice alone. The study also demonstrated the potential effectiveness of VHW counseling on reducing water pipe use. For LMICs, TDT programs in primary care settings with a referral system to VHW-led cessation counseling might be a promising and potentially scalable model for increasing access to evidence-based treatment.

Evaluation of a national tobacco dependence treatment program in Uruguay 2017

Evaluation of a national tobacco dependence treatment program in Uruguay 2017

Implementation of Tobacco Dependence Treatment Programs in Oncology Settings.

To discuss strategies for implementing tobacco dependence treatment in cancer care and the role of oncology nurses. Evidence-based clinical practice guidelines for tobacco dependence treatment, published literature and Web sites. There are many benefits of quitting smoking after a diagnosis of cancer. Implementation of tobacco dependence treatment can improve patient outcomes but requires system changes. The electronic health care record, access to telephone quit lines for smoking cessation, resources for providers, and changes in insurance coverage all facilitate the delivery of treatment. Oncology nurses can play an important role in championing tobacco dependence treatment in cancer care.

The effectiveness of the tobacco, alcohol and drug dependence treatment program (SAMBA) on drug users in probation

In this research, the aim is that searching the effectiveness of a structured treatment program over treatment process on substance abusers, who are sent to medical institutions because of compulsory treatment within the scope of probation. Methods: Two hundred and fourteen substance users who were sent to Erenkoy Mental Health and Neurological Diseases Hospital AMATEM Clinic within the scope of probation have been taken under research, consecutively. The tobacco, alcohol and drug dependence treatment program (SAMBA) has been applied to substance users. Before and after application, Addiction Profile Index Clinic Form (BAPI-K) and a questionnaire to assess knowledge of drug users about addiction has been applied. They have attended the SAMBA program, once in 15 days, 6 times in total and they have all been made urine tests at each time. Urine tests have been made for 6 weeks. People who have not participated in the program once or in whose urine tests substance has been found once have been considered as incompatible with treatment. Findings: The 62.8% of the sample (n=76) have completed the SAMBA program; the urine test results of 33.1% of them (n=40) have been evaluated as positive. The risk that having positive urine test results on those who did not complete the program, has been found nine times more (odds ratio 9.02) than those who completed. When scores are compared before and after implementation; while leaving the substance motivation subscale scores has been increased, BAPI total, craving, depression and anxiety scores have been found to be decreased. Also a statistically significant increase in the Knowledge Assessment Survey scores has been observed. Those who have high scores of craving and novelty-seeking behavior initially, have lower rate of completing the program. Conclusion: It has been shown that SAMBA program is an increasing factor for adherence to treatment on substance users, who were directed to treatment because of probation, users who have craving and novelty-seeking behavior carry a risk about completing structured treatment program.

Evaluation of a Comprehensive Tobacco Dependence Treatment Program: Dental Students’ Perceptions of Preparedness and Clinical Practice

The aims of this study were to assess dental students' perceptions of their preparedness for providing treatment for tobacco dependence and to determine if their training resulted in successful practice in the dental school clinic. Since the tobacco dependence treatment program began at the University of Detroit Mercy School of Dentistry, all third- and fourth-year dental students have been required to complete an online survey about their attitudes and experience with tobacco dependence treatment. This descriptive study and retrospective analysis utilized these survey data from the initiation of the program in fall 2002 through 2010 (615 third-year and 590 fourth-year students, for a total of 1,205, all of whom participated in the surveys). The results showed that most of the students believed they were at least adequately prepared to provide treatment. The majority said they ask patients about tobacco use and advise patients about its negative health consequences, yet the average of their perception of patient interest in quitting was below 18%. Although the students reported being at least adequately prepared to assess patient interest in quitting, their assessment was much lower than the nearly 70% of U.S. tobacco users that general studies have found are interested in quitting. These students' perception of such low patient interest reflects a misconception they may have about their own preparedness, and it suggests a barrier exists for them in providing effective tobacco dependence treatment services. This perception signals a need for curriculum and assessment changes to increase the effectiveness of this school's tobacco dependence treatment program.

Validity of the Italian version of the Severity of Dependence Scale (SDS) for nicotine dependence in smokers intending to quit.

The objective was to test the psychometric properties of an Italian version of the Severity of Dependence Scale, a five-item measure designed to assess the compulsive dimension of drug dependence. 635 smokers enrolled in a tobacco dependence treatment program served as the participants. The Fagerström Test for Nicotine Dependence was used as a comparative measure. Dimensionality of the Severity of Dependence Scale and the Fagerström Test for Nicotine Dependence was assessed by factor analysis. Prediction of smoking at one year was evaluated by logistic regression. Factor analysis yielded a two-factor solution; however, the second factor explained very little variance. Factor 1 had a Cronbach's alpha of .66 (overall Scale coefficient = .44). The total Severity of Dependence Score predicted smoking at one year (OR = 1.10).

Provider-Delivered Tobacco Dependence Treatment to Medicaid Smokers

Smoking prevalence is 49% among Medicaid enrollees in Ohio. The objective of this pilot project was to test a comprehensive tobacco dependence treatment program targeting rural Medicaid-enrolled smokers for both physician-level and smoker-level outcomes. Using a group-randomized trial design, intervention group physicians (n = 4) were exposed to systems-level changes in their clinics, and smokers in these clinics were offered 12 weeks of telephone cessation counseling. Control group physicians (n = 4) were given the clinician's version of the U.S. Public Health Serivce (USPHS) Clinical Practice Guideline, and smokers in these clinics were given information about the Ohio Tobacco Quitline. Physician-level and smoker-level outcomes were assessed at 1 week and 3 months, respectively. Costs per quit were estimated. A total of 214 Medicaid smokers were enrolled. At 1 week, there were no reported differences in rates of being asked about tobacco use (68% intervention, 58% control) or advised to quit (69% intervention, 63% control). However, 30% of intervention and 56% of control smokers reported receiving a prescription for pharmacotherapy (p < .01). At 3 months, there were no differences in quit attempts (58% intervention, 64% control), use of pharmacotherapy (34% intervention, 46% control), or abstinence (24% intervention, 16% control for self-reported abstinence; 11% intervention, 3.5% control for cotinine-confirmed abstinence). The intervention group proved more cost-effective at achieving confirmed quits ($6,800 vs. $9,700). We found few differences in outcomes between physicians exposed to a brief intervention and physicians who were intensively trained. Future studies should examine how tobacco dependence treatment can be further expanded in Medicaid programs.

Trust in Physicians Among Rural Medicaid‐Enrolled Smokers

Associations have been found between trusting patient-physician relationships and use of preventive care and a greater adherence to prescribed care. The objectives of this study were to assess the level of trust rural Medicaid smokers have in their physicians and whether trust was related to patient characteristics or physician behavior. This was a cross-sectional study of smokers who were enrolled in a tobacco-dependence treatment program. Participants were rural Medicaid-enrolled adults, age 18 and older, who were current smokers. Participants were enrolled from 8 primary care clinics as they came in for an appointment with their physician. The Trust in Physician Scale was completed at the baseline visit. One week later, an interview was conducted with the smoker to determine whether the physician provided tobacco-dependence treatment counseling at the visit. Mixed models were used to model the relationship between trust and participant characteristics and physician behaviors. Medicaid smokers in this study exhibited a high level of trust in their health care provider, as levels were similar to those reported in the general population of patients. Trust was significantly higher among individuals with better self-reported health. Rural Medicaid smokers appeared to have similar levels of trust in their physician as other patients. Future research should explore the role trust plays in shaping interactions between underserved populations and physicians within the context of smoking cessation counseling.

Socioeconomic Disparities in Community-Based Treatment of Tobacco Dependence

We examined socioeconomic disparities in a community-based tobacco dependence treatment program. We provided cognitive-behavioral treatment and nicotine patches to 2739 smokers. We examined treatment use, clinical and environmental, and treatment outcome differences by socioeconomic status (SES). We used logistic regressions to model end-of-treatment and 3- and 6-month treatment outcomes. The probability of abstinence 3 months after treatment was 55% greater for the highest-SES than for the lowest-SES (adjusted odds ratio [AOR] = 1.55; 95% confidence interval [CI] = 1.03, 2.33) smokers and increased to 2.5 times greater for the highest-SES than for the lowest-SES smokers 6 months after treatment (AOR = 2.47; 95% CI = 1.62, 3.77). Lower-SES participants received less treatment content and had fewer resources and environmental supports to manage a greater number of clinical and environmental challenges to abstinence. Targets for enhancing therapeutic approaches for lower socioeconomic groups should include efforts to ensure that lower-SES groups receive more treatment content, strategies to address specific clinical and environmental challenges associated with treatment outcomes for lower-SES smokers (i.e., higher dependence and stress levels and exposure to other smokers), and strategies to provide longer-term support.

A pilot test of a combined tobacco dependence treatment and lung cancer screening program

Lung cancer screening with computed tomography has demonstrated a significant reduction in mortality. While these findings are important for the lung cancer research field, the most important risk factor for lung cancer, i.e. smoking, should not be ignored. We performed a pilot study to examine the feasibility of delivering a program that included both tobacco dependence treatment and lung cancer screening. The objectives of this study were to: (1) estimate the proportion of smokers who complied with a 12-week treatment protocol that included both tobacco dependence treatment and lung cancer screening, (2) obtain preliminary estimates of abstinence and quit attempts at 4 and 6 months, and (3) obtain preliminary estimates of the cognitive social health information processing (C-SHIP) constructs and how they change following the intervention. In this randomized pilot study, 18 volunteers completed a 12-week protocol: half received the tobacco dependence treatment program before a CT scan (BCT) and the other received the CT scan first, followed by the treatment program (ACT). The treatment protocol included both nurse-delivered telephone counseling and either nicotine replacement therapy or varenicline. Only one person did not complete all follow-up evaluations. At 4 months post enrollment, the carbon monoxide confirmed quit rates were 33.3% in the BCT arm and 22.2% in the ACT arm (27.8% overall), and all but one had made a 24-h attempt to quit. At 6 months the confirmed abstinence decreased to 22.1% in the BCT arm and 11.1% in the ACT arm (16.7% overall), and 72.2% of participants had made a 24-h quit attempt. These preliminary results suggest that it might be better to deliver treatment before the screening test. Future randomized trials with a larger sample size are needed to confirm these findings.

PRS63 Faciliators and Barriers Associated with the Use of Pharmacological – Behavioral Combination Therapy to Smoking Cessation

We aimed to explore patients' perceived positive and negative factors associated with the use of pharmacological-behavioral combination therapy to smoking cessation. Each patient who visited a drug dependent treatment center was assessed using structured clinical interviews and the Fagerström Test for Nicotine Dependence (FTND). In-depth interviews were conducted with patients who agreed to participate in the study. These patients were treated with behavioral therapy combined with bupropion or nicotine gum and followed up for three consecutive months. The interview responses were recorded, transcribed and organized thematically based on emerging codes using an inductive analysis. Seventeen key informants participated in this study and the mean age was 38.2 years. Their FTND score varied from 3.0-5.0 and the number of cigarettes smoked was 3-40 per day. Among these patients 11.8% were able to quit smoking within 1 month, 29.4% within 2 months, 29.4% within 3 months, and 29.4% could not quit smoking in any period of the study. Supportive factors to smoking cessation included supports from family and colleagues, poorer health, role model for acquaintances, household cost saving, practical advice from encouraging physicians, fear of social blame, smoking-free policy at workplace, and the patients' proactive strategies to avoid smoking temptation. Nevertheless, some barriers to smoking cessation were lacking in initiative and readiness to quit smoking; lacking of family support; incompliance to pharmacological-behavioral therapy; gaining weight; triggers such as nicotine withdrawal symptoms, stress, being in a party with smokers; using tobacco as a substitute of other substance; and inconvenient service time and facility at the treatment center. This study provides a framework of interrelated social factors associated with the use of pharmacological-behavioral combination therapy to smoking cessation. There is a need for developing tobacco dependence treatment programs and enabling factors tailored to meet the needs of patients.

Smoking and Predictors of Nicotine Dependence in a Homeless Population

To assess prevalence rates of tobacco use and dependence in a sample of homeless individuals and to investigate trends for demographic and clinical characteristics across different levels of nicotine dependence (nonsmokers vs. lowly dependent smokers vs. highly dependent smokers). A cross-sectional study of 489 homeless men and women in 3 Canadian cities. Each subject was assessed using structured clinical interviews and the Fagerström Test for Nicotine Dependence (FTND). Cochran-Armitage trend tests were applied to determine unadjusted trends in sociodemographic and clinical variables across levels of nicotine dependence. A generalized logit model was computed to adjust for potential confounding. The mean age was 37.9 years; 39.2% of the participants were women. About 80.8% were current smokers; the mean FTND score was 5.0. Although no significant differences were found between nonsmokers and smokers with low nicotine dependence, smokers with high nicotine dependence were only half as likely as nonsmokers to be Aboriginal, were 2.39 times more likely to have ever been incarcerated, and 2.44 times more likely to have current drug dependence. There were significant trends for the use of cocaine, opioids, and alcohol, with nonsmokers having the lowest and highly dependent smokers having the highest rates of using these substances. Available public health smoking cessation treatment opportunities should be made available within health care services for the homeless. There is also a need for developing and implementing tobacco dependence treatment programs, which are accessible and tailored to meet the needs of this specific population, accounting for polysubstance use and concurrent substance dependence and mental health disorders.