While the overall smoking rate in Minnesota has decreased dramatically, certain communities, such as communities of color, American Indians, immigrants and refugees, LGBTQ community members, and people with mental illness and substance use disorders have much higher rates of commercial tobacco use. This has led to disparities in secondhand smoke exposure and risk for and incidence of smoking related-disease and death. These health inequities stem from cultural/social norms around commercial tobacco use; the targeting of these communities by the tobacco industry through misinformation and predatory marketing tactics; and lack of funding for tobacco prevention efforts—especially for those that utilize effective, culturally specific approaches. To address these issues, in 2015 the Center for Prevention at Blue Cross and Blue Shield of Minnesota began a funding initiative called Communities Eliminating Tobacco Inequities (CETI), which aimed to reduce commercial tobacco use in communities by supporting community-driven, culturally specific efforts that raise awareness, shift cultural/social norms and/or influence organizational and local public policy. This initiative acknowledged and respected the sacred, medicinal and traditional use of tobacco by American Indians and other groups, distinguishing traditional tobacco from commercial tobacco products which are manufactured and sold for a profit. The eight selected organizations worked in partnership with their communities on topics related to Minnesota's unique demographics. These communities included new immigrants/refugees, like the Somali, Karen, Lao and Latinx communities, American Indians, people with mental illness and substance use disorders and Lincoln Park, the most racially and socio-economically diverse neighborhood in Duluth.

These were the key strategies that the CETI-funded organizations chose to implement:

• Educate the community on the harms of commercial tobacco
• Create community health settings using a holistic place-based approach
• Eliminate tobacco in indoor and outdoor settings through organizational and/or local policy change

This session will share findings from the initiative’s evaluation and what the “C” in CETI stands for - Communities. It is a communities’ knowledge, expertise, and experiences that determines and creates change. With this belief, CETI values:

• Culturally responsive approaches that includes a community’s context and engages community leaders and members
• Community members, leaders both formal and informal, community-based organizations
• Sacred, medicinal and traditional tobacco use by American Indians and other groups
• Disaggregated data gathered in language, at the community, regional, state or national level – on commercial tobacco use, secondhand and thirdhand smoke exposure and risk for and incidence of smoking related-disease and death

Policy, systems and environmental change to reduce commercial tobacco use and exposure

Background: Measures of health behaviors such as smoking are typically sourced from surveys that are not representative at small areas. State level measures of smoking mask local variation, particularly in larger states such as Texas. Birth records can be used to generate local-level measures of smoking during pregnancy, which provide a window into a community’s overall tobacco use. This study assessed prevalence of smoking during pregnancy at the ZIP-code level in Texas in 2015, and explored variation by urbanicity and race/ethnicity.

Methods: Texas birth records (2015) were used to generate ZIP-code-level measures of smoking during pregnancy in ZIP codes with at least 100 births during the year. Geographic Information Systems (GIS) were used to map prevalence estimates by ZIP code among all mothers and by mothers of Hispanic, non-Hispanic black, and non-Hispanic white descent. Median ZIP-code-level prevalence estimates in urban and nonurban ZIP codes were compared using a nonparametric k-sample equality-of-medians test.

Results: In 2015, 3.6% of Texas births were to women who smoked during pregnancy. Among the 853 included ZIP codes, median ZIP-code-level prevalence of smoking during pregnancy was 2.6% (IQR: 1.1 – 6.4, range: 0.0 – 25.4). The median ZIP-code-level prevalence among non-Hispanic white women was 4.9% (IQR: 2.2 – 10.3, range: 0.0 – 35.5) among 478 included ZIP codes. The median ZIP-code-level prevalence of smoking during pregnancy outside of urbanized areas was 3.8 times greater than the median of urbanized area ZIP codes (6.9% vs. 1.8%, p < 0.001) for all women. The pattern of higher smoking prevalence in less urbanized areas was consistent across racial/ethnic populations.

Conclusions: This study demonstrated the substantial geographic and racial/ethnic variation in smoking during pregnancy in Texas. These data can be a useful resource for community-level tobacco use prevention and cessation efforts targeting not only pregnant women but the broader population.

Background: The prevalence of smoking in the general U.S. population has declined to 14% in 2017. However, this has not been true for persons living with HIV (PLWH) who have disproportionately high smoking rates (40-70%). Tobacco use causes higher rates of morbidity and mortality in PLWH than smokers in the general population demonstrating the need for developing smoking cessation interventions for this health disparate population.

Methods: We conducted 6 focus group sessions with 45 PLWH (25 male, 20 female) who smoke in order to understand barriers to tobacco cessation, strategies for overcoming these barriers and the acceptability of the Path2Quit App, a mobile app integrated with a sensor to detect smoking motions when a person “lights up.”

Results: Our study sample was exclusively African American. Mean age of study participants was 52 years. Participants identified the following barriers to smoking cessation: 1) Social circles include other people who smoke; 2) habit; 3) weight gain after quitting smoking; 4)addictive personality; and 5) afraid of change. To overcome these barriers, participants suggested the use of a telephone support system, decreasing access to cigarettes in their neighborhood, and an appreciation for how they would improve their health and save money by quitting smoking. Participants were enthusiastic on the utility of the Path2Quit App for reinforcing tobacco cessation, explaining that the App would help them become accountable.

Conclusions. This is one of the first studies to assess the barriers to tobacco cessation among African American smokers living with HIV and demonstrated the acceptability of the Path2Quit App for PLWH.

Background: Telomere length is an indicator for biological ageing; as each time a cell divides, telomeres shorten. Shorter and longer than expected telomeres are associated with increased cancer risk and other chronic diseases. Although telomere length varies by racial/ethnic group, research on how tobacco use and exposure affect telomere length across age groups by minority racial/ethnic status is scarce.

Methods: Time varying effect modeling (TVEM) was employed on the 1999-2002 National Health and Nutrition Examination Survey to observe the effects of active tobacco use and environmental exposure - measured through serum cotinine - and mean telomere length of adults 19 to 85 years old (N=7827; M=1.03 T/S ratio, SD=0.28). Models included Mexican American, other Hispanic, Non-Hispanic Black, and other race/multi-racial and were controlled by sex, SES, education, and ever-smoker status.

Results: The association of serum cotinine levels with mean telomere length (mTL) varied by age and racial/ethnic groups. Mexican American smokers had an increase in mTL (0.0076 T/S ratio) at approximately 52 years of age, which was higher than other Hispanics (0.0073 T/S ratio) at age 68. Serum cotinine levels decreased mTL on non-Hispanic Blacks (-0.0046 T/S ratio) at age 66; other race/multiracial also decreased (-0.0114 T/S ratio) at age 28.

Conclusion: Findings indicate that mTL increases or decreases with serum cotinine at different ages by race/ethnicity, which may be indicative of differential health risks. Using TVEM, cross-sectional data can be modeled longitudinally to innovatively observe trends to find optimal point of intervention, while expanding health disparities research.

Background

Socio-economic and sexual orientation inequalities in cigarette smoking are well-documented. However, it is not understood how these two dimensions of inequalities act in combination. Using an intersectional framework, we 1) assessed the joint, referent and excess intersectional inequalities in cigarette smoking at the intersection of sexual orientation and socio-economic status; and 2) examined key factors and processes contributing to these inequalities.

Methods

We used data from Wave 2 (2014-2015) of the Population Assessment of Tobacco and Health (PATH) Study (28,362 adults). Educational level (less than high school; high school or more) and sexual orientation (heterosexual; Lesbian/Gay/Bisexual/Queer or Questioning (LGBQ)) were cross-classified to form four intersectional positions. We estimated prevalence differences in smoking corresponding to joint, referent, and excess intersectional inequalities using weighted linear binomial regression. Analysis was adjusted for gender, age, and race/ethnicity. Using non-linear Oaxaca decomposition, we then decomposed the joint inequality, referent socio-economic inequality, and referent sexual orientation inequality by demographic, material, tobacco marketing-related, and intrapersonal factors.

Results

The joint inequality amounted to a 7.6 percentage points (p.p.) (95% CI: 2.5, 12.8) difference in smoking between the doubly advantaged (heterosexual with high school education or more) and doubly disadvantaged (low-educated LGBQ adults) intersectional positions. There was also a substantial negative excess intersectional inequality (-14.6 p.p. (-20.8, -8.3)), attributed to an unexpectedly low prevalence of smoking among low-educated LGBQ adults. Material conditions (annual household income, housing, and health insurance) made the largest contribution to the explained component of the joint inequality (140.9%), referent socio-economic inequality (128.4%), and referent sexual orientation inequality (59.8%).

Conclusions

The two dimensions of inequalities in smoking (i.e. education and sexual orientation) did not add up in expected patterns. Material disadvantage was the most important social process explaining inequalities in cigarette smoking at the intersection of education and sexual orientation.

Background. California's diverse population includes many adults who identify as lesbian, gay, or bisexual (LGB). Sexual minority adults amoke at greater rates than their heterosexual counterparts, but the impact of cigarette smoking on healthcare costs has not been analyzed for this group.

Methods. We analyzed data on 6,158 adults aged 18-70 who self-identified as LGB from the 2005-2014 California Health Interview Surveys. Utilization of doctor visits, emergency room (ER) visits, asthma medication, and blood pressure medication was analyzed using multivariable linear regression and multivariable logistic regression models. Models were specified as a function of smoking status, sociodemographic characteristics, and survey year. The estimated models were used to calculate predicted healthcare utilization for LGB smokers under an actual and a counterfactual scenario in which current and former smokers were the same as in the actual scenario, except they were assumed to be never smokers. The difference between the actual and counterfactual predictions is the smoking-attributable healthcare utilization, which was multiplied by unit costs from the 2014 Medical Expenditures Panel Survey to derive smoking-attributable healthcare costs. Costs were converted to 2018 dollars using the CPI for medical care.

Results. Currently smoking lesbian and bisexual women had almost 200,000 excess doctor visits and over 10,000 excess ER visits per year compared to their never smoking counterparts. In addition, over 3,000 gay and bisexual male former smokers per year reported excess use of asthma medications compared to their never smoking counterparts. There were no significant differences in use of blood pressure medications by smoking status. Total smoking-attributable costs were $70.2 million for the sexual minority community (in 2018 dollars).

Conclusions. The LGB population is particularly vulnerable to the negative impact of tobacco use due to high smoking prevalence and incurs high healthcare costs as a result. While California has a strong tobacco control program, there remains a need to develop targeted tobacco control efforts for the LGB community.

Background: Various cognitive, social, and environmental factors influence youths’ likelihood of smoking initiation. Some such factors include level of sensation-seeking, parental approval of smoking, peers’ perceptions of smoking, and number of smokers in the household. Using data from a nationally representative survey, we explored the relationship between these factors and ones’ smoking behavior. More specifically, we are interested in how race moderates the relationship between risk factors of smoking and actual smoking behavior. Thus, the goal of this study is to examine the ways in which youth’s racial identities might influence the effects of their calculated risk of smoking.

Method: Survey participants were 13 to 25-year-olds who were contacted by phone at two time points. Secondary analyses were performed to investigate the effect of youths’ smoking risk at baseline on their smoking intentions upon recontact. At time 1 N=11,847 and at time 2 N=4470.

Results: OLS regression models showed higher aggregated risk scores were associated with greater intentions to initiate smoking (b=1.182, p<.001, 95% CI=.998 – 1.365). Additionally, despite having lower intentions to smoke overall, Black youth were more sensitive to the risk factors that predisposed youths to smoking compared to White youth (b=-.848, p<.001, 95% CI=-1.307 – -.388). There were no significant differences in the effects of risk on the other racial minority groups, compared to whites.

Conclusions: Although Black youth are less likely to become regular smokers than their White peers, they are more sensitive to the effects of a number of smoking risk-factors. Prevention efforts should take these risk factors into consideration among all youth and should especially be emphasized in efforts targeting Black youth. Also, continued investigation into smoking risk factors will allow for the development of more tailored intervention strategies.

Background:

Over the last fifty years, the adult smoking rate in the United States (US) declined dramatically, from 42 to 15.5% (2016). Despite this success, smoking remains the single leading cause of preventable death and disease in the US impeding “creating the healthiest nation”. Moreover, smoking has emerged as a health disparity among population subgroups—with higher rates for those who are low-income, burdened with adverse health/social conditions, and racial/ethnic or other minorities. Consequently, new smoking cessation approaches are needed. California’s Tobacco Control Program (CTCP) is leading this effort with novel strategies and a paradigm shift: “The End Game” which aspires to achieve 0% smoking by 2035. The CTCP strategy of interest for this project is a statewide health care redesign initiative called CA Quits. CA Quits proposes stewarding collaborations between three health care sectors: health departments, Medicaid plans, and safety net health care providers to integrate cessation interventions in clinical settings and create and a continuum of care via referrals to the state's Helpline or other community based cessation services. CA Quits is guided by the Collective Impact (CI) change theory which posits that large-scale societal problems are best resolved using cross-sector stakeholder collaborations focused on a singular goal. This project is a formative evaluation of the CA Quits’ concepts including its application of CI.

Methods:

This qualitative study used key informant interviews (n=21: 6 public health, 6 Medicaid plans, 6 providers, 3 sector leaders) derived from a purposive sample across six California counties, two each in three regions of the state, North, Central and South. The key informants were recruited using network connections (n=6), snowball (n=2), and cold call (n=13) approaches. Semi-structured interviews were conducted using 10 open ended questions along two domains (health priorities/collaborations). Thematic analysis was undertaken of the barriers and drivers to addressing smoking among low-income populations and collaborating with partners across the three sectors. Two questions are addressed by the formative evaluation: 1) Are stakeholder incentives sufficiently aligned to motivate participation in the CA Quits project? and 2) Is CI applicable to the CA Quits concept and targeted stakeholders?

Results:

Nine major themes emerged from the data including three drivers and six barriers to addressing smoking disparities and collaborating across sectors. Primary drivers: Government and funder mandates, and leadership imperatives provide a structural impetus to address smoking. Primary barriers: local politics, emerging recreational marijuana use, complex health needs, and social determinants confound effective intervening in smoking behaviors.

Conclusions:

Multisector incentives to address smoking among safety net patient populations sufficiently align but tailored engagement approaches per sector are required. Where there are imperatives and mandates to prioritize addressing smoking gaps also exist and less than optimal procedures prevail. Each sector has work flow processes, data challenges and time constraints that can be improved by working collaboratively, across sectors and with the support of CA Quits. Barriers reveal population needs and additional motivation to address smoking. CI is an appropriate change theory.

Patient-provider communication plays a vital role in encouraging healthy outcomes. However, providers' knowledge of electronic cigarettes is mixed, and they do not feel confident in advising about e-cigarettes despite the increase in usage and marketing strategies as a safer alternative to traditional combustion cigarettes. Differences in e-cigarette awareness and usage between racial groups also exist, specifically a higher prevalence among white populations. Therefore, the purpose of this paper is to examine how perceived patient-provider communication quality (PPCQ) influences perceptions of e-cigarette harmfulness and the moderating role of race/ethnicity.

A pooled cross-sectional analysis investigating the associations between perceived PPCQ (i.e., allowing for questions, attentiveness, shared decision-making, using plain language), race/ethnicity, and perceptions of e-cigarette harmfulness. The sample consisted of 9,973 adult respondents from the Health Information National Trends Survey (HINTS) 2012-2014 and 2017-2018 cycles. Multiple linear regression models were used; a subset of current and former smokers was examined exclusively in the relationship between PPCQ and perceptions of e-cigarette harmfulness. Control variables included demographics and health-related variables (health coverage, frequency of provider visits). The dependent variable, perception of e-cigarette harmfulness, was measured by a 5-point Likert scale. Racial/ethnic categories included, Non-Hispanic White, Non-Hispanic Black, Hispanic, Non-Hispanic Asian, and Non-Hispanic Other.

Black individuals had more positive associations with their providers (p<0.01). Race/ethnic groups of color viewed e-cigarettes as less harmful (p<0.01), and there were significant associations between a higher perception of e-cigarette harmfulness with higher perceived PPCQ (p<0.001).

Providers’ opinions and knowledge on e-cigarettes are mixed, translating to missed opportunities to sufficiently counsel smokers on addressing their tobacco dependencies. Our findings confirm that racial disparities remain in perceived PPCQ with associated conflicting perceptions of e-cigarette harmfulness. Standard best practices are needed for consultations regarding e-cigarettes. Policymakers should devise policies to adequately train providers to achieve this standard of care.

Cancer is the leading cause of morbidity and mortality for Latinx followed by African Americans (CDC, 2017), particularly, cancers of the breast, lung, colon, rectum, and prostate (ACS, 2015). Screening can increase the rate of early detection and treatment success. However, the rates of compliance for screening are typically lower among Latinx, which may contribute to decreased diagnosis and increased risk of disease in comparison to their Euro-American counterparts (ACS, 2015). Access to screening services and ability to pay are among the commonly cited barriers for screening compliance. For Latinx communities, there are unique sociocultural barriers that need to be addressed. The Illinois Department of Public Health recommends incorporating patient navigator (PN) models in community health clinics and communitywide events to increase health literacy, knowledge, and delivery, and quality of care including compliance with screening methods. Building on the Institute of Medicine’s health care disparities framework (IOM, 2003) to address environmental as well as sociocultural barriers, the University of Illinois (UI) Cancer Center (UICC) works in partnership with the UI Health Mile Square Health Center (MSHC) to implement a bilingual, bicultural PN model for conducting comprehensive cancer prevention and screening services that promote breast, cervical, colorectal, lung, and prostate health among Latinx, African Americans, and underserved communities in Chicago. A culturally responsive evaluation using a mixed methods approach was conducted to evaluate the patients’ perceptions and experiences with patient navigator encounters and support services. The authors facilitated a series of semi-structured interviews and survey questionnaires, as well as data abstracted from patient records. Provider interviews were conducted to understand provider knowledge and attitudes of navigator services. Additionally, navigators were interviewed to capture benefits and challenges of incorporating navigation services at the Mile Square clinics. This paper validates the implementation of PN models at federally qualified health centers as an asset to patients and providers in facilitating health education, increasing patient screening compliance, and improving access to health care services. PNs also work collaboratively with MSHC medical providers from across the UI MSHCs to complement their work and build their capacity as appropriate for reducing structural and sociocultural barriers to delivery of care for cancer screening among Latinx patients. Examples of structural barriers include decreasing screening, diagnosis, and treatment time and decreasing distance between service delivery settings and target population. Sociocultural barriers include language and linguistic differences as well as health literacy. Comprehensive cancer screening maximizes resources, contains healthcare costs, and improves the quality of life and health outcomes of underserved Latinx and African American patients who are navigated to services. PN-provider partnerships are introduced as a hallmark of the program’s success in identifying at-risk patients and navigating them to appropriate and timely medical screening, diagnostic, and treatment services. Future directions for incorporating and evaluating culturally responsive, bilingual, bicultural PN models at FQHCs, community clinics, and school based clinics are shared to inform public policy for rapid cycle monitoring of protective health cancer interventions and early detection services for Latinx and African American patients in Chicago