Bethany Shorey Fennell

This study examined differences between daily and non-daily nicotine pouch (NP) use by adults across various contexts in the United States (U.S.). Data were drawn from a cross-sectional survey of adults (≥18 years) reporting past-year NP use (N = 1009). Differences between daily and non-daily use groups were assessed using chi-square tests. Among the sample, 17.5% reported daily NP use. Daily use was associated with greater intensity, higher nicotine strength, and distinct situational use, including at home, while commuting, and at work or school (all p < 0.01). Adults who used daily more often endorsed motivations related to stress reduction, craving management, convenience, and product appeal (p ≤ 0.03). Daily use was linked to perceiving NPs as less harmful relative to combustible and smokeless tobacco, and more addictive relative to combustible, vaporized, and smokeless products (p < 0.05). Current and former use of combustible tobacco products, but not other substances, was common and varied by daily/non-daily use. Finally, adults who used daily were more likely to report a diagnosed mental or behavioral health condition (p = 0.002). Daily NP use reflects more intensive and contextually flexible use with distinct motivations and perceptions, underscoring heterogeneity in use patterns and the need for continued surveillance and longitudinal research on potential health implications.

Recruiting special populations to smoking cessation trials is challenging and approaches beyond in-clinic recruitment may be beneficial. This secondary analysis of data from a smoking cessation RCT for individuals with a history of cervical cancer or cervical intraepithelial neoplasia (CIN) explored differences associated with in-clinic vs. online recruitment. Participants were recruited from clinics within a university-based NCI-designated cancer center (n=87) and online nationally via Facebook (n=115). Baseline measures included sociodemographics, smoking history, and cancer or CIN history. Study retention and smoking abstinence were assessed 12 months post-baseline. Group differences in baseline characteristics were evaluated. Retention and abstinence were evaluated while controlling for group differences and predictors. Participants recruited online (vs. in-clinic) had higher educational attainment (p=.01) and health literacy (p=.003). They were more likely to have CIN vs. cancer, to be further from the time of diagnosis, and to have completed active treatment (p values<.001). While controlling for these group differences and independent predictors, retention was higher among participants recruited online (log-likelihood χ²(1)=11.41, p<.001). There were no recruitment differences in self-reported (p=.90) or biochemically confirmed smoking abstinence (p=.18). Compared to individuals recruited in-person, individuals recruited online were more educated, had higher health literacy, and presented with a different clinical profile (i.e., more likely to have CIN vs. cancer and to have completed active treatment). There were few differences in participant characteristics between recruitment approaches, and no differences on any smoking-related variables. Online recruitment has the potential to improve enrollment of cancer survivors to smoking cessation trials. People with a history of CIN or cervical cancer recruited to a smoking cessation RCT online (vs. in-clinic) were more likely to have a diagnosis of CIN vs. cancer and were more educated and health literate. Participants recruited online were more likely to be retained in the study and there were no differences in smoking abstinence rates at 12-months. Incorporating online recruitment increased the reach of tobacco treatment efforts to a larger and more diverse sample. This could reduce the burden of tobacco-related disease, improve CIN and cancer treatment outcomes, and reduce secondary malignancies and morbidity among this underserved group.

Background: The prevalence of smoking remains high in many low- and middle-income countries (LMICs), including the Southeast Asian nation of Cambodia. Smoking is especially hazardous for people with HIV. In Cambodia, approximately 43%-65% of men with HIV and 3%-5% of women with HIV smoke cigarettes. Thus, there is a critical need for cost-effective smoking cessation interventions for Cambodian people with HIV. This paper describes the design, methods, and data analysis plans for a randomized controlled trial assessing the efficacy of a theory-based mobile health smoking cessation intervention in Cambodian people with HIV. Objective: This 2-group randomized controlled trial compares the efficacy of a mobile health–based automated messaging (AM) intervention versus standard care (SC) in facilitating smoking cessation among Cambodian people with HIV. Methods: Cambodian people with HIV who currently smoke and are receiving antiretroviral treatment (target, N=800) will be randomized to (1) SC or (2) the AM intervention. SC participants will receive brief advice to quit smoking, written self-help materials, nicotine patches, and will complete weekly app-delivered dietary assessments for 26 weeks. AM participants will receive all SC components (but will complete smoking-related weekly assessments instead of dietary assessments), in addition to a fully automated tailored messaging program driven by the weekly assessments to facilitate smoking cessation. In the Phase-Based Model of smoking cessation, the cessation process is partitioned into 4 phases: motivation, preparation (precessation), cessation (quit date to 2 weeks post quit), and maintenance (up to 6 months post quit). Our AM program targets processes within these phases, including increasing motivation to quit, enhancing self-efficacy, obtaining social support, skills to cope with nicotine withdrawal symptoms and stress, and skills to maintain abstinence. All participants will complete baseline and 3-, 6-, and 12-month in-person follow-up assessments. The primary outcome is biochemically confirmed abstinence at 12 months, with 3- and 6-month abstinence as secondary outcomes. Potential mediators and moderators underlying treatment effects will be explored, and cost-effectiveness will be assessed. Results: This study was approved by all relevant domestic and international institutional and ethical review boards. Participant recruitment commenced in January 2023. Data collection is expected to conclude by the end of 2025. Conclusions: By demonstrating the greater efficacy and cost-effectiveness of AM relative to SC, this study has the potential to transform HIV care in Cambodia and prevent tobacco-related diseases. Furthermore, it may be adapted for use in other Cambodian populations and in other low- and middle-income countries. Ultimately, the AM approach to smoking cessation could greatly improve public health in the developing world and beyond. Trial Registration: ClinicalTrials.gov NCT05746442; https://clinicaltrials.gov/ct2/show/NCT05746442 International Registered Report Identifier (IRRID): PRR1-10.2196/48923

BACKGROUND The prevalence of smoking remains high in many low- and middle-income countries (LMICs), including the Southeast Asian nation of Cambodia. Smoking is especially hazardous for people with HIV. In Cambodia, approximately 43%-65% of men with HIV and 3%-5% of women with HIV smoke cigarettes. Thus, there is a critical need for cost-effective smoking cessation interventions for Cambodian people with HIV. This paper describes the design, methods, and data analysis plans for a randomized controlled trial assessing the efficacy of a theory-based mobile health smoking cessation intervention in Cambodian people with HIV. OBJECTIVE This 2-group randomized controlled trial compares the efficacy of a mobile health–based automated messaging (AM) intervention versus standard care (SC) in facilitating smoking cessation among Cambodian people with HIV. METHODS Cambodian people with HIV who currently smoke and are receiving antiretroviral treatment (target, N=800) will be randomized to (1) SC or (2) the AM intervention. SC participants will receive brief advice to quit smoking, written self-help materials, nicotine patches, and will complete weekly app-delivered dietary assessments for 26 weeks. AM participants will receive all SC components (but will complete smoking-related weekly assessments instead of dietary assessments), in addition to a fully automated tailored messaging program driven by the weekly assessments to facilitate smoking cessation. In the Phase-Based Model of smoking cessation, the cessation process is partitioned into 4 phases: motivation, preparation (precessation), cessation (quit date to 2 weeks post quit), and maintenance (up to 6 months post quit). Our AM program targets processes within these phases, including increasing motivation to quit, enhancing self-efficacy, obtaining social support, skills to cope with nicotine withdrawal symptoms and stress, and skills to maintain abstinence. All participants will complete baseline and 3-, 6-, and 12-month in-person follow-up assessments. The primary outcome is biochemically confirmed abstinence at 12 months, with 3- and 6-month abstinence as secondary outcomes. Potential mediators and moderators underlying treatment effects will be explored, and cost-effectiveness will be assessed. RESULTS This study was approved by all relevant domestic and international institutional and ethical review boards. Participant recruitment commenced in January 2023. Data collection is expected to conclude by the end of 2025. CONCLUSIONS By demonstrating the greater efficacy and cost-effectiveness of AM relative to SC, this study has the potential to transform HIV care in Cambodia and prevent tobacco-related diseases. Furthermore, it may be adapted for use in other Cambodian populations and in other low- and middle-income countries. Ultimately, the AM approach to smoking cessation could greatly improve public health in the developing world and beyond. CLINICALTRIAL ClinicalTrials.gov NCT05746442; https://clinicaltrials.gov/ct2/show/NCT05746442 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/48923

Ask-Advise-Connect (AAC) efficiently links smokers in healthcare settings with evidence-based Quitline-delivered tobacco treatment through training clinic staff to systematically ask patients about smoking status, advise smokers to quit, and connect patients with state Quitlines using the electronic health record. This study utilized a mixed-methods approach, guided by the RE-AIM framework, to evaluate the implementation of AAC in a Federally Qualified Health Center (FQHC). AAC was implemented for 18 months at a FQHC serving primarily low-socioeconomic status (SES) Latinos and Latinas. Results are presented within the RE-AIM conceptual framework which includes dimensions of reach, effectiveness, adoption, implementation, and maintenance. Quantitative patient-level outcomes of reach, effectiveness, and Impact were calculated. Post-implementation, in-depth interviews were conducted with clinic leadership and staff (N = 9) to gather perceptions and inform future implementation efforts. During the implementation period, 12.0% of GNHC patients who reported current smoking both agreed to have their information sent to the Quitline and were successfully contacted by the Quitline (Reach), 94.8% of patients who spoke with the Quitline enrolled in treatment (Effectiveness), and 11.4% of all identified smokers enrolled in Quitline treatment (Impact). In post-implementation interviews assessing RE-AIM dimensions, clinic staff and leadership identified facilitators and advantages of AAC and reported that AAC was easy to learn and implement, streamlined existing procedures, and had a positive impact on patients. Staff and leadership reported enthusiasm about AAC implementation and believed AAC fit well in the clinic. Staff were interested in AAC becoming the standard of care and made suggestions for future implementation. Clinic staff at a FQHC serving primarily low-SES Latinos and Latinas viewed the ACC implementation process positively. Findings have implications for streamlining clinical smoking cessation procedures and the potential to reduce tobacco-related disparities. Ask-Advise-Connect (AAC) simplifies and streamlines the process of asking patients about their smoking status, advising smokers to quit, and connecting patients through the electronic health record with free, evidence-based tobacco cessation treatment offered by state Quitlines. This study is the first to evaluate perceptions of AAC among clinic leadership and staff. After an 18-month implementation of AAC at a clinic serving mostly low-income Latinos and Latinas, clinic staff (e.g., medical assistants) and leaders were interviewed. Respondents reported that AAC streamlined their efforts to get patients to quit smoking, was easy to carry out, and fit well into the clinic flow. Staff wanted to keep AAC as the standard of care and made suggestions to improve how AAC works. They reported positive feedback from patients. In addition, a similar proportion of smokers enrolled in Quitline treatment as in other AAC trials. Thus, AAC worked well for patients and clinic staff. Having AAC in other clinics could improve enrollment in evidence-based smoking cessation treatment, facilitate successful smoking cessation among low-income primary care patients, and reduce burden on healthcare providers.

Objectives: Self‐affirmation approaches for health behaviour demonstrate consistent small to medium effects on message acceptance, health intentions and behaviour change. There are several forms of self‐affirmation (e.g., values affirmations, implementation intentions), but few empirical comparisons to guide selection in empirical work. Further, there has been little emphasis on the putative mechanisms of self‐affirmation driving behaviour change. The current investigation compared a control and four self‐affirmation approaches: values, social, implementation intention, and perspective taking. Methods: Participants were recruited through CloudResearch ( N = 666) and reported baseline sun exposure and protection behaviour at Time 1. One week later (Time 2), returning participants ( N = 535) were randomly assigned to condition, viewed a message conveying risks of sun exposure, and reported sun exposure and protection intentions for the next week. Follow‐up one week later (Time 3; N = 449) assessed past week sun exposure (i.e., number of days spent outside during peak hours), sun protection behaviour (e.g., sunscreen use), future sun exposure and protection intentions and engagement with resources conveying further health information (i.e., viewing infographics, following links to websites with more information). The association of putative mechanisms with self‐affirmation conditions and health outcomes was also examined. Results: Unexpectedly, there were few differences between self‐affirmation conditions and the control on intentions, information seeking, or behaviour at follow‐up. At follow‐up, perspective circle participants reported fewer days spent outside, spent longer viewing infographics, and, along with social values participants, followed more weblinks seeking information than control participants. The putative mechanisms were unrelated to health outcomes. Conclusions: The current investigation was a first step in comparing novel online self‐affirmation approaches and had largely null findings. Results suggest that the perspective circle performed best at promoting information seeking and, to some extent, behaviour change. Suggestions for future directions are discussed.