published_or_final_version / Public Health / Master / Master of Public Health

Background: Chronic Obstructive Pulmonary Disease (COPD) poses a substantial burden to Hong Kong. Smoking is the single most important risk factor for COPD. Intensive smoking cessation in COPD patients slows disease progression. Community pharmacy based smoking cessation in healthy smokers could forestall COPD onset. Each of these programs has been proven effective and cost-effective worldwide. Currently there are smoking cessation clinics in Hong Kong. But community pharmacy-based smoking cessation services are not available. The present study firstly attempts to identify the disease burden of COPD; secondly, to investigate if community pharmacy-based smoking cessation services are applicable in Hong Kong; finally, to examine if establishing the services would be cost effective in reducing the burden of COPD. Methods: A series of data analysis of mortality, morbidity and cost of hospitalization (length of stay × standard daily ward cost) was conducted to understand the burden of COPD in Hong Kong. Cost effectiveness analysis based on a Markov model evaluated smoking cessation strategies against usual care: (1) minimal counseling in smoking cessation clinics (MiniC) for COPD patients; (2) intensive counseling with pharmacotherapy in smoking cessation clinics (IC_pharm) for COPD patients; (3) community pharmacist-assisted service (CPA) for healthy smokers; (4) combination of CPA and MiniC (CPA+MiniC); (5) combination of CPA and IC_pharm (CPA+IC_Pharm). The Markov model was constructed by sex, smoking status and COPD severity to calculate the lifetime cost of COPD, cost of smoking cessation programs and QALYs. Both effectiveness and cost were discounted at 3%. Incremental cost effectiveness ratios (ICERs), i.e. cost per one QALY gain, served as the decision making rule. One way sensitivity analysis, threshold analysis and probabilistic sensitivity analysis were performed to explore the uncertainty around the parameters. Results: The overall age adjusted mortality of COPD increased from 28.8 per 100 000 in 1981 to 30.14 per 100 000 in 2008. Numbers of people aged 65+ with known COPD was projected to be over 100 000 by 2036. There were 3.8 and 7.8 years of life lost (YLL) and 3.6 and 5.6 QALYs lost due to COPD for male and female smokers respectively. Medical costs of hospitalization were estimated to be over HK$ one billion (US$132 million) in 2008. Seventy one COPD cases could be avoided in the simulated cohort by CPA. If the threshold value was HK$247 332 for one QALY gain, CPA was more cost effective than IC_Pharm, with an ICER of HK$47 717. CPA+MiniC dominated CPA. CPA+IC_Pharm was more cost effective than CPA+MiniC (ICER, HK$36 000). The probability of CPA+ IC_pharm being the most cost effective strategy was approaching 0.8 if one QALY was worth HK$96 000, and it was associated with the maximum expected QALYs if societal value for one QALY was no less than HK$80 000. Conclusion: The model-based economic evaluation demonstrated that CPA+IC_Pharm would be the most cost-effective smoking cessation strategy. Community pharmacy based (CPA) smoking cessation services could be applicable and should be proposed in Hong Kong to reduce the burden of smoking related diseases. / published_or_final_version / Public Health / Doctoral / Doctor of Philosophy

Objectives: Menthol is an organic compound synthesized or naturally obtained from peppermint or other mint oils and once added to cigarettes, is believed to have caused extra adverse health consequences (Kolawole S. Okuyemi 2004) compared with non-menthol cigarettes. This review has multi-purposes: First, to review and summarize the causes of African Americans’ high preference over menthol cigarettes; Second, to review smoking cessation studies and determine the association between menthol cigarettes and reduced quitting rates for African American smokers; Third, to gather information of evidence-based interventions for menthol cigarette smoking cessation. Methods: This article reviewed 16 journal articles through PubMed search using the following key words: menthol cigarette, smoking cessation, African American. And only one Chinese article was found by searching the key word “薄荷?” in CNKI Chinese database. Further search was done by using Google search engine and got 11 electronic articles or webpages for this topic. According to the objectives of this article, 3 journal papers were reviewed for examining the causes of African American smokers’ high preference over menthol cigarettes; 8 journal papers were reviewed for determining the association between menthol cigarettes and reduced quitting rates for African American smokers. In this section, the inclusion criteria include: age (18-65); gender (male, female); study design (cohort, cross-sectional, RCT). At last, 5 journal papers and 5 electronic resources including news were reviewed to gain an up-to-date insight for possible interventions of menthol cigarette smoking. Results: The leading causes for African American smokers’ high preference over menthol cigarettes include: like the minty/cool flavor; perceive menthol cigarette as having medicinal effects; menthol smokers’ influences from one’s social network; tobacco companies’ tailored marketing strategies. Overall, there were lower quitting rates for menthol cigarette smokers compared to non-menthol cigarette smokers at least among African American smokers. For menthol cigarettes and smoking cessation among African American smokers, 4 studies got significant results. For menthol cigarette and non-menthol cigarette smoking cessation among African American smokers: study 1 (TABLE 2), 6 weeks abstinence rate 28.3% vs. 41.5%, p=0.006; study 2 (TABLE 2), 4 weeks abstinence OR=0.32, 95% CI [0.16, 0.62], p<0.05, 6 months abstinence OR=0.48, 95% CI [0.25, 0.9], p<0.05; study 3 (TABLE 2), 6 months abstinence OR=0.23, 95% CI [0.17, 0.31], p<0.05. Study 4 (TABLE 2) compared African menthol cigarette smokers to Whites non-menthol cigarette smokers, OR=0.72, 95% CI [0.53, 0.97], p=0.031. For another 4 studies, they got non-significant results but still revealed such an association. Conclusions: Causes for African American smokers’ high preference over menthol cigarettes were identified as: tailored marketing strategies; physical properties of menthol cigarette (taste, smell); and demographic/social/psychological/cultural/attitudinal causes. There were significantly lower quitting rates for menthol cigarette smokers compared to non-menthol cigarette smokers at least among African American smokers. For menthol cigarette smoking cessation interventions, whether or not a ban on menthol would be implemented or not, comprehensive programs that include educational program, clinical menthol cigarette smoking cessation aids, taxation for price control, and smoke free and related regulations are needed. At last, China should learn experiences from the US regarding analysis of preference and possible clinical, educational, and policy interventions for menthol cigarette smoking cessation and prevention. / published_or_final_version / Medicine / Master / Master of Public Health

This study examined the effects of a smoking cessation program using vouchers as reinforcers with individuals with traumatic brain injury and a history of substance abuse. The intervention was conducted at a residential facility that houses individuals with Traumatic Brain Injury (TBI). Vouchers were delivered contingent on reductions of carbon monoxide (CO) samples of 5 ppm or less across a shaping phase, and an abstinence induction phase. A standard pay phase was added at the end of the study to examine the effects of a standardized reinforcement scale with the abstinence criterion set at 8 ppm or less. Reductions in CO were not robust in the shaping and abstinence induction phase. The standard pay schedule showed some improvements in CO levels with less variability for two of the three participants.

published_or_final_version / abstract / toc / Nursing Studies / Master / Master of Philosophy

Nicotine, the main addictive compound in tobacco, is metabolically inactivated to cotinine primarily by the hepatic enzyme CYP2A6. Substantial genetic variation in the CYP2A6 gene contributes to large variation in nicotine metabolism which alters numerous smoking behaviours. The goal of this study was to identify and characterize novel CYP2A6 variants. The CYP2A6 gene from African American phenotypically slow nicotine metabolizers was sequenced. Seven novel non-synonymous variants were identified: 468G>A (V68M), 1767C>G (I149M), 3515G>A (R265Q), 3524T>C (I268T), 4406C>T (T303I), 5661G>A (E390K), 6531T>C (L462P). They were introduced into a cDNA expression construct where they displayed lower protein expression, reduced nicotine metabolism to cotinine, and/or reduced stability as evaluated by western blotting and enzymatic activity. Genotyping assays were developed and assessed in 512 African Americans. Allelic frequencies ranged from 0.1-0.6% with a collective genotype frequency of 3.2%. Here we identified novel variants with reduced/loss of CYP2A6 activity, increasing our understanding of CYP2A6 variability.

Nicotine, the main addictive compound in tobacco, is metabolically inactivated to cotinine primarily by the hepatic enzyme CYP2A6. Substantial genetic variation in the CYP2A6 gene contributes to large variation in nicotine metabolism which alters numerous smoking behaviours. The goal of this study was to identify and characterize novel CYP2A6 variants. The CYP2A6 gene from African American phenotypically slow nicotine metabolizers was sequenced. Seven novel non-synonymous variants were identified: 468G>A (V68M), 1767C>G (I149M), 3515G>A (R265Q), 3524T>C (I268T), 4406C>T (T303I), 5661G>A (E390K), 6531T>C (L462P). They were introduced into a cDNA expression construct where they displayed lower protein expression, reduced nicotine metabolism to cotinine, and/or reduced stability as evaluated by western blotting and enzymatic activity. Genotyping assays were developed and assessed in 512 African Americans. Allelic frequencies ranged from 0.1-0.6% with a collective genotype frequency of 3.2%. Here we identified novel variants with reduced/loss of CYP2A6 activity, increasing our understanding of CYP2A6 variability.

Individuals with a substance addiction and/or mental illness use tobacco at rates much higher than the general population. Approximately 21% of the U.S. population smokes, yet 40%-80% of substance abuse and mental health patients smoke and consume more than 44% of all the cigarettes sold in the United States each year. As a result, these individuals experience increased tobacco related morbidity and mortality. Tobacco use is common and accepted within this population, and has become a norm even within treatment programs. Only 30%-40% of treatment facilities offer smoking cessation resources, and many organizations are hesitant to address cessation or to adopt a tobacco-free campus policy. This toolkit addresses the unique barriers and challenges that a residential substance addiction facility will face when adopting a tobacco-free policy. A tobacco-free campus policy protects all individuals from dangerous secondhand smoke and promotes the health and recovery of clients from all addictions, including nicotine. This toolkit provides step-by-step information and resources to allow a facility to become tobacco-free and implement a full smoking cessation program over a six month time period. This project helps fill a need for specific resources related to concurrent smoking cessation and substance abuse/mental health treatment. This resource will be made available to residential substance abuse facilities in Georgia and will be provided to the Substance Abuse and Mental Health Service Administration’s Smoking Cessation Leadership Center.

This qualitative study used interpretative phenomenological analysis to explore the question, How do women cigarette smokers experience and perceive their occupational transition from smoker to non-smoker? The sample consisted of seven women, aged 35-55, living in New Brunswick, Canada, who quit smoking for at least twelve months, but no longer than 24 months. Data were collected through in-depth, face-to-face interviews. The occupation of smoking was shown to be a valued and meaningful occupation with both positive and negative aspects that influenced the occupational transition process. The occupational transition of smoking cessation was described as a cyclical journey that required building skills and occupational competence, not only to support occupational adaptation and engagement in meaningful occupations, but also to overcome barriers and occupational losses throughout the transition process. This also fostered the occupational identity of non-smoker, by allowing the women to become and express the self they wanted to be.

Cancer is devastating. Medical advances have resulted in the ability to diagnose cancer at its earliest stages and increase survivorship. Unfortunately, Black Americans possess a disproportionate cancer burden, with the highest mortality and lowest survival rate of any racial/ethnic group. Lung cancer is the most deadly, yet most treatable cancer. The purpose of this study was to determine the impact that the healthcare education program had on healthcare students’ level of cultural development and awareness of disparities regarding Black Americans and tobacco cessation. In light of the data substantiating that health disparities stem from a combination of racial and ethnic inequities in the access of the healthcare system, healthcare professionals’ low levels of cultural development, and the missed opportunities for promoting Black American tobacco cessation, the following questions were developed to frame the research: Research Question #1: How will the level of healthcare students’ cultural development change as a result of a healthcare education program? This question corresponds to the following hypotheses being tested in this study: Methods to answer this question included evaluation of findings from 1) comparison of pre and post-program Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals – Revised (IAPCC-R) mean scores by degree of study and by gender; and 3) comparison of pre and post-program Tobacco Cessation Assessment (TCA) mean scores by degree of study and by gender. Research Question #2: What is the relationship between cultural competence and increased awareness of disparities regarding Black Americans and tobacco cessation? Methods utilized to answer this question included evaluation of findings from comparison of results of knowledge gains in TCA vs. IAPCC-R mean scores, including using the Pearson’s correlation coefficient to determine existence and strength of the relationship. Findings were 1) level of cultural development increased; 2) awareness of disparities regarding Black Americans and tobacco cessation increased; and 3) weak, but statistically significant relationship between higher level of cultural development and increased awareness of disparities regarding Black Americans and tobacco cessation. This study could serve as a model for future partnerships with researchers, faculty, and healthcare professionals, linking pre-profession preparation with continuing professional education. / Department of Educational Studies