Thesis (Ph.D.) - University of Queensland, 2005. / Includes bibliography.

Thesis (M.S.)--Georgia State University, 2006. / Title from title screen. Yu-Sheng Hsu, committee chair; Gengsheng (Jeff) Qin, Xu Zhang, committee members. Electronic text (116 p.) : digital, PDF file. Description based on contents viewed May 17, 2007. Includes bibliographical references (p. 61-67).

Introduction This study aims to provide an assessment of tobacco control methods (e.g., smoking ban policies and smoking cessation services) implemented in mental health facilities (MHFs) by characteristics such as facility type, ownership, Joint Commission Accreditation Healthcare Organization (JCAHO) status, and region in the United States. Methods Secondary analysis was conducted using the 2010-2011 National Mental Health Services Survey (N-MHSS). Binomial frequency, chi-square, and logistic regression were used to determine the proportion of tobacco control methods, the relationship between characteristics and tobacco control methods, and predictors of facilities that use tobacco control methods, respectively. Results Findings show smoking ban policies were in less than half of MHFs and smoking cessation services were offered in less than a quarter of all MHFs. Analyses revealed a strong association across all characteristics and tobacco control methods in MHFs. Multivariate analysis showed that when compared to inpatient facilities, residential treatment centers for adults were less likely to have a smoking ban policy, OR=0.050, CI (0.039-0.065) and less likely to offer smoking cessation services, OR=0.072 CI (0.054- 0.095). Compared to MHFs accredited by JCAHO, MHFs unaccredited by JCAHO were less likely to have a smoking ban policy, OR =0.386 CI, (0.354-0.423) and less likely to offer smoking cessation services, OR =0.295, CI, (0.267-0.327). Discussion There is a clear deficit in tobacco control methods that vary across facility characteristics of MHFs. Findings of facility characteristics and tobacco control methods may direct future researchers, program interventionists, policymakers to target facilities where tobacco control is needed the most.

Although the adverse health effects of cigarette smoking are well known, many college students continue to initiate and maintain cigarette smoking. While some college students are making quit attempts, they have limited success. Past research has identified graduation as one life event around which college students plan to quit smoking. Therefore, the college senior may be at a reachable moment related to cessation interventions. It was one purpose of the present study to examine whether attitudes, self-efficacy, and subjective norms might influence a college senior's intention to quit smoking at graduation. Past research has also identified friends and peers as an influencing factor related to initiation and maintenance of student smoking. A second purpose was to examine the influence of peer group norms and strength of group identification on intentions to quit smoking among college seniors. The theory of planned behavior provided the theoretical framework for the study. Using a nonexperimental cross sectional design, data were collected from 573 undergraduate college seniors via a web-based survey. Sixty three percent of the respondents were female and thirty seven percent were male. Of respondents, 26.5% (n= 152) reported being current smokers (had smoked at least one cigarette in the last thirty days) and of the current smokers, 48.7% (n=74) were daily and 51.3% (n=78) were occasional smokers. Independent sample t–tests revealed that, although the original hypothesis (daily smokers would have more positive intentions toward quitting than nondaily smokers) was not supported, nondaily smokers did have more positive intentions to quit smoking than daily smokers. When intentions were examined by sex, no statistical difference was found between males and females in intentions to quit smoking at graduation. Multiple regression revealed that the attitude a smoker holds about quitting was the strongest predictor of quitting intentions, followed by the confidence in one's ability to quit (self-efficacy). The importance of the beliefs held by important others (subjective norms) about quitting was also predictive of intentions to quit, but to a lesser extent than attitudes and self-efficacy. Respondents chose a “most important peer group” (i.e. people I live with, other students in my major), which they used to answer survey questions related to peer group norms and strength of group identification. When group norms and strength of group identification variables were entered into multiple regression, the effects of group norms and group identification were not significant predictors. Strength of group identification was not found to be a moderating variable for group norms when predicting intentions to quit cigarette smoking. The present study used two concepts (subjective norms and group norms) to examine social influence on behavioral intentions. Future studies will be useful in establishing how social influences can best be conceptualized.

Dados da literatura indicam que os fumantes apresentam distúrbios psiquiátricos e psicológicos em maior frequência do que os não fumantes. Esses fatores podem contribuir para o início do tabagismo, bem como para sua manutenção, e induzir dificuldades no abandono. Entretanto, não existe na literatura nenhuma escala construída com a finalidade de avaliar as características emocionais de fumantes frente aos cigarros, de maneira simples e rápida. Este estudo teve como finalidade desenvolver uma escala que avaliasse o estado emocional geral dos fumantes em face ao uso do tabaco. Para tanto, fumantes que procuravam ambulatórios de cessação de tabagismo em hospitais públicos do Município de Ribeirão Preto foram submetidos a entrevistas padronizadas. Indivíduos não fumantes foram selecionados entre funcionários dessas mesmas instituições e entre acompanhantes e familiares dos fumantes. Inicialmente, níveis de Ansiedade, Depressão, Estresse Percebido, Autoestima e Solidão de um grupo de 120 fumantes (idade mediana: 54,6 anos; 74 mulheres) foram comparados com os de um grupo de 76 não fumantes (idade mediana: 45,5 anos; 47 mulheres). Os fumantes mostraram valores significantemente piores do que os não fumantes, em todas as medidas investigadas. Correlações entre os escores dessas medidas psicológicas, além da característica Apego aos Cigarros, foram feitas com as medidas do Teste de Dependência a Nicotina de Fagerström (TDNF) no grupo de fumantes. Os parâmetros psicológicos mostrando as melhores correlações com o TDNF foram selecionados para fazer parte de uma escala de 6 itens chamada Teste Emocional do Fumante (TEF). As pontuações do TEF deste grupo inicial e de uma amostra adicional de fumantes (n = 102; idade mediana= 52,6 anos; mulheres = 63) foram submetidas a análises psicométricas e testes de validação. O TEF mostrou uma estrutura consistente de dois fatores, ansiedade / depressão e apego aos cigarros. As pontuações de TEF apresentaram correlações significativas com o TDNF (r=0,418), número de cigarros defumados (r=0,299), tempo antes de sentir necessidade de um novo cigarro (r=-0,441) e prazer em fumar (r=0,346). A consistência interna do TEF foi maior do que a dos escores de TDNF (alfa de Cronbach: respectivamente 0,712 e 0,542). A confiabilidade teste-reteste do TEF foi excelente (coeficiente de correlação intraclasse=0,944). As pontuações de TEF superiores a 4 puderam distinguir fumantes de não fumantes com sensibilidade de 87,3% e especificidade de 92,7%. Pode-se concluir que o TEF é um instrumento simples que dá uma estimativa do status emocional relacionado ao tabagismo e pode definir um novo e valioso constructo da dependência do tabaco. O TEF tem potencial para se tornar uma ferramenta útil nas intervenções de cessação do tabagismo / Literature data show that smokers exhibit psychiatric and psychological abnormalities in higher frequency than non smokers. These factors may contribute to smoking beginning, as well as to its continuity, and bring obstacles for quitting. However, there is not in the literature any scale designed to evaluate the emotional features of smokers. This study aimed at developing a new scale to evaluate the overall emotional status of smokers in face of tobacco use. Smokers who look for treatment in public smoking cessation clinics of Ribeirão Preto city were submitted to standardized interviews. Non smokers were selected among workers from these facilities and companions and relatives from the smokers. Levels of Anxiety, Depression, Perceived Stress, Self Esteem, and Loneliness of a group of 120 smokers (median age: 54.6 years; 74 women) were compared with those of a group of 76 non smokers (median age: 45.5 years; 47 women). Smokers showed scores significantly worsen than non smokers regarding these measures. Correlations between these psychological scores, plus the feature Attachment to Cigarettes, and FTND counts were explored among smokers. Psychological features showing the best correlations with FTND were selected to be part of a 6 item scale called Smoker\'s Emotional Test (TEF). TEF scores of this initial group and of an additional sample of smokers (n=102; age= 52.6; women= 63) were submitted to psychometric analyses and validation tests. Results: TEF showed a consistent structure of two factors, Anxiety/Depression and Attachment to Cigarettes. TEF scores showed significant correlations with TDNF (r=0.418), number of smoked cigarettes (r=0.299), time to urge for a new cigarette (r=-0.441) and pleasure of smoking (r=0.346). The internal consistency of TEF was higher than that of FTND scores (Cronbach\'s alpha: respectively 0.712 and 0.542). The test-retest reliability of TEF was excellent (intraclass correlation coefficient=0.944). TEF scores higher than 4 could distinguish smokers from nonsmokers with sensitivity of 87.3% and specificity of 92.7%. In conclusion, TEF is a simple instrument that gives an estimative of smoking-related emotional status and may define a new valuable construct of tobacco addiction. TEF has the potential to become a useful tool in smoking cessation interventions.

Objective: To explore the role of interprofessional collaboration in the delivery of team-based tobacco dependence treatments within primary care. Methods: A narrative review of the literature was completed to examine FHT team functioning in Ontario, followed by a single, multi-site qualitative exploratory case study. Results: Interprofessional collaboration contributed to changes in tobacco dependence treatment through the initiation of system-wide change, cultivation of collective action, and supporting enhanced quality of smoking cessation care. Conclusion: Interprofessional collaboration can enhance the comprehensive delivery of evidence-based treatments for individuals trying to quit smoking. Supportive public policy, education for patients and providers, and evaluation research is needed to advance FHT functioning.

Cigarette smoking causes many chronic diseases that are costly and result in frequent hospitalization and re-hospitalization. Smoking cessation leads to improved morbidity and reduced risk of death. Hospital-initiated smoking cessation interventions increase the likelihood that patients will become smoke-free. Despite this, few Canadian hospitals have in place policies, protocols, and reminder systems that support the consistent and effective identification and treatment of tobacco users. The Ottawa Model for Smoking Cessation (OMSC), developed at the University of Ottawa Heart Institute (UOHI), is a systematic approach to identifying and treating smokers in the hospital setting. In order for health care funders and hospital administrators to begin supporting effective prevention interventions, like the OMSC, a compelling cost-effectiveness argument must be made. Few studies have looked at the downstream health, health care, and cost implications of such programs, particularly in the Canadian context and none using actual health care administrative data. In response to this gap, three studies were completed, applying theories and methodologies related to health services and population health research. Study 1: From the hospital payer’s perspective, what is the short-term (one year) and long-term (lifetime) cost-effectiveness of the OMSC intervention, as compared to a usual care condition, among high-risk smokers with chronic diseases? A cost-effectiveness analysis was completed based on a decision-analytic model to assess smokers hospitalized in Ontario, Canada for acute myocardial infarction, unstable angina, heart failure, and chronic obstructive pulmonary disease, their risk of continuing to smoke, and the effects of quitting on re-hospitalization and mortality over a one year period. Short- and long-term cost-effectiveness ratios were calculated. The primary outcome was one-year cost per quality-adjusted life year (QALY) gained. Study 2: What are the effects of the OMSC intervention on: 1) mortality, and 2) downstream health care utilization? An effectiveness study was completed comparing patients who received the OMSC intervention (n=726) to usual care controls (n=641). The study took place at 14 hospitals in Ontario. Baseline data was linked to Ontario health care administrative data. Unadjusted and adjusted competing-risks regression models were constructed, clustered by hospital, to compare the cumulative incidence of death, re-hospitalization, emergency department (ED) visits, and physician visits at 30 days, one, and two years following index hospitalization between groups. Study 3: From the health system perspective, what are the cumulative mean health care costs at 30-day, 1-year, and 2-year follow-up among smoker-patients that receive the OMSC compared to those that do not? What are the predictors of direct health care costs for patients that receive the OMSC compared to those who do not? Expanding on Study 2, a cost-analysis was completed to assess 30-day, 1-year, and 2-year health care costs between intervention and control groups. Costs were broken down by service type (e.g. inpatient, ED visits, laboratory, physician visits). To calculate cumulative mean costs, costs were grouped into the study’s 24 monthly intervals and weighted by the inverse probability of not being censored at the beginning of each month. Covariate-adjusted generalized linear models were performed for each of the 24 monthly intervals to determine the association between independent variables and health care costs.

Objective: To examine sociodemographic, medical, and substance use factors associated with smoking continuation during pregnancy. Methods: Data from 221 consecutive prenatal patients were analyzed. Results: Of the 67% who were pre-pregnancy smokers (n=148), 27% quit during pregnancy, whereas another 43% reduced by > 1/4 pack/day. Women who continued to smoke had lower incomes, more prior pregnancies, were less likely to have adequate prenatal care, and smoked more and for more years than did women who quit during pregnancy. Conclusion: Several characteristics predicted pregnancy smoking in this sample. Results suggest ways to more effectively target pregnant women for successful smoking cessation.

Indiana University-Purdue University Indianapolis (IUPUI) / The United States spends more on healthcare than any other country in the world, but still trails most other countries when it comes to important health indicators. There has been an increasing recognition that in order to address this discrepancy, the U.S. health system must begin to address the underlying social determinants contributing to poor health outcomes. In light of this, the concept of “population health” has emerged as a framework and model for how to better address the social determinants contributing to unhealthy behaviors and increased rates of morbidity and mortality in the U.S. Various national initiatives, including reform related to how doctors and hospitals are paid, have been developed with the purpose of increasing the adoption of strategies to address population health among public and private organizations. In this dissertation I attempt to assess how these national policies are driving behavior and outcomes related to improving population health in private and public sectors. It is comprised of three papers focused on 1) a systematic review of literature to assess how hospitals are responding to policies that encourage them to form partnerships to address population health, 2) a quantitative analysis of how the Affordable Care Act has impacted population health by addressing tobacco use with policies to increase Medicaid coverage for tobacco cessation services, and 3) an empirical examination to identify hospital strategic partnerships to address population health and determine hospital and market characteristics associated with these partnerships. The main findings of this study indicate that while there is a growing amount of peer reviewed literature focused on hospital partnerships for population health there is still a need for more generalizable studies with rigorous study designs in this area; Medicaid Expansion as a part of the Affordable Care Act is associated with lower prevalence of tobacco use; and policies, such as Accountable Care Organization and Bundled Payment models, may be influencing hospitals to engage with a broad set of partners to support population health activities. Collectively these studies provide new evidence to suggest that national policies may be driving behavior in private and public sectors related to population health. / 2022-04-06

Cigarette smoking is the leading cause of preventable morbidity and mortality in the United States. While smoking rates have steadily declined among the general population, smoking is becoming increasingly concentrated among socioeconomically disadvantaged groups due to higher initiation and lower cessation rates. This dissertation examines determinants and mechanisms of smoking cessation in the context of the Kick it for Good study (KIG), a community smoking intervention for Boston public housing residents. In the first study, we explored mediators and moderators of the KIG intervention effect on smoking cessation. We did not find any significant mediators for 3-mo cessation outcomes, although there was modest evidence for mediation by self-efficacy to quit at 12-months. We found living with other smokers and perceived stress were moderators of the KIG intervention effect on smoking cessation. In the second study, we examined predictors of attitudes and knowledge of nicotine replacement therapy (aNRT). We found discussing smoking cessation with a healthcare provider and use of nicotine replacement therapy (NRT) were associated with more positive attitudes and greater knowledge of NRT. The KIG intervention did not impact aNRT outcomes throughout the study period. In the third study, we examined the effect of depression on smoking cessation and whether this effect was moderated by social support. We found smokers with depression classified by the 10-item Center for Epidemiologic Studies Depression Scale (CES-D-10) were more likely to report smoking abstinence than those without depression. Social support did not moderate the effect of depression on cessation. We also conducted a sensitivity analysis to determine if the cutoff of 10 for the CES-D was valid in this population of low-income and racially/ethnically diverse smokers. We did not find evidence of depression misclassification by the CES-D-10, although there remains the need to validate the scale in socioeconomically disadvantaged populations. These findings provide valuable information on how smokers living in Boston public housing were able to achieve smoking abstinence in the context of a cessation intervention. The insights gained from these results may be applied to future intervention studies to help address the disparity in smoking rates among socioeconomically disadvantaged smokers.