Live Research Spotlight 6: Tobacco Control and Nicotine-Related Behavior

Background: Quitting smoking after a cancer diagnosis improves survival and quality of life. Cessation counseling and medications increase quit rates, yet a minority of patients engage. We previously described factors aiding engagement with tobacco cessation treatment in the oncology setting among patients who engaged in services. The current study evaluated barriers to treatment engagement as perceived by patients who declined tobacco cessation services.
Methods: As part of the National Cancer Institute’s Moonshot Initiative, the Stanford Cancer Center offers a menu of telehealth services to all patients who report recent tobacco use (opt-out model). Services include cessation medication management, individual and group counseling, text-to-quit programs, and digital health apps. To optimize outreach efforts and enhance care delivery, we conducted in-depth, semi-structured interviews with 14 patients who declined treatment between 2020 and 2022. Patients shared their barriers to engagement, treatment preferences, and general recommendations; indicated their motivation to quit (1-10); and rated the importance of different treatment offerings (1-5). The interviews were audio-recorded, transcribed, and iteratively coded by two team members using a content analysis approach.
Results: The patient sample (M age=75, 64% female, 86% White, 7% Hispanic) reported cigarette (71%), vape (7%), smokeless tobacco (7%), and dual tobacco use (7%) beginning by a mean age of 19 (SD=11.5). A subset (7%) had quit. The mean motivation to quit was 4.69 (SD=3.55); the primary reason cited was a desire to improve health. Top identified barriers to engagement centered on a lack of readiness to quit, advanced illness, and a desire to quit independently. Recommendations included offering an inpatient tobacco treatment program and offering treatment after (rather than during) active cancer treatment. Most (64%) patients were open to follow-up by the Stanford team, while many (46%) were unsure how to contact the clinic. The highest-rated treatment components included the telehealth delivery (M=4.67, SD=.65), cost-coverage (M=4.62, SD=.76), and the individual counseling offering (M=4.62, SD=.65).
Conclusion: Findings suggest proactive and ongoing outreach throughout the care continuum may motivate tobacco cessation engagement. Future directions include improving clinic contact accessibility and exploring the impact of gain-frame messages for smoking cessation in the cancer context.

Presenter - Annemarie D. Jagielo, M.S.,
PGSP-Stanford PsyD Consortium

Co-Author - Amy Chieng, B.A.,
Stanford Prevention Research Center, Department of Medicine, Stanford University

Co-Author - Eli Feldman, M.S.,
PGSP-Stanford PsyD Consortium

Co-Author - Ann Cao-Nasalga, MBA,
Health Education, Engagement and Promotion, Stanford Health Care

Co-Author - Judith J. Prochaska, PhD, MPH,
Stanford Prevention Research Center, Department of Medicine, Stanford University

Background: The co-use of cannabis and tobacco is common, and use rates are higher among sexual minority vs heterosexual individuals. Prior research suggests that flavors facilitate the use of tobacco products, such as cigarettes, electronic cigarettes (e-cigarettes), and cigars. Less is known regarding how flavors might influence concurrent use of tobacco products and cannabis and whether sexual minority identity influences these relationships.
Methods: Data were collected from a nationally representative sample of n=5094 youth and young adults (aged 15-24 at enrollment) from the Truth Longitudinal Cohort from September 2020 to March 2021. Differences in flavored e-cigarette, cigarette, and cigar use across cannabis use status (never used; ever used, but not current; and current use) and sexual minority (SM) identity (heterosexual/straight vs gay/lesbian, bisexual, other, or not at all sure) were assessed using Chi-square tests of differences.
Results: Current cannabis use was higher among SM vs heterosexual/straight individuals (22.4% vs 14.4%). Of youth and young adults who were current users of cannabis, 97.4%, 49.9%, and 66.5% report concurrent use of flavored e-cigarettes, cigarettes, and cigars, respectively. No differences were found across flavored e-cigarette, cigarette, or cigar use by cannabis use status for those who identified as heterosexual/straight or as a sexual minority. However, irrespective of cannabis use status, flavored cigar use differed by SM identity. A greater proportion of those identifying as SM (vs heterosexual/straight) reported use of fruit (48.2% vs. 25.6%, p-value = <0.001), clove or spice (8.8% vs. 2.7%, p-value = 0.009), candy, desserts, or other sweet flavored cigars (32.0% vs. 19.3%, p-value = 0.022).
Discussion: A large proportion of youth and young adult current cannabis users report also using flavored e-cigarettes, cigarettes, and cigars. Findings highlight disparities in flavored cigar use across sexual identity, as those who identified as a SM reported higher rates of fruit, clove or spice, and candy, dessert, or other sweet-flavored tobacco products, compared to those who identified as heterosexual/straight. Given that flavored tobacco products are easier to initiate and harder to quit, the elevated use of flavored cigars may predispose those who identify as a sexual minority to long-term addiction and negative health outcomes.

Author - Elizabeth K. Do, PhD, MPH,
Truth Initiative

Co-Author - Elexis C. Kierstead, MPH,
Truth Initiative

Co-Author - Tatum McKay, MPH,
Truth Initiative

Co-Author - Amy M. Cohn, PhD,
University of Oklahoma Health Sciences Center

Co-Author - Elizabeth C. Hair, PhD,
Truth Initiative

Significance The Fox Chase Cancer Center Tobacco Treatment Program (TTP) works to increase cessation among cancer patients. The TTP recently expanded to serve all Temple University Health System, a historically underserved community. Patient navigation, an evidence-based approach, offers individualized assistance in the cancer care setting and helps to reduce disparities in healthcare. With collaboration from the clinical and research programs of the TTP and the Office of Community Engagement and Outreach, a feasibility pilot was designed and conducted to determine the acceptability and feasibility of adding a patient navigation intervention to the TTP.

Methods This study had two arms, pre-intervention (P) and intervention (I). The P group received the standard of care services. The I group met with the Patient Navigator (PN) two weeks after their first visit and two weeks after their second visit. The TTP providers, PN, and research team collaborated to ensure continuity of care. The navigation intervention supplemented the TTP services and assessed and addressed barriers in two primary areas: direct barriers to tobacco cessation, e.g. ability to purchase NRT and psychosocial barriers, e.g., addressing other familial and community barriers. Barriers were assessed at each visit and through patient surveys at baseline, one and six-months after the first visit.

Results There were 85 patients in the study, 28 in the P arm and 57 in the I arm. The racial/ethnic breakdown of the study is ~60% of patients were White, ~40% were Black, ~ 90% were not Hispanic. At baseline, using tobacco to manage stress was the most common barriers to cessation (70%+) of patients and remained the most commonly indicated barrier at 1 and 6 months, despite fewer people indicating it as a barrier at each time. Over 80% of patients said the PN was either very or extremely helpful in addressing concerns about quitting and would recommend patient navigation to others. The most commonly used resources recommended by the PN were transportation, social work, and free NRTs.

Conclusion This pilot provided important insights into the barriers faced by cancer patients in quitting and the feasibility of integrating navigation into tobacco treatment for cancer patients. Our goal is to use data from this pilot to design a randomized trial focused on the efficacy of the navigation intervention and consequently improving quit rates across a diverse patient population.

Co-Author - Allison Zambon, MHS, MCHES,
Fox Chase Cancer Center

Co-Author - Donna Edmondson, MSN, CRNP, AOCNP,
Fox Chase Cancer Center

Co-Author - Carolyn Zawislak, PA-C,
Fox Chase Cancer Center

Co-Author - Linda Fleisher, PhD, MPH,
Fox Chase Cancer Center

Background. Few smoking cessation campaigns have focused on people who smoke menthol cigarettes, missing an important opportunity to amplify the benefits of menthol cigarette bans and encourage cessation in jurisdictions where menthol is not yet banned. To inform the development of a smoking cessation campaign, this study aimed to understand reactions to quit smoking campaign messages among adults who smoke menthol cigarettes.

Methods. To obtain feedback on campaign messages, we conducted 6 semi-structured online focus groups, each with 7-9 US adults age 21+ years, who smoked menthol cigarettes (n = 50 total). Four of the focus groups were with priority populations (i.e., Black and lesbian, gay and bisexual adults). We developed 12 campaign messages based on three themes: self-efficacy, response-efficacy, and motivation, that aimed to encourage quitting smoking (e.g., "You can start your quit journey today" and "You've got this!"). Messages were developed with input from people who smoke menthol cigarettes and people with expertise in tobacco control for these priority populations. Focus groups explored reactions to the messages. We transcribed each focus group and conducted qualitative thematic analyses.

Results. Messages perceived as the most motivating to encourage quitting had a positive tone, celebrated small steps towards quitting, and were perceived as credible and scientific. Participants had negative reactions to messages that they saw as demanding, had an all-or-northing tone (e.g., “Quit now”), or elicited negative emotions such as guilt. Participants had mixed reactions to messages that addressed the money potentially saved by quitting smoking and the mental health benefits of quitting. Some felt that a message that specifically included the term “menthol” unfairly targeted Black people who smoke, while others noted that it was effective in capturing their attention. Participants requested messages that encouraged or energized them to quit smoking along with straightforward, tangible steps they could take to quit.

Conclusions. Findings highlight the need for nuanced health communication strategies, including tailoring messages to support quitting smoking among priority populations. Messages that use a positive tone and celebrate small wins hold promise for appealing to people who smoke menthol cigarettes and encouraging them to quit.

Presenter - Shayna Farris, BS,
University of North Carolina at Chapel Hill

Co-Author - Mayank Sakhuja, PhD,
University of North Carolina at Chapel Hill

Co-Author - Rhyan N. Vereen, PhD,
University of North Carolina at Chapel Hill

Co-Author - Jennifer Mendel Sheldon, MPH,
University of North Carolina at Chapel Hill

Co-Author - Chisom Ojukwu, MPH,
University of North Carolina at Chapel Hill

Co-Author - Emmanuel Saint-Phard, MPH,
University of North Carolina at Chapel Hill

Co-Author - Sarah D. Mills, PhD,
University of North Carolina at Chapel Hill

Co-Author - Carrie Rosario, PhD,
University of North Carolina at Greensboro

Co-Author - Kurt M. Ribisl, PhD,
University of North Carolina at Chapel Hill

Co-Author - Allison J. Lazard, PhD,
University of North Carolina at Chapel Hill

Co-Author - Paschal Sheeran, PhD,
University of North Carolina at Chapel Hill

Co-Author - Noel T. Brewer, PhD,
University of North Carolina

Co-Author - Marissa G. Hall, PhD,
University of North Carolina at Chapel Hill

Background. The US now requires e-cigarette packaging to have a single warning about nicotine addiction. To inform the selection of new warnings in the US, our trial examined the effect of text and pictorial health warnings for e-cigarettes.

Methods. Participants were 1,369 adults from California and Georgia, US who currently used e-cigarettes. In a preregistered trial conducted from 2023-2024, we randomly assigned participants to receive either control, text, or pictorial warnings on their vaping devices for 4 weeks. The warning topics were chemical exposure, DNA mutation, lung damage, and cardiovascular problems. The primary trial outcome was vaping quit intentions (range: 1 to 5). Intent-to-treat analysis used general linear regression, with the text warning arm as the referent group.

Results. Text warnings elicited higher intentions to quit vaping than control warnings ((M(SD)=2.5 (1.3) vs. 2.2(1.0), p<.05). Text and pictorial warnings yielded similar intentions to quit vaping (2.5 (1.3) vs. 2.5(1.1), p=.77). Text warnings led to higher rates of quitting vaping by the end of the trial than control warnings (7.2% vs 3.7%, p<.05) and to more often forgo a vape (p = .01). Relative to control, text warnings elicited higher consumer understanding of 4 of 4 measures (knowledge of the harms of vaping, thinking about the warnings and vaping harms, perceiving vaping as harmful, and negative affect elicited by the warnings, all p<001). Text warnings also elicited higher information seeking and sharing than controls (both p<.001). Regarding unintended consequences, text warnings elicited lower inaccurate risk perceptions about vaping (p = 0.02) but higher stigma (p<.001) than controls. Pictorial warnings had more favorable outcomes than text warnings on 2 of 4 consumer understanding variables, 1 of 2 information seeking/sharing variables, no behavior change variables, and 1 of 2 unintended consequences (all p>.05).

Conclusion. Text e-cigarette device warnings increased intentions to quit, forgoing e-cigarette use, and quitting e-cigarettes as well as consumer understanding about the harms of e-cigarette use and negative affect. Pictorial e-cigarette warnings had limited benefits beyond those of text warnings. Our trial findings suggest that expanding e-cigarette warnings to cover topics beyond addiction would discourage use.

Presenter - Noel T. Brewer, PhD,
University of North Carolina at Chapel Hill

Co-Author - Tara L. Queen, PhD,
University of North Carolina at Chapel Hill

Co-Author - Mayank Sakhuja, PhD,
University of North Carolina at Chapel Hill

Co-Author - Shayna Farris, BS,
University of North Carolina at Chapel Hill

Co-Author - Jennifer M. Sheldon, MPH,
University of North Carolina at Chapel Hill

Co-Author - Kurt M. Ribisl, PhD,
University of North Carolina at Chapel Hill

Co-Author - Allison J. Lazard, PhD,
University of North Carolina at Chapel Hill

Co-Author - Marissa G. Hall, PhD,
University of North Carolina at Chapel Hill