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Culturally-Tailored Cessation Research: Results from recent TRDRP-funded studies

One of the main goals of the Tobacco-Related Disease Research Program (TRDRP) is to support communities most vulnerable to tobacco-related health disparities by providing them with real time, relevant, and actionable research.

Our work is overseen by the Tobacco Education and Research Oversight Committee (TEROC), which sets guidelines for research and education projects. TEROC’s 2021-2022 plan, titled “Achieving Health Equity Toward a Commercial Tobacco Free California” aims to guide efforts to end the epidemic of commercial tobacco use in California by 2035. To reach that goal, TRDRP has an ambitious program to fund scientifically meritorious research proposals designed with culturally-tailored cessation strategies in “priority populations” — those having either higher tobacco-use rates or which suffer health disparities linked to tobacco product use.

“At TRDRP, our mission is to transform these tobacco taxes into cutting edge research to reduce commercial tobacco use and tobacco related disease,” says TRDRP Director Tracy McKnight. “We want to know why people smoke and how we can help them quit.”

Below are some of the cutting-edge studies we have funded, with results that can shed light into broader cessation strategies. Let us know if you have any questions!

Smoking Among People with Mental Health Disorders

“In a lot of treatment clinics, when people are undergoing treatment for mental health or substance use disorder, they're allowed to smoke,” says McKnight. Researchers hypothesize that smoking is used as a self-medication for acute anxiety, but does it help? Researchers suspected that while smoking may reduce anxiety in the short term, it may increase agitation and anxiety over the long term. And they were right.

This TRDRP-funded study included 38 patients with a diagnosis of schizophrenia who were at inpatient clinics for at least three months. The study found that patients who smoked used anxiety medication more than non-smokers, which suggests that in the long-term, smoking appeared to increase anxiety, or at least the need for anxiolytic medications.

Adds McKnight, this is a “wonderful example of some of our researchers spanning that translational and discovery research divide” by learning how to target smoking cessation strategies within this priority population.

Study: Hassanzadah M, et al. 2019. A Retrospective Cohort Study of the Prevalence and Agitation in Schizophrenic Smokers and the Unmet Needs of Smoking Cessation Programs. Medicine (Baltimore) 98(40):e17375. DOI:10.1097/MD.0000000000017375.
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Do Tobacco-Free Policies in Substance Use Programs Work?

People with Substance Use Disorder not only have higher smoking rates than the general U.S. population, but they're also heavier smokers and they're less successful in quitting. As mentioned above, most mental health facilities — whether resident or outpatient facilities — only have partial smoke-free policies, while prohibiting other kinds of drugs and alcohol. Could eliminating smoking at such facilities be a strategy to reduce smoking in certain populations?

This survey-based study of nearly 400 patients from three different facilities (men only, women-only, and mixed gender) had two objectives. First, to see whether imposing a tobacco free-ground policy would reduce smoking rates, and secondly, whether the $2 per pack increase in California’s tobacco tax, which went into effect in April 2017, reduced smoking.

The study found the tobacco-free policy was effective at reducing smoking while increased cigarette prices were not associated with a change in smoking behavior in this population. However, previous studies have found that an increase in tobacco taxes does reduce smoking rates in the general population.

“The odds of residents being current smokers and the number of cigarettes smoked per day were both lower after they implemented this tobacco-free grounds policy,” says McKnight. While the grounds were tobacco-free, patients could still walk further away to smoke. What isn’t known is how long this change lasted after the patients returned to their lives. Additional research is needed into this question.

Study: Gubner NR, et al. 2019. Smoking Related Outcomes Before and After Implementation of Tobacco-free Grounds in Residential Substance Use Disorder Treatment Programs. Drug and Alcohol Dependence 197: 8–14. DOI: 10.1016/j.drugalcdep.2019.01.001.
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Curbing High Smoking Rates in Vietnamese American Men

While the adult smoking rate in California is relatively low, on the order of 10%, in some populations it’s much higher. In Vietnamese men, the smoking rate is 24.4%, and in those with low English proficiency, it’s 45%. Interestingly, Vietnamese American women have low smoking rates, on the order of 8%.

This TRDRP-funded study looked at how lay (or community) health workers and family support could help Vietnamese men be successful at quitting smoking. Health workers used interventions such as flip charts with culturally appropriate graphics used in educational sessions, provided information such as the Vietnamese language smoking quitline, and details on smoking cessation medications. A key component of the study was empowering a family member in how best to support the person attempting to quit.

After going through the program, the men reported feeling more accountable for their own health behaviors. Smoking changes were reinforced by the family members, peers and lay health workers who worked with the men during the program. “It's really an excellent example of how culturally appropriate interventions with a multi-pronged approach, multiple social support mechanisms can be very, very powerful,” emphasizes McKnight.

Study: Kenny JD, et al. 2021. Keeping Each Other Accountable: Social Strategies for Smoking Cessation and Healthy Living in Vietnamese American Men. Family & Community Health 44(3):215-224. DOI: 10.1097/fch.0000000000000270.  
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Smoking in Sexual and Gender Minority Populations

Sexual and gender minorities (SGM), defined as people who are not heterosexual or who do not identify with their sex assigned at birth, have higher-than-average smoking rates; furthermore, they experience barriers to substance use treatment including tobacco cessation, whether due to dissatisfaction with available health care services, or just lack of affordable health care. Young adults are generally less likely to participate in smoking cessation treatments, as well.

The scientists behind the study came up with a unique strategy of using social media, specifically secret groups on Facebook, to bring cigarette smoking cessation to these SGM young adults instead of having them go someplace to receive cessation treatment. Groups were tailored to people ready to quit in the next 30 days and not ready to quit.

The study of 165 SGM young adults compared two different types of social media interventions: one that was tailored towards sexual and gender minority youth, and one that wasn't tailored. “Participants that have the tailored intervention were more likely to reduce their smoking rates and intensity at three and six months,” says McKnight. Specifically, the study found people with tailored interventions reported more abstinence at 3 and 6 months, but biochemically-verified smoking abstinence did not differ between the groups. The researchers believe that the disparity was due to testing kit errors and potential use of e-cigarettes, cessation of which was not part of the intervention.

Study: Vogel EA, et al. 2020. The Put it Out Project (POP) Facebook Intervention for Young Sexual and Gender Minority Smokers: Outcomes of a Pilot, Randomized, Controlled Trial study. Nicotine and Tobacco Research 22(9):1614-1621. DOI: 10.1093/ntr/ntz184.
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Does Melanin Affect Nicotine Addiction?

African American smokers have a disproportionately high burden of smoking and greater difficulty quitting than white smokers. Some studies on nicotine pharmacokinetics have shown that nicotine has a higher affinity for melanin, which, of course is higher in Black individuals, and in those with darker skin. “The thought is that maybe [this affinity] has an influence on how nicotine is metabolized and allowed to bind to other receptors, and that this difference in the metabolism may actually enhance dependence,” explains McKnight.

Fifty-four Black participants were given IV-infusions of deuterium-labeled nicotine and cotinine, a metabolite formed after nicotine enters the body. The study did not find any significant difference among people with different melanin index levels in tobacco dependence, or in nicotine or cotinine pharmacokinetics. Further, the volume of distribution at steady state (Vss) — a measure of nicotine metabolism — was similar to that of white smokers in other studies. However, since other studies have found an affinity between melanin and nicotine, so further study is warranted.

Study: Liakoni E, et al. 2019. Relationship Between Skin Melanin Index and Nicotine Pharmacokinetics in African American Smokers. Drug and Alcohol Dependence 204: 107474. DOI: 10.1016/j.drugalcdep.2019.04.039.  
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How to Quit: Research on Cessation Strategies Tailored to Specific Priority Populations (one-pager)

Wendee Nicole Holtcamp, 

help sign with cigarette butts on the floor