To assess the prevalence of depressive symptomatology or significant distress, we administered the Center for Epidemiologic Studies Depression Scale .We used a standard threshold score of 16 or more to categorize depressive symptomatology or significant distress.We described sample characteristics and reported smoking and quitting behaviors from the enrollment interview using means for continuous variables and proportions for categorical variables. We examined bivariate associations between ever-smokers and never-smokers at enrollment. Using multi-variable logistic regression, we examined factors associated with making a quit attempt at enrollment, adjusting for age, sex, race/ethnicity, and residential history in the 6 months prior to enrollment. We examined the following self-reported quitting behaviors at 6-months follow-up among current smokers who completed both the enrollment and 6-month follow-up interviews: quit attempt for at least 1 day during the 6-month follow-up, and 30-day and 90-day abstinence among those who had made a quit attempt. We examined the use of all FDA-approved medications and other strategies for smoking cessation during the last quit attempt at 6-month follow-up, and their association with abstinence. Using multivariable logistic regression, we examined factors that were predictive of a quit attempt at follow-up among current smokers who completed both the enrollment and follow-up interviews. We included in the model all covariates that achieved a significance of less than 0.1 in bivariate analysis. We included variables on demographics, depression, and smoking from the enrollment visit,modular green house grow rack and residential history in the past 6 months from the 6-month follow-up visit. We conducted these analyses using Stata, version 11.
In this cohort of older homeless adults, the prevalence of current smoking was at least 3 times higher than similarly aged members of the general population. The quit attempt and 30-day and 90-day abstinence rates were similar to that observed among older adults from a nationally representative sample of the general population.However the quit ratio , an indicator of successful quitting, was at least three times lower than the national average.Findings from our study confirm previous research that homeless adults are interested in quitting smoking,but are less successful compared to those who are not homeless. Contrary to our hypothesis, staying in shelters or meeting criteria for depressive symptomatology or significant distress on the CES-D scale was not associated with current smoking. Given that the more than half the participants reported a shelter stay or depressive symptomatology, these characteristics may not have differentiated smokers and nonsmokers in our study sample. Persons who reported a jail or prison stay in the past 6 months at enrollment had a non-significantly higher likelihood of being a smoker than those without a history of incarceration. Consistent with our hypothesis and previous studies,use of illicit substances and alcohol use were associated with current smoking among participants in our study. Comorbid substance use disorders pose significant challenges to smoking cessation because the use of illicit substances may provide social cues to smoking and augment the pleasurable effects of nicotine.Given these findings, there is mounting evidence for the integration of treatment for nicotine dependence with that of substance use treatment.A meta-analysis showed that treating nicotine addiction during substance use treatment may enhance short-term smoking cessation and lead to prolonged abstinence from alcohol and other illicit substances.Lower cigarette consumption and prior quit attempts were associated with increased likelihood of a subsequent quit attempt at follow-up. Time to first cigarette after waking, a nicotine dependence measure predictive of smoking cessation,was not associated with making a quit attempt in adjusted analysis. Concurrent use of other tobacco products, which is common among homeless adults,may reduce reliance on cigarettes and may reduce the predictive validity of time to first cigarette after waking as a predictor of cigarette quit attempts.
Contrary to our hypothesis and previous studies that have shown an association with depression and decreased quit attempts,our results showed a higher likelihood of quit attempts among those who with depressive symptomatology . In post hoc analysis we found that persons with depressive symptomatology showed a non-statistically significant higher likelihood of having received advice from a healthcare provider to quit smoking, suggesting that these individuals may have been both more engaged in health care and more likely to receive advice to quit and/ or other resources for smoking cessation. Staying in a shelter was associated with an increased likelihood of a quit attempt. Shelters have smoke-free policies that may motivate individuals to make quit attempts.Few shelters offer on-site resources, but most provide referrals to community-based resources for smoking cessation.These factors may also encourage quit attempts among homeless clients. Previous research has shown that the majority of smokers who attempt to quit smoking relapse back to smoking,but the longer the duration of smoking abstinence, the higher the likelihood of successful quitting.In a study of former smokers in the general population, only 12% of those who had abstained from smoking for less than 1 month at baseline were continuously abstinent from smoking at follow-up 1 year later; almost 50% had resumed smoking at follow-up.Only three participants reported sustained abstinence at 6 months follow-up. The results of this study highlight the difficulty of quitting smoking successfully, a task that is much more challenging when faced with the stress of material resource constraints and social disorganization common in homelessness.Given that a significant proportion of the sample was engaged in quitting behaviors during the study interval, our findings highlight the need for more effective therapies that increase the rate of successful quitting among older homeless smokers.
Previous studies have identified limited access or poor adherence to smoking cessation aids, depression, lack of access to smoke-free homes, illicit substance use, and stress from social stressors as factors associated with relapse.Despite being socioeconomically disadvantaged, about one-fourth of the participants in the current study reported that they had used NRT or FDA-approved medications during the last quit attempt, a proportion that is similar to the general population.Although a minority of our study population reported achieving 30-day or 90-day abstinence, use of cessation medications was not associated with abstinence. We may have been under powered to detect a meaningful difference in abstinence rates between those who did and did not use NRT, highlighting a need for studies that explore the efficacy of NRT for smoking cessation in this population. Other factors may influence the efficacy of NRT for smoking cessation in the homeless population including intensity of smoking,use of concurrent tobacco products, frequency of use of NRT, and access to other treatments for cessation; these factors merit further exploration. Examining access to smoke-free living environments, identifying messages to convey smoking-related health effects,movable grow racks and identifying perceptions of current tobacco control strategies may provide additional insights into developing effective interventions for smoking cessation among this population. Our study had several limitations. As in our previous work,we relied on self-reports of tobacco cessation behaviors, potentially leading to recall bias and over- or under-estimation of cessation rates. The lack of biomarker-verified measures of abstinence could result in potential inaccuracies in the estimates of prolonged abstinence. The slightly lower 6-month follow-up rate among smokers than nonsmokers may have led to a potential differential misclassification bias in estimates of tobacco cessation at follow-up. While we were able to assess whether participants switched to other tobacco products for cigarette smoking cessation, we were unable to assess concurrent use of other tobacco products with cigarette smoking. We were unable to determine whether receipt of tobacco cessation services in homeless shelters could have influenced sheltered participants’ decision to make a quit attempt. Our study sample that included predominantly African American participants may not be generalizable to other populations of older homeless adults across the United States. However, given the increased tobacco-related disease burden among African American smokers,our study provides insight into smoking cessation behaviors that might guide intervention development for this population. Despite these limitations, this is among the first studies on tobacco use and cessation to focus specifically on older homeless adults. The high prevalence of smoking and the low rates of successful quitting highlight numerous opportunities to intervene to increase quitting rates among this population.
Among these, increasing access to smoke-free living environments and identifying effective cessation therapies will be critical to reducing tobacco-related disease burden among older homeless adults.Health complications related to preterm birth may impose lifelong sequelae or death.In the United States, 17% to 34% of infant deaths within the first year of life are attributable to prematurity.Children born preterm are more likely to have vision or hearing loss, cerebral palsy, and physical or learning delays.The societal economic burden associated with preterm birth in the United States was estimated to be over $26 billion annually more than a decade ago.Years of study have identified numerous risk factors for preterm birth, including obesity, hypertension, diabetes, smoking, drug or alcohol dependence/abuse during pregnancy and a short interval between pregnancies.Few protective factors against preterm birth have been identified, but include maternal birth outside of the United States and interpregnancy interval of 24 to 60 months.Identification of risk and protective factors has not decreased preterm birth rates in the United States – instead rates have been showing an upward trend. In an effort to improve infant health outcomes, there has been a recent upsurge in efforts to reduce preterm birth rates in the United States.This effort is challenging, due to the complex biology of preterm birth, various clinical presentations, and socioeconomic and psychosocial influences.Due to the need for multi-pronged approaches to decrease preterm birth rates, a collaborative place-based approach may be an effective way to decrease rates locally. A place-based approach is designed to take into account the unique local and contextual conditions of specific locations, engage a diverse range of sectors in a collaborative decision making process, and leverage local talent, knowledge, and assets.By addressing drivers of preterm birth that may be more frequent based on location , this method recognizes that one size may not fit all, either in terms of drivers or interventions. California reports a 2016 preterm birth rate of 8.5%, with the highest rate in Fresno County, located in the Central Valley region.Fresno County has just under one million residents, half of whom are Hispanic, and has the highest value of agricultural crops by any county in the United States.Fresno County reports the highest poverty rate in California, with 32.3% of families with children living below the poverty level, and is considered a Primary Care Health Professional Shortage Area.In this study we evaluated the influences of maternal characteristics and obstetric factors on timing of birth in Fresno County to evaluate both risk and prevalence of risk by urban, suburban, and rural residence. We aimed to identify risk and protective factors for birth before 37 weeks’ gestation that can inform policy and health care priorities designed to reduce preterm birth rates in Fresno County. In this retrospective cohort study, our sample was drawn from California live births between January 1, 2007 and December 31, 2012. The sample was restricted to women with singleton births with best obstetric estimate of gestation at delivery between 20 and 44 weeks, linked to the birth cohort database maintained by the California Office of Statewide Health Planning and Development, with no known chromosomal abnormalities or major structural birth defects, and a Fresno County census tract . The birth cohort database contained linked birth and death certificates, as well as detailed information on maternal and infant characteristics, hospital discharge diagnoses and procedures recorded as early as one year before delivery and as late as one year post-delivery. Data files provided diagnoses and procedure codes based on the International Classification of Diseases, 9th Revision, Clinical Modification .Structural birth defects for the study were considered “major” if determined by clinical review as causing major morbidity and mortality that would likely be identified in the hospital at birth or lead to hospitalization during the first year of life.The sample of Fresno County women was stratified by residence in urban, suburban and rural census tracts as defined by the Medical Service Study Areas . MSSAs “are recognized by the U.S. Health Resources and Services Administration, Bureau of Health Professions’ Office of Shortage Designation as rational service areas for purposes of designating Health Professional Shortage Areas , and Medically Under served Areas and Medically Under served Populations ”.Within each of these residence strata, known maternal preterm birth risk factors were compared for women who delivered before 37 weeks’ gestation to those of women who delivered between 37 and 44 completed weeks’ gestation, using Poisson logistic regression to calculate crude relative risks and 95% confidence intervals .