Predictors of Pharmacotherapy for Tobacco Use Among Veterans Admitted for COPD: The Role of Disparities and Tobacco Control Processes

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Abstract

<div class="section"> <a class="named-anchor" id="d586358e171">  </a> <h5 class="section-title" id="d586358e172">BACKGROUND</h5> <p id="d586358e174">Many smokers admitted for chronic obstructive pulmonary disease (COPD) are not given smoking cessation medications at discharge. The reasons behind this are unclear, and may reflect an interplay of patient characteristics, health disparities, and the receipt of inpatient tobacco control processes. </p> </div><div class="section"> <a class="named-anchor" id="d586358e176">  </a> <h5 class="section-title" id="d586358e177">OBJECTIVES</h5> <p id="d586358e179">We aimed to assess potential disparities in treatment for tobacco use following discharge for COPD, examined in the context of inpatient tobacco control processes. </p> </div><div class="section"> <a class="named-anchor" id="d586358e181">  </a> <h5 class="section-title" id="d586358e182">PARTICIPANTS</h5> <p id="d586358e184">Smokers aged ≥ 40 years, admitted for treatment of a COPD exacerbation within the VA Veterans Integrated Service Network 20, identified using ICD-9 discharge codes and admission diagnoses from 2005–2012. </p> </div><div class="section"> <a class="named-anchor" id="d586358e186">  </a> <h5 class="section-title" id="d586358e187">MAIN MEASURES</h5> <p id="d586358e189">The outcome was any tobacco cessation medication dispensed within 48 hours of discharge. We assessed potential predictors administratively up to 1 year prior to admission. We created the final logistic regression model using manual model building, clustered by site. Variables with <i>p</i> < 0.2 in biviariate models were considered for inclusion in the final model. </p> </div><div class="section"> <a class="named-anchor" id="d586358e194">  </a> <h5 class="section-title" id="d586358e195">RESULTS</h5> <p id="d586358e197">We identified 1511 subjects. 16.9 % were dispensed a medication at discharge. In the adjusted model, several predictors were associated with decreased odds of receiving medications: older age (OR per year older 0.96, 95 % CI 0.95–0.98), black race (OR 0.34, 95 % CI 0.12–0.97), higher comorbidity score (OR 0.89, 95 % CI 0.82–0.96), history of psychosis (OR 0.40, 95 % CI 0.31–0.52), hypertension (OR 0.75, 95 % CI 0.62–0.90), and treatment with steroids in the past year (OR 0.80, 95 % CI 0.70–0.90). Inpatient tobacco control processes were associated with increased odds of receiving medications: documented brief counseling at discharge (OR 3.08, 95 % CI 2.02–4.68) and receipt of smoking cessation medications while inpatient (OR 5.95, 95 % CI 3.19–11.10). </p> </div><div class="section"> <a class="named-anchor" id="d586358e199">  </a> <h5 class="section-title" id="d586358e200">CONCLUSIONS</h5> <p id="d586358e202">Few patients were treated with tobacco cessation medications at discharge. We found evidence for disparities in treatment, but also potentially beneficial effects of inpatient tobacco control measures. Further focus should be on using novel processes of care to improve provision of medications and decrease the observed disparities. </p> </div><div class="section"> <a class="named-anchor" id="d586358e204">  </a> <h5 class="section-title" id="d586358e205">Electronic supplementary material</h5> <p id="d586358e207">The online version of this article (doi:10.1007/s11606-016-3623-4) contains supplementary material, which is available to authorized users. </p> </div>

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Smoking and mental illness: results from population surveys in Australia and the United States

David Lawrence, Francis Mitrou, Stephen Zubrick (2009)

Background Smoking has been associated with a range of mental disorders including schizophrenia, anxiety disorders and depression. People with mental illness have high rates of morbidity and mortality from smoking related illnesses such as cardiovascular disease, respiratory diseases and cancer. As many people who meet diagnostic criteria for mental disorders do not seek treatment for these conditions, we sought to investigate the relationship between mental illness and smoking in recent population-wide surveys. Methods Survey data from the US National Comorbidity Survey-Replication conducted in 2001–2003, the 2007 Australian Survey of Mental Health and Wellbeing, and the 2007 US National Health Interview Survey were used to investigate the relationship between current smoking, ICD-10 mental disorders and non-specific psychological distress. Population weighted estimates of smoking rates by disorder, and mental disorder rates by smoking status were calculated. Results In both the US and Australia, adults who met ICD-10 criteria for mental disorders in the 12 months prior to the survey smoked at almost twice the rate of adults without mental disorders. While approximately 20% of the adult population had 12-month mental disorders, among adult smokers approximately one-third had a 12-month mental disorder – 31.7% in the US (95% CI: 29.5%–33.8%) and 32.4% in Australia (95% CI: 29.5%–35.3%). Female smokers had higher rates of mental disorders than male smokers, and younger smokers had considerably higher rates than older smokers. The majority of mentally ill smokers were not in contact with mental health services, but their rate of smoking was not different from that of mentally ill smokers who had accessed services for their mental health problem. Smokers with high levels of psychological distress smoked a higher average number of cigarettes per day. Conclusion Mental illness is associated with both higher rates of smoking and higher levels of smoking among smokers. Further, a significant proportion of smokers have mental illness. Strategies that address smoking in mental illness, and mental illness among smokers would seem to be important directions for tobacco control. As the majority of smokers with mental illness are not in contact with mental health services for their condition, strategies to address mental illness should be included as part of population health-based mental health and tobacco control efforts.

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Clinicians' implicit ethnic/racial bias and perceptions of care among Black and Latino patients.

Irene V Blair, John Steiner, Diane L Fairclough … (2013)

We investigated whether clinicians' explicit and implicit ethnic/racial bias is related to black and Latino patients' perceptions of their care in established clinical relationships.

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A nationwide analysis of US racial/ethnic disparities in smoking behaviors, smoking cessation, and cessation-related factors.

Abigail D. Trinidad, Halbert L. White, Karen Messer … (2011)

We used nationally representative data to examine racial/ethnic disparities in smoking behaviors, smoking cessation, and factors associated with cessation among US adults. We analyzed data on adults aged 20 to 64 years from the 2003 Tobacco Use Supplement to the Current Population Survey, and we examined associations by fitting adjusted logistic regression models to the data. Compared with non-Hispanic Whites, smaller proportions of African Americans, Asian Americans/Pacific Islanders, and Hispanics/Latinos had ever smoked. Significantly fewer African Americans reported long-term quitting. Racial/ethnic minorities were more likely to be light and intermittent smokers and less likely to smoke within 30 minutes of waking. Adjusted models revealed that racial/ethnic minorities were not less likely to receive advice from health professionals to quit smoking, but they were less likely to use nicotine replacement therapy. Specific needs and ideal program focuses for cessation may vary across racial/ethnic groups, such that approaches tailored by race/ethnicity might be optimal. Traditional conceptualizations of cigarette addiction and the quitting process may need to be revised for racial/ethnic minority smokers.