In 2006, the Brazilian Health Council approved a National Health Policy for the Black Population. The Policy is striking because it promotes the image of a biologically and culturally discrete black population in a nation where racial classification has historically been relatively fluid and ambiguous. It transforms established patterns of racialization by collapsing "brown" (pardo) and "black" (preto) Brazilian Census categories into a single "black population" (população negra) to be considered a special- needs group by the public health apparatus. This construction resembles the United States' dominant mode of racialization based on hypodescent and represents a significant departure from hegemonic portrayals of Brazil as a racially mixed nation. Furthermore, the Policy challenges national ideologies of racial and cultural unity by affirming the existence of an essential black body with specific health concerns, as well as an essential Afro-Brazilian culture that materializes in recommendations for culturally competent health care. As such, the Policy constitutes an important site for new negotiations of racial and cultural identity in Brazil. In this dissertation, I explore the political and social implications of treating racial and ethnic groups differently within Brazilian health care. I examine how the re-definition and medicalization of racial and cultural identities unfolds in public clinics, temples of Afro-Brazilian religion, and social movements based in São Luís and São Paulo, Brazil. Through an analysis of ethnographic data that I collected over twenty-four months, I assess the impact of recent developments in race- conscious health policy on Brazilians' lived experiences of race, ethnicity, and health disparities. I argue that the new Policy, and its associated health programs, signals the emergence of a new biopolitical paradigm in which the Brazilian state formalizes citizens' racial and ethnic differences in order to address inequalities among them. I also show that many aspects of these programs, which incorporate global discourses and concepts related to health equity, fail to resonate with Brazilian citizens' notions about race and health. Consequently, patients and healthcare providers often resist the new measures. The result is a disjuncture between policy and practice that ultimately hinders Brazil's efforts to reduce health inequalities among its citizens

Introduction

Smoking rates among addiction treatment clients are 3-4 times higher than those of the general population. Recent studies indicate that ceasing tobacco use during treatment may improve recovery outcomes. Across the United States, publicly funded addiction treatment programs vary widely in terms of their tobacco policies and tobacco cessation services offered to clients.

Methods

The study reported here is the qualitative component of a larger study. Twenty-four programs were recruited from a random sample of publicly funded programs participating in the NIDA Clinical Trials Network. Semi-structured interviews were administered by phone to program directors. ATLAS.ti software was used to facilitate thematic analysis of interview transcripts.

Findings

While all directors expressed interest in helping clients to quit smoking, they cited numerous barriers to implementing tobacco policies and services. These included smoking culture, client resistance, lack of resources, staff smoking, and environmental barriers. Directors also cited several factors that they believed would support tobacco cessation. These included financial support, enhanced leadership, and state mandates against smoking in addiction treatment programs.

Conclusion

Addiction treatment programs are beginning to place more emphasis on tobacco cessation during treatment. However, furthering this goal requires substantial infrastructural and cultural change. These qualitative study findings may help to inform Single State Agencies (SSAs) to support publicly funded addiction treatment programs in their tobacco cessation efforts. In order to maximize effectiveness, state-level policies regarding tobacco cessation during treatment should be informed by ongoing dialogue between service providers and SSAs.

Objective

This research examined electronic cigarette (e-cigarette) use by individuals in treatment for substance abuse, a population with a high prevalence of tobacco use and poor smoking cessation outcomes.

Methods

We surveyed 1127 individuals from 24 substance abuse treatment centers across the United States. Bivariate analyses and logistic regression were used to examine factors associated with daily (N = 87) versus weekly (N = 81) e-cigarette use.

Results

Among the full sample, 59.8% reported any lifetime use of e-cigarettes, with 23.6% reporting past 30-day use. Daily e-cigarette users were more likely to have used second-generation, tank-type e-cigarettes, χ2(1,N = 165) = 11.54, p = .001, used more flavors overall, t(168) = 2.15, p = .03, and were more likely to report using their e-cigarette continuously throughout the day, χ2(4,N = 168) = 16.7, p = .002, compared to weekly e-cigarette users. Over half (57.7%) of the daily and weekly e-cigarette users reported having an e-cigarette device that broke. The logistic regression model adjusting for clinic type and days with poor mental health found that daily e-cigarette users were significantly more likely than weekly e-cigarette users to be from methadone clinics (adjusted odds ratio [AOR] = 2.40, p = .04), and former smokers (AOR = 6.37, p < .002).

Conclusions

Daily e-cigarette users in substance abuse treatment were more likely to be from methadone clinics and former cigarette smokers. However, the majority (73.6%) of daily e-cigarette users were current cigarette smokers. E-cigarette device type reliability (eg, breakage) may be an important factor to consider among drug treatment and other populations with lower socioeconomic status.

Implications

This study found several differences in the device type, flavors, and use characteristics of daily versus weekly e-cigarette users. While majority of e-cigarette users in substance abuse treatment were current cigarette smokers, daily e-cigarette users were more likely to be former cigarette smokers. Administrators of substance abuse treatment programs should evaluate potential benefits and harms of e-cigarettes when developing program policies.

Background

Differences in tobacco use behaviors have been identified between Latinos and non-Latino whites in the general US population. Little is known about cigarette smoking and quitting behaviors of Latinos in treatment for substance use disorders (SUDs), who represent two major tobacco-vulnerable groups.

Objectives

To compare, in a national sample of persons enrolled in SUD treatment, demographic, drug use, and smoking and quitting prevalence and behaviors between Latinos and non-Latino whites.

Methods

We surveyed 777 SUD treatment clients, sampled from 24 clinics selected at random from the National Institute on Drug Abuse Clinical Trials Network (Latino client n = 141; 40% female). We then conducted univariate and multivariate analyses to identify correlates of smoking behaviors by Latino/non-Latino white ethnicity.

Results

Latinos' smoking prevalence resembled that of non-Latino whites (78.7% vs. 77.4%). In regression analyses, Latino smokers (n = 111) tended to smoke fewer cigarettes per day (CPD) than non-Latino white smokers (n = 492); were more often nondaily smokers and menthol smokers; more often reported a smoking quit attempt in the last year; and tended to report higher numbers of past-year quit attempts. Among Latino smokers, those with less education and those reporting opioids as their primary drug of use reported higher CPD.

Conclusions

Latinos in SUD treatment are at equally high risk of being current heavy smokers as compared to non-Latino whites in SUD treatment. At the same time, Latinos in SUD treatment exhibit ethnic-specific smoking and quitting behaviors that should be considered when designing smoking interventions for this group.

Objectives. We used admissions data from the New York State addiction treatment system to assess patient self-reported tobacco use and factors associated with tobacco use. Methods. We compared prevalence of tobacco use in the state addiction treatment system with that of a national sample of people receiving addiction treatment and with that of the New York general population in 2005 to 2008. A random effects logistic model assessed relationships between patient- and program-level variables and tobacco use. Results. Prevalence of tobacco use in the New York treatment system was similar to that in national addiction treatment data and was 3 to 4 times higher than that in the general population. Co-occurring mental illness, opiate use, methadone treatment, and being a child of a substance-abusing parent were associated with higher rates of tobacco use. Conclusions. We call on federal leadership to build capacity to address tobacco use in addiction treatment, and we call on state leadership to implement tobacco-free grounds policies in addiction treatment systems.

Graphic warning labels (GWLs) on cigarette packs have been tested among diverse groups at high risk for tobacco use. However, little is known about the effectiveness of GWL interventions for persons with substance use disorders, whose smoking prevalence is 3 to 4 times that of the general population. After an experimental study which exposed clients in residential addiction treatment to GWLs for 30 days, we conducted five focus groups with trial participants (N = 33) to explore how exposure to the labels may have impacted their readiness to quit smoking. Focus group interviews were analyzed thematically. Interviewees reported that GWLs were more effective than text-based warnings for increasing quit intentions due to greater cognitive and emotional impact. Male and female interviewees expressed gender-specific reactions to the labels. Addiction treatment programs are a strategic site for GWL and other tobacco interventions due to the tobacco-vulnerable populations they serve.

Background

Urban emergency department (ED) patients have elevated smoking and substance use compared with the general population. We analyzed gender differences in smoking among an urban ED sample and assessed the contribution of substance use, demographic, and couple factors.

Methods

We conducted a secondary analysis of data obtained from a cross-sectional, observational survey (N = 1037 participants) on drinking, drug use, and intimate partner violence (IPV). Gender-specific logistic regression models for current (past 30-day) smoking and multinomial regression models for smoking intensity (light: ⩽5 cigarettes per day [CPD]; moderate: 6 to 10 CPD; heavier: >10 CPD) were estimated.

Results

Smoking prevalence was higher among men than women (35.5% vs 18.9%; P < .001). Substance use (frequency of intoxication, marijuana, amphetamine, and cocaine use), demographic (food insufficiency, unemployment), and couple-related factors (having a spouse/partner who smoked, IPV involvement, being in a same-gender couple) were differentially associated with current smoking and level of intensity among men and women.

Conclusions

Emergency department staff should consider the impact of polysubstance use, food insufficiency, unemployment, and whether both partners in the couple smoke when screening patients for smoking and formulating cessation treatment plans. Women in same-gender relationships and those who have experienced IPV involvement may require additional referral.

Introduction

The COVID-19 pandemic may present special challenges for residential substance use disorder (SUD) treatment facilities, which may lack infrastructure and support to implement infection control protocols while maintaining on-site treatment services. However, little is known about how residential SUD treatment programs are impacted by the COVID-19 pandemic.

Methods

The research team conducted semi-structured interviews with 17 directors of 20 residential SUD treatment programs across California during the state's shelter-in-place order. The researchers then analyzed qualitative interview data thematically and coded them using ATLAS.ti software.

Findings

Thematic analyses identified six major themes: program-level impacts, staff impacts, client impacts, use of telehealth, program needs, and positive effects. "Program-level impacts" were decreased revenue from diminished client censuses and insufficient resources to implement infection control measures. "Staff impacts" included layoffs, furloughs, and increased physical and emotional fatigue. "Client impacts" were delayed treatment initiation; receipt of fewer services while in treatment; lower retention; and economic and psychosocial barriers to community re-entry. "Use of telehealth" included technical and interpersonal challenges associated with telehealth visits. "Program needs" were personal protective equipment (PPE), stimulus funding, hazard pay, and consistent public health guidance. "Positive effects" of the pandemic response included increased attention to hygiene and health, telehealth expansion, operational improvements, and official recognition of SUD treatment as an essential health care service.

Conclusion

Study findings highlight COVID-related threats to the survival of residential SUD treatment programs; retention of the SUD treatment workforce; and clients' SUD treatment outcomes. These findings also identify opportunities to improve SUD service delivery and suggest avenues of support for residential SUD treatment facilities during and after the COVID-19 pandemic.

Few studies explore racial/ethnic disparities in tobacco use and access to cessation services among people with substance use disorders (SUD). We collected data from Hispanics (n = 255), non-Hispanic Whites (n = 195), and non-Hispanic Blacks (n = 126) across 24 Californian residential SUD treatment programs. Data were analyzed via regression models adjusting for demographics, cigarettes per day, past quit attempts, intent to quit in the next 30 days, and physical health status. Non-Hispanic Whites smoked at a higher rate (68.7%) than both Hispanics (54.9%) and non-Hispanic Blacks (55.6%) and smoked more cigarettes per day (M = 11.2, SD = 6.5). Hispanics were more likely than non-Hispanic Whites to receive a referral to a cessation specialist (adjusted odds ratio; AOR = 2.34, 95% CI = 1.15, 4.78) and tobacco-cessation counseling (AOR = 2.68, 95% CI = 1.28, 5.62). Non-Hispanic Blacks were also more likely than non-Hispanic Whites to receive cessation counseling (AOR = 3.61, 95% CI = 1.01, 12.87) and NRT/pharmacotherapy (AOR = 2.65, 95% CI = 1.57, 4.47). Despite their decreased smoking prevalence and severity, REMs were accessing smoking cessation services while in treatment, suggesting that SUD treatment could serve as a place to address tobacco-related racial inequities.

There are higher rates of menthol cigarette smoking within certain population subgroups. Limited research has examined menthol use among individuals in treatment for substance use disorders (SUD), a population with a high prevalence of cigarette smoking, poor smoking cessation outcomes, and high tobacco disease burden. Survey data were collected from 863 smokers sampled from 24 SUD treatment programs affiliated with the NIDA Clinical Trials Network (CTN) in the United States. Prevalence of menthol cigarette smoking was examined for the sample. Bivariate and multivariate analyses were used to examine demographic and tobacco use characteristics associated with menthol cigarette smoking. Overall, the prevalence of menthol smoking among individuals in SUD treatment was 53.3%. Smoking menthol versus non-menthol cigarettes was associated with being female (AOR=1.61, p=0.003), African American (AOR=7.89, p<0.001), Hispanic/Latino (AOR=3.39, p<0.001), and lower odds of having a college degree (AOR=0.49, p=0.015). Controlling for demographic factors, menthol smokers were more likely to report marijuana (AOR=3.33, p<0.007) as their primary drug compared to alcohol. Lastly, menthol smokers were more likely to report interest in getting help for quitting smoking (AOR=1.53, p=0.01), although they were not more likely to report making a past year quit attempt. In conclusion, use of menthol cigarettes was higher among smokers in SUD treatment than in general population smokers. Regulatory policies targeting the manufacture, marketing, or sale of menthol cigarettes may benefit vulnerable populations, including smokers in SUD treatment.