We included measures of employment indicating whether respondents were employed, temporarily unemployed or seeking work, or part of a residual category that included retirees, students, and stay-at-home spouses or partners. The study was approved as exempt by the UCSF institutional review board on July 16, 2016. The 2016 survey contained 3,058 respondents. Weighted probabilities of use in each category, by sociodemographic characteristics, are shown in Table 1. Overall prevalence rates were 14.5% for cigarette smoking, 5.6% for ENDS use, and 9.5% for cannabis use. Prevalence of separate use for tobacco and cannabis, for all modalities, was 6.1% and prevalence of simultaneous tobacco and cannabis use was 3.4%. As shown in Table 1, rates of cigarette smoking, ENDS use, and cannabis use were higher for men than women. Rates of cigarette smoking and combined cannabis and tobacco use decreased with higher levels of education, but were not associated with higher education levels for ENDS use, cannabis use, or combined use. Rates of cigarette smoking, ENDS use, cannabis use, and combined use were highest among those unemployed and seeking work and persons with disabilities, relative to those who were employed or retired. Over half of cigarette smokers who initiated smoking over the age of 18 reported smoking in the past 30 days.For cigarette smoking, there was a lower odds ratio among those with at least a bachelor’s degree and those with household incomes greater than $100,000, as shown in Table 2. There was a significantly greater odds ratio among persons with disabilities and those who had begun smoking at 15 or older. For ENDS use, grow tables 4×8 there was a significantly lower odds ratio among those aged 55 or older. For all cannabis use, women were approximately half as likely to use as men .
Additionally, those with household incomes from $25,000–$49,999 were half as likely to use cannabis as those who had incomes of less than $25,000 . For combined tobacco and cannabis use, there was a significantly lower odds ratio among some lower-income groups. There was a significantly greater odds ratio for those who were unemployed and seeking work. For using tobacco and cannabis simultaneously, there was a significantly lower odds ratio for those with incomes $25,000–$49,999 and greater than$75,000. There was a significantly higher odds ratio for those who were unemployed and seeking work or and persons with disabilities. Past research has identified the practice and consequences of simultaneous tobacco and cannabis use among adolescents, however there has been limited data on the prevalence of this practice in different population subgroups or relative to other consumption, such as use of individual substances or separate use . Existing research suggests that young adults may be more likely to engage in simultaneous use, particularly given the increase in new modalities of use , however surveillance data has not yet verified this expectation . Our findings suggest that in contrast to findings from previous research, rates of simultaneous use may be highest among those who were involuntarily unemployed and persons with disabilities rather than among youth. We also found that more people used either cannabis or ENDS than smoked cigarettes, despite the relative novelty of these products. These results suggest a transition toward modalities that allow simultaneous use, a trend that could continue or accelerate as these novel products become increasingly normalized. Research on simultaneous use suggests that such a transition would lead to more dependence and reduced quit attempts , a concern given that these sub-populations are likely to have lower income and co-occurring conditions . Our findings have limitations. The data are based solely on California residents and responses reflect a policy environment that for 20 years has focused on reducing tobacco use and increasing access to medical marijuana.
These policy changes preceded similar changes made in many other states, suggesting that these data , primarily provide insight into how use patterns may change over time in those states that also legalized medical marijuana prior to recreational cannabis. Survey responses were based on self-report and did not biochemically validate responses; previous research suggests that respondents may under report use . As a result, our findings may have failed to identify other groups at risk of simultaneous use. As states continue to legalize medical marijuana and recreational cannabis, it is critical to monitor shifts in patterns of tobacco and cannabis use. Adolescents and young adults have been a focus of prior research, particularly in light of their susceptibility to uptake of novel delivery devices such as JUUL . However our findings suggest that young adults are not necessarily the population with the highest prevalence or highest risk of simultaneous use. Simultaneous use is linked with more severe consequences than using tobacco or cannabis alone, or with separate use of these products. Our findings that simultaneous users in California were not disproportionately young adults are relevant for developing targeted prevention and cessation interventions for individuals at high risk. In addition to emphasizing risks faced by adolescents and young adults, our findings suggest that public health interventions should expand their focus to address other vulnerable populations, including persons who are involuntarily unemployed and those with disabilities. Disproportionately more rural veterans are enrolled in Department of Veterans Affairs healthcare than their urban counterparts . Most rural veterans receive care from smaller VA community based outpatient clinics established by VA expressly to improve access to care, including mental health care. Rural veterans who utilize VA community-based clinics are typically older, sicker and poorer, and experience significantly greater MH burden and poorer clinical outcomes than their urban counterparts receiving care at VA medical centers.
VA mandates that all veterans, including those receiving care at VA community-based clinics, have access to evidence-based MH treatments. Minimally adequate MH treatment has been defined as ≥ 8 MH treatment sessions or receiving ≥ 2 months of psychiatric medication plus > 4 visits within 1 year. Nevertheless, despite access to VA community-based clinics, rurality remains one of the strongest predictors of poorMH treatment engagement. Roughly, only 20% of rural veterans with MH conditions initiate any MH treatment and even fewer complete a full course of evidence-based MH treatment. Rural veterans’ lack of engagement in MH treatment reflects a myriad of logistical barriers, paramount among them geographical distance, and lack of access to consistently available MH services. Other barriers are cultural norms in rural communities, including negative beliefs surrounding MH treatment, stigma against needing or seeking MH treatment, and stoicism, with rural veterans preferring to address MH and emotional problems within their own communities, families, and religious organizations. Motivational interviewing is an evidence-based approach to facilitating behavioral change, and multiple studies over decades have demonstrated MI’s effectiveness for MH treatment engagement among veterans. One pilot trial of 73 younger Iraq and Afghanistan veterans who screened positive for MH symptoms demonstrated that 4 brief sessions of telephone MI conducted by trained research staff resulted in 62% initiating MH treatment versus 26% assigned to receive 4 brief neutral telephone sessions . Of note, this trial was conducted in younger, urban veterans by research staff with backgrounds in psychology. However, none of these trials were conducted among rural veterans who might experience greater barriers to MH treatment engagement. In addition, ebb flow tray most prior trials have used MH clinicians to deliver MI. There is emerging evidence that peers who may have shared experiences and “speak the same language” as the populations they serve may encounter less resistance and be more effective in promoting positive change, including engagement in MH care, especially in rural populations. Here, we describe the results of a multisite pragmatic randomized controlled trial , “Motivational Coaching to Enhance Mental Health Engagement in Rural Veterans,” hereafter abbreviated as “COACH.” The trial tested a veteran peer-delivered telephone motivational coaching intervention for veterans receiving care atpredominantly rural VA community-based clinics in either Northern California or Louisiana who had screened positive for ≥1 MH symptoms but were not engaged in MH treatment. We hypothesized that veterans who received MI-consistent feedback about MH screen results and MH referrals plus several sessions of veteran peer delivered telephone motivational coaching would be more likely to engage in clinician-directed MH treatment than veterans who received MH screen results and a referral without motivational coaching . Secondarily, we hypothesized that veterans assigned to veteran peer-delivered telephone motivational coaching would experience improvements in MH symptoms, quality of life indicators, and self-care as a direct effect of peer coaching itself compared to those randomized to the control condition. Qualitative exit interviews of participants in the intervention arm were conducted to better understand trial results.VA administrative databases were used to identify veterans with the following criteria: had received primary care within 1 year of study enrollment at 1 of 8 participating VA community-based outpatient clinics: 4 facilities in Northern California and 4 in Louisiana ; and had screened positive on ≥ 1 VA MH screens or had received ≥ 1 MH diagnosis, but had never attended an MH visit , or had attended up to 2 MH visits , but without follow-up within 90 days of recruitment.
Veterans identified through VA administrative data were mailed a study information sheet and a postcard they could mail back to indicate interest in study participation. If participants indicated interest or if no postcard was received after 2 weeks, study staff attempted to contact veterans by phone. In addition, VA community-based outpatient clinic providers were encouraged to refer patients to the study and flyers were posted in their clinics. Veterans deemed eligible and interested on initial telephone screening underwent informed consent prior to enrollment. Participants were enrolled from October 29, 2015, to October 19, 2017, and the study concluded June 1, 2018. The study protocol was approved by the VA Central Institutional Review Board and the local Research and Development Committees at the participating VA enrollment sites.60-min baseline assessment by telephone to collect baseline data and verify trial eligibility. Information was collected on sociodemographics, VA service connection/disability status, and prior VA and non-VA mental health treatment experiences in the past 5 years and past 60 days. Psychometrically valid assessment instruments with published cut points were used to determine participants’ symptom status for 5 target MH disorders: posttraumatic stress disorder , depression , anxiety , panic disorder , and alcohol and illicit substance use . Additional instruments were used to assess: quality of life across 4 domains: physical health, psychological health, social relationships, and environment ; importance, confidence, and readiness for MH treatment; and logistical, stigma- and beliefs-related barriers to MH treatment . Results from the telephone baseline assessment were entered directly into a web-based data collection system and scored in real time to verify non-MH treatment-engaged participants who screened positive for ≥ 1 MH problems, thereby confirming trial eligibility. This was defined as: scoring in the “mild” range on at least 2 MH screening instruments ; or scoring in the “moderate” range on at least 1 MH screening; or scoring in the “mild” range for at least 1 substance and in the “mild” range on at least 1 MH screen.The study was a single-blind, 2-arm pragmatic effectiveness RCT comparing MI-styled veteran peer-delivered feedback on MH screen results and referrals plus 4 sessions of telephone motivation alcoaching versus veteran peer-delivered MH results and referrals without motivational coaching . The study was designed as a Hybrid Type 2 pragmatic implementation effectiveness study, in which the implementation of the trial intervention was tailored to meet the needs, resources, and preferences of stakeholders at each VA community-based clinic study site. Thus, prior to trial implementation, a formative evaluation was conducted at each of the 8 VA community-based clinic sites, beginning with qualitative interviews with study stakeholders—veterans and VA staff—to understand barriers and facilitators of MH treatment for veterans at the clinic and in the local communities. Subsequently, the study team convened lunchtime meetings with study stakeholders at each of the VA community-based clinics to review evidence for the motivational coaching intervention, provide feedback from the qualitative interviews, and to engage study stakeholders in decision making about flexible components of the trial. For instance, some clinic stakeholders preferred to be more involved with recruitment efforts than others. Also, in this formative stage, the study outcomes related to MH treatment engagement were broadened to reflect rural veterans’ preferences for self-care activities based on input from VA stakeholders at the 8 participating VA community-based outpatient clinic sites.