The strategic targeting of females by transnational tobacco companies in South Korea following trade liberalization

BACKGROUND

In 1988 South Korea opened its cigarette market to foreign companies under the threat of US trade sanctions. Despite strong social stigma against female smoking in South Korea, and restrictions on tobacco marketing to women and children, smoking rates among young Korean females increased from 1.6% in 1988 to 13% in 1998. Previous analyses describe how Asian countries have been targeted by transnational tobacco companies for new markets, with Asian females offering substantial future growth potential. An understanding of the strategies used by TTCs to increase smoking among Korean females is critical to public health efforts to adopt a stronger gender perspective in implementing the Framework Convention on Tobacco Control.

METHODS

Internal documents of transnational tobacco corporations were systematically searched using keywords focused on the targeting of the female market since market liberalization in 1988. Industry documents were analysed alongside primary and secondary data on the tobacco industry in South Korea.

RESULTS

TTCs have targeted Korean females since the late 1980s, conducting market research to understand consumer preferences, cultural characteristics and social changes affecting women and girls. Brands designed to appeal to females have focused on "slim" and "superslim" cigarettes, "light" and "mild" claims, and marketing which appeals to the growing numbers of young women entering the labour force. Strategies for overcoming legal restrictions on marketing to women and children have included the use of company rather than brand names, retail distribution at venues frequented by females, trademark diversification and sponsorship.

CONCLUSION

Given the high male smoking rates in South Korea, tobacco control efforts have given limited attention to girls and women. The limited data available on female smoking behaviour suggests that, despite legal restrictions and social stigma, smoking among females has increased since market opening, notably within younger age groups. In addition to more detailed trend data, there is an urgent need for the development and implementation of gender-sensitive tobacco control measures. Part of South Korea's accession to the FCTC should include emphasis on measures to address the strategic targeting of Korean females by TTCs.

Leadership in public health

The modern public health model for leadership will unlikely be the omniscient figure with easy answers.51 Rather the public health leader of the future may well be the transcendent, collaborative «servant leader»50,52 who knits and aligns disparate voices together behind a common mission. They pinpoint passion and compassion, promote servant leadership, acknowledge the unfamiliar, the ambiguous, and the paradoxical, communicate succinctly to reframe, and understand the «public» part of public health leadership. By working between and above the levels of leadership of self, others and organizations, these transcendent leaders can ultimately shift the paradigm from «no hope» to «new hope» and create a renewed sense of community.

Such leadership will be vital as the 21st century progresses. Beginning the journey to new hope may start by motivating underdogs who nurture the spirit, discover a passion to serve, cultivate interdependence, and create uncommon bonds. These emerging leaders can tap into their unique talents, passion, and compassion to promote a mission of «the highest attainable standard of health» for all, in every community.

After the master settlement agreement: targeting and exposure of youth to magazine tobacco advertising

Targeting and exposure of youth to magazine advertising of tobacco products is associated with increased smoking initiation. National magazine advertising and youth exposure declined in the period following the Master Settlement Agreement (MSA). However, tobacco companies continued targeting youth with brands that were popular among them through magazine advertising and placement of ads in magazines with high youth readership. Existing restrictions, followed by enforcement through litigation, have achieved a marked reduction in overall magazine advertising but may be less adequate compared with pending federal legislation to fully protect youth from the marketing of tobacco products designed to appeal to them.

Tobacco industry control of menthol in cigarettes and targeting of adolescents and young adults

OBJECTIVES

We examined whether tobacco manufacturers manipulate the menthol content of cigarettes in an effort to target adolescents and young adults.

METHODS

We analyzed data from tobacco industry documents describing menthol product development, results of laboratory testing of US menthol brands, market research reports, and the 2006 National Survey on Drug Use and Health.

RESULTS

The tobacco industry attracted new smokers by promoting cigarettes with lower menthol content, which were popular with adolescents and young adults, and provided cigarettes with higher menthol content to long-term smokers. Menthol cigarette sales remained stable from 2000 to 2005 in the United States, despite a 22% decline in overall packs sold.

CONCLUSIONS

Tobacco companies manipulate the sensory characteristics of cigarettes, including menthol content, thereby facilitating smoking initiation and nicotine dependence. Menthol brands that have used this strategy have been the most successful in attracting youth and young adult smokers and have grown in popularity.

Coronary heart disease deaths and decreased smoking prevalence in Massachusetts, 1993-2003

We used the previously validated IMPACT coronary heart disease (CHD) mortality model to estimate the CHD deaths attributable to reductions in smoking prevalence following the introduction of the Massachusetts Tobacco Control Program (MTCP) in 1993. A 29% and 31% decline in smoking prevalence and CHD mortality rates occurred, respectively (from 1993 to 2003). A total of 425 fewer CHD deaths, which generated approximately 3365 extra life-years, were attributable to decreased smoking prevalence. With these results in mind, a comprehensive tobacco control program should be sustained and supported.

Regionalization of local public health systems in the era of preparedness

Post-9/11, preparedness planning has catalyzed intrastate regionalization of local public health resources throughout the United States. Investigating this trend unveils several regionalization themes, relevant in other sectors of government, which are applicable to local public health. In this review article, we begin by briefly examining the lessons learned from regionalization for police and fire services, drawing comparisons to public health. Then we provide a brief history of the accelerating regionalization of local public health services sparked by the current attention to emergency preparedness. In particular, we offer case studies from Massachusetts and the National Capital Region to highlight examples of regionalization outcomes related to networking, coordination, standardization, and centralization of public health services. The impact of social capital on preparedness is also explored. Finally, we summarize research needs for the future.

Reduced lung cancer deaths attributable to decreased tobacco use in Massachusetts

BACKGROUND

Approximately 88% of the lung cancer deaths in men and 71% in women occurring in the US are attributable to cigarette smoking, with almost 3,700 annual lung cancer deaths in Massachusetts. In the state, male lung cancer death rates are showing a per year annual decline following a peak in the early 1990s. Such recent declines could be mostly attributed to tobacco control efforts over the past 40 years.

METHOD

This study predicts how many fewer lung cancer deaths have occurred in Massachusetts possibly attributable to tobacco control activities. The study employs the US National Cancer Institute's "Joinpoint" Regression Analysis Program (version 3.0) using statewide age-standardized (2000 US Standard Population) lung cancer death rates from 1931 to 2003 for each of the sexes. 95% confidence intervals (CI) were also calculated.

RESULTS

Modeled male lung cancer death rates stabilized from the calendar year 1977 onwards but showed significant decline from 1992 onwards, while females showed a deceleration in rising lung cancer rates from 1993 onwards. Therefore, based on their corresponding beta-coefficients (slope) and standard error for each of the two calendar years 19,665 (95% CI: 18,655; 20,765) fewer lung cancer deaths in males and 3,855 (95% CI: 3,630; 4,055) fewer lung cancer deaths in females were estimated to have occurred from 1977 to 1993 onwards, respectively, largely because of the anti-smoking interventions in the past.

CONCLUSIONS

Reductions in tobacco smoking are a major factor in the decrease in lung cancer mortality rates. Sustained progress in tobacco control is essential.

Asian American Network for Cancer Awareness, Research, and Training's legacy. The first 5 years

The Asian American Network for Cancer Awareness, Research, and Training (AANCART) is the first special populations network for Asian Americans on a national basis and includes collaborating organizations from Boston, New York, Houston, Seattle, San Francisco, Los Angeles, Hawaii, and Sacramento (where it is headquartered at the University of California, Davis). NCI funding of AANCART in 2000 brought together investigators and leaders from 9 cities across 6 states to establish an infrastructure for addressing cancer awareness, research, and training. Since 2000, AANCART has conducted needs assessments, held community awareness activities and trainings, trained trainees, sponsored National Asian American Cancer Control Academies, and produced presentations, publications, and grants. All specific aims have been attained, including the establishment of an infrastructure to promote Asian American cancer awareness, research, and training in 4 targeted regions; the establishment of partnerships to promote accrual to clinical trials, training, and pilot studies; and the formulation and successful implementation of grant-funded research to reduce the cancer burden among Asian Americans. AANCART's first 5 years have increased cancer awareness, trained special populations scientists, and advanced the field of Asian American cancer control research. Cancer 2006. (c) 2006 American Cancer Society.

A statewide public health approach to improving organ donation: the Massachusetts Organ Donation Initiative

Despite the growing disparity between organ supply and demand in the United States, few initiatives have attempted to close the gap through systematic population-based public health endeavors. We examined the evolution, implementation, and outcomes of the Massachusetts Organ Donation Initiative, a statewide effort that included a unique partnership among organ procurement organizations, major teaching hospitals, and the state's department of public health. Lessons from this initiative have contributed to growing national efforts for increasing organ supply and have provided insights for addressing this continuing public health challenge.

A randomized trial to improve early detection and prevention practices among siblings of melanoma patients

BACKGROUND

Identifying high-risk individuals for melanoma education and risk reduction may be a viable strategy to curb the incidence of melanoma, which has risen precipitously in the past 50 years. The first-degree relatives of melanoma patients represent a risk group who may experience a 'teachable moment' for enhanced education and risk reduction.

METHODS

We report a randomized trial testing an intervention that provided personalized telephone counseling and individually tailored materials to siblings of recently-diagnosed melanoma patients. The purpose of this study was to test whether an intervention could lead to improvements in siblings' skin cancer risk reduction practices. Intervention condition participants received the following: (1) an initial motivational and goal-setting telephone intervention session delivered by the health educator; (2) three sets of computer-generated materials specifically tailored to individual responses from the baseline survey; (3) three telephone counseling sessions with the health educator, timed to follow receipt of the mailed materials; and (4) linkages to free screening programs. Families in the usual care arm received the suggestion from the physician that patients diagnosed with melanoma notify the family members about their diagnosis and encourage the family members to be screened.

RESULTS

494 siblings were recruited to the study and 403 siblings remained in the study through at least 6 months. At 12 months, intervention siblings were more likely to examine all moles, including those on the back (OR, 1.76; 95% CI, 1.06-2.91). Compared with baseline, the number of participants in both groups that had received a skin cancer examination more than doubled, with no differences between groups. At 12 months, two-thirds of siblings in both groups reported routine use of sunscreen, but there were no differences in change over baseline between the two groups.

CONCLUSIONS

This study is the one of the first, to our knowledge, to address skin cancer risk-reduction strategies in a sample of individuals who have a recent family diagnosis of melanoma. Diagnosis of melanoma in a family member provides an important opportunity to intervene with others in that family. The components of the intervention may provide a useful foundation for future efforts to target the more than half million siblings at risk for melanoma, a lethal but preventable disease.

Sun protection practices among offspring of women with personal or family history of skin cancer

OBJECTIVE

Family history of skin cancer is an important determinant of skin cancer risk for offspring. No previous study of the effect of personal or family history of skin cancer on the sun protection behaviors of the offspring has been published.

METHODS

A retrospective study was conducted of the sun protection behaviors of the adolescent participants in the Growing Up Today Study (GUTS), who were offspring of mothers from the Nurses Health Study II. Adolescents' surveys were matched with their mothers' reports of a personal or family history of skin cancer and compared with adolescents whose mothers did not report a personal or family history of skin cancer. The outcome measures were (1) occurrence of frequent sunburns during the past summer, (2) use of a tanning bed during the past year, and (3) routine use of sunscreen. Frequent sunburns were defined as the report of > or = 3 sunburns during the past summer. We compared those who reported having used a tanning bed in the past year at least once with those who reported no tanning bed use in the past year. Routine use of sunscreen was defined as a respondent who replied that he or she "always" or "often" used sunscreen with sun protection factor of 15 or more when he or she was outside for > 15 minutes on a sunny day during the past summer. General estimating equations were used to calculate odds ratios and 95% confidence intervals adjusted for gender, age, color of untanned skin, and number of friends who were tanned. We also conducted an additional analysis restricted to children whose mothers had received a diagnosis of skin cancer in which we assessed sun protection behaviors according to the child's age and mother's age at the time of the mother's diagnosis and the number of years that had passed since the diagnosis of the mother's skin cancer.

RESULTS

In 1999, 9943 children reported their sun protection behaviors; 8697 of their mothers had not received a diagnosis of skin cancer or reported a family history of melanoma, 463 participants' mothers had received a diagnosis of skin cancer, and 783 participants' mothers reported a family history of melanoma. Between 1989 and 1999, 371 mothers of GUTS participants received a diagnosis of skin cancer: melanoma (n = 44), squamous cell (n = 39), and basal cell cancer (n = 311); 23 mothers received a diagnosis of > 1 type of skin cancer. Because GUTS includes siblings from the same family, the 371 mothers with skin cancer had 463 offspring in GUTS. Offspring of mothers with skin cancer were slightly more likely to report frequent sunburns in the past year compared with those with neither maternal diagnosis nor family history (39% vs 36%). Tanning bed use was not significantly different among those with either a maternal diagnosis of skin cancer or family history of melanoma as compared with nonaffected adolescents (8% vs 9% vs 10%). Sunscreen use among offspring of mothers with skin cancer was higher than among those whose mothers had a family history of melanoma or mothers with no personal history of skin cancer (42% vs 33% vs 34%). Tan-promoting attitudes were also similar across all groups. Only 25% thought that a natural skin color was most attractive, and on average, 25% in each group agreed that it was worth burning to get a tan. Children of mothers who had received a diagnosis > 2 years in the past were less likely to use sunscreen, more likely to sunburn, and more likely to use tanning beds than children of mothers with a more recent diagnosis, although the results did not reach statistical significance.

CONCLUSION

Frequent sunburns, suboptimal sunscreen use, and high rates of tanning bed use are commonplace even among the children of health professionals who are at risk for developing skin cancer themselves as a result of personal or family history. With new information on family risk, pediatricians can use the potential of a teachable moment to ensure optimal sun protection for children who are at risk.

Sun Protection Policies and Practices at Child Care Centers in Massachusetts

We assessed the relationship between sun protection policies and practices at child care centers in Massachusetts. We hypothesized that centers with sun protection policies were more likely to have regular sun protection practices in place compared to centers without these policies. We conducted a telephone survey with directors or assistant directors at 327 child care centers during the summer of 2002. The main outcome measure was sun protection practices, which included time spent outside during mid-day and the use of sunscreen, hats, and protective clothing by the majority of children assessed over the last 5 program days. The 36-item survey also inquired about the center's sun protection policy and included demographic questions. Most centers (73%) reported having a written sun protection policy. Sun protection policies were positively associated with reported sunscreen (chi squared = 14.63, p = 0.0001) and hat use (chi squared = 30.98, p < 0.0001) and inversely associated with time outside (chi squared = 10.76, p = 0.001). Seventy-seven percent of centers followed recommended sunscreen practices. However, centers were far less likely to have recommended hat use (36%) and protective clothing (1.5%) practices. A formal sun protection policy may be an effective way to increase sun protection practices in the child care setting. Further research should assess this relationship in other states. Improving and expanding existing state regulations may be a reasonable strategy to increase sun protection at child care centers.

The first decade of the Massachusetts Tobacco Control Program

This article provides a comprehensive overview of the first decade of the Massachusetts Tobacco Control Program (MTCP). Born after Massachusetts passed a 1992 ballot initiative raising cigarette excise taxes to fund the program, MTCP greatly reduced statewide cigarette consumption before being reduced to a skeletal state by funding cuts. The article describes the program's components and goals, details outcomes, presents a summary of policy accomplishments, and reviews the present status of MTCP in the current climate of national and state fiscal crises. The first decade of the MTCP offers many lessons learned for the future of tobacco control.

New Cigarette Brands With Flavors That Appeal To Youth: Tobacco Marketing Strategies

Tobacco manufacturers have recently introduced a proliferation of exotic brands featuring candylike flavors. We reviewed internal tobacco industry documents and patents to assess the role of flavored cigarettes in the targeting of young smokers. This research revealed the development of flavor delivery technologies hidden from consumers and public health professionals, including the use of a plastic pellet placed in the cigarette filter. These findings raise concerns as to the potential added health risks associated with using new flavored tobacco products, and they underscore the need for effective assessment and monitoring of tobacco products.

A public health approach to reducing morbidity and mortality among homeless people in Boston

Urban homeless populations suffer disproportionately high rates of premature death. In response to a wave of highly publicized deaths on the streets of Boston during the winter of 1998-1999, the Massachusetts Department of Public Health (MDPH) convened a task force to investigate these deaths and implement an integrated response to this public health crisis. Comprised of a broad coalition of public and private agencies as well as homeless persons and advocacy groups, the MDPH Task Force reviewed the circumstances surrounding the 13 deaths, monitored subsequent deaths among homeless persons in Boston, and implemented a comprehensive plan to address critical needs and prevent further deaths. Contrary to the task force's initial assumption, the 13 decedents had multiple recent contacts with the medical, psychiatric, and substance abuse systems. In response to this finding, the MDPH Task Force sought to improve continuity of care and prevent future deaths among Boston's street population. Coordination of needed services was achieved through the creation of new, and often unconventional, partnerships. This case study exemplifies a public health practice response to the vexing health care challenges confronting homeless people who must struggle to survive on the streets and in shelters.

Using public health data systems to understand and eliminate cancer disparities

Identifying and eliminating social disparities in cancer depend upon the availability and ready use of public health surveillance data at the national, state and local levels. As an example of advancing a statewide research agenda in cancer disparities, we present descriptive statistics from major public health surveillance data systems in Massachusetts. Disparities highlighted include higher breast cancer mortality rates among African-American women than women of other racial groups, lower rates of colorectal and cervical cancer screening among Asian-American residents, and striking gradients in cancer risk factor prevalence and screening by income and education. Challenges in utilizing public health surveillance data include lack of information in many domains of social inequity beyond race/ethnicity, uneven quality, and lack of stable, reportable data for smaller populations. Opportunities to maximize the usefulness of cancer registry data include application of geographic information systems and linkage with other data systems tracking information on health services outcomes and clinical trial participation. Analyses of surveillance data can spark advances not only in community-based participatory research but also in programs and policies that may ultimately eliminate disparities along the cancer continuum.

Preventing 3 million premature deaths and helping 5 million smokers quit: a national action plan for tobacco cessation

In August 2002, the Subcommittee on Cessation of the Interagency Committee on Smoking and Health (ICSH) was charged with developing recommendations to substantially increase rates of tobacco cessation in the United States. The subcommittee's report, A National Action Plan for Tobacco Cessation, outlines 10 recommendations for reducing premature morbidity and mortality by helping millions of Americans stop using tobacco. The plan includes both evidence-based, population-wide strategies designed to promote cessation (e.g., a national quitline network) and a Smokers' Health Fund to finance the programs (through a 2 US dollar per pack excise tax increase). The subcommittee report was presented to the ICSH (February 11, 2003), which unanimously endorsed sending it to Secretary Thompson for his consideration. In this article, we summarize the national action plan.

Skin cancer prevention and detection practices among siblings of patients with melanoma

BACKGROUND

Family members of patients with melanoma have an increased risk of the disease, and families with multiple affected members account for about 10% of melanoma cases. These statistics suggest that first-degree relatives of patients with melanoma, who are at particularly high risk, warrant targeted public health action.

OBJECTIVE

We sought to document rates for dermatologist examinations for cutaneous lesions, the practice of skin self-examination, and sunscreen use in this at-risk group.

METHODS

Before participation in a randomized trial, 404 siblings of recently diagnosed patients with melanoma completed a survey on beliefs and practices regarding skin cancer prevention and detection.

RESULTS

Sixty-two percent of participants had carefully examined their skin, 54% routinely used sunscreen, and 27% had received a skin cancer examination by a dermatologist during the past year; 47% had never received a dermatologist examination. Multivariate analysis found modifiable positive predictors for skin self-examination and dermatologist examinations, including having a clinician with whom to talk about melanoma and believing in the importance of regular skin examinations by a physician. Significant modifiable negative predictors included enjoyment of being tanned, not being sure what to look for when examining moles, and feeling uncomfortable having others look at their skin.

CONCLUSIONS

Skin self-examination rates among these high-risk siblings are markedly higher than in population-based studies. However, many siblings were not screened for skin cancer by a dermatologist despite having strong risk profiles, being nearly fully insured, and being under care of primary care physicians. Improvements in communication between physicians and high-risk families and changes in office systems to assess family history of melanoma could increase screening rates for the estimated 1 million siblings of patients with melanoma.

Should the skin cancer examination be taught in medical school?

BACKGROUND

The fact that thin melanomas are associated with a greater than 95% survival rate, while later, more deeply invasive melanomas have a 5-year survival rate of less than 10%, demonstrates the potential personal and public health impact of early detection. The majority of patients with skin lesions are seen by nondermatologists who infrequently counsel patients about skin cancer prevention or perform a complete skin examination as part of routine care. We documented the antecedents of physician practice by evaluating medical students' observation, training, performance, and self-reported skill level for the skin cancer examination and sun protection counseling.

METHODS

Surveys were administered and completed in classrooms and student workshops in each of the 4 medical school years during the spring of 1996 and 1997. We concentrate our analysis on the graduating fourth-year students.

RESULTS

Of the 302 fourth-year students enrolled at Boston University School of Medicine, Boston, Mass, in 1996 and 1997, 223 (74%) completed surveys. Among fourth-year students, 52% rated themselves as unskilled in skin cancer examinations. Twenty-eight percent of fourth-year students had never observed a skin cancer examination, 40% had received no training, and 35% had never practiced the examination. However, fourth-year students reporting at least 1 opportunity to observe, train, or practice an examination were 3 times as likely to report themselves as moderately to very skilled as students without such opportunities.

CONCLUSION

If medical student training rates for the skin cancer examination are equally low elsewhere, as is likely, the present data suggest that even brief additions to the current curriculum, integrated into systems teaching, would augment student exposure and likely boost student skill levels.

Evaluation of a cancer prevention and detection curriculum for medical students

BACKGROUND

Undergraduate medical education needs revision to ensure that medical students graduate with the skills necessary to assist their patients in cancer prevention and detection. We sought to implement and incorporate a cancer education curriculum into the students' core curriculum and to assess their skill levels prior to (1996), during (1997), and at the peak (1998-1999) of the incorporation of new hours.

METHODS

We conducted pretest and posttest surveys of students at Boston University School of Medicine (medical student years 1-4) enrolled in each of the four study years (1996-1999). A total of 1,956 surveys (response rate, 82%) were completed. The primary outcome measure was the student's self-reported skill level (with responses ranging from 1 (very unskilled) to 5 (very skilled)) for counseling for tobacco cessation, tobacco prevention, and sun protection and for the early detection of breast, skin, and cervical cancer. Mean scores were computed for each chronological year of the study and medical school year. Differences and trends over time in mean scores of students in each medical school year were evaluated using multiple regression analysis.

RESULTS

The number of hours of cancer education increased from 6 in 1996 to 15 in 1999. Strong improvements in self-rated skill levels were recorded for four of the six measures. In particular, tobacco cessation counseling skill rose from 2.16 (1996) to 3.13 (1999) for second year students (P < 0.001) and from 3.27 (1996) to 4.17 (1999) for fourth year students (P < 0.001). Among fourth year students, the percentage reporting that cancer prevention was given too little emphasis declined from 62% (1996) to 26% (1999) (P < 0.001), suggesting that the expanded curriculum reflected the students' preferences.

CONCLUSIONS

Cancer education can be interwoven into the existing medical school curriculum and produce improvements in students' skill levels for counseling and examinations. Strategies to enhance prevention teaching can use this model.

Reliability and validity of systemic lupus activity measure-revised (SLAM-R) for measuring clinical disease activity in systemic lupus erythematosus

New clinical scales for semiquantitating disease activity in systemic lupus erythematosus (SLE) are widely used in research. They are reliable and valid measures. One of the original scales, the Systemic Lupus Activity Measure (SLAM), has been modified based on experience with it in multi-observer studies and training of individuals in its use. We tested the psychometric properties of the revised SLAM (SLAM-R). SLAM-R was tested on 30 SLE patients, who fulfilled 1997 revised ACR criteria and were selected to represent a range of disease activity. The patients were evaluated independently by two physicians, who studied the instruction booklet and who had never used SLAM-R, on two occasions 2-4 weeks apart. At the first visit, the physician's global assessment of activity using visual analog scale, anti-dsDNA Ab, C3 and C4 were checked for construct validity. The psychometric properties were analyzed with nested analysis of variance and Pearson's correlation coefficient using SAS. All patients were female, the median age was 31 (15-52) y, and the mean score of SLAM-R was 10.5 +/- 5.3 (3-26). Estimates of reliability were 0.78 of inter-rater, 0.61 of inter-visit, 0.76 of physician 1 between visits, and 0.56 of physician 2 between visits. Among subcategories except 'Eye,' the 'Gastrointestinal' category had the highest (0.96) and the 'Neuromotor' category had the lowest inter-rater reliability (0.50). With respect to construct validity, the correlation of SLAM-R scores with the disease activity variables except C4 was high and statistically significant. In conclusion, the SLAM-R is reliable and valid for measuring clinical disease activity in SLE.

FcgammaRIIa/IIIa polymorphism and its association with clinical manifestations in Korean lupus patients

The aim of this study was to determine the distribution of the FcgammaRlla and FcgammaRIIIa polymorphisms and their association with clinical manifestations in Korean lupus patients. Three hundred SLE (systemic lupus erythematosus) patients (48 male, 252 female) meeting 1982 ACR criteria and 197 Korean disease-free controls were enrolled. Genotyping for FcgammaRlla 131 R/H and FcgammaRIIIa 176 F/V was performed by PCR of genomic DNA using allele-specific primers and the FcgammaRIIIa genotype was confirmed by direct sequencing of PCR product in some cases. There was significant skewing in the distribution of the three FcgammaRIIa genotypes between the SLE and the controls (P=0.002 for R/R131 vs R/H131 and H/H131, OR 2.5 (95% Cl 1.4-4.5), but not in FcgammaRIIIa genotypes. FcgammaRIIa-R allele was a significant predictor of lupus nephritis, as compared with SLE patients without nephritis (P=0.034 for R131 vs H131, OR 1.4 (95% Cl 1.03-1.9)), but proliferative nephritis (WHO class III and IV) was less common in patients with FcgammaRlla-R/R131 and in FcgammaRIIa-R allele. In 300 SLE patients, high binding allele combination H131/V176 was less common in SLE with nephritis than in SLE without nephritis. Hemolytic anemia was less common in R131/F176 allele combination among four FcgammaRIIa/FcgammaRIIIa allelic combinations. Male SLE patients showed a higher frequency of renal involvement, serositis, thrombocytopenia, malar rash and discoid rash than female SLE, and male SLE had a higher frequency of FcgammaRIIa-R/R131 or R131-allele than male controls, but FcgammaRIIa or FcgammaRIIIa genotypes had no association with renal involvement in male SLE patients. FcgammaRIIa-H/H131 showed a higher frequency of hemolytic anemia and less pulmonary complications in male SLE. Female SLE patients showed higher frequency of any hematologic abnormality, lymphopenia, anticardiolipin antibody (+) and anti-Ro antibody (+) than male SLE, and had earlier onset of first symptoms. There was no skewing in FcgammaRIIa or FcgammaRIIIa genotypes between female SLE and female controls, but FcgammaRIIa-R131 allele showed skewing between female SLE with nephritis and female SLE without nephritis. The age at onset of thrombocytopenia was earlier in FcgammaRIIa R/R131 among three FcgammaRIIa genotypes, and serositis in FcgammaRIIIa-F/F176 among three FcgammaRIIIa genotypes. FcgammaRIIa-R131 homozygote was a major predisposing factor to the development of SLE and FcgammaRIIa-RI31 homozygote and R131 allele were a predisposing factor, and H131/V176 was a protective allele combination in lupus nephritis. In contrast to other ethnic patients, in our study cohort, clinical manifestation was different between male and female, and FcgammaRIIa and FcgammaRIIIa showed somewhat different clinical associations between the genders.

Sun protection practices in preadolescents and adolescents: a school-based survey of almost 25,000 Connecticut schoolchildren

Sun protection practices in children and adolescents fall well below national recommendations. We present the results of a survey of sun protection use and other health-related behaviors in a sample of Connecticut Caucasian students aged 9 through 18 years (N = 24,645). Our objectives were to estimate the prevalence of sun protection use and to evaluate the relationship between sun protection use and health-risk behaviors and attitudes about appearance. We present data from 1988 through 1995 from the Connecticut Health Check, a health risk appraisal survey sponsored by the Connecticut Department of Public Health. Students enrolled in public and private elementary junior as well as senior high schools took the self-administered anonymous survey, which included multiple-choice questions about use of sun protection, cigarettes, and alcohol and about body image and self-esteem. We report prevalence proportions for use of sun protection by demographic features. We compared the proportion of students in 3 categories of outcome (always, sometimes, and never use sun protection) who reported various health-risk behaviors. Twenty percent of the sample reported always using sun protection; this is well below national goals set forth in the Healthy People 2000 recommendations. Sun protection use was inversely related to age and was higher among girls than boys at all ages. At all ages, students who did not use sun protection were more likely than those who did to report other health risk behaviors, such as use of cigarettes and alcohol. The data suggested that use of sun protection is associated with positive attitudes about appearance and self-image. Use of sun protection may be one component of an overall mode of health awareness and behavior. Programs promoting safe sun practices should target boys and be integrated into an overall campaign aimed at other risk-taking behaviors.

A public health response to emerging technology: expansion of the Massachusetts newborn screening program

The development of a new technology, called tandem mass spectrometry (tandem MS), has challenged governments worldwide to consider expanding universal newborn screening for rare metabolic disorders. In 1997 the Massachusetts Department of Public Health developed a public process to meet this challenge. After addressing significant medical, legal, ethical, and logistical issues raised by tandem MS, Massachusetts incorporated one new disorder into the mandatory newborn screen and developed an optional pilot program for 20 additional disorders. The Massachusetts experience has wide relevance for other nations and states. As screening protocols are contemplated for entire populations-for newborns and others- it will remain essential that the public participate in an open process of reviewing the justification for and logistics of screening.

Cancer skills laboratories for medical students: a promising approach for cancer education

BACKGROUND

Most medical students graduate without the skills necessary to assist patients in cancer control. To address this problem, the authors developed a cancer skills laboratory for second-year medical students.

METHODS

The skills laboratory consists of two hours of training, with 15 minutes allotted per station (six to eight students assigned per station). Faculty and fellows lead the stations on prostate cancer, breast cancer, colorectal cancer, skin cancer, counseling for smoking cessation, and a discussion of anti-tobacco advertisements. Students completed pre- and post-laboratory surveys consisting of ten brief questions.

RESULTS

Overall, 94% of eligible students in 1997 and 1998 completed the surveys. Using a five-point scale, self-rated skill level increased from 2.12 to 3.83 when all modalities were averaged (p < .001).

CONCLUSIONS

Cancer skills laboratories are a promising new means for cancer education.

Genetically engineered transgenic plants with the domain 1 sequence of tobacco mosaic virus 126 kDa protein gene are completely resistant to viral infection

In many plant RNA viruses, Domains 1, 2 and 3 are conserved in replicase proteins. In order to examine the interference of viral replication by the Domain 1 sequence, we generated transgenic plants transformed with DNA corresponding to the Domain 1 sequence of the TMV 126 kDa protein. This DNA sequence includes the TMV RNA from nucleotides 1 to 2,149, which comprises both the 5'-untranslated and methyl transferase region. The transgenic plants obtained showed complete resistance to TMV infection. The presence of the Domain 1 sequence in the plants completely prevented local necrosis in Nicotiana tabacum cv. Xanthi nc, and any systemic development of symptoms in Nicotiana tabacum Xanthi upon TMV inoculation. Most transgenic plants sustained the conferred resistance even under TMV inoculum concentrations up to as high as 1,000 microg/ml. To detect any accumulation of TMV coat protein or viral RNA in infected transgenic plants, immunochemical tests and Northern blot analyses were carried out. Neither viral RNA or coat protein was detectable in the systemic leaves of the completely resistant transgenic plants, whereas they were accumulated in large quantities in all of the control plants. Because of the conservation of Domain 1 in many plant RNA viruses, the acquisition of resistance to virus infection using the Domain 1 sequence appears to be a very effective strategy for breeding of viral resistant plants.

Screening for malignant melanoma: A cost-effectiveness analysis

BACKGROUND

Skin cancer is the most common cancer in the United States. Increasing evidence suggests that screening for malignant melanoma is effective, but its cost-effectiveness has not been determined.

OBJECTIVE

We attempted to determine the effectiveness and costs of a visual screen to diagnose malignant melanoma in high-risk persons.

METHODS

We developed a decision analysis comparing no skin cancer screen with a single screen by a dermatologist. Clinical outcomes included malignant melanoma, nonmelanoma skin cancer, or no skin cancer. Life expectancy and costs of care were projected on the basis of clinical findings.

RESULTS

Skin cancer screening increased average discounted life expectancy from 15.0963 years to 15.0975 years. Based on the prevalence of malignant melanoma, however, this translates into an increased discounted life expectancy of 0.9231 years for each person with diagnosed melanoma. Using a cost of $30 per screen, total skin cancer-related costs for a cohort of 1 million people increased from $826 million with no screen to $861 million with screening, with an increase of 1200 years of life. This results in an incremental cost-effectiveness ratio of $29,170 per year of life saved (YLS) with screening. Sensitivity analysis showed that the cost-effectiveness ratio for screening remained below $50,000/YLS if the prevalence of melanoma in the screened population was at least 0. 0009, the probability that a melanoma detected in screening was localized was at least 94.8%, or the cost of each screen was below $57.

CONCLUSION

Skin cancer screening in high-risk patients is likely to be associated with a small increase in discounted life expectancy and is reasonably cost-effective compared with other cancer screening strategies.

Chemotherapy with etoposide, vincristine, doxorubicin, bolus cyclophosphamide, and oral prednisone in patients with refractory cutaneous T-cell lymphoma

BACKGROUND

This Phase II study was undertaken to assess the efficacy and toxicity of chemotherapy with etoposide, vincristine, doxorubicin, bolus cyclophosphamide, and oral prednisone (EPOCH regimen) in patients with advanced, refractory cutaneous T-cell lymphoma (CTCL).

METHODS

Fifteen patients were treated with a 96-hour continuous infusion of etoposide, vincristine, doxorubicin, bolus cyclophosphamide, and oral prednisone, followed by granulocyte-colony stimulating factor support and trimethoprim/sulfamethoxazole prophylaxis. The median age of the patients was 53 years (range, 17-82 years). Six patients had Sézary syndrome (SS), four patients had visceral involvement, and four patients had anaplastic large cell morphology, three with Ki-1 (CD30) positivity. All patients had disease that was refractory to prior chemotherapy or electron beam irradiation and eight of these patients had received cyclophosphamide, doxorubicin, vincristine, and prednisone. Seven patients had received prior interferon therapy and nine patients had received fludarabine and/or 2-CDA.

RESULTS

After a median of 5 cycles (range, 1-9 cycles), 4 patients achieved a complete response (27%) and 8 patients achieved a partial response (53%) for an overall response rate of 80% (95% confidence interval, 52-96%). Three patients with visceral involvement, two of three patients with anaplastic large cell morphology, and one patient with human T-cell lymphoma virus leukemia/lymphoma did not respond. All 12 responders had improvement in skin disease; 2 of 6 patients with SS had complete disappearance of circulating Sézary cells. The median progression free survival was 8.0 months (range, 3-22 months). After a median follow-up of 11.4 months (range, 2-56+ months), the median patient survival was 13.5 months. Grade 3 or 4 hematologic toxicity occurred in 8 patients (61%); 5 of these 8 patients had febrile neutropenia. Six patients developed staphylococcal bacteremia, two patients had disseminated herpes infection, and one patient had Pneumocystis carinii pneumonia. Grade 3 neurotoxicity occurred in one patient. Two patients had a significant decrease in left ventricular ejection fraction and one patient had supraventricular tachycardia.

CONCLUSIONS

EPOCH chemotherapy has a high response rate with acceptable toxicity in patients with advanced and refractory CTCL.

Public knowledge, awareness, and perceptions of the association between skin aging and smoking

BACKGROUND

Although the tobacco industry promotes images of glamour, 2 decades of epidemiologic research have concluded the opposite: smokers have enhanced facial aging and skin wrinkling compared with nonsmokers.

OBJECTIVE

The purpose of this study was to obtain information on the public's awareness of the association between cigarette smoking and skin aging.

METHODS

In the spring of 1994, the Maine-wide Cooperative Telephone Survey conducted telephone interviews in 678 randomly selected, nonseasonal dwelling units in Maine. From each dwelling unit, one randomly selected adult resident was interviewed to assess awareness of the association of skin aging with smoking.

RESULTS

Fifty-eight percent of those persons interviewed had smoked at least 100 cigarettes, and among them, 24% were current smokers (28% men, 21% women). After adjusting for sex, age, and education, current smokers remained less likely to be aware of this association compared with former (prevalence ratio, 0.78; 95% confidence interval, 0.64-0.95) and never smokers (prevalence ratio, 0.87; 95% confidence interval, 0.70-1.07). However, nearly one fourth of smokers in this study believed that most or some smokers would consider this information in their decision to quit, with slightly higher findings in young smokers.

CONCLUSION

These findings are of public health importance. While strategies for framing messages about the association between smoking and facial aging await further study, this association deserves to be considered in all tobacco control and counter-advertising campaigns.

The Falmouth Safe Skin Project: evaluation of a community program to promote sun protection in youth

A multidimensional community-based skin cancer prevention program was conducted in Falmouth, Massachusetts, combining community activism with publicity campaigns and behavioral interventions to improve sun protection knowledge; attitudes; and practices in parents, caregivers, and children. The program was associated with improvements in target outcomes, based on two telephone surveys of random samples of parents (n = 401, 404). After program implementation, fewer parents reported sunburning of their children, particularly among children 6 years old or younger (18.6% in 1994 vs. 3.2% in 1997), and more parents reported children using sunscreen, particularly continuous use at the beach (from 47.4% to 69.9% in younger children). Hat and shirt use did not increase. Improvements also were seen in parent role modeling of sun protection practices, parents' self-efficacy in protecting children from the sun, and sun protection knowledge. While these findings must be interpreted cautiously, they do suggest that this project was effective in promoting sun protection.