Factors associated with transitions in tobacco product use states among young adults aged 18-29 years

BACKGROUND AND OBJECTIVES

This study examined young adults' tobacco use transitions based on their past 30-day use states, and identified factors associated with their transitions.

METHODS

Participants (N = 12377) were young adults aged 18-29 years at Wave 1 of the Population Assessment of Tobacco and Health (PATH) study. Self-reported tobacco use states were categorized by the number of past-month use days (0, 1-4, 5-8, 9-12, 13-30 days) for cigarettes, electronic cigarettes [e-cigarettes], traditional cigars, filtered cigars, cigarillos, smokeless tobacco (SLT), and hookah. Multistate Markov models examined transitions between use states across Waves 1-5 of unweighted PATH data and multinomial logistic regressions examined predictors of transitions.

RESULTS

Most young adults remained nonusers across adjacent waves for all products (88%-99%). Collapsed across waves, transitioning from use at any level to nonuse (average 46%-67%) was more common than transitioning from nonuse to use at any level (average 4%-10%). Several factors that predicted riskier patterns of use (i.e., transitioning to use and/or remaining a user across adjacent waves) were similar across most products: male, Black, Hispanic, lower education levels, and lower harm perceptions. In contrast, other factors predicted riskier patterns for only select products (e.g., e-cigarette and SLT use among Whites).

DISCUSSION AND CONCLUSIONS

Few sampled young adults escalated their tobacco use over time, and escalations for many products were predicted by similar factors.

SCIENTIFIC SIGNIFICANCE

Prevention and regulatory efforts targeted towards adolescents should continue, but also be expanded into young adulthood. These same efforts should consider both shared and unique factors that influence use transitions.

Longitudinal transitions in adolescent polytobacco use across waves 1-4 of the Population Assessment of Tobacco and Health study

AIMS

This study aims to identify adolescent patterns of polytobacco use and measure transitions between patterns over time.

DESIGN

Longitudinal analysis using data derived from waves 1-4 (2013-18) of the Population Assessment of Tobacco and Health (PATH) study. Transitions in tobacco use patterns were examined via latent transition analysis, and then, socio-demographic characteristics were used to predict transitions via logistic regression.

SETTING

United States.

PARTICIPANTS

Participants included 975 adolescents who used at least one tobacco product at any wave (W1 mean age = 13.29, standard deviation = 0.86; W4 54.2% male; 54.5% white, 25.9% Hispanic).

MEASUREMENTS

Measurements included past 30-day use of cigarettes, electronic cigarettes (e-cigs), traditional cigars, cigarillos, filtered cigars, snus, smokeless tobacco (SLT) or hookah.

FINDINGS

Six latent classes were identified. Cigarette users (43.5-58.8%) and SLT users (50.8-79.6%) tended to persist in their use over time. E-cig users began to probably transition to non-users (80.0%), but became more likely to persist in this use over time (31.1%). Non-users at a given wave were most likely to transition to e-cig users (8.5-43.7%) or cigarette users (6.7-28.6%). Cigarillo/poly-users and hookah/poly-users displayed more variable transition patterns. Adolescents were more likely to transition to non-use (versus become/remain e-cig users) if they were older (cigarette users, SLT users), younger (e-cig users), other race (SLT users), male (SLT users) or had less-educated parents (SLT users) compared with their counterparts. Hispanic (versus white) cigarette users were more likely to transition to non-users than to persist in this use.

CONCLUSIONS

Among adolescents in the United States, patterns of tobacco use characterized by the use, mainly, of single, specific products appear to be stable, particularly by late adolescence. In contrast, patterns characterized by polytobacco use appear to be more variable and may represent experimentation without specialization.

Socioecological Predictors of Change in Adolescent Tobacco Use Across Waves 1-4 of the Population Assessment of Tobacco and Health Study

BACKGROUND

Despite decreases in adolescents' cigarette use over the past decade, overall rates of adolescent tobacco use have increased. Research examining adolescents' changes across a range of tobacco products reflective of the current market, as well as multilevel predictors of use trajectories is needed.

METHODS

Data derive from Waves 1-4 (W1-4; 2013-2018) of the Population Assessment of Tobacco and Health (PATH) study. Participants included 975 adolescents who used ≥1 tobacco product (cigarettes, electronic cigarettes [ECIGs], traditional cigars, cigarillos, filtered cigars, snus, smokeless tobacco [SLT], hookah) at any wave (W1 Mage = 13.29 [0.86], 54.2% male; 54.5% White, 25.9% Hispanic).

RESULTS

Utilizing latent growth curve modeling (separate models per product), adolescents displayed increases in their past 30-day use of all tobacco products from W1-4. Greater W1 use was predicted by identifying as non-Hispanic (cigarettes); lower parent education (SLT); greater externalizing problems (cigarillos); greater motives (all products except cigarillos); greater youth-reported household smoking rules (cigarillos); and greater isolation (ECIGs). More use across time (i.e., higher slope) was predicted by older age (cigarettes); identifying as male (ECIGs, SLT), Black (vs. White; cigarillos), White (vs. Black, Hispanic; ECIGs, SLT); fewer externalizing problems (SLT); fewer motives (ECIGs); fewer youth-reported rules (cigarillos, SLT); and greater geographic isolation (cigarettes, SLT).

DISCUSSION

Although some individual-level factors (i.e., motives, externalizing problems) predicted greater W1 use (i.e., intercept) only, interpersonal- (parent rules) and community-level (geographic isolation) factors were associated with changes in use over time (i.e., slope). Intervention efforts may address such factors to reduce adolescents' escalations in use.

Community-engaged research in vascular surgery: An approach to decrease amputation disparities and effect population-level change

Community-engaged research (CEnR) is a powerful tool to create sustainable and effective change in health outcomes. CEnR engages community members as equal partners, amplifying their voices and priorities by including them throughout the research process. Such engagement increases the relevance and meaning of research, improves the translation of research findings into sustainable health policy and practice, and ultimately enhances mutual trust among academic, clinical, and community partners for ongoing research partnership. There are a number of key principles that must be considered in the planning, design, and implementation of CEnR. These principles are focused on inclusive representation and participation, community empowerment, building community capacity, and protecting community self-determination. Although vascular surgeons may not be equipped to address these issues from the ground up by themselves, they should work with a team who can help them incorporate these elements into their CEnR project designs and proposals. This may be best accomplished by collaborating with researchers and community-based organizations who already have this expertise and have established social capital within the community. This article describes the theory and principles of CEnR, its relevance to vascular surgeons, researchers, and patients, and how using CEnR principles in vascular surgery practice, research, and outreach can benefit our patient population, with a specific focus on reducing disparities related to amputation.

Measurement of cigarette smoking: Comparisons of global self-report, returned cigarette filters, and ecological momentary assessment

Prior work suggests that prospective measurement of cigarette use may be more reliable and valid than retrospective self-reports. Despite several studies comparing retrospective and prospective methods, there are a myriad of prospective methods that have not been directly compared, including spent cigarette filters that are returned to the laboratory by participants and diary logs of cigarette use on an electronic device via ecological momentary assessment. The current secondary data analysis compared the reliability of retrospective global self-report, returned cigarette filters, and electronic diary logs among a sample of cigarette smokers that also use smokeless tobacco (SLT; N = 51) over two consecutive weeks. CPD values also were compared to salivary cotinine levels to determine whether any method was associated more strongly with nicotine/tobacco exposure. Results indicated that CPD values via global self-report were significantly larger than returned filter and diary log daily averages across both weeks (t(50) = 8.28 to 9.35; p < .001). Both prospective measures showed less digit bias and more variation in smoking behavior across days than global self-reports. Only returned CPD values were correlated significantly with salivary cotinine levels (r(593) = 0.09, p = .024). Importantly, most reliability outcomes for returned filters and logged CPD did not differ significantly, suggesting that they may be comparable prospective methods for measuring cigarette use. Because returned filters and diary logs did not differ from one another, researchers' selection of a prospective measurement method should rely on considerations of participant compliance, protocol burden, and specific research questions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Transitions in tobacco use profiles among adolescents: Results from the Population Assessment of Tobacco and Health (PATH) study waves 3 and 4

INTRODUCTION

Despite increases in adolescents' polytobacco use, little work has utilized recent national data to examine transitions in polytobacco use over time or predictors of such transitions.

METHODS

Data derived from the Population Assessment of Tobacco and Health (PATH) study. Participants used at least one tobacco product (cigarettes, electronic cigarettes [ECIGs], traditional cigars, cigarillos, filtered cigars, snus, smokeless tobacco [SLT], hookah) at Wave 3 (W3; 2015-2016) or 4 (W4; 2016-2018) and had Wave 1 (W1) data (N = 1072; Mage= 13.71, SD =1.71, 46.4% female; 56.6% White, 23.2% Hispanic). Latent transition analysis (LTA) examined probabilities of transitioning between classes across waves and sociodemographic correlates of transitions.

RESULTS

Five latent classes were identified: Low Users (n = 372, 34.7% W3; n = 249, 23.3% W4), ECIG Users (n = 256, 23.8% W3; n = 286, 26.7% W4), Cigarette Users (n = 215, 20.1% W3; n = 293, 27.3% W4), SLT Users (n = 91, 8.5% W3; n = 92, 8.6% W4), and Polytobacco Users (n = 138, 12.9% W3; n = 152, 14.1% W4). Cigarette Users and SLT Users displayed the highest probabilities for class stability. Low Users were most likely to transition to ECIG Users or Cigarette Users, whereas Polytobacco Users were most likely to transition to Low Users. ECIG Users were likely to transition to Low Users or Cigarette Users. Older and White adolescents were more likely to display riskier transitions.

CONCLUSIONS

Although Cigarette Users and SLT Users remained largely stable in membership, findings demonstrate greater movement across polytobacco use classes relative to previous research and suggest that ECIGs may be the most common entry point to tobacco use.

Perceptions and Expectations of School-Based Professionals Surrounding School-Based Mindfulness Training in Appalachia During the COVID-19 Pandemic: A Qualitative Study

Background

School-based professionals often report high burnout, particularly in geographic areas like Appalachia, where school-aged children are exposed to high levels of adverse childhood experiences, which may be exacerbated by the COVID-19 pandemic. While school-based mindfulness trainings can reduce burnout, their efficacy is influenced by the expectations of intervention personnel ahead of implementation. The present study assessed expectations and perceptions of a school-based mindfulness training among school personnel in 21 Appalachian schools during the COVID-19 pandemic.

Methods

Upon enrollment in the training, staff (N = 191) responded to open ended survey questions regarding perceived impacts of COVID-19 on students, expected benefits and barriers to school-based mindfulness, and perceived community acceptance of mindfulness.

Results

School personnel identified social isolation and lack of structure as negative impacts of COVID-19 on students. Expected benefits of classroom mindfulness included improved coping skills, focus, and emotion regulation, whereas barriers included lack of time and student ability level (e.g., age, attention). While most respondents indicated that their community was accepting of mindfulness practices, some noted resistance to and misperceptions of mindfulness, which may illustrate the influence of local cultural norms and values on the acceptability of mental health interventions.

Conclusions

Overall, these findings suggest positive expectations and relative perceived support for mindfulness practices within these Appalachian communities, including in response to negative impacts of the COVID-19 pandemic on students. Adapting practices and language to accommodate barriers such as time, student ability, and cultural misconceptions of mindfulness may increase the feasibility and efficacy of these interventions.

Timing of smoking cessation treatment integrated into outpatient treatment with medications for opioid use disorder: Feasibility trial

INTRODUCTION

Cigarette smoking rates among individuals with opioid use disorder (OUD) are notoriously high and may be improved by considering the timing of treatment integration for these two substances. The current study examined the feasibility of a method for assessing the timing of integrating smoking cessation pharmacotherapy within three different phases of outpatient treatment with medication for OUD (MOUD).

METHODS

Seventy-four buprenorphine-maintained smokers were enrolled in a quasi-experimental study across three MOUD treatment phases: 0-90 (Phase 1), 91-365 (Phase 2), and > 365 days of MOUD treatment (Phase 3). During a 12-week varenicline-based intervention, the study assessed outcomes daily via text messages (cigarette smoking, varenicline adherence, side effects) or monthly at in-person visits (quit motivation and carbon monoxide levels).

RESULTS

Thirty-five participants completed the study, with a lower retention rate in Phase 1 (37.5%) relative to Phases 2 (53.5%) or 3 (57.1%). A trend occurred for Phase 1 participants to report aversive side effects (e.g., abnormal dreams, gastrointestinal distress) on more study days. Among completers, adherence to text messaging and varenicline use was high and independent of MOUD treatment phase. Participants in all phases reported declines in cigarette smoking and increases in quit motivation over time; the study observed biochemically verified tobacco abstinence among only a few participants from Phases 2 or 3.

CONCLUSIONS

This feasibility study demonstrates a method to evaluate the timing of treatment integration for cigarette smoking and MOUD. Method strengths include a study schedule that coincided with the MOUD clinic schedule and use of text messaging to encourage varenicline adherence and evaluate outcomes regularly.

Reimagining Rural: Shifting Paradigms About Health and Well-Being in the Rural United States

Rural health disparities have attracted increased national attention, compelling an expanded focus on rural health research. In this manuscript, we deconstruct the definitions and narratives of "rural" communities and suggest that a paradigm shift is needed that centers the complexity and strength of rural places. We discuss the relevance of health equity frameworks, implementation science, and community-engaged approaches to promote rural well-being. Focusing on rural in its own right will lead to intervention innovations and reinvention with implications beyond rural areas. We conclude with suggestions for research and practice to inspire renewed interest in partnering with rural communities to promote health equity. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Cumulative disadvantage as a framework for understanding rural tobacco use disparities

Traditional tobacco product (cigarettes and smokeless tobacco) and polytobacco use rates are significantly higher among rural adolescents and adults compared to their nonrural counterparts. Such disparities are due to several factors that promote tobacco use initiation and continuation, including individual-level psychopharmacological factors and structural-level factors such as fewer tobacco control efforts (e.g., fewer smoke-free policies and lower tobacco excise taxes), targeted tobacco marketing, less access to health-relevant resources, and more positive cultural norms surrounding tobacco use in rural communities. In this review, we use cumulative disadvantage theory as a framework for understanding how psychopharmacological and structural-level factors serve as drivers of tobacco use in rural areas. We start by describing how structural-level differences between rural-nonrural communities impact psychopharmacological influences and, when available, how these factors influence tobacco use. We conclude by discussing the interplay between factors, providing suggestions for ways to assess our application of cumulative disadvantage theory empirically and making recommendations for research and policy implementation in rural areas. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Geographic isolation predicts tobacco product use among youth: A latent class analysis

PURPOSE

The purpose of the current study was to evaluate associations between geographic rurality and tobacco use patterns among adolescents.

METHODS

High school students (N = 566) from north-central Appalachia reported on their lifetime and/or current use of cigarettes, electronic cigarettes (ECIGs), cigars, and smokeless tobacco. Geographic rurality was measured via the Isolation scale, whereby residential ZIP Codes determined the degree to which respondents have access to health-related resources. Latent class analysis (LCA) was used to identify discrete classes of adolescent tobacco users based on their use of tobacco products. Then, associations between participants' geographic rurality and class membership were evaluated using a series of multinomial logistic regressions.

FINDINGS

LCA classified participants as Nonusers, Current ECIG Users, Cigarette/ECIG Experimenters, and Polytobacco Users. Individuals with higher Isolation scores were more likely to be Polytobacco Users and Cigarette/ECIG Experimenters than Nonusers, and were more likely to be Polytobacco Users than Current ECIG Users.

CONCLUSIONS

The continuous Isolation scale used in the present study predicted polytobacco use patterns among adolescents in a manner that is consistent with, while simultaneously expanding upon, prior work. Tobacco control practices and policies should be viewed through a lens that considers the unique needs of geographically isolated areas.

Usability testing of an electronic health application for patient activation on weight management

BACKGROUND

Obesity is a leading public health concern in the United States. One promising method for enhancing patient activation to engage in health promoting behaviors is with technology in the primary care setting. The primary purpose of this study was to test the usability of a patient activation tool, called mWRAPPED, for weight management during primary care wait times.

METHODS

A two-cycle approach to usability testing was followed by a pragmatic usability study in the primary care setting. The application was subsequently revised based on patient feedback. A convenience sample of patients completed usability testing in the clinical setting. Patients completed the System Usability Scale throughout all testing phases.

RESULTS

First cycle patients provided an average score of 76.5 on the System Usability Scale. After revising mWRAPPED, the average patient System Usability Scale score increased to 80.5. mWRAPPED received an average System Usability Scale score of 77.9 when tested in the clinical setting. mWRAPPED demonstrated initial usability for primary care patients in an academic outpatient family medicine clinical setting.

CONCLUSIONS

Results of the current study will help to support the use of this application in future studies as a novel approach to delivering guideline-based weight management information to patients.

Amplifying Expertise in Rural West Virginia through Project ECHO: Impactful Partnerships and Community-Engagement

BACKGROUND

Limited specialty care access is a major contributor to rural health disparities. Extensions for Community Healthcare Outcomes (ECHO) is an innovative training and education strategy to address the need for trained specialty care in rural areas, such as West Virginia (WV). This article describes the successful implementation of ECHO projects in diverse subject areas facilitated by unique partnerships between the WV Clinical and Translational Science Institute (WVCTSI) and its practice partners. WV Project ECHO aims to provide education and training in specialty areas through the use of technology and partnerships.

METHODS

A case-based session coupled with a brief relevant didactic presentation is used to amplify rural provider specialty expertise through education of primary care physicians (PCPs) in specific clinical areas. Foundational partnerships and impact are described.

CONCLUSIONS

Key lessons learned include leveraging existing partnerships and implementing projects based on provider needs. A unique result of WV Project ECHO is WV Medicaid's decision to accept case presentations made during the Hepatitis C ECHO session as the specialty consultation requirement (e.g., hepatologist or infectious diseases) for Medicaid coverage of hepatitis C drugs, thus increasing the number of patients receiving Hepatitis C treatment. A multi-partnered community approach facilitated by the widespread use of a technology-based provider education platform has facilitated the availability of curative therapy for a potentially fatal disease.

Cigarette smokers' concurrent use of smokeless tobacco: dual use patterns and nicotine exposure

BACKGROUND

The concurrent use of cigarettes with other tobacco products, such as smokeless tobacco (SLT), is increasingly common. Extant work with cigarette smokers who also use SLT is based heavily on retrospective reports and between-group comparisons. The purpose of this study was to assess prospectively the patterns of dual users' product use and nicotine exposure on days when cigarettes were smoked exclusively (single use) versus concurrently with SLT (dual use).

DESIGN

Forty-six dual cigarette-SLT users recorded their product use in real time via ecological momentary assessment for a 2-week longitudinal design. They responded to questions about situational factors (eg, location, mood) using this same diary, and collected saliva samples each night for later cotinine measurement. At the end of this 2-week period, users reported on their reasons for and beliefs about SLT use.

RESULTS

Cotinine levels were significantly higher on dual versus single use days (mean±SEM=374.48±41.08 ng/mL vs 300.17±28.13 ng/mL, respectively; p<0.01), and the number of cigarettes logged was higher on dual versus single use days (11.13±0.98 vs 9.13±1.11, respectively; p<0.01). Product use was distinguished by situational factors, with the strongest predictor being location of use. Moreover, the most common reason for initiating (56.52%) and continuing (67.39%) SLT use was to circumvent indoor smoking restrictions.

CONCLUSIONS

Results support the idea of product supplementation rather than replacement among this convenience sample of dual users. For smokers whose primary motivation for SLT use involves situations where they would otherwise be tobacco free, the potential benefits of clean indoor air laws may be diminished.

Piloting a clinical laboratory method to evaluate the influence of potential modified risk tobacco products on smokers' quit-related motivation, choice, and behavior

Research methods are needed that can predict whether the availability of potential modified risk tobacco products (MRTPs) may influence smokers' quit-related motivation, choice, and behavior. This pilot study assessed the primary outcomes of feasibility and adherence to address this need using an electronic cigarette (ECIG) as a model MRTP. Cigarette smokers were randomly assigned to use only their own brand of cigarettes (OB-only) or a second-generation ECIG (18 ng/ml nicotine) plus their OB cigarettes (ECIG+OB) ad libitum for four weeks. Participants logged products using a mobile device, collected used cigarette filters, and provided saliva samples every day for analysis of cotinine. They returned to the lab once per week to provide a breath sample and accept or decline a choice to quit all tobacco products (i.e., cigarettes and/or ECIGs). They also returned for a one-month follow-up visit. Of those participants randomized (n = 60), 56.7% completed the 4-week intervention and 40.0% completed the follow-up visit. The primary reason for withdrawal was poor adherence with mobile device use. Comparable numbers of participants in each group chose to make a quit attempt, although more OB-only participants chose to quit during the first two weeks and more ECIG+OB participants during the last two weeks. With protocol modifications to reduce participation burden, the current method might ultimately be used by regulators to predict how smokers' quit-related motivation, choice, and behavior are influenced by current and future MRTPs.

A Comparison of Rural and Academic Training Environments for Third-Year Medical Students on a Family Medicine Rotation

BACKGROUND AND OBJECTIVES

Medical students have been training in rural environments for many years. However, there is sparse research demonstrating that training in a rural environment provides an equivalent learning experience to training in an academic medical setting. This study addresses that gap by comparing student performance after training in rural or community environment versus an academic setting while completing the family medicine clerkship.

METHODS

Participants in this retrospective cohort study were students who completed an 8-week family medicine third-year clerkship between 2013 and 2016. Half spent the first 4 weeks in a rural or community setting while the other half were in an academic setting. These placements were reversed after midterm exams. Data were collected from both student academic files and from rural rotation tracking systems at two time points: midterm and following the 8-week rotation.

RESULTS

Results from our sample of 159 medical students (89 [56.0%] male and 70 [44.0%] female) revealed no statistically significant differences in students' midterm (P=.63) and final scores (P=.74) based on training locations.

CONCLUSIONS

Study findings suggest that rural and academic clerkships provide equivalent levels of knowledge for family medicine students. This finding has particular relevance for students whose intent is to practice in a rural location. Additional research is needed to identify if these findings are generalizable to other medical schools and locations.

Physical Activity and Quit Motivation Moderators of Adolescent Smoking Reduction

OBJECTIVES

We examined participant characteristics as moderators of adolescents' smoking cessation outcomes as a function of intervention: Not-on-Tobacco (N-O-T), N-O-T with a physical activity (PA) module (N-O-T+FIT), or Brief Intervention (BI).

METHODS

We randomly assigned youth (N = 232) recruited from public high schools to an intervention, and measured their baseline levels of PA and motivation to quit. The number of cigarettes/day for weekdays and weekends was obtained at baseline and 3-month follow-up.

RESULTS

Across timepoints, cigarette use declined for youth in N-O-T (p = .007) and N-O-T+FIT (ps < .02), but not BI (n.s.). For N-O-T+FIT youth, the steepest declines in weekday smoking occurred for those with high PA levels (p = .02). Weekend cigarette use decreased for N-O-T+FIT youth with moderate-high levels of intrinsic motivation to quit (ps < .04).

CONCLUSIONS

Adolescents may benefit from interventions designed to address the barriers faced during a quit attempt, including their motivation to make a change and their engagement in other healthy behaviors such as physical activity.

Lessons of Partnership: Successes and Challenges Associated with the Dissemination of the Not-On-Tobacco Program within Cooperative Extension Service Framework

Not-On-Tobacco (N-O-T) is a voluntary smoking cessation program for teens. The West Virginia Prevention Research Center (WVPRC) partnered with West Virginia University Extension Service to test a regional implementation model of N-O-T within the current 4-H infrastructure. Directed content analysis was used to allow for pre-determined themes and categories to be assessed by identifying barriers and successes at each phase of model implementation. The project effectively set a foundation of collaboration between Extension and the WVPRC, highlighted the differences between prevention theories and positive youth development ideology and showcased that Extension’s efforts are more successful when county based.

The Impact of Not on Tobacco on Teen Smoking Cessation

This review summarizes end-of-program quit rates from 6 controlled and 10 field-based Not on Tobacco (NOT) evaluations. Approximately 6,130 youth from 5 states and 489 schools participated. Intent-to-treat and compliant quit rates were calculated at 3 months postbaseline (end-of-program). Results from controlled evaluations revealed an aggregate quit rate of 15% and 19%, respectively. The field-based evaluations revealed an aggregate quit rate of 27% and 31%, respectively. NOT youth were two times more likely to quit than comparison youth (OR = 1.94; p = .002; 95% CI 1.267-2.966). This is the first multiyear, multisite review of a teen smoking cessation program reported in the literature and the first longitudinal review of NOT. NOT participants showed consistent, significant positive smoking behavior change across evaluations.

Linking Research and Practice: Two Academic–Public Health Collaborations That Are Working

In this commentary, two examples of successful collaboration between academic research centers and public health agencies at a statewide level are described. One program sought to reduce tobacco use, whereas the other has the goal of improving physical activity and nutrition among children and youth and reducing child and adolescent obesity and subsequent health risks. The features of the collaboration contributing to their success are outlined, as is the federal role in fostering these partnerships.

Patient Attitudes toward Weight Related Discussions in Rural Appalachian Primary Care Clinics

Purpose

West Virginia (WV) consistently has one of the highest rates of obesity, nationally, yet previous studies suggest that conversations about weight with providers are infrequent. This study's aim was to determine frequency and type of weight-related discussions occurring in WV primary care clinics and whether discussions differed according to weight status.

Methods

A cross-sectional survey was completed by patients in rural primary care practices. Participants answered questions related to demographics, obesity related illnesses, experience receiving a physician mediated discussion, and attitude and beliefs related to weight.

Results

Among the total of 490 surveys collected, a little more than half of the participants (56.9%) have discussed weight with their physician; a majority of participants (89.5%) thought a physician should tell risks associated with an unhealthy weight; 78.3% participants felt weight loss is important to them; 86.1% participants believed weight affects their health. Participants with obesity were more likely than participants who are overweight to discuss weight with their physician (71.8 vs.44.0%, p<0.0001), and believed that their physicians helped them lose weight previously (29.4% vs 9.9%, p<0.0001) and can help them lose weight in the future (92.9% vs. 71.1, p<0.0001).

Conclusion

Physicians are often having weight related discussions with patients with obesity however this discussion happens less with overweight patients. Practitioners may want to be more attentive to addressing weight related issues in overweight patients.

Understanding Genomic Knowledge in Rural Appalachia: The West Virginia Genome Community Project

PURPOSE

Rural communities have limited knowledge about genetics and genomics and are also underrepresented in genomic education initiatives. The purpose of this project was to assess genomic and epigenetic knowledge and beliefs in rural West Virginia.

SAMPLE

A total of 93 participants from three communities participated in focus groups and 68 participants completed a demographic survey. The age of the respondents ranged from 21 to 81 years. Most respondents had a household income of less than $40,000, were female and most were married, completed at least a HS/GED or some college education working either part-time or full-time.

METHOD

A Community Based Participatory Research process with focus groups and demographic questionnaires was used.

FINDINGS

Most participants had a basic understanding of genetics and epigenetics, but not genomics. Participants reported not knowing much of their family history and that their elders did not discuss such information. If the conversations occurred, it was only during times of crisis or an illness event. Mental health and substance abuse are topics that are not discussed with family in this rural population.

CONCLUSIONS

Most of the efforts surrounding genetic/genomic understanding have focused on urban populations. This project is the first of its kind in West Virginia and has begun to lay the much needed infrastructure for developing educational initiatives and extending genomic research projects into our rural Appalachian communities. By empowering the public with education, regarding the influential role genetics, genomics, and epigenetics have on their health, we can begin to tackle the complex task of initiating behavior changes that will promote the health and well-being of individuals, families and communities.

Development and validation of a smoking expectancies measure for adolescents seeking to quit smoking

BACKGROUND

A more comprehensive understanding of factors that affect smoking cessation outcomes among adolescents may help enhance treatment interventions. One promising but underexplored factor that may influence cessation success is teens' specific expectancies or beliefs about smoking outcomes. The present study evaluated the validity and reliability of a new measure of expectancies and its association with cessation outcomes among 762 adolescent smokers participating in studies of the American Lung Association's Not On Tobacco cessation program.

METHODS

Self-report questionnaires were collected prior to and following participation in a smoking cessation program. Self-reported cigarette use was verified with expired-air carbon monoxide. A multistep exploratory and confirmatory factor analysis and reliability and validity analyses were performed.

RESULTS

Four theoretically related yet empirically independent factors were identified by the Smoking Expectancies Questionnaire (SEQ): (1) Positive Reinforcement, (2) Negative Reinforcement-Emotional Regulation, (3) Negative Reinforcement-Addiction and Withdrawal, and (4) Negative Outcomes/Risk. These factors could be subsumed by a single SEQ factor that reflected an overall concept of smoking expectancies relevant for adolescent smoking cessation. An overall SEQ Function score reflecting the balance between positive and negative expectancies predicted both preintervention cigarettes per day and cessation outcomes.

CONCLUSIONS

A single, overall SEQ Function score may prove useful for understanding the associations among individual, social, and contextual factors in predicting treatment outcomes. Additionally, study findings may assist with modifying smoking expectancies among cessation program participants, thereby enhancing treatment outcomes with diverse youth smoking populations.

Developing a Dissemination Model to Improve Intervention Reach among West Virginia Youth Smokers

The not-on-tobacco program is an evidence-based teen smoking cessation program adopted by the American Lung Association (ALA). Although widely disseminated nationally via ALA Master Trainers, in recent years, adoption and implementation of the N-O-T program in West Virginia (WV) has slowed. WV, unfortunately, has one of the highest smoking rates in the US. Although it is a goal of public health science, dissemination of evidence-based interventions is woefully understudied. The present manuscript reviews a theoretical model of dissemination of the not-on-tobacco program in WV. Based on social marketing, diffusion of innovations, and social cognitive theories, the nine-phase model incorporates elements of infrastructure development, accountability, training, delivery, incentives, and communication. The model components as well as preliminary lessons learned from initial implementation are discussed.

Parental influences on 7-9 year olds' physical activity: a conceptual model

OBJECTIVE

Models characterizing parental influence on child and adolescent physical activity (PA) over time are limited. Preschool and Adolescent Models (PM and AM) of PA are available leaving the need to focus on elementary-aged children. We tested current models (PM and AM) with a sample of 7-9 year-olds, and then developed a model appropriate to this specific target population.

METHODS

Parent-child dyads completed questionnaires in 2010-2011. All models were assessed using path analysis and model fit indices.

RESULTS

For adequate power, 90 families were needed, with 174 dyads participating. PM and AM exhibited poor fit when applied to the study population. A gender-specific model was developed and demonstrated acceptable fit. To develop an acceptable model for this population, constructs from both the PM (i.e. parental perception of child competency) and AM (i.e., child-reported self-efficacy) were used. For boys, self-efficacy was a strong predictor of PA, which was influenced by various parental variables. For girls, parental PA demonstrated the greatest strength of association with child PA.

CONCLUSION

This new model can be used to promote PA and guide future research/interventions. Future studies, particularly longitudinal designs, are needed to confirm the utility of this model as a bridge between currently available models.

Gender differences in cigarette smoking, social correlates and cessation among adolescents

BACKGROUND

Despite well-established gender differences in adult smoking behaviors, relatively little is known about gender discrepancies in smoking behaviors among adolescents, and even less is known about the role of gender in smoking cessation among teen populations.

METHOD

The present study examined gender differences in a population of 755 adolescents seeking to quit smoking through the American Lung Association's Not-On-Tobacco (N-O-T) program. All participants enrolled in the N-O-T program between 1998 and 2009. All participants completed a series of questionnaires prior to and immediately following the cessation intervention. Analyses examined gender differences in a range of smoking variables, cessation success and direct and indirect effects on changes in smoking behaviors.

RESULTS

Females were more likely to have parents, siblings and romantic partners who smokes, perceive that those around them will support a cessation effort, smoke more prior to intervention if they have friends who smoke, and to have lower cessation motivation and confidence if they have a parent who smokes. Conversely, males were more likely to have lower cessation motivation and confidence and be less likely to quit if they have a friend who smokes.

CONCLUSIONS

Gender plays an important role in adolescent smoking behavior and smoking cessation. Further research is needed to understand how these differences may be incorporated into intervention design to increase cessation success rates among this vulnerable population of smokers.

Effects of physical activity on teen smoking cessation

OBJECTIVE

To understand the influence of physical activity on teen smoking-cessation outcomes.

METHODS

Teens (N = 233; 14-19 years of age) from West Virginia high schools who smoked >1 cigarette in the previous 30 days were included. High schools with >300 students were selected randomly and assigned to brief intervention (BI), Not on Tobacco (N-O-T) (a proven teen cessation program), or N-O-T plus a physical activity module (N-O-T+FIT). Quit rates were determined 3 and 6 months after baseline by using self-classified and 7-day point prevalence quit rates, and carbon monoxide validation was obtained at the 3-month follow-up evaluation.

RESULTS

Trends for observed and imputed self-classified and 7-day point prevalence rates indicated that teens in the N-O-T+FIT group had significantly higher cessation rates compared with those in the N-O-T and BI groups. Effect sizes were large. Overall, girls quit more successfully with N-O-T compared with BI (relative risk [RR]: >∞) 3 months after baseline, and boys responded better to N-O-T+FIT than to BI (RR: 2-3) or to N-O-T (RR: 1-2). Youths in the N-O-T+FIT group, compared with those in the N-O-T group, had greater likelihood of cessation (RR: 1.48) at 6 months. The control group included an unusually large proportion of participants in the precontemplation stage at enrollment, but there were no significant differences in outcomes between BI and N-O-T (z = 0.94; P = .17) or N-O-T+FIT (z = 1.12; P = .13) participants in the precontemplation stage.

CONCLUSIONS

Adding physical activity to N-O-T may enhance cessation success, particularly among boys.

Beyond reach and effectiveness: evaluating the not-on-tobacco (N-o-T) program in West Virginia from 2000 to 2005

Despite most teenage smokers wanting to quit, their likelihood of success resembles that of flipping a coin. Evidence-based cessation programs, like the American Lung Association's Not-On-Tobacco (N-O-T) program, are effective. Evaluation of program dissemination is critical. This study uses the RE-AIM framework to evaluate the N-O-T program in West Virginia from 2000 to 2005. RE-AIM components consisted of four measures. Regional dissemination was measured using comparative differences between Regional Educational Service Agency regions (RESAs). Significant associations were found between RESAs for numerous characteristics. Among the RE-AIM components, two measures of Implementation were significantly different between RESAs. Variability between RESAs provided valuable descriptive evidence of N-O-T program dissemination in West Virginia. Therefore, geographical tailoring grounded in community-based participatory research could increase the N-O-T program's overall dissemination.

Smoking and breast cancer screening in West Virginia: opportunities for intervention

Smoking has been increasingly identified as a risk factor for breast cancer among women. West Virginia has high rates of smoking, which can be further examined in relation to breast cancer screening and smoking related variables. This study used 2006 Behavioral Risk Factor Surveillance System (BRFSS) data to examine the relationship between smoking related variables and breast cancer screening behaviors among women in West Virginia age 40 and older. Findings showed that approximately 21.6% of women in the sample were current smokers, with a majority of these women smoking every day (82.5%). Half of the women in the study sample had made at least one past year quit attempt. Current smokers were less likely to have had breast cancer screening in the past one or two years, and among these women who smoke, every day smokers were less likely to obtain breast cancer screening. Smokers who did not make a quit attempt during the past year were also significantly less likely to have had mammography screening. Study results highlight an unmet need and opportunity for intervention related to breast cancer screening among women who smoke, and especially those with higher smoking intensity. Smoking status and smoking intensity should be recognized as predictors of women who are less likely to obtain breast cancer screening. These women can be identified and targeted as an important high risk population with unmet need for smoking cessation and breast cancer screening interventions.

Who wants to quit? Characteristics of American Indian youth who seek smoking cessation intervention

No group is more at-risk for tobacco-related health disparities than are American Indian youth. Little is known about their readiness to quit smoking and the extent to which cessation programs may require cultural tailoring related to recruitment, implementation, or content. This study identifies unique characteristics of American Indian teen smokers who enrolled in a school-based smoking cessation program, Not On Tobacco (called N-O-T). Using data from N-O-T intervention trials conducted in North Carolina between 2001 and 2004, the present study (a) describes the characteristics of American Indian participants (n = 91); (b) determines if basic demographics and smoking history affect intervention readiness; and (c) compares findings with non-Native participants (n = 138) enrolled in N-O-T within the same state. Upon enrollment, 80% of the sample reported that they planned to quit smoking in the next 1-6 months. We found significant differences between American Indian and non-Native youth on smoking history, with non-Natives smoking with greater intensity and frequency. Contrary to previous reports, American Indian youth in this study smoked with less intensity and were more ready to quit smoking than non-Native youth. Results reveal previously unreported characteristics of American Indian teen smokers. Study findings may advance the development of effective marketing, recruitment, and programming among American Indian teen smokers into cessation programs, particularly N-O-T, which is the only teen smoking cessation program which includes an adaptation specifically for American Indians.

Beyond quitting: predictors of teen smoking cessation, reduction and acceleration following a school-based intervention

There remains a great need for effective, cost-efficient, and acceptable youth smoking cessation interventions. Unfortunately, only a few interventions have been demonstrated to increase quit rates among youth smokers, and little is known about how elements of cessation interventions and participants' psychosocial characteristics and smoking histories interact to influence program outcomes. Additionally, few studies have examined how these variables lead to complete smoking abstinence, reduction or acceleration over the course of a structured cessation intervention. Data for the present investigation were drawn from a sample of teen smokers (n=5892) who voluntarily participated in either a controlled study or field study (i.e., no control group) of the American Lung Association's Not On Tobacco (N-O-T) program between 1998 and 2006 in five states. Results suggest that those who reduce smoking (but do not achieve full abstinence) are similar to those who quit on most measures except stage of change. Furthermore, it was found that those who increased smoking were heavier smokers at baseline, more addicted, were more likely to have parents, siblings, and significant others who smoked and reported less confidence in and less motivation for quitting than did those who quit or reduced smoking. Finally, a path model demonstrated how peers, siblings and romantic partners affected tobacco use and cessation outcomes differently for males and females. Implications for interventions are discussed.

A profile of teen smokers who volunteered to participate in school-based smoking intervention

OBJECTIVES

Although a number of population-based studies have examined the characteristics of teens who attempt to quit smoking, few have identified the characteristics of youth who participate in structured cessation interventions, particularly those with demonstrated effectiveness. The purpose of the present study is to describe the sociodemographic and smoking-related characteristics of teen smokers who participated in the American Lung Association's Not On Tobacco (N-O-T) program, spanning eight years. N-O-T is the most widely used teen smoking cessation program in the nation.

METHODS

Drawn from multiple statewide N-O-T studies, this investigation examined data from 5,892 teen smokers ages 14-19 who enrolled in N-O-T between 1998-2006. We demonstrate similarities and differences between N-O-T findings and existing data from representative samples of US teen smokers where available and relevant.

RESULTS

N-O-T teens started smoking earlier, were more likely to be poly-tobacco users, were more dependent on nicotine, had made more previous attempts to quit, and were more deeply embedded in smoking contexts than comparative samples of teen smokers. Additionally, N-O-T teens were moderately ready to quit smoking, believed important people in their lives would support their quit efforts, yet had deficits in their confidence with quitting.

CONCLUSION

This profile of N-O-T teens can guide efforts for targeted recruitment strategies to enhance intervention reach for teen smoking cessation. Findings provide guidance for marketing and recruitment efforts of intensive, school-based cessation interventions among established teen smokers, particularly those who want to quit. Study results may shed light upon who is and is not enrolling in N-O-T.

Evidence-Based Review and Discussion Points

Background Traditional efficacy research alone is insufficient to move interventions from research to practice. Motivational interviewing has been adapted for brief encounters in a variety of health care settings for numerous problem behaviors among adolescents and adults. Some experts suggest that motivational interviewing can support a population health approach to reach large numbers of teen smokers without the resource demands of multisession interventions.

Objectives To determine the reach, implementation fidelity, and acceptability of a brief motivational tobacco intervention for teens who had treatment in a hospital emergency department.

Methods Among 74 teens 14 to 19 years old, 40 received a brief motivational tobacco intervention and 34 received brief advice/care as usual at baseline. Follow-up data were collected from the interventional group at 1, 3, and 6 months and from the control group at 6 months. For the interventional group, data also were collected from the teens’ parents, the health care personnel who provided the intervention, and emergency department personnel.

Results Findings indicated low levels of reach, high levels of implementation fidelity, and high levels of acceptability for teen patients, their parents, and emergency department personnel. Data suggest that practitioners can operationalize motivational interventions as planned in a clinical setting and that patients and others with an interest in the outcomes may find the interventions acceptable. However, issues of reach may hinder use of the intervention among teens in clinical settings.

Conclusions Further investigation is needed on mechanisms to reduce barriers to participation, especially barriers related to patient acuity.

Feasibility of a smoking cessation intervention for teens in the emergency department: reach, implementation fidelity, and acceptability

BACKGROUND

Traditional efficacy research alone is insufficient to move interventions from research to practice. Motivational interviewing has been adapted for brief encounters in a variety of health care settings for numerous problem behaviors among adolescents and adults. Some experts suggest that motivational interviewing can support a population health approach to reach large numbers of teen smokers without the resource demands of multi-session interventions.

OBJECTIVES

To determine the reach, implementation fidelity, and acceptability of a brief motivational tobacco intervention for teens who had treatment in a hospital emergency department.

METHODS

Among 74 teens 14 to 19 years old, 40 received a brief motivational tobacco intervention and 34 received brief advice/care as usual at baseline. Follow-up data were collected from the interventional group at 1, 3, and 6 months and from the control group at 6 months. For the interventional group, data also were collected from the teens' parents, the health care personnel who provided the intervention, and emergency department personnel.

RESULTS

Findings indicated low levels of reach, high levels of implementation fidelity, and high levels of acceptability for teen patients, their parents, and emergency department personnel. Data suggest that practitioners can operationalize motivational interventions as planned in a clinical setting and that patients and others with an interest in the outcomes may find the interventions acceptable. However, issues of reach may hinder use of the intervention among teens in clinical settings.

CONCLUSIONS

Further investigation is needed on mechanisms to reduce barriers to participation, especially barriers related to patient acuity.

Efficacy of an emergency department-based motivational teenage smoking intervention

INTRODUCTION

Motivational interviewing techniques have been minimally researched as a function of a teenage smoking intervention. The present study examined the efficacy of a theory-based motivational tobacco intervention (MTI).

METHODS

A randomized two-group design was used to compare 6-month post-baseline quit and reduction rates among teenagers who received the MTI with those who received brief advice or care as usual. Participants were smokers aged 14 to 19 years (N = 75) who presented for treatment in a university-affiliated hospital emergency department (ED). Motivational interviewing techniques were used by trained providers to facilitate individual change; stage-based take-home materials also were provided.

RESULTS

Similar to past clinic-based studies of motivational interviewing with teenage smokers, our study found negative results in terms of intervention efficacy for cessation. Six-month follow-up cessation rates were nonsignificant--two teenagers quit smoking. Among teenagers who were available at follow-up, a medium effect size (Cohen's h = .38) was found for reduction and a large effect size (Cohen's h = .69) was found for percentage reduction, although these results also were not statistically significant.

CONCLUSION

Although the major findings of this study were not significant, the reductions in tobacco use suggest that motivational interviewing may be a clinically relevant counseling model for use in teenage smoking interventions. However, many questions remain, and the current literature lacks studies on trials with significant outcomes using motivational interviewing in smoking cessation. Additionally, more research is needed to examine the suitability of the ED for MTI-type interventions.

Applying community-based participatory research principles to the development of a smoking-cessation program for American Indian teens: "telling our story"

Community-based participatory research provides communities and researchers with opportunities to develop interventions that are effective as well as acceptable and culturally competent. The present project responds to the voices of the North Carolina American Indian (AI) community and the desire for their youth to recognize tobacco addiction and commercial cigarette smoking as debilitating to their health and future. Seven community-based participatory principles led to the AI adaptation of the Not On Tobacco teen-smoking-cessation program and fostered sound research and meaningful results among an historically exploited population. Success was attributed to values-driven, community-based principles that (a) assured recognition of a community-driven need, (b) built on strengths of the tribes, (c) nurtured partnerships in all project phases, (d) integrated the community's cultural knowledge, (e) produced mutually beneficial tools/products, (f) built capacity through co-learning and empowerment, (g) used an iterative process of development, and (h) shared findings/ knowledge with all partners.

Quit and reduction rates for a pilot study of the American Indian Not On Tobacco (N-O-T) program

INTRODUCTION

American Indian youths smoke cigarettes at high rates, yet few smoking-cessation programs have been developed for them. The objective of this study, conducted during 2003 and 2004, was to determine the preliminary quit and reduction outcomes of the American Lung Association's newly adapted American Indian Not On Tobacco (N-O-T) program.

METHODS

Seventy-four American Indian youths aged 14 to 19 years in North Carolina were enrolled in the American Indian N-O-T program or a brief 15-minute intervention. Quit and reduction rates were compared 3 months after baseline using compliant subsamples and intention-to-treat analyses.

RESULTS

Among males in the American Indian N-O-T program, between 18% (intention-to-treat) and 29% (compliant subsample) quit smoking. Six males (28.6%) in the American Indian N-O-T program reported quitting smoking; one male (14.3%) in the brief intervention reported quitting. No females in either group quit smoking. More females in the American Indian N-O-T program reduced smoking than females in the brief intervention.

CONCLUSION

These pilot results suggest that the American Indian N-O-T program offers a useful and feasible cessation option for American Indian youths in North Carolina. Program modifications are necessary to improve outcomes for American Indian females, and recruitment issues require in-depth study. Further study is warranted to determine program efficacy.

Stage of change and smoking cessation outcomes among adolescents

This study examined the association between stage of change and smoking cessation outcomes among youth receiving two interventions of varying intensity: a 10-min brief self-help smoking cessation intervention (BI) or the American Lung Association's 10-week, Not-on-Tobacco (N-O-T) smoking cessation program. At baseline, the participants were classified into three stages (e.g., precontemplation, contemplation, and preparation) based on their intention to change their smoking behavior. Smoking behavior, stage of change, self-efficacy, and beliefs about smoking were assessed at baseline and 3 months postbaseline. Results demonstrated that the relationship between stage of change and cessation outcomes varied by treatment intensity. Logistic regression analyses revealed that BI participants in the preparation stage were 25 times more likely to quit smoking at postbaseline than were participants in the contemplation or precontemplation stages. In contrast, N-O-T was effective for youth regardless of baseline stage. Additionally, N-O-T participants demonstrated greater forward stage movement from baseline to postbaseline than did BI participants.

Exploring the Relationship Between Mental Health and Smoking Cessation: A Study of Rural Teens

This study examined the association between mental health and smoking cessation among rural youth. Participants were 113 male and 145 female adolescents ages 14-19 from rural West Virginia and North Carolina. Participants were enrolled in the American Lung Association's 10-week Not On Tobacco (N-O-T) program or a 15-min single-dose brief intervention. Baseline and postprogram measures were completed on smoking status (i.e., quit, reduction), nicotine dependence, smoking history, and depression and anxiety. Results showed that more N-O-T participants quit and reduced smoking than did brief intervention participants. Intervention group, baseline smoking rate, and the Group x Gender, Group x Anxiety, and Group x Depression interactions were significant predictors of change in smoking behavior from baseline to postprogram. In conclusion, more N-O-T participants demonstrated favorable changes in smoking than did brief intervention participants. Approximately 1/3 of youth exhibited mental health pathology; more females than males. Levels of depression and anxiety improved from baseline to postprogram, overall. Although the extent of the impact of mental health on cessation outcomes was inconclusive, findings suggest that rural youth who smoke may be at risk for pathological depression and anxiety. Future cessation programming with rural youth should consider the inclusion of coping and stress management skills and mental health referral protocols as significant program components.

Adolescent nicotine dependence and smoking cessation outcomes

The purpose of the present study was to examine adolescent nicotine dependence and its impact on smoking cessation outcomes with two treatments of varying intensity: a brief, self-help intervention and an intensive, multisession, school-based cessation curriculum called Not On Tobacco (N-O-T). A majority (80%) of adolescent smokers in this study were moderately to highly nicotine-dependent, using the Fagerstrom Tolerance Questionnaire. Further, nicotine dependence was positively correlated with duration of smoking and number of cigarettes smoked daily (P<.05). Data showed that the more cigarettes teens smoked daily and the longer they had smoked, the more dependent they were. Some teens (20%), however, had low nicotine dependence despite years of smoking and high smoking rates. Results showed that the relationship between nicotine dependence and cessation outcomes varied by treatment intensity. The brief intervention was successful with only low-dependent smokers, whereas the intensive, multisession, N-O-T intervention was effective with smokers possessing a range of nicotine dependence, including high-dependent smokers.

A 2-year efficacy study of Not On Tobacco in Florida: an overview of program successes in changing teen smoking behavior

BACKGROUND

Adolescent smoking has been an issue of major concern in the United States. This has led to a need for the development, evaluation, and dissemination of effective youth cessation programs. The purpose of this paper is to report the results of a 2-year demonstration study (1999-2000) of the American Lung Association's teen smoking cessation program, the Not On Tobacco (NOT) program.

METHODS

The study used a "matched" design wherein each NOT school was matched to a brief intervention (BI) school. The study consisted of 20 NOT and 20 BI Florida high schools encompassing 627 students. The primary outcome measures were carbon monoxide-validated quit and reduction rates for NOT and BI schools at 5.2 months postprogram.

RESULTS

NOT smoking cessation and reduction outcomes were significantly better than those of the brief intervention. Further, data indicate that NOT was more effective than the brief intervention for females compared with males; males showed successful quit attempts in both intervention groups. Overall, more NOT youth either quit or reduced smoking than did BI youth.

CONCLUSIONS

These positive smoking behavior changes suggest that NOT is an effective teen smoking cessation option.

Combined therapy with glibenclamide and ultralente insulin in lean patients with NIDDM with secondary failure of sulfonylureas. Follow up at two years

Nine lean diabetic patients with secondary failure of oral hypoglycemic agents and with a poor residual insulin release under treatment with glibenclamide (15 mg/day) entered a cross-over study, in which ultralente insulin was administered alone or in combination with glibenclamide (15 mg/day). Combined therapy was accompanied by increased serum free-insulin levels and was more effective than glibenclamide alone on daily blood glucose profile, on glycosylated haemoglobin (HbA1C) and on Beta-OH butyrate; in 6 patients a near normalization of blood glucose control (daily blood glucose levels less than 180 mg/dl) occurred. C peptide release, evaluated as daily profile and as response to i.v. glucagon, did not significantly change. When patients received insulin alone, daily blood glucose profile and HbA1C worsened, and serum free-insulin levels and C peptide release decreased, while Beta-OH butyrate levels remained low. These data indicate that combined therapy is effective since it maintains insulin release and enhances free insulin levels in insulinopenic patients. Four responders continued combined therapy for 2 years: the treatment was still effective and was accompanied by an increased C peptide release, probably due to persistent euglycemia.