Gender and Age Differences in Levels, Types and Locations of Physical Activity among Older Adults Living in Car-Dependent Neighborhoods

BACKGROUND

A thorough understanding of gender differences in physical activity is critical to effective promotion of active living in older adults.

OBJECTIVES

To examine gender and age differences in levels, types and locations of physical activity.

DESIGN

Cross-sectional observation.

SETTING

Car-dependent urban and rural neighborhoods in Worcester County, Massachusetts, USA.

PARTICIPANTS

111 men and 103 women aged 65 years and older.

MEASUREMENTS

From 2012 to 2014, participants were queried on type, frequency and location of physical activity. Participants wore an accelerometer for 7 consecutive days.

RESULTS

Compared to women, men had a higher mean daily step count (mean (SD) 4385 (2122) men vs. 3671(1723) women, p=0.008). Men reported higher frequencies of any physical activity and moderate-to-vigorous physical activity, and a lower frequency of physical activity inside the home. Mean daily step counts and frequency of physical activity outside the home decreased progressively with age for both men and women. Women had a sharper decline in frequencies of self-reported physical activity. Men had a significant decrease in utilitarian walking, which women did not (p=0.07). Among participants who reported participation in any physical activity (n=190), more women indicated exercising indoors more often (59% vs. 44%, p=0.04). The three most commonly cited locations for physical activity away from home for both genders were streets or sidewalks, shopping malls, and membership-only facilities (e.g., YMCA or YWCA). The most common types of physical activity, performed at least once in a typical month, with over 40% of both genders reporting, included light housework, brisk walking, leisurely walking, and stretching.

CONCLUSION

Levels, types and location preferences of physical activity differed substantially by gender. Levels of physical activity decreased progressively with age, with greater decline among women. Consideration of these gender differences is necessary to improve the effectiveness of active living promotion programs among older adults.

Association Between Post-Cancer Diagnosis Dietary Inflammatory Potential and Survival in WHI Observational Study and Dietary Modification Trial

Background: Inflammation regulates key biologic processes in chronic disease and can be modulated by diet. Our objective was to use the dietary inflammatory index (DII), a novel tool to characterize the inflammatory potential of diet, to examine how post-cancer diagnosis dietary quality is associated with overall survival in the Women's Health Initiative (WHI) Observational Study (OS) and Dietary Modification Trial (DM). Methods: After excluding baseline cancers and energy outliers, the analytical cohort had 4,241 postmenopausal women (19% of total cancer cases), aged 50 to 79 years at baseline, in the WHI OS (n = 1,852) and DM (n = 2,389), who developed invasive cancer during follow-up and completed a food frequency questionnaire after diagnosis. These women were followed from dietary assessment until death from any cause. Energy-adjusted DII scores from food only and from food plus supplement (any reported dietary supplement related to DII parameters) after cancer diagnosis for each subject were calculated by multiplying the inflammatory effect scores determined based on extensive literature review and intake values for each food parameter, and then summing across all the food parameters. Death was ascertained by clinical center follow-up or by searching the National Death Index with central or local adjudication. Cox proportional hazards models were fit to estimate multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CI) for all-cause mortality comparing women in higher DII quartiles with those in the first quartile. Results: After a median 11.2 years of follow-up, 1,470 deaths occurred. After adjustment for key covariates, women who consumed a more pro-inflammatory diet (in higher quartiles of DII score from food only) after a cancer diagnosis had a significantly higher risk of death from any cause compared to women consuming a more anti- inflammatory diet (HR Q4:Q1 = 1.18; 95% CI, 1.01–1.38; P trend = 0.015). In analyses using DII score from both diet and supplements, a pro-inflammatory DII score was associated with even higher risk of all-cause mortality (HRQ4:Q1 = 1.63; 95% CI, 1.40–1.91; P trend < 0.0001). Conclusions: Consuming a more pro-inflammatory diet after cancer diagnosis was associated with increased risk of death from any cause.

Development of symptoms of tobacco dependence in youths: 30 month follow up data from the DANDY study

OBJECTIVE

To determine if there is a minimum duration, frequency or quantity of tobacco use required to develop symptoms of dependence.

DESIGN AND SETTING

A retrospective/prospective longitudinal study of the natural history of tobacco dependence employing individual interviews conducted three times annually in two urban school systems over 30 months. Detailed histories of tobacco use were obtained including dates, duration, frequency, quantity, patterns of use, types of tobacco, and symptoms of dependence.

PARTICIPANTS

A cohort of 679 seventh grade students (age 12-13 years).

MAIN OUTCOME MEASURES

The report of any of 11 symptoms of dependence.

RESULTS

Among 332 subjects who had used tobacco, 40% reported symptoms, with a median latency from the onset of monthly smoking of 21 days for girls and 183 days for boys. The median frequency of use at the onset of symptoms was two cigarettes, one day per week. The report of one or more symptoms predicted continued smoking through the end of follow up (odds ratio (OR) 44, 95% confidence interval (CI) 17 to 114, p < 0.001).

CONCLUSIONS

Symptoms of tobacco dependence commonly develop rapidly after the onset of intermittent smoking, although individuals differ widely in this regard. Girls tend to develop symptoms faster. There does not appear to be a minimum nicotine dose or duration of use as a prerequisite for symptoms to appear. The development of a single symptom strongly predicted continued use, supporting the theory that the loss of autonomy over tobacco use begins with the first symptom of dependence.

Primary care-based smoking interventions

The primary care setting is an important place for promoting smoking cessation. Randomized clinical trials (RCTs) testing the effect of brief smoking interventions and comprehensive programs delivered in a primary care setting present excellent evidence that such interventions significantly increase patients' smoking cessation rates and that as the dose of intervention increases, the effect increases. Unfortunately, despite widespread dissemination of preventive services guidelines and positive physician attitudes towards such services, the current level of delivery of smoking cessation intervention by physicians in real-world settings is not high, making this a major research and public health concern. Interventions to increase the rate of implementation provider-delivered brief smoking interventions can be grouped broadly into: provider education; clinical systems and procedures (e.g., screening and tracking of patients); and organizational policy (e.g., reimbursement, coverage, performance measures). Given the significant effect that primary care-based interventions can have on smoking cessation, it is important to investigate methods to increase their rate of delivery and their effect. Examples of research to motivate to intervene questions include: what are the best incentives or combination of incentives for physicians? What are the most effective strategies to remind providers to intervene? How can each of these be best implemented in different types of settings and systems? How can a stepped-care and patient-treatment matching model be used? The study of factors such as reimbursement policies and covered benefits do not lend themselves well to tightly-controlled randomized trials. Therefore, use of quasi-experimental designs, and application of qualitative strategies are needed. These designs represent a different challenge to the research community.

Behavioral risk factors among members of a health maintenance organization

BACKGROUND

Co-occurrence of risk behaviors (RBs) substantially increases the risk of disease. This study examines the co-occurrence of four health risk behaviors (i.e., smoking, high-fat diet, sedentariness, and high-risk drinking) and demographic and psychosocial variables associated with number of RBs in a sample of members of a health maintenance organization who participated in the Seasonal Variation in Cholesterol (Seasons) study.

METHODS

Seasons study baseline data were used. Subjects completed a self-administered questionnaire packet containing questions on demographics, smoking history, and leisure-time physical activity, a 7-day dietary recall instrument, and various psychosocial measures. Results presented here are based on 496 subjects with complete data on all RBs.

RESULTS

Forty-three percent of participants had > or = two RBs. The most prevalent RB combination was high-fat diet/sedentariness, with 30% of subjects reporting both RBs. Associations between RBs were observed. A greater number of RBs were observed among younger and less-educated subjects, those with higher depression scores, and subjects who perceived their health as poor.

CONCLUSIONS

Findings highlight the importance of designing and evaluating primary care-based screening programs and interventions for multiple RBs.

Change in women's diet and body mass following intensive intervention for early-stage breast cancer

OBJECTIVE

To determine the effectiveness of an intensive dietary intervention on diet and body mass in women with breast cancer.

DESIGN

Randomized clinical trial.

SUBJECTS

172 women aged 20 to 65 years with stage I or II breast cancer.

INTERVENTION

A 15-session, mainly group-based and dietitian-led nutrition education program (NEP) was compared to a mindfulness-based stress reduction clinic program (SRC); or usual supportive care (UC).

MAIN OUTCOME MEASURES

Dietary fat, complex carbohydrates, fiber, and body mass were measured.

STATISTICAL ANALYSIS

In addition to descriptive statistics, analysis of variance was conducted to test for differences according to intervention group.

RESULTS

Of the 157 women with complete dietary data at baseline, 149 had complete data immediately postintervention (at 4 months) and 146 had complete data at 1 year. Women randomized to NEP (n = 50) experienced a large reduction in fat consumption (5.8% of energy as fat) at 4 months and much of this reduction was preserved at 1 year (4.1% of energy) (both P < .0002) vs no change in either SRC (n = 51) or UC (n = 56). A 1.3-kg reduction in body mass was evident at 4 months in the NEP group (P = .003) vs no change in the SRC and UC groups. Women who had higher-than-average expectations of a beneficial effect of the intervention experienced larger changes.

APPLICATIONS

Dietitians' use of group nutrition interventions appear to be warranted. Increasing their effectiveness and maintaining high levels of adherence may require additional support, including the involvement of significant others, periodic individual meetings, or group booster sessions.

Facilitating dietary change: the patient-centered counseling model

Recent data indicate that the patient-centered counseling model enhances long-term dietary adherence. This model facilitates change by assessing patient needs and subsequently tailoring the intervention to the patient's stage in the process of change, personal goals, and unique challenges. This article describes this model, including its theoretical foundations, a 4-step counseling process, and applications. This behavioral counseling model can help nutrition professionals enhance patient adherence to nutrition care plans and dietary guidelines.

Development of a state wide tobacco treatment specialist training and certification programme for Massachusetts

OBJECTIVE

To describe the research conducted to structure and develop a statewide tobacco training and certification programme for tobacco treatment specialists (TTSs) in Massachusetts.

DESIGN

Qualitative research strategies were used to obtain information on certification development and opinions regarding TTS training and certification from key informants. A role definition and validation study was then conducted to determine the core competencies for TTSs. A comprehensive training programme was developed, piloted, and finalised, and a certification programme was initiated.

PARTICIPANTS

Key informants included: individuals involved in the development of their professional certification programmes; tobacco treatment providers from across Massachusetts; and national tobacco treatment experts.

MAIN OUTCOME MEASURES

Participants' opinions about the need for and structure of a training and certification programme for individuals specialising in the provision of moderate to intensive tobacco treatment; delineation of core competencies for TTSs, using the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) clinical practice guideline as a foundation for the development of evidence based standards of practice for the treatment of nicotine dependence.

RESULTS

The data support a comprehensive training and certification programme for TTSs in Massachusetts. Main concerns include the cost of obtaining certification, the potential to exclude uncertified healthcare professionals from delivering basic tobacco treatment, and the role of the TTS in the healthcare delivery system and the community. The training programme developed for Massachusetts was piloted, and the structure of a statewide training and certification programme for TTSs was finalised.

CONCLUSIONS

The research provides support for the need and acceptance of a training and certification programme for TTSs in Massachusetts, and presents the challenges to be addressed. We demonstrated the feasibility of developing and implementing an evidence based training programme, and of initiating a statewide certification programme in Massachusetts. This work will add to a national dialogue on the development of a training and certification programme for tobacco treatment providers and encourage further research into the potential impact of statewide and national certification.

Dietary adherence: characteristics and interventions

This paper reviews issues regarding dietary adherence. Issues and barriers unique to dietary adherence, in contrast to adherence to physical activity or medication regimens, are discussed. These include decision making, social and cultural contexts, perceptions and preferences, and environmental barriers. We review factors known to increase adherence in dietary interventions, including education, motivation, behavioral skills, new and modified foods, and supportive interactions. We conclude with directions for future study, such as improved measurement of diet-related behavior and longitudinal, culturally sensitive interventions. Control Clin Trials 2000;21:206S-211S

Predictors of adherence to behavior change interventions in the elderly

Considering factors at the individual, interpersonal, and environmental level may enhance adherence to interventions in the elderly. A collaborative practitioner-participant relationship is also essential. Control Clin Trials 2000;21:200S-205S

Initial symptoms of nicotine dependence in adolescents

OBJECTIVES

It has been assumed that nicotine dependence has a slow onset and occurs only after prolonged daily use of tobacco. A cohort of young adolescents was followed to determine when the first symptoms of nicotine dependence occur with respect to the duration and frequency of tobacco use.

DESIGN

A cohort of 681 seventh grade students (age 12-13 years) from seven schools in two small cities in central Massachusetts was followed over one year. Detailed information regarding tobacco use was obtained in individual confidential interviews conducted in school three times over the year. The latency time to the onset of symptoms of nicotine dependence was measured from the time a subject first smoked at a frequency of at least once per month.

RESULTS

22% of the 95 subjects who had initiated occasional smoking reported a symptom of nicotine dependence within four weeks of initiating monthly smoking. One or more symptoms were reported by 60 (63%) of these 95 subjects. Of the 60 symptomatic subjects, 62% had reported experiencing their first symptom before smoking daily or began smoking daily only upon experiencing their first symptom.

DISCUSSION

The first symptoms of nicotine dependence can appear within days to weeks of the onset of occasional use, often before the onset of daily smoking. The existence of three groups of individuals-rapid onset, slower onset, and resistant-distinguishable from one another by their susceptibility to nicotine dependence, is postulated.

Nicotine replacement prescription practices of obstetric and pediatric clinicians

OBJECTIVE

To assess smoking cessation counseling and nicotine replacement therapy prescription and recommendation practices among obstetric and pediatric providers.

METHODS

We sent out a self-administered survey to 61 obstetric and pediatric nurse practitioners and physicians at six community health centers in the Boston area.

RESULTS

Obstetric providers were more likely to view smoking cessation counseling as their responsibility in treating pregnant women than pediatric providers did in treating infants with mothers who smoked (mean +/- standard deviation [95% confidence interval] 4.5 +/- 0.76 [4.2, 4.8] versus 4.0 +/- 0.8 [3.7, 4.3] on a five-point scale; P <.05). Obstetric providers believed that smoking cessation counseling was more effective than did pediatric providers (3.45 +/- 1.1 [3.0, 3.9] versus 2.8 +/- 0.8 [2.5, 3.1] on a five-point scale; P <.05) and were more likely to report provision of cessation assistance than pediatric providers (63% [44%, 82%] versus 17% [5%, 29%]; P <.05). Obstetric providers were more likely to prescribe or recommend over-the-counter nicotine replacement therapy than pediatric providers (44% [25%, 63%] versus 11% [1%, 21%], P =.004). Reasons for not prescribing nicotine replacement differed according to specialty; however, perceived lack of efficacy was not a typical reason given by clinicians in either specialty. Only two of 47 practitioners who did not prescribe or recommend those therapies listed that as a factor in their decisions.

CONCLUSION

We found that nicotine replacement therapies are commonly prescribed or recommended to pregnant smokers by obstetric providers, but less commonly to lactating women by pediatric providers.

Provider education to promote implementation of clinical practice guidelines

STUDY OBJECTIVES

Although the interest in and promulgation of clinical practice guidelines have significantly increased in the past 2 decades, concern exists about their actual implementation. This article focuses on one strategy to encourage guideline implementation at the clinician level: clinician education. The objectives of the article are to review educational strategies, to consider them within the context of complementary strategies carried out at the organizational and clinic setting levels, and to outline challenges and recommendations for clinicians' continuing education.

METHODS

Experience and data from relevant randomized clinical trials within an educational framework are reviewed.

OBSERVATIONS

Implementation of clinical practice guidelines requires a variety of skills, including assessment, appropriate delineation of a treatment and monitoring plan, patient tracking, and patient counseling and education skills. Continuing education strategies must reflect the content and teaching methods that best match the learning objectives. The pressures of current-day practices place limits on the resources, particularly clinician time, that are available for continuing education. Organizational resources must be committed to build the complementary supportive systems necessary for improved clinician practice. In addition to physicians, education must be directed at nonphysician clinicians, office staff, and administrators who also are responsible for guideline implementation.

CONCLUSIONS

To meet the challenges of developing clinician motivation, balancing competing demands, and treating patients with complex medical conditions, all within time constraints, clinical leaders need to design education activities that have leadership support, reflect compelling evidence, use multiple strategies and teaching techniques, and engage learners in skill building and problem solving.

Prevalence and co-occurrence of health risk behaviors among high-risk drinkers in a primary care population

BACKGROUND

Approximately 10% of patients seen in the primary care setting meet criteria for high-risk (HR) drinking. Little data are available about the co-occurrence of other risk behaviors (RBs) in this population. This study examines the co-occurrence of smoking, poor diet, and sedentariness, and several change-related variables, among 479 HR drinkers participating in Project Health, a NIAAA-funded study testing the effectiveness of a provider-delivered intervention to reduce HR drinking.

METHOD

Data were collected at study entry via standardized interview and questionnaire.

RESULTS

The prevalence of additional RBs among HR drinkers was smoking, 35%; poor diet, 28%; and sedentariness, 44%. In addition to HR drinking, 67% of participants had at least one RB, and 61% reported smoking, sedentariness, or both. Perception of drinking as a problem was generally low (20%), as was intention to change drinking. Seventy-two percent of participants with multiple RBs perceived at least one of these RBs as a problem. Younger, unmarried, less-educated, blue-collar, and non-working participants were more likely to have multiple RBs than white-collar workers.

CONCLUSION

Additional RBs are common among HR drinkers and may increase their already elevated health risks. Implications of these findings for interventions integrating multiple RBs into primary care settings are discussed.

Relapse and maintenance issues for smoking cessation

This article reviews short-term (6 months) and longer term (12-24 months) maintenance of cessation and relapse in adult smokers and the factors and treatments that affect these outcomes. MedLine and PsycLIT searches were done for research published in English between 1988 and 1998 meeting a defined set of criteria. Intensive intervention, telephone counseling, and use of pharmacotherapy were found to improve outcomes; however, compared with public health approaches, they reach relatively few smokers. Brief interventions during medical visits are cost-effective and could potentially reach most smokers but are not consistently delivered. Predictors of relapse include slips, younger age, nicotine dependence, low self-efficacy, weight concerns, and previous quit attempts. Potential areas for research, recommendations for longer follow-up assessments, and standard definitions for slip, relapse, and long-term maintenance are discussed.

Smoking cessation counseling with pregnant and postpartum women: a survey of community health center providers

OBJECTIVES

This study assessed providers' performance of smoking cessation counseling steps with low-income pregnant and postpartum women receiving care at community health centers.

METHODS

WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) program staff, obstetric clinicians, and pediatric clinicians at 6 community health centers were asked to complete surveys. Smoking intervention practices (performance), knowledge and attitudes, and organizational facilitators were measured. Factors associated with performance were explored with analysis of variance and regression analysis.

RESULTS

Performance scores differed significantly by clinic and provider type. Providers in obstetric clinics had the highest scores and those in pediatric clinics had the lowest scores. Nurse practitioners and nutritionists had higher scores than other providers. Clinic type, greater smoking-related knowledge, older age, and perception of smoking cessation as a priority were independently related to better counseling performance.

CONCLUSIONS

Mean performance scores demonstrated room for improvement in all groups. Low scores for performance of steps beyond assessment and advice indicate a need for emphasis on the assistance and follow-up steps of national guidelines. Providers' own commitment to helping mothers stop smoking was important.

Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work?

BACKGROUND

There is a need for primary care providers to have brief effective methods to intervene with high-risk drinkers during a regular outpatient visit.

OBJECTIVE

To determine whether brief physician- and nurse practitioner-delivered counseling intervention is efficacious as part of routine primary care in reducing alcohol consumption by high-risk drinkers.

METHODS

Academic medical center-affiliated primary care practice sites were randomized to special intervention or to usual care. From a screened population of 9772 patients seeking routine medical care with their primary care providers, 530 high-risk drinkers were entered into the study. Special intervention included training providers in a brief (5- to 10-minute) patient-centered counseling intervention, and an office support system that screened patients, cued providers to intervene, and made patient education materials available. The primary outcome measures were change in alcohol use from baseline to 6 months as measured by weekly alcohol consumption and frequency of binge drinking episodes.

RESULTS

Participants in the special intervention and usual care groups were similar on important background variables and potential confounders except that special intervention participants had significantly higher baseline levels of alcohol usage (P = .01). At 6-month follow-up, in the 91% of the cohort who provided follow-up information, alcohol consumption was significantly reduced when adjusted for age, sex, and baseline alcohol usage (special intervention, -5.8 drinks per week; usual care, -3.4 drinks per week; P = .001).

CONCLUSIONS

This study provides evidence that screening and very brief (5- to 10-minute) advice and counseling delivered by a physician or nurse practitioner as part of routine primary care significantly reduces alcohol consumption by high-risk drinkers.

The patient exit interview as an assessment of physician-delivered smoking intervention: a validation study

In evaluating the efficacy of physician-delivered counseling interventions for health behavior changes such as smoking cessation, a major challenge is determining the degree to which interventions are implemented by physicians. The Patient Exit Interview (PEI; J. Ockene et al., 1991) is a brief measure of a patient's perception of the content and quantity of smoking cessation intervention received from his or her physician. One hundred eight current smokers seen in a primary care clinic completed a PEI following their physician visit. Participants were 45% male, 95% Caucasian, with a mean age of 42 years and an average of 22 years of smoking. The PEI correlated well with a criterion measure of an audiotape assessment of the physician-patient interaction (r = .67, p < .001). When discrepancy occurred, in general it was due to patients' over-reporting of intervention as compared with the criterion measure. Implications and limitations of these findings are discussed.

The perceptions and practices of pediatricians: tobacco intervention

OBJECTIVES

To investigate pediatrician self-reported intervention practices related to tobacco use and cessation. We queried about practices with three groups 1) children/adolescents who do not smoke; 2) children/adolescents who smoke; and 3) parents, and the relationship of counseling practices with the personal and professional practice-related factors of pediatricians.

DESIGN

Mailed anonymous survey regarding their self-reported tobacco use prevention and cessation intervention practices.

POPULATION

Random sample of 350 pediatricians in one state.

RESULTS

A response rate of 75% was achieved. Pediatricians reported the greatest counseling practice in encouraging children/adolescents to not start smoking, followed by counseling adolescents who smoke. The lowest practice score was for intervening with parents who smoke. The age, gender, site of practice (eg, HMO, solo practice), and subspecialty status of the pediatricians were not related to practice. Pediatricians who reported at least some community involvement in local tobacco control efforts reported significantly higher levels of smoking cessation counseling with both children and adolescents and with parents who smoke. Pediatricians who reported previous training in counseling about tobacco issues also reported significantly higher levels of counseling of both adolescent smokers and parents who smoke but not of children and adolescents who do not smoke. Higher role perception, believing that smoking cessation counseling provided by pediatricians can be effective, and self-efficacy, were predictive of intervention with all three groups. The perceived barriers scale was not related to intervention with any group.

CONCLUSIONS

Pediatricians are missing opportunities to help their patients to stop smoking and to prevent smoking initiation. Pediatricians are intervening least frequently with parents who smoke. Practices should be tailored to the specific target group.

A dietitian-delivered group nutrition program leads to reductions in dietary fat, serum cholesterol, and body weight: the Worcester Area Trial for Counseling in Hyperlipidemia (WATCH)

OBJECTIVE

To assess the effectiveness of a dietitian-based nutrition counseling and education program for patients with hyperlipidemia.

DESIGN

A 4-session program implemented as a complement to a randomized physician-delivered intervention.

SUBJECTS/SETTING

From 12 practice sites of the Fallon Clinic, 1,162 subjects with hyperlipidemia were recruited, 645 of whom had data sufficient for our primary analyses.

INTERVENTION

Two individual and 2 group sessions conducted over 6 weeks.

MAIN OUTCOME MEASURES

Total and saturated fat levels; serum low-density lipoprotein cholesterol levels; and body weight, measured at baseline and after 1 year.

STATISTICAL ANALYSES

Multiple linear regression was used to evaluate changes in outcome measures.

RESULTS

After 1 year, there were significant reductions in outcome measures for subjects attending 3 or 4 nutrition sessions vs subjects attending fewer than 3 sessions or those never referred to a nutrition session. Reductions (mean +/- standard error) in saturated fat (measured as percent of energy) were 2.7 +/- 0.5%, 2.1 +/- 0.5%, and 0.3 +/- 0.1%, respectively. These reductions correspond to roughly a 22% relative change from baseline in those attending 3 or 4 sessions. Corollary reductions were observed for total fat (measured as percent of energy): 8.2 +/- 1.4%, 5.0 +/- 1.4%, and 0.7 +/- 0.4%; low-density lipoprotein cholesterol: 0.48 +/- 0.11 mmol/L, 0.13 +/- 0.11 mmol/L, and 0.02 +/- 0.03 mmol/L; and body weight: 4.5 +/- 0.9 kg, 2.1 +/- 0.8 kg, and 1.1 +/- 0.2 kg. The specified changes were additive to those of the physician-delivered intervention.

APPLICATIONS/CONCLUSIONS

This investigation provides empirical data demonstrating the effectiveness of a dietitian-delivered intervention in the care of patients with hyperlipidemia.

Effect of physician-delivered nutrition counseling training and an office-support program on saturated fat intake, weight, and serum lipid measurements in a hyperlipidemic population: Worcester Area Trial for Counseling in Hyperlipidemia (WATCH)

OBJECTIVE

To evaluate the effectiveness of a training program for physician-delivered nutrition counseling, alone and in combination with an office-support program, on dietary fat intake, weight, and blood low-density lipoprotein cholesterol levels in patients with hyperlipidemia.

PARTICIPANTS AND METHODS

Forty-five primary care internists at the Fallon Community Health Plan, a central Massachusetts health maintenance organization, were randomized by site into 3 groups: (1) usual care; (2) physician nutrition counseling training; and (3) physician nutrition counseling training plus an office-support program. Eleven hundred sixty-two of their patients with blood total cholesterol levels in the highest 25th percentile, having previously scheduled physician visits, were recruited. Physicians in groups 2 and 3 attended a 3-hour training program on the use of brief patient-centered interactive counseling and the use of an office-support program that included in-office prompts, algorithms, and simple dietary assessment tools. Primary outcome measures included change at 1-year of follow-up in percentage of energy intake from saturated fat; weight; and blood low-density lipoprotein cholesterol levels.

RESULTS

Improvement was seen in all 3 primary outcome measures, but was limited to patients in group 3. Compared with group 1, patients in group 3 had average reductions of 1.1 percentage points in percent of energy from saturated fat (a 10.3% decrease) (P = .01); a reduction in weight of 2.3 kg (P<.001); and a decrease of 0.10 mmol/L (3.8 mg/dL) in low-density lipoprotein cholesterol level (P = .10). Average time for the initial counseling intervention in group 3 was 8.2 minutes, 5.5 minutes more than in the control group.

CONCLUSION

Brief supported physician nutrition counseling can produce beneficial changes in diet, weight, and blood lipids.

Weight suppression and weight rebound in ex-smokers treated with fluoxetine

Fluoxetine's effect (30 mg, 60 mg, and placebo) on postcessation weight gain was studied among participants from a randomized, double-blind 10-week smoking cessation trial who met strict criteria for abstinence and drug levels. It was hypothesized that (a) fluoxetine would dose-dependently suppress postcessation weight gain and (b) drug discontinuation would produce dose-dependent weight rebound. During the on-drug phase, placebo participants gained weight linearly (M = 2.61 kg). exceeding both fluoxetine groups (30-mg group M = 1.33 kg, 60-mg group M = 1.25 kg). Weight suppression was initially greater for 60 mg than 30 mg, but both were followed by weight gain. Six months off drug produced greater dose-dependent weight rebound for 60 mg than 30 mg or placebo. Considering both on- and off-drug phases, weight gain for 60 mg of fluoxetine (M = 6.5 kg) was comparable with that for placebo (M = 4.7 kg) but greater than that for 30 mg (M = 3.6 kg). Fluoxetine appears to forestall postcessation weight gain, allowing time for the weight-conscious smoker to focus on quitting smoking rather than on preventing weight gain.

The patient exit interview as an assessment of physician-delivered smoking intervention: a validation study

In evaluating the efficacy of physician-delivered counseling interventions for health behavior changes such as smoking cessation, a major challenge is determining the degree to which interventions are implemented by physicians. The Patient Exit Interview (PEI; J. Ockene et al., 1991) is a brief measure of a patient's perception of the content and quantity of smoking cessation intervention received from his or her physician. One hundred eight current smokers seen in a primary care clinic completed a PEI following their physician visit. Participants were 45% male, 95% Caucasian, with a mean age of 42 years and an average of 22 years of smoking. The PEI correlated well with a criterion measure of an audiotape assessment of the physician-patient interaction (r = .67, p < .001). When discrepancy occurred, in general it was due to patients' over-reporting of intervention as compared with the criterion measure. Implications and limitations of these findings are discussed.

An automated telephone-based smoking cessation education and counseling system

Automated patient education and counseling over the telephone is a convenient and inexpensive method for modifying health-related behaviors. A computer-controlled, telecommunications technology called Telephone-Linked Care (TLC) was used to develop a behavioral intervention to assist smokers to quit and to prevent relapse. The education and counseling is offered through a series of interactive telephone conversations which can take place in the smoker's home. The system's automated dialogues are driven by an expert system that controls the logic. The content is derived from the Transtheoretical Model of behavioral change, principles of Social Cognitive Theory, strategies of patient-centered counseling and recommendations of clinical experts in smoking cessation. The system asks questions, provides information, gives positive reinforcement and feedback, and makes suggestions for behavioral change. Information that the patient communicates is stored and is used to influence the content of subsequent conversations.

Weight suppression and weight rebound in ex-smokers treated with fluoxetine

Fluoxetine's effect (30 mg, 60 mg, and placebo) on postcessation weight gain was studied among participants from a randomized, double-blind 10-week smoking cessation trial who met strict criteria for abstinence and drug levels. It was hypothesized that (a) fluoxetine would dose-dependently suppress postcessation weight gain and (b) drug discontinuation would produce dose-dependent weight rebound. During the on-drug phase, placebo participants gained weight linearly (M = 2.61 kg). exceeding both fluoxetine groups (30-mg group M = 1.33 kg, 60-mg group M = 1.25 kg). Weight suppression was initially greater for 60 mg than 30 mg, but both were followed by weight gain. Six months off drug produced greater dose-dependent weight rebound for 60 mg than 30 mg or placebo. Considering both on- and off-drug phases, weight gain for 60 mg of fluoxetine (M = 6.5 kg) was comparable with that for placebo (M = 4.7 kg) but greater than that for 30 mg (M = 3.6 kg). Fluoxetine appears to forestall postcessation weight gain, allowing time for the weight-conscious smoker to focus on quitting smoking rather than on preventing weight gain.

Coronary Artery Smoking Intervention Study (CASIS): 5-year follow-up

The authors compared the effect of a behavioral multicomponent smoking cessation special intervention (SI) to an advice-only intervention (AO) on smoking status at 5 years for smokers with coronary disease (n = 160). Regression analyses revealed an interaction between intervention type and disease severity such that patients in the SI group with greater degrees of coronary artery disease showed significantly higher cessation rates (odds ratio = 344 for 3-vessel disease in the SI vs. AO, p = .01). Factors predicting maintained abstinence included having 12 or more years of education, contemplating quitting smoking or being ready to begin action to quit at baseline, and having a higher self-efficacy score.

The effects of a health promotion-health protection intervention on behavior change: the WellWorks Study

OBJECTIVES

This study assessed the effects of a 2-year integrated health promotion-health protection work-site intervention on changes in dietary habits and cigarette smoking.

METHODS

A randomized, controlled intervention study used the work site as the unit of intervention and analysis; it included 24 predominantly manufacturing work sites in Massachusetts (250-2500 workers per site). Behaviors were assessed in self-administered surveys (n = 2386; completion rates = 61% at baseline, 62% at final). Three key intervention elements targeted health behavior change: (1) joint worker-management participation in program planning and implementation, (2) consultation with management on work-site environmental changes, and (3) health education programs.

RESULTS

Significant differences between intervention and control work sites included reductions in the percentage of calories consumed as fat (2.3% vs 1.5% kcal) and increases in servings of fruit and vegetables (10% vs 4% increase). The intervention had a significant effect on fiber consumption among skilled and unskilled laborers. No significant effects were observed for smoking cessation.

CONCLUSIONS

Although the size of the effects of this intervention are modest, on a populationwide basis effects of this size could have a large impact on cancer-related and coronary heart disease end points.

Alcohol counseling: physicians will do it

OBJECTIVE

To assess the use of a brief provider-delivered alcohol counseling intervention of 5 to 10 minutes with high-risk drinking patients by primary care provider* trained in the counseling intervention and provided with an office support system.

DESIGN

A group randomized study design was used. Office sites were randomized to either a usual care or special intervention condition, within which physicians and patients were nested. The unit of analysis was the patient.

SETTING

Primary care internal medicine practices affiliated with an academic medical center.

PARTICIPANTS

Twenty-nine providers were randomized by practice site to receive training and an office support system to provide an alcohol counseling special intervention or to continue to provide usual care.

INTERVENTION

Special intervention providers received 2 1/2 hours of training in a brief alcohol-counseling intervention and were then supported by an office system that screened patients, cued providers to intervene, and made patient education materials available as tip sheets.

MEASUREMENTS AND MAIN RESULTS

Implementation of the counseling steps was measured by patient exit interviews (PEI) immediately following the patient visit. The interval between the date of training and the date of the PEI ranged from 6 to 32 months. Special intervention providers were twice as likely as usual care providers to discuss alcohol use with their patients. They carried out every step of the counseling sequence significantly more often than did usual care providers (p < .001). This intervention effect persisted over the 32 months of follow-up.

CONCLUSIONS

Physicians and other health-care providers trained in a brief provider-delivered alcohol intervention will counsel their high-risk drinking patients when cued to do so and supported by a primary care office system.

Coronary Artery Smoking Intervention Study (CASIS): 5-year follow-up

The authors compared the effect of a behavioral multicomponent smoking cessation special intervention (SI) to an advice-only intervention (AO) on smoking status at 5 years for smokers with coronary disease (n = 160). Regression analyses revealed an interaction between intervention type and disease severity such that patients in the SI group with greater degrees of coronary artery disease showed significantly higher cessation rates (odds ratio = 344 for 3-vessel disease in the SI vs. AO, p = .01). Factors predicting maintained abstinence included having 12 or more years of education, contemplating quitting smoking or being ready to begin action to quit at baseline, and having a higher self-efficacy score.

Gender differences among smokers and quitters in the Working Well Trial

BACKGROUND

Gender differences in smoking and smoking cessation among participants in the Working Well Trial are characterized.

METHODS

A prospective randomized matched-pair evaluation was conducted among 90 predominantly blue-collar worksites. Cross-sectional surveys of employees' tobacco use behaviors were conducted at baseline and after a 2.5-year smoking cessation intervention. Respondents included 5,523 females and 12,313 males at baseline and 4,663 females and 10,919 males at follow-up. The main outcome measures included self-reported continuous smoking abstinence rates for 7 days and for 6 months.

RESULTS

Smoking prevalence was significantly higher for women than for men at baseline, but not at follow-up. Variables believed to influence smoking cessation were compared at baseline. Significant gender differences were found for number of cigarettes smoked/day, number of previous quit attempts, job strain, stage of change, and behavioral processes of change. At follow-up, no gender differences in quit rates were observed; however, women in the intervention condition were more likely to quit than women in the control condition, whereas no differences were seen among men by treatment condition.

CONCLUSIONS

Gender is not a strong predictor of smoking cessation in this population; however, women were more likely to quit with an intervention than without one.

Effectiveness of nicotine-containing gum in the Physician-Delivered Smoking Intervention Study

BACKGROUND

We tested the role of nicotine-containing gum (NCG) in conjunction with brief physician counseling in smoking cessation in the Physician-Delivered Smoking Intervention Project (PDSIP).

METHOD

Subjects were smokers randomized to the Counseling + NCG arm of the PDSIP. However, receipt and use of NCG were not randomized. Data from base-line, were not randomized. Data from baseline, pharmacy records, and 6-month monitoring calls were used in these post hoc analyses.

RESULTS

Of the 299 study subjects, 57% accepted NCG and 36% of acceptors used it for more than 7 days. Predictors of NCG acceptance included high desire to quit (OR = 1.21; 95% CI 1.10, 1.35), social support to quit (OR = 1.62; 95% CI 1.01, 2.59), being a general medicine patient compared with a family practice patient (OR = 3.22; 95% CI 2.01, 5.21), and receiving the intervention from a female physician (female physician-male patient OR = 2.27; 95% CI 0.95, 5.46; female physician-female patient OR = 1.94; 95% CI 1.06, 3.57) relative to the male physician comparisons. Subjects who refilled the NCG prescription had higher cessation rates than those who did not refill or did not accept the prescription (37% vs 19% and 20%, respectively; P = 0.04). Predictors of 6-month cessation among NCG users included a previous period(s) of abstinence > 3 months (OR = 1.23; 95% CI 1.04, 1.47), abstinence during illness (OR = 0.39; 95% CI 0.17, 0.86), and absence of smoking-related physical complaints the month prior to the physician-delivered intervention (OR = 0.40; 95% CI 0.17, 0.94).

CONCLUSION

Amount of NCG use in conjunction with physician-delivered smoking cessation counseling might have contributed in helping unselected smokers quit.

Gender differences in social desirability and social approval bias in dietary self-report

Social desirability (the tendency to respond in such a way as to avoid criticism) and social approval (the tendency to seek praise) are two prominent response set biases evident in answers on structured questionnaires. These biases were tested by comparing nutrient intakes as estimated from a single 24-hour diet recall interview (24 HR) and a 7-day dietary recall (7DDR). Data were collected as part of the Worcester Area Trial for Counseling in Hyperlipidemia, a randomized, physician-delivered nutrition intervention trial for hypercholesterolemic patients conducted in Worcester, Massachusetts, from 1991 to 1995. Of the 1,278 total study subjects, 759 had complete data for analysis. Men overestimated their fat and energy intakes on the 7DDR as compared with the 24HR according to social approval: One unit increase in the social approval score was associated with an overestimate of 21.5 kcal/day in total energy intake and 1.2 g/day in total fat intake. Women, however, underestimated their dietary intakes on the 7DDR relative to the 24HR according to social desirability: One unit increase in the social desirability score was associated with an underestimate of 19.2 kcal/day in energy intake and 0.8 g/day in total fat. The results from the present study indicate that social desirability and social approval biases appear to vary by gender. Such biases may lead to misclassification of dietary exposure estimates resulting in a distortion in the perceived relation between health-related outcomes and exposure to specific foods or nutrients. Because these biases may vary according to the perceived demands of research subjects, it is important that they be assessed in a variety of potential research study populations.

Provider training for patient-centered alcohol counseling in a primary care setting

OBJECTIVE

To assess the impact of a brief training program on primary care providers' skills, attitudes, and knowledge regarding high-risk and problem drinking.

DESIGN

Training plus pretesting and posttesting for program efficacy.

SETTING

Ambulatory primary care clinic; academic medical center.

PARTICIPANTS

Fourteen attending physicians, 12 residents, and 5 nurse practitioners were randomized by clinical team affiliation to a Special Intervention or usual care condition of a larger study. We report the results of the training program for the Special Intervention providers.

INTERVENTION

Providers received a 2-hour group training session plus a 10- to 20-minute individual tutorial session 2 to 6 weeks after the group session. The training focused on teaching providers how to perform patient-centered counseling for high-risk and problem drinkers.

MAIN OUTCOME MEASURES

Alcohol counseling skills; attitudes regarding preparedness to intervene and perceived importance and usefulness of intervening with high-risk and problem drinkers; and knowledge of the nature, prevalence, and appropriate treatment of alcohol abuse in primary care populations.

RESULTS

After training, providers scored significantly higher on measures of counseling skills, preparedness to intervene, perceived usefulness and importance of intervening, and knowledge.

CONCLUSION

A group training program plus brief individual feedback can significantly improve primary care providers' counseling skills, attitudes, and knowledge regarding high-risk and problem drinkers.

Physician-based smoking intervention: a rededication to a five-step strategy to smoking research

It is well established that physicians can have a significant effect on the smoking behavior of their patients. To do this, attention must be paid to putting in place multiple strategies or mechanisms in the organization where the physician practices, as well as in the macroenvironment (i.e., social and public policy). It has been questioned whether or not there is stagnation in the field of clinical smoking intervention requiring a rededication to basic research regarding smoking. With respect to physician-based smoking intervention, we alternatively suggest that recommitment to all phases of research is essential for moving forward physician-based smoking interventions in the rapidly changing health services and social environment. In this article, we first review the essential framework of the National Cancer Institute's research science approach to cancer prevention and control. Evidence concerning physician-based interventions is then reviewed, followed by a schematic of a comprehensive framework for thinking about the process and intervention components needed for physician-based smoking intervention to take place in the health-care setting, the impact they have, and the eventual outcome of such interventions. There is a discussion of the challenges for the delivery of smoking-cessation services presented by the rapidly changing healthy delivery system of the 1990s. Finally, we present recommendations concerning research priorities for physician-based smoking intervention and the research funding process.

A longitudinal study of students' depression at one medical school

PURPOSE

Using a standardized measure of depression at three assessment points, to examine depression in medical students during their training.

METHOD

Students entering the University of Massachusetts Medical School in the fall in 1987, 1988, and 1989 were mailed a recruitment letter and baseline questionnaire four weeks prior to the start of classes. Subsequent assessments took place in the middles of year 2 and year 4 and included only the students who had participated in the baseline assessment. The baseline assessment included the Center for Epidemiological Studies Depression (CES-D) scale, the Bortner Type A Behavior scale, the Spielberger Trait Anger scale, and the Spielberger Anger Expression scale. In addition, the baseline package included a rating of perceived stress, a demographics questionnaire, and a social-life survey. The follow-up assessments included the CES-D scale, the rating of perceived stress level, and the social-life survey. Analytic methods used were univariate descriptive statistics, correlation, and multiple-linear-regression analyses, two-sample t-tests, analysis of variance, and chi-square tests.

RESULTS

Of the initial pool of 300 students, 264 responded at the baseline assessment (88% response rate; 53% men); 171 of these participated in the year-2 assessment (65% response rate; 51% men), and 126 participated in the year-4 assessment (48% response rate; 48% men); a total of 99 students participated in all three assessments. CES-D scores > or =80th percentile were obtained for 18% of the entering students. This rose to 39% at year 2 and 31% at year 4 (p = .0001). No gender difference was found at baseline; however, the women experienced higher depression levels than did the men at year 2 (p = .004) and at year 4 (p = .04). Overall, gender and increases in perceived stress (from baseline to year 2) were significant predictors of increased CES-D scores (from baseline to year 2; p = .01 and p = .0001, respectively). For the women, increased perceived stress, angerin, and frequency of social contacts outside work/school were significant predictors of the magnitude of increases in CES-D scores (baseline to year 2; p = .0001, p = .02, and p = .03, respectively).

CONCLUSION

These preliminary data support the view that, upon entering medical school, students' emotional status resembles that of the general population. However, the rise in depression scores and their persistence over time suggest that emotional distress during medical school is chronic and persistent rather than episodic. Also, the women had more significant increases in depression scores than did the men.

Society for Research on Nicotine and Tobacco

The proceedings of the second annual scientific conference of the Society for Research on Nicotine and Tobacco are summarized. The goal of the annual conference was to disseminate information about ongoing nicotine research from biological, behavioral and social perspectives. Data were presented describing our current understanding of the structure and function of neuronal nicotinic acetylcholine receptors, by which nicotine exerts most, if not all, of its effects in the brain. The conformational complexity of receptor subunits expressed in different brain areas contributes significantly to the complexity of responses observed to nicotinic agonists. Nicotine is being developed as a medication that might be used to maintain smoking cessation and to treat various medical diseases. The potential toxicity of nicotine, apart from cigarette smoking, is an important variable in assessing the benefits and risks of such therapeutic applications. The risks of nicotine-containing medications appear to be far less than those associated with tobacco use. Recent data indicate that cigarette smoking is increasing among young in the United States. Adolescent smokers are interested in quitting and make frequent quit attempts, but are usually not successful. Effective methods are needed to manage adolescent smokers before they become heavily addicted. Nicotine replacement as a pharmacological treatment for smoking cessation has made a significant contribution in improving quit rates. New medications have been developed that target specific populations of smokers.

Lung cancer mortality after 16 years in MRFIT participants in intervention and usual-care groups. Multiple Risk Factor Intervention Trial

PURPOSE

The Multiple Risk Factor Intervention Trial (MRFIT), a randomized clinical trial for the primary prevention of coronary heart disease, enrolled 12,866 men (including 8194 cigarette smokers) aged 35-57 years at 22 clinical centers across the United States. Participants were randomized either to special intervention (SI), which included an intensive smoking cessation program, or to usual care (UC). After 16 years of follow-up, lung cancer mortality rates were higher in the SI than in the UC group. Since rates of smoking cessation in SI were higher than those for UC for the 6 years of the trial, and since risk of lung cancer mortality is known to decline with smoking cessation, these results were unexpected. The purpose of the present study was to investigate hypotheses that could explain the higher observed lung cancer mortality rates in the SI as compared with the UC group.

METHODS

Analytic methods were employed to determine whether SI and UC participants differed either in baseline characteristics or in characteristics that changed during the trial and to determine whether these differences could explain the higher rates of lung cancer mortality among SI as compared to UC participants. Rates of mortality from coronary heart (CHD) were examined to explore the possibility that prevention of CHD death may have contributed to greater mortality due to lung cancer in the SI group.

RESULTS

From randomization through December 1990, 135 SI and 117 UC participants died from lung cancer. The relative difference between the SI and U groups adjusted for age and number of cigarettes smoked per day, was 1.17 (95% CI:0.92-1.51). The greatest difference between the SI and UC groups in lung cancer mortality rates occurred among the heaviest smokers at baseline who did not achieve sustained smoking cessation by year 2. In this group the rates of death from CHD were approximately the same among the SI and UC subjects. No differences in baseline characteristics were found between SI and UC smokers who did not achieve sustained cessation by year 2, and there were no differences in follow-up characteristics between the two study groups that could explain the difference in lung cancer mortality.

CONCLUSIONS

None of the hypotheses proposed to explain the unexpected higher rates of lung cancer mortality among SI as compared with UC subjects were sustained by the data. Thus we conclude that the difference observed is due to chance, and that a longer period of sustained smoking cessation plus follow-up is necessary to detect a reduction in lung cancer mortality as a result of smoking cessation intervention in a randomized clinical trial.

Tobacco control activities of primary-care physicians in the Community Intervention Trial for Smoking Cessation. COMMIT Research Group

OBJECTIVE

To compare tobacco control practices of physicians and their staff in Intervention communities with those in Comparison communities of the Community Intervention Trial for Smoking Cessation (COMMIT).

DESIGN

COMMIT was a randomised trial testing community-based intervention for smoking cessation carried out over four years.

SETTING

Eleven matched pairs of communities assigned randomly to Intervention and Comparison conditions.

PARTICIPANTS AND INTERVENTIONS

Physicians in the Intervention communities participated in continuing medical education (CME). Training for office staff focused on tobacco control and office intervention "systems".

OUTCOME MEASURES

Smoking control attitudes and practices reported by primary-care physicians in the 22 communities, smoking policies, and practices of 30 randomly selected medical offices in each community, and patient reports of physician intervention activities.

RESULTS

Response rates to the physicians' mail survey were 45% and 42% in Intervention and Comparison communities, respectively. Telephone interviews of office staff had response rates of 84% in both conditions. Physicians in Intervention communities were more likely to attend training than those in Comparison communities (53% and 26%, respectively (P<0.0005)). In both conditions, training attendees perceived themselves as being better prepared to counsel smokers than non-attendees (P < or = 0.01) and reported more activity in smoking intervention. Intervention communities carried out more office-based tobacco control activities (P = 0.002). Smokers in Intervention communities were more likely to report receiving reading material about smoking from their physicians (P = 0.026). No other differences in physician intervention activities were reported by smokers between the Intervention and Comparison communities.

CONCLUSIONS

The COMMIT intervention had a significant effect on some reported physician behaviours, office practices, and policies. However, most physicians still did not use state-of-the-art smoking intervention practices with their patients and there was little, or no, difference between patient reports of intervention activities of physicians in the Intervention and Comparison communities. Better systems and incentives are needed to attract physicians and their staff to CME and to encourage them to follow through on what they learn. The recently released Agency for Health Care Policy and Research clinical practice guideline for smoking cessation and other standards and policies outline these systems and offer suggestions for incentives to facilitate adoption of these practices by physicians.

Use of the nicotine skin patch by smokers in 20 communities in the United States, 1992-1993

OBJECTIVE

To measure the characteristics of smokers associated with the use of the nicotine skin patch in the general population and to evaluate whether use of the patch is associated with successful smoking cessation.

DESIGN

Data from two surveys conducted in 20 communities in the United States as part of the National Cancer Institute's Community Intervention Trial for Smoking Cessation (COMMIT) study. Nicotine patch prevalence was estimated using data from a 1993 cross-sectional survey of 13691 current and former smokers. The effectiveness of the nicotine skin patch as a smoking cessation aid was evaluated adjusting for other covariants using data from a cohort tracking study of 9809 smokers who were followed between 1988 and 1993. As the nicotine patch was not available to consumers until January 1992, analyses were restricted to respondents who reported themselves to be current smokers in 1993 or former smokers who reported quitting after January 1992.

OUTCOME MEASURES

Current and former smokers who reported having made a serious effort to stop smoking in the past five years were asked to indicate whether they had used the nicotine skin patch to help them stop smoking. Those answering "Yes", were classified as nicotine patch users. Smoking cessation was based on self-report. A "quitter" was defined as someone who had been a smoker as of January 1992 who reported in 1993 not smoking any cigarettes for the preceding six months or longer.

RESULTS

The prevalence of nicotine patch use by smokers averaged across the 20 study communities was 12.8%, making the patch one of the most popular cessation methods used by smokers. Compared with non-users, patch users were more likely to be female, white, have higher annual household incomes, be more motivated to stop smoking, and to smoke more heavily. Among low-income smokers (annual household income below US$10000), nicotine patch use was significantly higher among those who lived in a state where the public insurance programme (Medicaid or Medi-Cal) included the patch as a benefit (12.1% vs 7.7%). Among those who made an attempt to quit smoking, the likelihood of successful quitting was more than twice as high among patch users compared with non-users. Among patch users, the highest quit rates were observed among those who used the patch for between one and three months.

CONCLUSIONS

The nicotine skin patch is a popular and effective means of smoking cessation. Use of the nicotine patch, especially by low-income smokers, could be increased by reducing the out-of-pocket expenditure required for smokers to get the product.

Effect of training and a structured office practice on physician-delivered nutrition counseling: the Worcester-Area Trial for Counseling in Hyperlipidemia (WATCH)

We examined the effectiveness of a training program for physician-delivered nutrition counseling, alone and in combination with a structured office practice environment for nutrition management, on physicians' counseling practices. Forty-five primary care internists and 1,278 of their patients in the top quarter of the cholesterol distribution at a central Massachusetts health maintenance organization (the Fallon Clinic) were enrolled into a randomized controlled trial. Physicians were randomized by site into three conditions: (1) usual care, (2) physician nutrition counseling training, and (3) physician nutrition counseling training plus a structured office practice environment for nutrition management (prompts and the provision of lipid results and counseling algorithms). A randomly selected 325 patients were given a 10-item patient exit interview (PEI) assessing whether the physician provided advice; assessed past changes, barriers, and resources; negotiated specific plans and goals; provided patient materials; referred the patient to a dietitian; and developed plans for follow-up. Condition 3 physicians demonstrated significantly greater implementation of the nutrition counseling sequence than did physicians in either of the other two conditions (P < .0001). Referrals to nutrition services were markedly reduced in condition 2, despite PEI scores no different than those in condition 1. Higher PEI scores for patients seen by physicians in condition 3 were stable for as long as two years beyond training. Primary care internists, when provided with both training in counseling techniques and a supportive office environment, will carry out patient counseling appropriately. Training alone, however, is not sufficient and may be counterproductive. Medical Subject Headings (MeSH): hypercholesterolemia, diet therapy, coronary disease, health behavior, primary health care, medical education, managed care programs.

Smoking in Ecuador: prevalence, knowledge, and attitudes

OBJECTIVE

To evaluate the prevalence of, attitudes towards, and knowledge about cigarette smoking in Ecuador in 1991.

DESIGN

Survey using in-person interviews; stratified and multiple regression analyses.

SUBJECTS AND SETTING

Eight hundred people (> or = 18 years old) representative of the adult populations in the cities of Quito and Guayaquil, Ecuador.

MAIN OUTCOME MEASURES

Smoking prevalence, daily cigarette consumption, reasons for smoking, desire to quit smoking, knowledge about the health effects of smoking.

RESULTS

About a third of the population in the two major cities of Ecuador are cigarette smokers. Men are not only more likely to be smokers than women (45% vs 17%, respectively), but when they do smoke, they also smoke significantly more cigarettes per day (60% more) than women. Cigarette smoking appears to be more common among younger populations, and among more educated people. Housekeepers are significantly less likely to be smokers compared with people in other occupations. About 80% of smokers consume fewer than 10 cigarettes per day. In Quito, a 40% increase in the number of cigarettes smoked per day on weekdays compared with weekends suggests an effect of the environment on smoking patterns. About 60% of smokers stated their desire to quit smoking, and there was almost universal knowledge about the harmful effects of cigarette smoking on the health of active and passive smokers.

CONCLUSIONS

About a third of the population in the two major cities of Ecuador reported smoking cigarettes. Smoking is more common among men, those of younger age, and the more educated. The findings in this study should help the development of antismoking policies in Ecuador and other countries in the region.

Double jeopardy: workplace hazards and behavioral risks for craftspersons and laborers

PURPOSE

To address three specific questions in a sample of craftspersons and laborers: (1) Do craftspersons and laborers exposed to workplace hazards have higher behavioral risks, such as smoking and high-fat diets, than those with few job risks? (2) Compared to workers with few job risks, do workers exposed to risks on the job have higher intentions to reduce their behavioral risks? (3) Does concern about the level of exposure to risks on the job increase workers' intentions to reduce behavioral risks?

DESIGN

A cross-sectional self-administered survey was conducted in participating worksites.

SETTING

Twenty-two predominantly manufacturing worksites in Massachusetts.

SUBJECTS

Craftspersons and laborers responding to the survey and employed in these 22 worksites (completion rate = 61%, N = 1841).

MEASURES

By using standardized items, this survey measured self-reported exposure to workplace hazards, concern about job exposures, smoking status, fat and fiber intake, readiness to quit smoking, plans to reduce fat intake, plans to eat more fruits and vegetables, and sociodemographic variables.

RESULTS

Workers reporting exposure to chemical hazards on the job were significantly more likely to be smokers than were unexposed workers, even when results were controlled for gender. Compared with unexposed workers, smokers exposed to chemical hazards were significantly more likely to be thinking of quitting or taking action to quit, when results were controlled for gender, race, and education. Among workers exposed to occupational chemical hazards, concern about this exposure was significantly associated with intentions to decrease fat intake and increase fruit and vegetable intake, and, among men, intentions to quit smoking.

CONCLUSIONS

Efforts aimed at integrating health promotion and health protection are needed to address simultaneously the job risks and personal risks these workers face.

Worker participation in an integrated health promotion/health protection program: results from the WellWorks project

According to prior reports, blue-collar workers are less likely to participate in worksite health promotion programs than are white-collar workers. This study examined worker participation in the WellWorks worksite cancer prevention intervention, which integrated health promotion and health protection. Analyses were conducted to assess relationships among participation in health promotion and health protection programs, and workers' perceptions of management changes to reduce potential occupational exposures. Results indicate that blue-collar workers were less likely to report participating in health promotion activities than white-collar workers. A significant association was observed between participation in nutrition- and exposure-related activities, suggesting that participation in programs to reduce exposures to occupational hazards might contribute to blue-collar workers' participation in health promotion activities. Furthermore, when workers were aware of changes their employer had made to reduce exposures to occupational hazards, they were more likely to participate in both smoking control and nutrition activities, even when controlling for job category. These findings have clear implications for future worksite cancer prevention efforts.

Tobacco curriculum for medical students, residents and practicing physicians

Smoking and other tobacco exposure have been recognized for several decades as the most significant preventable factors in premature morbidity and mortality. Most physicians believe they should address the issue of tobacco intake with their patients but are rarely provided with adequate training or support to do so effectively. Recent research identifies several ways in which physicians can have substantial impact on patient smoking rates, by use of very brief patient-centered counseling and by prescribing nicotine replacement therapies. This paper describes a model curriculum for medical students, residents, medical faculty and community physicians that can be integrated into current training and teaching practices. The goal is to create a "preventive" intervention perspective to smoking that is effective, practical, efficacious and cost-effective.

Barriers to lifestyle change, and the need to develop an integrated approach to prevention

Many barriers exist to the delivery of preventive services by both cardiologists and other physicians. These barriers can be overcome by appropriate training and the development of supportive infrastructures. In addition, institutional priorities must change in a direction that encourages such efforts. Cardiologists must recognize the importance of risk-factor modification, and training programs in cardiology should teach appropriate counseling techniques, the use of risk factor-lowering pharmacologic agents, and the manner in which cardiologists should interface with dietitians and other ancillary personnel. In addition, we need to recognize and teach, both by didactics and by example, that counseling patients and carrying out long-term preventive interventions can be as gratifying and interesting as performing dramatic procedures that although valuable and rewarding take place at a very late point in the patient's clinical course and perhaps could have been averted by greater attention to risk-factor modification. Increasingly, the public and governmental agencies are becoming involved in encouraging these endeavors, and cardiologists should be in the vanguard of such efforts, not reluctantly bringing up the rear.