Physical therapy vs internet-based exercise training for patients with knee osteoarthritis: results of a randomized controlled trial

OBJECTIVE

To compare the effectiveness of physical therapy (PT, evidence-based approach) and internet-based exercise training (IBET), each vs a wait list (WL) control, among individuals with knee osteoarthritis (OA).

DESIGN

Randomized controlled trial of 350 participants with symptomatic knee OA, allocated to standard PT, IBET and WL control in a 2:2:1 ratio, respectively. The PT group received up to eight individual visits within 4 months. The IBET program provided tailored exercises, video demonstrations, and guidance on progression. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC, range 0 [no problems]-96 [extreme problems]), assessed at baseline, 4 months (primary time point) and 12 months. General linear mixed effects modeling compared changes in WOMAC among study groups, with superiority hypotheses testing differences between each intervention group and WL and non-inferiority hypotheses comparing IBET with PT.

RESULTS

At 4-months, improvements in WOMAC score did not differ significantly for either the IBET or PT group compared with WL (IBET: -2.70, 95% Confidence Interval (CI) = -6.24, 0.85, P = 0.14; PT: -3.36, 95% (CI) = -6.84, 0.12, P = 0.06). Similarly, at 12-months mean differences compared to WL were not statistically significant for either group (IBET: -2.63, 95% CI = -6.37, 1.11, P = 0.17; PT: -1.59, 95% CI = -5.26, 2.08, P = 0.39). IBET was non-inferior to PT at both time points.

CONCLUSIONS

Improvements in WOMAC score following IBET and PT did not differ significantly from the WL group. Additional research is needed to examine strategies for maximizing benefits of exercise-based interventions for patients with knee OA.

TRIAL REGISTRATION

NCT02312713.

Developing a Multi-Dimensional Early Elementary Mathematics Screener and Diagnostic Tool: The Primary Mathematics Assessment

There is a critical need to identify primary level students experiencing difficulties in mathematics to provide immediate and targeted instruction that remediates their deficits. However, most early math screening instruments focus only on the concept of number, resulting in inadequate and incomplete information for teachers to design intervention efforts. We propose a mathematics assessment that screens and provides diagnostic information in six domains that are important to building a strong foundation in mathematics. This article describes the conceptual framework and psychometric qualities of a web-based assessment tool, the Primary Math Assessment (PMA). The PMA includes a screener to identify students at risk for poor math outcomes and a diagnostic tool to provide a more in-depth profile of children's specific strengths and weaknesses in mathematics. The PMA allows teachers and school personnel to make better instructional decisions by providing more targeted analyses.

Perceived Health Risks of Snus and Medicinal Nicotine Products

INTRODUCTION

Perceived health risk (PHR) of a tobacco product may influence both uptake and continued use. In this study, we examined PHRs of snus and medicinal nicotine using the PHR scale and the relationship of PHR responses to use of these products in smokers seeking an alternative to smoking.

METHODS

Smokers were randomly assigned to snus or to medicinal nicotine for a period of 12 weeks and asked to only use the assigned product. The PHR scale involves rating the extent of perceived risk of a product for different diseases and was given at baseline and weeks 4 and 12 during treatment. Relationships between PHR scale scores and study attrition, compliance with only using the product, and continued use of the product after treatment were determined.

RESULTS

Response to the PHR scale showed no significant differences between the snus and medicinal nicotine for perceived risks for lung cancer, emphysema, and bronchitis. However, significant differences were observed for other cancers, heart disease, stroke and risk for addiction, particularly after product use, with higher scores among those assigned to snus. Scores on the PHR scale were not related to any of the trial outcome variables.

CONCLUSIONS

Among smokers seeking an alternative to smoking in a clinic setting, PHR of a product changes after product use but may not be related to product use patterns.

IMPLICATIONS

PHRs of snus or medicinal nicotine in smokers assigned to these products become more accurate after product use. PHR does not appear to be associated with patterns of product use; rather satisfaction with a product is a better indicator as to whether a smoker is compliant with only using the product or continues to use the product.

Subjective responses to oral tobacco products: scale validation

INTRODUCTION

Several noncombusted oral tobacco products have been introduced that are primarily marketed to cigarette smokers. An important component of evaluating these products involves assessment of subjective responses to the product. To date, few studies have been undertaken to examine the validity of subjective response questionnaires for oral tobacco products. The goal of this study is to examine the extent subjective responses to a product are related to product preference and extent of product use.

METHODS

Data from a study examining oral tobacco product preference were used. Smokers were asked to sample a variety of oral tobacco products that differed in formulation (snus versus dissolvables) and dose of nicotine. At the end of the sampling period, subjects were asked to choose the product that they would use to completely substitute for cigarettes for the next 2 weeks. During the sampling period, subjects completed a Product Evaluation Scale (PES) that describes subjective responses to the product. During the treatment phase, they kept record of amount of product use.

RESULTS

Subjective responses to the product on the PES were related to product choice and to some extent, the amount of product use. Product choice was associated with different characteristics of the product and smoker needs.

CONCLUSION

The PES may be a useful tool for the evaluation or oral tobacco products.

Evaluate, assess, treat: development and evaluation of the EAT framework to increase effective communication regarding sensitive oral-systemic health issues

Oral healthcare providers are likely to encounter a number of sensitive oral/systemic health issues whilst interacting with patients. The purpose of the current study was to develop and evaluate a framework aimed at oral healthcare providers to engage in active secondary prevention of eating disorders (i.e. early detection of oral manifestations of disordered eating behaviours, patient approach and communication, patient-specific oral treatment, and referral to care) for patients presenting with signs of disordered eating behaviours. The EAT Framework was developed based on the Brief Motivational Interviewing (B-MI) conceptual framework and comprises three continuous steps: Evaluating, Assessing, and Treating. Using a group-randomized control design, 11 dental hygiene (DH) and seven dental (D) classes from eight institutions were randomized to either the intervention or control conditions. Both groups completed pre- and post-intervention assessments. Hierarchical linear models were conducted to measure the effects of the intervention whilst controlling for baseline levels. Statistically significant improvements from pre- to post-intervention were observed in the Intervention group compared with the Control group on knowledge of eating disorders and oral findings, skills-based knowledge, and self-efficacy (all P < 0.01). Effect sizes ranged from 0.57 to 0.95. No statistically significant differences in outcomes were observed by type of student. Although the EAT Framework was developed as part of a larger study on secondary prevention of eating disorders, the procedures and skills presented can be applied to other sensitive oral/systemic health issues. Because the EAT Framework was developed by translating B-MI principles and procedures, the framework can be easily adopted as a non-confrontational method for patient communication.

Smokeless tobacco use in military personnel

Military personnel are more than twice as likely as civilians to use smokeless tobacco (ST), and recent studies indicate that military prevalence rates are rising. However, few studies have examined factors related to ST use in the military. The present study evaluated the characteristics of ST use in 785 active duty military personnel. The results indicated that the average age of initiation was 17.7 years, participants had used ST for 12.3 years, and they used approximately four tins or pouches of tobacco per week. Army personnel were more likely than Air Force personnel to be older, to have used ST longer, and to be heavier users. Officers had used ST longer than enlisted personnel and were more likely to have had a recent quit attempt. Enlisted personnel were more than three times as likely to report concurrent cigarette smoking. These results indicate that there are significant differences in ST use patterns in military personnel, and cessation programs should be tailored to meet these differences.

Smokeless tobacco use among professional baseball players: survey results, 1998 to 2003

OBJECTIVE

The use of smokeless tobacco (ST) (snuff and chewing tobacco) has long been associated with baseball in the USA. This article reviews six years of survey data from major and minor league baseball players to evaluate trends in tobacco use and quitting patterns over time in order to gain insight into the effects of past interventions and to document continued intervention needs.

METHOD

Surveys were distributed by athletic trainers to major and minor league professional baseball players during spring training session in the six years from 1998 to 2003. The surveys were anonymous and identified only by team, level of league, and other self reported demographic data.

RESULTS

ST use among professional baseball players remains much higher than among young males in the general population, and use is most prevalent among white non-Hispanic players. There was a significant decrease in ST use among minor league players from 1998 to 2003, with seven day self reported use declining from 31.7% in 1998 to 24.8% in 2003. No significant year to year changes were observed for major league players. Major league players' self reported past week use rates, estimated at 35.9% in 1998 and at 36% in 2003, were consistently higher than those of minor league players. Self reported prevalence of past month cigarette and cigar smoking was much lower than ST use for both major and minor league players.

CONCLUSIONS

Six years of survey data confirm a continuing high use of ST among professional baseball players. Results suggest that the effects of the broad spectrum ST control efforts launched over the past decade may have been stronger among minor than major league players. Stronger policy interventions at the major league level and multi-level efforts, including programmes to increase the use of effective quitting aids and assistance, at both levels of play are needed. Future research is needed to further clarify changes in ST practices among professional players and set policy intervention directions.

Who enrolls in a self-help cessation program for smokeless tobacco?

To further our understanding of the representativeness of the smokeless tobacco (SLT) user recruited to various treatment settings, and to suggest gaps in services available to SLT users, we first compared participants who enrolled in a self-help cessation program with two samples of nontreatment-seeking SLT users: SLT users identified through a random digit dialing (RDD) survey, and SLT users who came to 1 of 75 dental practices for a routine cleaning visit. We found that those in the self-help SLT cessation program were older, more educated, more likely to have made a serious quit attempt, and used more SLT weekly than those who did not seek treatment. Secondly, we compared SLT users seeking treatment in three different treatment settings varying in accessibility and intensity: self-help study participants, SLT users enrolled in a clinic-based study, and callers to the California Help Line for SLT cessation. Participants differed across the three studies on demographics, some measures of dependence, and history of SLT use.

Tobacco cessation through dental office settings

There is increasing interest in broadly inclusive public health interventions that involve low-cost, self-help materials and minimal support from professionals. Dental health care workers (DHCWs) are a largely untapped resource for providing advice and brief counseling to tobacco-using patients, and there are good reasons to believe that they can be effective in this role. The results of our randomized clinical trials have shown that a brief dental office-based intervention can be effective in helping smokeless tobacco users to quit and smokers to reduce their use and become more ready to quit. A third clinical trial tested the effectiveness of two methods of disseminating the smokeless tobacco intervention to DHCWs throughout the western United States. Workshops were more effective than self-study in effecting behavior change, although our analyses indicate that self-study was more cost-efficient. These studies have demonstrated the viability of using dentists and dental hygienists to provide brief cessation advice and supportive materials in the context of regular oral health visits to encourage their patients to quit. The results of these studies also support the timeliness of further dissemination and diffusion of this program to practitioners, dental schools, and dental hygiene programs.

Maternal smoking cessation and relapse prevention during health care visits

BACKGROUND

Although effects of maternal smoking during pregnancy could be alleviated if women quit early in pregnancy, most do not. Relapse rates among quitters are high.

OBJECTIVE

To test the effects of a low-intensity, smoking-cessation/relapse-prevention intervention delivered by clinic staff and providers and based on stages-of-change constructs of the transtheoretical model and brief motivational interviewing techniques.

METHODS

A quasi-experimental prospective cohort design employed in obstetric, in-patient, and pediatric care delivery settings of a large health maintenance organization in Portland, Oregon. Subjects were pregnant smokers registered for their first prenatal visit. Primary outcome measures were sustained (self-reported) quit rates during pregnancy and smoking abstinence between 6 and 12 months after delivery.

RESULTS

Regression analyses found statistically significant improvement for intervention women in sustained pregnancy quit rates (OR=2.7, CI=1. 2-5.7) and on smoking abstinence between 6 and 12 months after delivery (OR=2.4, CI=1.1-5.3).

CONCLUSIONS

While these outcomes are based on self-report only, they emerged despite variable delivery of the intervention across clinics and represent clinically meaningful improvements in rates of nonsmoking. The intervention supports women who want to quit smoking during pregnancy and improves the likelihood of their remaining nonsmokers for the long term.

A self-help cessation program for smokeless tobacco users: comparison of two interventions

While the use of smokeless tobacco products has increased, there has been a paucity of research evaluating interventions to help users quit. This study is the first large-scale randomized trial evaluating two levels of self-help cessation intervention with adult smokeless tobacco (SLT) users. Smokeless users in five Northwest states were recruited to call a toll-free number and 1069 users were randomized to receive one of two interventions, Manual Only (MAN) or Assisted Self-Help (ASH), who received a video and two support phone calls in addition to the manual. The study demonstrated that low-cost minimal interventions done by mail and phone can help a sizable proportion of SLT users quit both SLT and all tobacco use. Follow-up data at 6 months showed that subjects in the ASH condition had a significantly higher quit rate for both smokeless (23.4% vs. 18.4%, p < 0.05) and all tobacco use (21.1% vs. 16.5%, p < 0.05), using an intent-to-treat model. Further analysis revealed that use of the recommended cessation procedures mediated the effect of intervention condition on outcomes. This may be the result of phone counselors getting subjects to carry out behavioral cessation procedures. Public health implications for this intervention are discussed.

Evaluating two self-help interventions for smokeless tobacco cessation

The need for effective, low-cost self-help treatment methods for smokeless tobacco (ST) addiction becomes more evident as rates of product use and associated morbidities increase. This study evaluated two self-help methods for ST cessation. One hundred ninety-eight ST users were randomized into two conditions: half received the LifeSign, a credit card-sized computer designed for gradual ST cessation, and half received the Enough Snuff self-help manual and a video. Subjects in both conditions received telephone support for their quit effort. The study was conducted entirely through phone and mail, allowing delivery of the intervention to both rural and urban users. Self-reported rates of sustained abstinence (no tobacco use at two months and six months) were 24.5% for the manual/video condition, and 18.4%, for the LifeSign condition.

Smokeless tobacco cessation

Smokeless tobacco use is increasing in the United States, especially among young men, but there are few resources to assist users in quitting their use of moist snuff or chewing tobacco. This article reviews some unique aspects of smokeless tobacco use and provides a systematic four-step clinical plan for providing cessation. The authors provide clear suggestions, measures, and aids for getting the user ready to quit, planning their quit, quitting, and staying quit. The procedures and measures have been validated in randomized clinical trials and provide empirical support for the recommended cessation procedures. Finally, a review of brief cessation interventions in the context of health care is provided.

A comparison of male and female smokeless tobacco use

This study explored the factors associated with female smokeless tobacco (ST) use and examined gender differences in factors related to use. Interviews were conducted either in person or by telephone with 51 female and 59 male users from the Pacific Northwest. The interview included both quantitative and qualitative items assessing personal, social, and substance use variables. Male and female users were found to be similar in a variety of areas, such as reasons for initiating use, use of ST in response to different mood states, and high rates of experimentation with other drugs. However, female users reported using ST for weight control more extensively, identified a greater influence by other female users, and reported fewer friends knowing about their use. Male users reported using ST more often during sports activities and in the workplace than did female users, and were almost three times more likely to be highly addicted to ST. The implications of the study for the development of prevention and cessation programs are discussed.

Health behavior, quality of work life, and organizational effectiveness in the lumber industry

A major incentive for work-site health promotion activities has been the promise of increased company profitability. Some critics have challenged the economic argument based on distal outcomes such as increased employee longevity and less morbidity later in life. The purpose of this study was to examine the relationships between employee health behavior, quality of work life, and proximal organizationally valued outcomes. Data were collected from a stratified random sample of employees working at Pacific Lumber Company (N = 146), the largest single-site lumber mill in California. Although employee sleep patterns predicted health care utilization and psychological well-being, for the most part employee health behaviors were not strong predictors of proximal organizational effectiveness factors. However, quality-of-work-life factors significantly predicted organizational commitment, absenteeism, and tardiness frequency. The findings suggest the value of improving the system of work in which employees are embedded as part of comprehensive work-site health promotion efforts.

Oral spit tobacco: addiction, prevention and treatment

The prevalence of smokeless tobacco is significant and reaches as high as 17% past month use in white males aged 18-25. Smokeless tobacco use is of concern because of the potential for addiction and the associated negative health consequences. This article reviews the basis for addiction to smokeless tobacco, examining the nicotine content in smokeless tobacco products, pharmacokinetics, psychoactive effects, tolerance, and withdrawal. It also explores the negative health consequences which include a number of oral pathologies and increased cardiovascular risk factors. Furthermore, it examines the factors associated with the initiation of smokeless tobacco use, and the current prevention programs that address these factors. Current smokeless tobacco treatment approaches are also discussed as well as predictors for abstinence. Finally, the future directions are discussed in light of the limited amount of research that has been conducted in the smokeless tobacco area, particularly related to prevention and treatment.

Using the hygiene visit to deliver a tobacco cessation program: results of a randomized clinical trial

To examine the effectiveness of advising patients who use tobacco to quit, the authors conducted a randomized clinical trial to test a brief office-based intervention with all tobacco users in 75 fee-for-service dental practices in Oregon. The authors found that the dental hygienist-delivered intervention was effective in getting smokeless tobacco users to quit at three and 12 months and to sustain abstinence at both three and 12 months. They found that the program was not effective for cigarette smokers. The authors discuss the public health implications of program dissemination and widespread program adoption.

Relationship between tobacco use and self-reported oral hygiene habits

A sample of 34,897 dental patients completed written surveys assessing their tobacco use, frequency of brushing and flossing and perception of oral health problems. Brushing two times per day was reported by 73.5 percent of the patients and flossing one time per day by 35.6 percent. Tobacco users brushed and, particularly, flossed much less frequently than did nonusers. Compliance with daily flossing regimens was particularly low among smokeless tobacco users. Tobacco users also reported more oral health problems.

Reducing maternal smoking and relapse: long-term evaluation of a pediatric intervention

BACKGROUND

Pediatric well-care visits provide a clinical opportunity to counsel new mothers about their smoking and the deleterious effects of environmental tobacco smoke (ETS) on infant health.

METHODS

Forty-nine Oregon pediatric offices enrolled 2,901 women who were currently smoking or had quit for pregnancy, using a brief survey at the newborn's first office visit. Randomly assigned offices provided advice and materials to mothers at each well-care visit during the first 6 months postpartum to promote quitting or relapse prevention.

RESULTS

The intervention reduced smoking (5.9% vs 2.7%) and relapse (55% vs 45%) at 6-month follow-up, but logistic regression analysis at 12 months revealed no significant treatment effect. The intervention had a positive effect on secondary outcome variables, such as readiness to quit and attitude toward and knowledge of ETS. Multiple logistic regression analysis indicated that husband/partner smoking was the strongest predictor of maternal quitting or relapse.

CONCLUSIONS

A pediatric office-based intervention can significantly affect smoking and relapse prevention for mothers of newborns, but the effect decreases with time. Consistent prompting of the provider to give brief advice and materials at well-care visits could provide a low-cost intervention to reduce infant ETS exposure.

Tobacco cessation interventions in health care settings: rationale, model, outcomes

Health care settings provide opportunities to reach populations of tobacco users with personalized cessation assistance. We describe a model for doing so which emphasizes a team approach, minimizes the burden on clinicians, and uses brief counseling by allied professionals, videos, written materials, and telephone calls to augment clinician advice. The model has been implemented in several diverse settings including outpatient, inpatient, and dental clinic managed care; fee-for-service dentistry and pediatric practices; and planned parenthood clinics. Data from several randomized trials support the effectiveness of the approach. The brief, low-intensity interventions derived from the model appear to be sustainable on a routine basis in many settings.

The organizational implications of smokeless tobacco use in the lumber mill industry

Although much is known about the characteristics of employees who smoke cigarettes, very little is known about workers who use smokeless tobacco. The current study was designed to understand the characteristics of smokeless tobacco users in relation to their performance at work and compare them with smokers and former tobacco users. Data were collected via interviews and questionnaires from a random sample of employees working at Pacific Lumber Company (N = 146), the largest single-site lumber mill in California. A total of 63 smokeless tobacco users (21 of whom also smoked cigarettes), 43 cigarette smokers, and 40 employees who had successfully quit using tobacco (34 of whom previously used cigarettes only) provided information about their health behavior, quality of work life, and performance at work. Analyses revealed that smokeless tobacco users reported less healthful sleep patterns, drank alcohol more often, were intoxicated more often, reported less job satisfaction and organizational commitment, and reported that both chewers and smokers do not work as hard and take more breaks than do tobacco-free employees (quitters). Specific differences among chewers-only, smokers-only, smokers-and-chewers, and quitters are presented. Results suggest the organizational value of developing worksite cessation programs for smokeless tobacco users.

Pediatric office-based smoking intervention: impact on maternal smoking and relapse

OBJECTIVE

To determine the impact of a brief smoking intervention delivered by pediatricians in the context of usual well baby office visits on postnatal maternal smoking and relapse.

SETTING

Forty-nine private pediatric practices including 128 practitioners.

DESIGN

Randomization of pediatric practices into minimal and extended intervention sites with all enrolled mothers of newborns within a practice receiving the same level of intervention.

INTERVENTION

Smoking mothers in minimal condition received a hospital packet containing written information about passive smoking and a letter advising them to quit. Those in extended condition received the hospital packet plus oral and written advice at usual well baby visits: 2 weeks, 2, 4, and 6 months.

MEASUREMENTS

Smoking and relapse rates at 6 months postpartum, demographics associated with smoking status, attitudes, and knowledge in regard to passive smoking, and recall surveys of mothers in regard to receiving advice or written materials.

RESULTS

Two-thousand nine-hundred-one mothers of newborns were enrolled in the study. Those in the extended condition had higher quit rates (5.9% vs 2.7%, P < .01) and lower relapse rates (45% vs 55%, P < .01) than those in the minimal condition. Mothers' educational status and the presence of a smoking partner in the home were the major demographic variables associated with smoking status at enrollment and at follow-up. Compared with smokers in the minimal condition, those in extended at 6 months postpartum had significantly better attitudes and knowledge regarding passive smoking and allowed less smoking in the home. Mothers attending extended practices reported much higher rates of receiving oral advice and written materials than those in the minimal condition.

CONCLUSIONS

A brief program can lead to major increases in the willingness of pediatricians to deliver smoking advice. A 1- to 2-minute intervention delivered in the context of usual well baby care can have a positive impact on maternal smoking and especially upon relapse prevention. A recent smoking history should be obtained from all mothers of newborns so that interventions can be aimed at both cessation and relapse prevention.

Measuring dependence in smokeless tobacco users

Two scales based on the Fagerstrom Tolerance Questionnaire were developed to measure dependence in smokeless tobacco users. The total score for both scales correlated positively with saliva cotinine levels in subjects, and several individual items produced equally positive correlations. Regression analyses yielded two subsets of three items from each scale that predicted cotinine level. Reports of using smokeless tobacco within 30 min of waking served as a predictor in both models. For the purposes of measuring smokeless tobacco dependence, attention should be given to individual items correlated with saliva cotinine levels that could be used to determine the direction of cessation efforts. Future research should also develop additional items specific to the use of snuff or chewing tobacco and eliminate questions not contributing to the overall scale.

Take heart: results from the initial phase of a work-site wellness program

OBJECTIVES

The purpose of this study was to evaluate the short-term effects of a low-intensity work-site heart disease risk reduction program using a matched pair design with work site as the unit of analysis.

METHODS

Twenty-six heterogeneous work sites with between 125 and 750 employees were matched on key organization characteristics and then randomly assigned to early or delayed intervention conditions. Early intervention consisted of an 18-month multifaceted program that featured an employee steering committee and a menu approach to conducting key intervention activities tailored to each site.

RESULTS

Cross-sectional and cohort analyses produced consistent results. At the conclusion of the intervention, early and delayed intervention conditions did not differ on changes in smoking rates, dietary intake, or cholesterol levels. There was considerable variability in outcomes among work sites within each condition.

CONCLUSIONS

Despite documented implementation of key intervention activities and organization-level changes in terms of perceived support for health promotion, this intervention did not produce short-term improvements beyond secular trends observed in control work sites. Research is needed to understand determinants of variability between work sites.

Predictors of smoking during and after pregnancy: a survey of mothers of newborns

BACKGROUND

Cigarette smoking during pregnancy represents a significant health risk to the fetus, but most women continue to smoke during pregnancy, and most who quit relapse postpartum. This study provides an assessment of psychosocial variables on women who quit, relapsed, cut down, or did not alter their smoking during pregnancy.

METHODS

Mothers of newborns in 49 pediatric practices (N = 13,495) were surveyed at the newborns' first well-care office visit to a pediatrician, and 2,901 mothers who smoked in the month prior to pregnancy were identified. Predictive information was obtained by comparing mothers who quit smoking with those who continued to smoke, mothers who stayed quit with relapsers, and mothers who reduced tobacco consumption with those who did not.

RESULTS

Thirty-five percent of mothers reported quitting smoking during pregnancy, and 52% had cut down for pregnancy. Factors related to quitting smoking for pregnancy were younger age, higher level of education, lower smoking level, having a partner who did not smoke, and not consuming alcohol. Mothers who quit also reported allowing less smoking in the home. Relapse for quitters was highly correlated with partner's smoking. For women who cut down but did not quit, smoking level and age were most significant.

Modifying dietary and tobacco use patterns in the worksite: the Take Heart Project

This article describes the conceptual basis, design, and intervention approach for a worksite-based heart disease risk reduction project. Baseline characteristics of the 26 moderate size worksites participating in the Take Heart Project are also described. The trial is designed to produce changes at both the organization and employee level on tobacco use, dietary fat intake, and serum cholesterol. A key feature of the intervention is creation of employee steering committees to enhance ownership and involvement. From a menu of brief, low-intensity health education and environmental change activities, these committees select activities best suited to their worksite. The baseline characteristics of organizations randomized to intervention and control conditions were similar, and indicated a relatively high level of worksite activity related to cholesterol and smoking.

Biochemical validation of smoking status: pros, cons, and data from four low-intensity intervention trials

Biochemical validation of smoking status has long been considered essential, but recent reports have questioned its utility in certain kinds of field trials. We describe efforts to biochemically validate self-reports of smoking cessation from participants in four large-scale randomized trials in outpatient clinics, hospitals, worksites, and dental clinics. These studies included over 5,000 adults smokers who participated in the population-based low-intensity intervention evaluations. At a 1-year follow-up, 798 subjects reported no tobacco use. We attempted to verify these reports using saliva continine/carbon monoxide validation procedures. Overall, there was a moderately high nonparticipation rate (27%), a low disconfirmation rate (4%), and a high self-reported relapse rate (12%) in the interval between survey and biochemical validation. There were no differences between intervention and control conditions on any of the above variables. Longer durations of self-reported abstinence were strongly related to increased probability of biochemical confirmation. Differences in results across projects were related to how biochemical validation was conducted. These results, as well as statistical power considerations, raise questions about whether biochemical validation procedures are practical, informative, or cost-effective in such population-based, low-intensity intervention research.

Smokeless tobacco habits and oral mucosal lesions in dental patients

As part of a smokeless tobacco (ST) intervention study, we collected data on tobacco use habits and oral health for 245 male ST users aged 15 to 77. The study sample was identified during routine dental office visits and represents a relatively diverse population of patients. Oral health data collection included grading the clinical appearance of oral mucosal lesions using Greer and Poulson's classification system, as well as identifying and recording the primary anatomic location of ST placement. Results show that 78.6 percent of ST users had observable oral lesions, 23.6 percent of which were in the most clinically advanced category (degree III). Of the lesions noted, 85 percent were in the same location the patient identified as his primary area of smokeless tobacco placement. In a comparison sample of 223 non-ST-users with the same age distribution, only 6.3 percent had observable lesions. A multiple logistic regression model for ST users showed that lesion presence and severity were most significantly related to current frequency of ST use.

Effective smokeless tobacco intervention for dental hygiene patients

This study was designed to test the effectiveness of a smokeless tobacco (ST) intervention delivered in the oral healthcare office setting. A total of 518 male ST users were identified by questionnaire in clinic waiting rooms and then randomly assigned to either a usual-care control group or a special intervention group. Dental hygienists took the primary role in delivering the intervention, which consisted of a soft-tissue examination with special attention to oral lesions, advice to quit ST, distribution of self-help materials, a short video on why and how to stop using smokeless tobacco, and encouragement to set a quit date. Follow-up assessments conducted three months after the office visit showed that a significantly greater proportion of intervention group patients had stopped using ST (32% of the intervention group participants versus 21% of control group patients, kappa 2 = 8.03, p less than .01). The intervention protocol is described in detail so that dental hygienists may adapt it for use in their practice.

Dental office practices for tobacco users: independent practice and HMO clinics

Surveys of independent dental practitioners and health maintenance organization (HMO) dentists and their adult male patients in Oregon found that cessation information and advice was being given to tobacco-using patients, especially smokeless tobacco users, and that the tobacco users surveyed expressed interest in obtaining help to quit. Oral health providers expressed an interest in further training in how to help their tobacco-using patients to quit.

The inside scoop on the stuff called snuff: an interview study of 94 adult male smokeless tobacco users

This interview study collected information from 94 adult males about a variety of factors related to their smokeless tobacco (ST) habit. Eighty-nine percent of this sample used moist snuff and most analyses focused on this group. Three measures of self-reported snuff use were intercorrelated and compared to a saliva cotinine assay. Correlations demonstrated potential usefulness of measures such as number of dips per day when biochemical measures are not practical. A majority (68%) of the Ss reported attempts to quit smokeless tobacco use, but relapsed from 1 to 3 months later. Ninety-six percent of snuff users reported awareness of cancer and other oral health risks and 56% reported an intention to quit in the next 12 months. A majority (67%) of subjects report receptivity to receiving advice to quit from medical and dental providers although only one-third had received such advice. The results are discussed in terms of designing an effective cessation intervention in dental clinics for ST users.

Psychosocial factors in the use of smokeless tobacco and their implications for P.L. 99-252

This article briefly reviews the prevalence of smokeless tobacco use by males in the United States, the relationship of smokeless tobacco use to cigarette use, and patterns of use that include dosage, topography, products, and function of use. The primary focus of the article is to describe the concurrent and predictive factors associated with onset, use, and cessation of smokeless tobacco. The implications of P.L. 99-252, the Comprehensive Smokeless Tobacco Act of 1986, are discussed in the context of what is known about the psychosocial variables associated with the use of smokeless tobacco.

An interpretative review of smokeless tobacco research in the United States: Part II

This is the second part of a two-part series reviewing the published literature of smokeless tobacco in the United States. The article explores smokeless tobacco as a pharmacologically addicting substance, educational interventions designed to prevent use or help users quit, and outlines areas of future research.

An interpretative review of smokeless tobacco research in the United States: Part I

The first part of a two-part series reviewing the published literature of smokeless tobacco in the United States and concomitant health effects associated with its use. This article delineates the current status of its prevalence, behavioral psychosocial factors associated with use, and review of the negative health effects associated with regular use.

Smokeless tobacco use among male adolescents: patterns, correlates, predictors, and the use of other drugs

Questionnaire data from a sample of 3,023 adolescents indicated that over 60% of boys have tried smokeless tobacco, and 7% use it daily. Daily users reported an average of 5.3 uses per day. Among boys the prevalence of smokeless tobacco use in the past 6 months (18.8%) was higher than that for cigarette use (10.4%). For 86% of boys, the initial use of smokeless tobacco occurred in a social setting with other boys. Split-sample discriminant analyses identified peer use of smokeless tobacco as a discriminator between users and nonusers. Male triers of smokeless tobacco were discriminated from those who had never tried it by whether they had also tried smoking, intended to smoke, or had peers who used smokeless tobacco. Nine-month longitudinal data indicated that onset of smokeless tobacco use was not well predicted. Among daily users, the initial rate of use was the best prospective predictor of rate of use at follow-up (r = 0.576). Smokeless tobacco use was related to the use of other drugs, with 83% of male daily users indicating concurrent use of alcohol, marijuana, and/or cigarettes (tau = 0.354, 0.210, and 0.284, respectively). The use of smokeless tobacco was a prospective risk factor for the onset or increased use of cigarettes, alcohol, or marijuana.

Adolescents' compliance with self-monitoring and physiological assessment of smoking in natural environments

Brief daily telephone calls were evaluated as a method of enhancing adolescents' compliance with self-monitoring and physiological assessments of cigarette smoking in the natural environment. Seven direct and indirect measures of compliance were devised. Results indicated that subjects receiving telephone calls complied significantly more than control subjects in providing saliva samples and recording detailed self-monitoring data.

A situational analysis of adolescent smoking

Forty-four adolescent smokers self-monitored their smoking for 1 week. Four 4 hr each day subjects recorded the person, place, and activity associated with each cigarette smoked. Seventy-one percent of all cigarettes were smoked in the presence of another person. Roughly half of those cigarettes were were smoked with peers. A surprising amount of smoking occurred in the subject's own home, suggesting that the smoking of the subjects is accepted, if not condoned , by their parents. The data generally confirm the social nature of adolescent smoking.

Chewing tobacco use by adolescents: prevalence and relation to cigarette smoking

The prevalence of teenage smokeless tobacco use and its relation to cigarette smoking was studied. Nine percent of 7th grade boys and 20% of 9th and 10th grade boys reported daily use. There was very little regular chewing among girls although about 20% reported having tried it. There was a strong association between smoking and chewing among 7th graders but only a weak association among 9th and 10th graders. Boys who chew tended to have friends who chew and/or smoke. The data suggested that chewing is affected by peer social influence processes in a manner similar to smoking.

Sampling bias due to consent procedures with adolescents

Positive consent was solicited from parents of 604 seventh grade students in four middle schools. Three hundred and fifty eight (59%) returned consents and completed a questionnaire under " bogus pipeline" conditions with saliva and air samples. Two weeks later both students with consent and those without were administered a second questionnaire without physiological measures. Comparison between consent and nonconsent students show significant differences in the smoking of cigarettes and marijuana, but no difference in the use of alcohol. Additional significant differences were found in exposure to smoking models, and level of education of both parents. The bias shown on significant dependent variables may adversely effect the generalizability of results of studies of adolescent drug use that depend upon positive parental consent.

Smoking treatment strategies, expectancy outcomes, and credibility in attention-placebo control conditions

Assessed credibility of the rapid smoking procedure, covert sensitization a combined approach, satiation, and a relaxation technique in a group of 38 self-reported cigarette smokers. The results suggested that while sex is not a factor in credibility ratings, different treatment strategies do elicit varying degrees of confidence in terms of positive treatment expectances. Scheffé's method of posttest comparisons revealed that satiation was least preferred, while the relaxation procedure was rated the highest in credibility. The other aversive treatment strategies did not differ significantly from either the relaxation or satiation procedures. These findings are discussed as they relate to credibility as a nonspecific treatment variable that smoking researchers may effectively manipulate through a rating procedure in creating a more sound experimental design in attention-placebo control conditions.

Cardiovascular stress during the rapid-smoking procedure

The effect of the rapid-smoking procedure on heart rate, blood pressure, and peripheral skin temperature as a measure of vasoconstriction was assessed for 6 women and 4 men who participated in a week long clinic. An analysis of heart rate, blood pressure, and skin temperature taken before, during, and after the procedure yielded a statistically significant effect across all three measures. The results are discussed in terms of their significance when compared to normal cigarette smoking and as they relate to the ethical issue raised in recommending this procedure based on these results.