Abstract P1-10-18: Contraception use in young women with breast cancer

Background: Young women with breast cancer need highly effective contraception given the potential implications of unplanned pregnancy for optimal treatment, and the teratogenic risks. We sought to determine the contraceptive methods used by young women after diagnosis (dx) of breast cancer and factors associated with use of less effective methods or no contraceptive method, which confers a 6-90% annual risk of pregnancy in sexually active women in contrast to highly effective methods (risk <1%).

Methods: As part of a randomized trial conducted in 54 sites to test an education and support intervention for young women with breast cancer and their oncologists, we surveyed women about their pre-dx, current, and planned contraceptive use, and about communication with their providers regarding contraception. Women enrolled within 3 months of dx; contraception items were included on 3- and 12-month post-enrollment surveys. Intrauterine device (IUD) use, tubal sterilization, hysterectomy or bilateral salpingo-oophorectomy (hyst/BSO) after dx, or male partner vasectomy were classified as highly effective methods; all other methods and non-use were categorized as less effective. We excluded women not at risk of pregnancy: hyst/BSO prior to dx, or no indication for contraception. We used logistic regression to explore factors associated with use of less effective methods.

Results: Of 424 women who completed the 3-month post-enrollment survey, median age at dx was 39 (range 22-45). 312 women at risk of pregnancy were included in this analysis, including 291 reporting sexual activity with a male partner within the last 6 months, and 21 reporting no recent sexual activity but reporting use of birth control. 123 women (39%) used highly effective contraceptive methods prior to dx; after dx, 161 (52%) reported current use of or a plan to use a highly effective method. 19 women (6%) reported use of a hormonal birth control method since dx; 7 (2%) reported withdrawal as their only contraceptive method; 25 (8%) reported no contraception. 30% of women did not recall a discussion of avoiding pregnancy or need for contraception during treatment with their providers. In multivariable analyses (N=310), desire for additional biologic children (OR 7.54, 95% CI 3.88-14.66) and provider discussion of contraception and pregnancy (OR 2.13 95% CI 1.20-3.78) were associated with use of less effective contraception. Age, race/ethnicity, disease stage, and partner status were not significantly associated with use of less effective methods.

Conclusion: About half of women who are at risk of pregnancy reported use or planned use of less effective contraceptive methods or no method of contraception following dx of breast cancer. Women with breast cancer and their providers may benefit from targeted education on contraceptive options and method effectiveness.

Citation Format: Rosenberg SM, Dutton CR, Ligibel J, Barry W, Ruddy KJ, Sprunck-Harrild K, Emmons KM, Partridge AH. Contraception use in young women with breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-18.

Abstract OT2-4-02: Young and strong: A randomized trial to evaluate a program for young women with breast cancer

Young women with newly diagnosed breast cancer face substantial challenges including higher risk of disease recurrence and likelihood of harboring a genetic mutation compared with older women. Many young women are also very concerned about their future fertility and this population often feels isolated from other breast cancer survivors due to their age and life stage. Some worry that their doctors are unsure of how to treat them. To address these issues, we developed a comprehensive program at our institution to coordinate and enhance the care, support, and education for young women with breast cancer. The Young and Strong study is a randomized clinical trial (RCT) to evaluate a virtual, exportable, scalable version of this program designed to improve the quality of care and the psychosocial well-being of this vulnerable population.

The specific aims of this program are:

1) To develop, pilot, and refine an exportable and sustainable educational and support intervention for young women with breast cancer and their oncology providers (Young Women's Intervention; YWI).

2) To determine the effect of the YWI compared to a contact-time control intervention focused on promoting physical activity (Physical Activity Intervention; PAI) on attention to fertility issues in a RCT: “Young and Strong”.

We initially conducted 4 focus groups (n = 36) and 20 key informant interviews, and developed, piloted, and refined the YWI as well as the PAI. Based on this successful work, we launched the Young and Strong study in June 2012 as a cluster-randomized trial at a total of 54 sites (40 community and 14 academic sites across the United States). Randomization is 1:1 between sites, and stratified by practice type (community vs. academic). Each community site will enroll 5-10 participants, each academic site 15 participants. Total recruitment will be 410-610 pts. The primary objective is to evaluate whether YWI, as compared to PAI, is associated with greater attention to fertility issues, assessed via medical record review. In addition, participants will complete assessments at baseline, 3, 6, and 12 months that assess satisfaction with care, psychosocial well-being, physical activity and anthropomorphic changes.

Young and Strong activated in June 2012 and all sites have been identified. As of 6/11/2013 the study has been initiated at 53 out of 54 sites, and total of 282 women have enrolled on the study.

Eligibility Criteria:

1. Women age 18-45 years at diagnosis

2. Stage I-III invasive breast cancer without known recurrence or metastatic disease

3. Newly-diagnosed (within 3 months of initial diagnosis)

4. Have 1st appt. with a medical oncologist at participating site after the site opens to enrollment

5. Able to read and write in English

For further information, contact Ann Partridge, MD, MPH at 888-814-3324.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-4-02.

Home matters: work and household predictors of smoking and cessation among blue-collar workers

OBJECTIVE

This study examined the joint influence of work- and household-related variables on smoking behavior among a population representative sample of blue-collar workers with live-in partners.

METHODS

The study used data on 1389 blue-collar workers from the Tobacco Use Supplement to the United States Current Population Survey 2002 to 2003 longitudinal overlap sample. Unadjusted and adjusted logistical regression analyses, which employed sampling and replicate weights to account for sampling design, were run to estimate independent and joint effects of the predictors.

RESULTS

In adjusted analyses, partner smoking (OR=4.97, 95%CI=3.02-8.18) and complete and partial home smoking policy (OR=0.16, 95%CI=0.09-0.29 and OR=0.39, 95%CI=0.23-0.68, respectively) were significant predictors of smoking status, but worksite smoking policies and presence of a young child under 5 in the household were not (p>0.05). Baseline complete home smoking ban was a significant predictor of subsequent cessation (OR=3.49, 95%CI=1.19-10.23), while partner smoking status, workplace smoking policy, and the presence of a young child in the home did not predict cessation (p>0.05).

CONCLUSION

Household-related variables were significant predictors of smoking status and cessation among blue-collar workers. Current efforts to decrease smoking in this group, which are mostly focused on work-related risk factors, should consider how to incorporate household risk factors.

Abstract P2-15-01: Long-Term Risk Perceptions and Quality of Life of Women with Ductal Carcinoma In Situ

Background: Research has demonstrated that many women with ductal carcinoma in situ (DCIS) overestimate their risk of future breast cancer events. However, no prior studies have evaluated risk perceptions in long-term follow-up.

Methods: As part of a multicenter longitudinal cohort study, we mailed long-term follow-up surveys to 315 of 392 women who had previously responded to a survey 18 months after they were diagnosed with DCIS (33 of the 392 were excluded because they were receiving follow-up care at outside centers, and 44 because of recurrence/death). We evaluated psychosocial distress by Hospitalized Anxiety and Depression Scale (HADS) and Revised Impact of Events Scale (RIES), quality of life (QOL) by Short Form Health Survey (SF-36), and risk perceptions with items used previously in the cohort.

Results: One hundred ninety-three women (61%) responded. They were a median age of 53 yrs (range 31-89) and a median of 5.8 yrs from diagnosis (range 4.3-7.0). Twelve were excluded due to report of recurrence. Of the 181 remaining, 32% perceived at least a moderate risk of developing DCIS again within 5 yrs; 43% perceived at least a moderate lifetime risk of developing DCIS again; 27% perceived at least a moderate risk of developing invasive breast cancer within 5 yrs; 38% perceived at least a moderate lifetime risk of developing invasive breast cancer; 24% perceived at least a moderate risk of DCIS spreading to other parts of their bodies. For qualitative responses of ≥ moderate perceived risk, median quantitative risk perception was 10% regarding 5-yr risk of DCIS or invasive cancer, 20% regarding lifetime risk, and 50% pertaining to risk of DCIS spreading. The proportion of women reporting ≥ moderate perceived risk of DCIS spreading remained stable over time (25% at baseline; 26% at 18 mos), but this proportion decreased for other perceptions of risk (e.g., at baseline and 18 mos, 51% and 50% of these same women perceived ≥ moderate risk of developing DCIS again within 5 yrs). In a multivariable model, worse financial status (OR 2.6, 95% CI 1.3-5.3) and higher perceived risk on earlier surveys (OR 24.4, 95% CI 12.7-47.2) were the only predictors of ≥ moderate perception of risk of DCIS spreading to other parts of the body in long-term follow-up. Non-significant covariates included age, race, education, grade of DCIS, comedonecrosis, mastectomy, radiation, marital status, employment status, comorbidity, and HADS and RIES scores. This contrasted with earlier survey data, which demonstrated an association between higher risk perceptions and anxiety by HADS and RIES. In long-term follow-up, only 7% were found to be anxious (HADS Anxiety ≥11) and 0.6% were depressed (HADS Depression ≥11). Median SF-36 scores were 48.9 (range 15.7-58.2) and 47.1 (range 23.6-60.3) for the physical and mental components, respectively, consistent with overall good QOL.

Conclusions: Women with a history of DCIS continue to harbor inaccurate perceptions of risk of future breast cancer events even at 6 yrs follow-up. Future research should evaluate how these excessive risk perceptions impact health behaviors. Interventions to improve risk perceptions are warranted.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-15-01.

Views of female breast cancer patients who donated biologic samples regarding storage and use of samples for genetic research

Although social and ethical issues related to the storage and use of biologic specimens for genetic research have been discussed extensively in the medical literature, few empiric data exist describing patients' views. This qualitative study explored the views of 26 female breast cancer patients who had consented to donate blood or tissue samples for breast cancer research. Participants generally did not expect personal benefits from research and had few unprompted concerns. Few participants had concerns about use of samples for studies not planned at the time of consent. Some participants did express concerns about insurance or employment discrimination, while others believed that current privacy protections might actually slow breast cancer research. Participants were generally more interested in receiving individual genetic test results from research studies than aggregate results. Most participants did not want individual results of uncertain clinical significance, although others believed that they should be able to receive such information. These data examined the range of participants' views regarding the storage and use of biologic samples. Further research with different and diverse patient populations is critical to establishing an appropriate balance between protecting the rights of human subjects in genetic research and allowing research to progress.

Environmental tobacco smoke: association with cardiovascular function at rest and during stress

Chronic exposure to environmental tobacco smoke (ETS) contributes to cardiovascular disease morbidity and mortality, and ETS alters cardiovascular performance during exercise stress. However, no study has examined whether those with ETS exposure have altered cardiovascular functioning during psychological stress, relative to those with no substantial ETS exposure. Seventy-eight healthy, nonsmoking adult men with either high levels of current ETS exposure at home and work or no current or significant lifetime ETS exposure were tested in a stress reactivity protocol. Blood pressure and heart rate were monitored during rest and during two psychological stressors. Those with high ETS exposure had significantly elevated heart rate and blood pressure at baseline, relative to those with no exposure. The groups did not differ on their cardiovascular stress responses. These data suggest that chronic ETS exposure is associated with altered cardiovascular functioning at rest, but not during stress. Results are discussed with regard to the role of ETS on the development of heart disease among nonsmokers.

Understanding the potential of teachable moments: the case of smoking cessation

The label 'teachable moment' (TM) has been used to describe naturally occurring health events thought to motivate individuals to spontaneously adopt risk-reducing health behaviors. This manuscript summarizes the evidence of TMs for smoking cessation, and makes recommendations for conceptual and methodological refinements to improve the next generation of related research. TM studies were identified for the following event categories: office visits, notification of abnormal test results, pregnancy, hospitalization and disease diagnosis. Cessation rates associated with pregnancy, hospitalization and disease diagnosis were high (10-60 and 15-78%, respectively), whereas rates for clinic visits and abnormal test results were consistently lower (2-10 and 7-21%, respectively). Drawing from accepted conceptual models, a TM heuristic is outlined that suggests three domains underlie whether a cueing event is significant enough to be a TM for smoking cessation: the extent to which the event (1) increases perceptions of personal risk and outcome expectancies, (2) prompts strong affective or emotional responses, and (3) redefines self-concept or social role. Research in TMs could be improved by giving greater attention to assessment of conceptually grounded cognitive and emotional variables, appropriately timed assessment and intervention, and inclusion of appropriate target and comparison samples.

Oral contraceptive use is associated with increased cardiovascular reactivity in nonsmokers

Women who smoke and take oral contraceptives (OCs) have significantly increased risk of cardiovascular disease, but the exact mechanismsfor the increased risk are not known. Cardiovascular reactivity to psychological stress may be one mechanism for the enhanced risk, but the small number of studies examining whether OC users who smoke have greater reactivity have produced mixed results. The purpose of this study was to examine the effect of chronic cigarette smoking, acute nicotine administration, and OC use on cardiovascular and lipid reactivity. Sixty healthy women, half of whom had been using OCs for at least the previous 6 months, participated in the study. Approximately two thirds were smokers and were randomized to be tested after either a 12-hr nicotine deprivation or administration of nicotine gum. One third were nonsmokers. Heart rate, blood pressure, and lipid measures were taken at rest, during a videotaped speech task, and during recovery from the task. Results indicated that, among OC nonusers, there was no effect of smoking status or nicotine administration on cardiovascular reactivity. However, among OC users, nonsmokers had significantly greater heart rate and diastolic blood pressure reactivity to stress. These data show that acute nicotine administration, in the form of nicotine gum, has no effect on cardiovascular or lipid stress reactivity in women. However OC use among nonsmoking women is associated with greater cardiovascular reactivity to stress.

Smoking-cessation counseling in the home. Attitudes, beliefs, and behaviors of home healthcare nurses

BACKGROUND

Despite advances in smoking treatment, cessation rates remain stagnant, possibly a function of the lack of new channels to reach heavily addicted smokers. This cross-sectional study examined home care nurses' attitudes, beliefs, and counseling behaviors regarding counseling their home care patients who smoke.

METHODS

Home healthcare nurses (N=98) from the Visiting Nurse Association of Rhode Island were randomly selected to participate in a study helping home-bound medically ill smokers to quit. At baseline, nurses completed a questionnaire that assessed a constellation of cognitive factors (self-efficacy, outcome expectations, perceived effectiveness, risk perception, motivation, and perceived patient adherence) as correlates of self-reported nurse counseling behaviors.

RESULTS

Nurses with higher outcome expectations spent more time counseling their patients about quitting (p<0.04). Nurses' self-efficacy was the only variable associated with consistent counseling (p<0.05). While the majority of nurses "asked and advised" their patients, a minority of nurses "assisted or arranged" follow-up. Perceived importance of counseling was associated with a greater likelihood of asking, advising and assisting (p<0.05). None of the nurses who currently smoked (n=13) provided follow-up to their patients. Nurses who reported higher levels of both risk perception (regarding the harmful effects of smoking) and perceived effectiveness were more likely to recommend the nicotine patch.

CONCLUSIONS

Attitudes and beliefs about smoking are significantly associated with nurse counseling behaviors. Helping nurses to overcome their barriers to smoking counseling may open up new channels for smoking intervention.

Using theory to understand the multiple determinants of low participation in worksite health promotion programs

Low participation at the employee or worksite level limits the potential public health impact of worksite-based interventions. Ecological models suggest that multiple levels of influence operate to determine participation patterns in worksite health promotion programs. Most investigations into the determinants of low participation study the intrapersonal, interpersonal, and institutional influences on employee participation. Community- and policy-level influences have not received attention, nor has consideration been given to worksite-level participation issues. The purpose of this article is to discuss one macrosocial theoretical perspective--political economy of health--that may guide practitioners and researchers interested in addressing the community- and policy-level determinants of participation in worksite health promotion programs. The authors argue that using theory to investigate the full spectrum of determinants offers a more complete range of intervention and research options for maximizing employee and worksite levels of participation.

Relationship among alcohol use, depression, smoking behavior, and motivation to quit smoking with hospitalized smokers

Relationships among depression, alcohol use, and motivation to quit smoking were examined in a sample of 350 hospitalized smokers. Multivariate multiple regression and logistic regression analyses indicated that participants with depressed mood were more likely to have a history of problematic drinking. Participants with depressed mood and a history of problematic drinking were more likely to be nicotine dependent and anticipated greater difficulty refraining from smoking while hospitalized. Alcohol use in heavier amounts was associated with a decreased concern with negative aspects of smoking, whereas history of depression was associated with increased concern in that area. Finally, current drinking was associated with increased confidence in quitting in 1 month whereas depressed mood was associated with decreased confidence in quitting. Overall, depression and alcohol use had stronger associations with smoking-related variables than with smoking cessation motivation variables.

The use of nicotine replacement therapy during hospitalization

Recent findings suggest that smokers who are hospitalized experience significant craving for cigarettes. Thus, nicotine replacement therapy (NRT) may be a particularly important tool for use during hospitalization. The goal of this study is to evaluate the utilization of the transdermal nicotine patch and/or nicotine gum by hospitalized smokers. The data represented in this article are from 580 smokers who participated in a study of a motivational intervention for smoking cessation that was delivered during hospitalization. The primary outcome for this analysis was use of NRT during hospitalization. The results revealed that, among the entire sample, only 7.1% of the overall sample used NRT during hospitalization; 6% of the hospitalized smokers used the transdermal nicotine patch, and 1.1% used nicotine gum. Use of NRT was significantly greater among patients who reported that they were doing anything to help themselves quit smoking at the time of admission (OR = 4.1), those who were seriously planning to quit smoking within the next 30 days (OR = 2.36), those who were nicotine dependent (OR = 2.81), and those for whom a physician had ever offered to prescribe NRT (OR = 1.9). The finding that there is a very low rate of NRT use during hospitalization provides important information to hospital-based care providers and smoking cessation intervention planners. Barriers to NRT use among hospitalized patients should be identified, and strategies designed to maximize use when appropriate. The AHCPR Guideline on Smoking Cessation recommends routine use of NRT in health care settings. Further research is needed to determine why NRT use was so low. In addition, these data suggest that efforts to increase NRT use during hospitalization are needed.

A randomized trial to reduce passive smoke exposure in low-income households with young children

OBJECTIVE

Passive smoke exposure among children is widespread in the United States; estimates suggest that almost 40% of children who are younger than 5 years live with a smoker. Few randomized studies of passive smoke exposure reduction among children have been conducted, and the impact of interventions that have been evaluated has been limited. The objective of this study was to determine whether a motivational intervention for smoking parents of young children will lead to reduced household passive smoke exposure.

METHODS

Project KISS (Keeping Infants Safe From Smoke), a theory-driven exposure reduction intervention targeting low-income families with young children, was a randomized controlled study in which participants-smoking parents/caregivers (N = 291) who had children who were younger than 3 years and who were recruited through primary care settings-were randomly assigned to either the motivational intervention (MI) or a self-help (SH) comparison condition was used. Follow-up assessments were conducted at 3 and 6 months. The MI condition consisted of a 30- to 45-minute motivational interviewing session at the participant's home with a trained health educator and 4 follow-up telephone counseling calls. Feedback from baseline household air nicotine assessments and assessment of the participant's carbon monoxide level was provided as part of the intervention. Participants in the SH group received a copy of the smoking cessation manual, the passive smoke reduction tip sheet, and the resource guide in the mail. Household nicotine levels were measured by a passive diffusion monitor.

RESULTS

The 6-month nicotine levels were significantly lower in MI households. Repeated measures analysis of variance across baseline, 3-month, and 6-month time points showed a significant time-by-treatment interaction, whereby nicotine levels for the MI group decreased significantly and nicotine levels for the SH group increased but were not significantly different from baseline.

CONCLUSIONS

This study targeted a large sample of racially and ethnically diverse low-income families, in whom both exposure and disease burden is likely to be significant. This is the first study to our knowledge that has been effective in reducing objective measures of passive smoke exposure in households with healthy children. These findings have important implications for pediatric health care providers, who play an important role in working with parents to protect children's health. Providers can help parents work toward reducing household passive smoke exposure using motivational strategies and providing a menu of approaches regardless of whether the parents are ready to quit.

Intervention and policy issues related to children's exposure to environmental tobacco smoke

BACKGROUND

Children's exposure to environmental tobacco smoke (ETS) is unacceptably high; almost 40% of children in the United States are regularly exposed to ETS.

METHODS

This paper presents a review of the literature that evaluates interventions designed to reduce ETS exposure among young children. In addition, it presents the study design for Project KISS (Keeping Infants Safe from Smoke), an intervention designed to utilize exposure-related feedback to increase parents' motivation for ETS reduction and to reduce household ETS levels. Baseline data are presented to illustrate factors that should be addressed in ETS interventions.

RESULTS

The literature review demonstrates the dearth of studies in the literature targeting ETS reduction among children. Participants in Project KISS believed that smoking had affected their children's health and were in later stages of motivational readiness to quit smoking than is typically observed. However, they face a number of challenges to smoking, such as high prevalence of nicotine dependence, high prevalence of living with other smokers, and socioeconomic and stress-related barriers.

CONCLUSIONS

The policy implications of this research are discussed, and recommendations are made for future research.

Motivational interviewing in health care settings. Opportunities and limitations

Motivational interviewing (MI) has been well studied in specialist settings. There has been considerable interest in applying MI to community health care settings. Such settings represent a significant departure from the more traditional, specialist settings in which MI has been developed and tested. The purpose of this paper is to provide a brief overview of MI and to identify and discuss the key issues that are likely to arise when adapting this approach to health care and public health settings. This paper provides an overview of important issues to consider in adapting an effective counseling strategy to new settings, and is intended to begin a dialogue about the use of MI in community health care settings.

Reported measures of environmental tobacco smoke exposure: trials and tribulations

OBJECTIVE

This report extends previous summaries of reported environmental tobacco smoke (ETS) exposure measures, reviews the empirical evidence of their validity for children's exposure, and discusses future research.

DATA SOURCES

Studies were identified by computer search and from the authors' research.

STUDY SELECTION

Studies were selected for inclusion of nicotine and/or cotinine and quantitative reported measures of ETS exposure.

DATA SYNTHESIS

Five studies found significant associations between reported quantitative exposure of children to ETS and either environmental nicotine or urine cotinine assays. Correlation coefficients between parent reports and nicotine ranged from 0.22 to 0.75. Coefficients for cotinine ranged from 0.28 to 0.71. Correlations increased over time and were stronger for parents' reports of their own smoking as a source of children's exposure than for reports of exposure from others.

CONCLUSIONS

Empirical studies show general concordance of reported and either environmental or biological measures of ETS exposure. Relationships were moderate, and suggest sufficient validity to be employed in research and service programs. Future studies need to identify the differences in types of reported or objective measures, population characteristics, etc, contributing to observed variability in order to understand better the conditions under which more valid reported ETS exposure and other measures can be obtained. Reported and either environmental or biological measures should be used in combination, and existing measures should be directed to interventions that may reduce ETS exposure among children.

Application of motivational interviewing to prenatal smoking cessation: training and implementation issues

OBJECTIVE

Three of the Smoke-Free Families projects incorporated motivational interviewing (MI) into prenatal smoking cessation interventions. This paper describes the process involved in training healthcare providers to use MI and the issues encountered in implementing the protocols.

DESIGN

Health care providers at all three sites attended local training workshops in which they learned to apply the basics of MI to their study protocol. All sites followed a similar outline and schedule for training and monitoring.

SETTINGS

The MI interventions were delivered through home visits in Boston, Massachusetts; phone based counselling calls to patients' homes in Southern California; and in urban and rural prenatal clinics throughout East Texas.

PARTICIPANTS

Public health nurse and social work case managers, who were already employed by health care agencies, delivered the MI interventions.

MEASURES

Pre- and postintervention assessments and feedback from trainers and investigators at all three sites.

RESULTS

Providers were enthusiastic about the training workshops, which they rated as effective in preparing them to deliver the intervention. Barriers to implementation included difficulty in contacting patients and competing demands on providers' time.

CONCLUSIONS

Conducting initial training for providers is the first step in developing skills to deliver motivational interventions. Additional time and resources are needed for ongoing skill building and monitoring of intervention delivery.

Stages of change versus addiction: a replication and extension

Data from the Working Well trial (n = 2379) were used to test the capacity of 19 variables to predict smoking cessation at 1- and 2-year follow-ups. Among the core constructs of transtheoretical model (TTM), stage of change was the best predictor. The processes of change and the pros and cons of smoking were relatively ineffective predictors. Among other variables, self-efficacy, cigarettes per day, duration of longest quit attempt during the previous year, and the contemplation ladder were the most effective stand-alone predictors. A composite of cigarettes per day and quit duration was particularly effective for predicting cessation. Consistent with Farkas et al. (Farkas AJ, Pierce JP, Zhu SH, Rosbrook B, Gilpin EA, Berry C, Kaplan RM, Addiction 91:1271-1280, 1996), multivariate analyses including the composite variable (cigarettes per day and quit duration) and the stages of change revealed the composite variable to be the better predictor of cessation.

The relationship between organizational characteristics and the adoption of workplace smoking policies

Organizational-level variables that are hypothesized to influence the level of smoking policy restrictions and the prevalence of smoking control activities were tested in a sample of 1 14 worksites that participated in the Working Well Trial, a national trial of worksite health promotion. Predictors related to more restrictive policies included smaller size, larger percentage of white-collar workers, larger number of complaints about environmental tobacco smoke, less complexity, more formalization, and having a CEO who valued health and employees' well-being. The number of smoking control activities offered in a worksite was predicted by having a larger blue-collar workforce, a higher percentage of female employees, higher levels of workforce stability, and a CEO who valued health and employees' well-being. Efforts to identify predictors of companies' adoption and implementation of workplace-based policies and interventions are an important part of tobacco control efforts and will enhance future intervention and research efforts.

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.

Behavioral risk factors among women presenting for genetic testing

Considerable research attention has been given to the impact of genetic testing on psychological outcomes. Participation in genetic testing also may impact on health behaviors that increase the risk of cancer and other chronic diseases. The purpose of this study is to describe behavioral cancer risk factors of women who requested genetic testing for breast and ovarian cancer susceptibility (BRCA1, BRCA2). Before participation in a genetic testing program, 119 women completed a series of questionnaires designed to assess their health behaviors, perception of risk, and depressive symptomatology. Eight percent of participants were current smokers, 27% did not engage in at least moderate exercise, 46% did not regularly protect themselves from the sun, 39% did not consume at least five servings of fruits and vegetables per day, and 9% drank at least one alcoholic beverage per day. Poisson regression analysis revealed that age was the only predictor of behavioral risk profiles, with older women having fewer cancer risk behaviors. These patients who presented for genetic testing generally had better health behaviors than the general population. However, given their possible high-risk status, these patients should consider further improving their preventable cancer risk factors and, in particular, their diet, sun protection, and physical activity levels. Inclusion of behavioral risk factor counseling in the context of the genetic testing process may be an important opportunity to reach this at-risk population.

Smoking cessation and tobacco control: an overview

Cigarette smoking is an intractable public health problem and the single largest risk factor for a variety of malignancies, including lung cancer. Worldwide, about 3 million people die each year of smoking-related disease, and this is expected to increase to > 10 million deaths per year. The Agency for Health Care Policy and Research has published a clinical practice guideline detailing available outcome data for various smoking cessation strategies. In particular, it has been recommended that all patients be screened for smoking status on every health-care visit, and that all patients who smoke be strongly advised to quit and offered assistance to do so. Health-care providers play a vital role in the effort to reduce the prevalence of smoking by delivering smoking cessation advice, supporting community-based efforts to control tobacco, and becoming involved in the tobacco control debate.

The Working Healthy Project: a worksite health-promotion trial targeting physical activity, diet, and smoking

Worksites are a key channel for delivery of interventions designed to reduce chronic disease among adult populations. Although some evaluations of worksite physical-activity interventions have been conducted, to date very few randomized trials of worksite health promotion have included the goal of increasing physical-activity levels as part of a comprehensive multiple risk factor approach to worksite health promotion. This article presents the results regarding behavior change found among the cohort of 2055 individuals who completed three health-behavior assessments as part of their worksites' participation in The Working Healthy Project (WHP), a multiple risk factor intervention implemented in 26 manufacturing worksites. In this study, a randomized matched-pair design was used. Fifty-one percent (n = 2,761) of the employees who completed the baseline assessment also completed the interim survey. Eighty-three percent of those who completed the interim assessment also completed the final survey. The WHP intervention targeted smoking, nutrition, and physical activity. At baseline, 38% of the sample reported engaging in regular exercise, and subjects reported consuming an average of 2.7 servings of fruits and vegetables per day, 7.9 grams of fiber per 1000 kilocalories, and 35.4% calories from fat per day; 28% of the sample were smokers. By the time of both the interim (intervention midpoint) and final (end of intervention) assessments, participants in the intervention condition had significantly increased their exercise behavior, compared with the control condition. There was also increased consumption of fruits and vegetables and fiber in the intervention condition by the time of the final assessment, compared with the control condition. No differences by condition were found with regard to percentage of calories from fat consumed or smoking cessation. These results suggest that among a cohort of participants in a worksite health promotion study, there were significant health behavior changes across two risk factors over time. These data suggest that further investigation of multiple risk factor worksite health promotion is warranted, particularly with a focus on ways to increase participation in these programs and to diffuse intervention effects throughout the entire workforce.

Do processes of change predict smoking stage movements? A prospective analysis of the transtheoretical model

The transtheoretical model (TTM) posits that processes of change and the pros and cons of smoking predict progressive movement through the stages of change. This study provides both a cross-sectional replication and a prospective test of this hypothesis. As part of a larger study of worksite cancer prevention (the Working Well Trial), employees of 26 manufacturing worksites completed a baseline and 2 annual follow-up surveys. Of the 63% of employees completing baseline surveys, 27.7% were smokers (N = 1,535), and a cohort of these smokers completed the 2-year follow-up. Cross-sectional results replicated previous studies with virtually all the processes of change and the cons of smoking increasing in linear fashion from precontemplation to preparation (all ps < .00001), and the pros of smoking decreasing (p < .01). However, contrary to the hypothesis, the baseline processes of change and the pros and cons of smoking failed to predict progressive stage movements at either the 1- or the 2-year follow-ups. Possible explanations for these findings and concerns about the conceptual internal consistency of the TTM are discussed.

A qualitative evaluation of the Harvard Cancer Risk Index

There is an extensive amount of information in the popular press about cancer risk factors. The volume and sometimes contradictory nature of this information makes it difficult for individuals to understand their own level of risk or how one risk factor compares with another. The Harvard Cancer Risk Index (HCRI) was developed by an interdisciplinary working group of epidemiologists and behavioral scientists to educate the public about the major risk factors associated with the 11 most common forms of cancer in the United States. Following the development and validation of the HCRI, we initiated a qualitative research study to obtain initial feedback on the wording and presentation of the index and to elicit information regarding the meaning of risks, perception of cancer, and interpretation of the HCRI results. The results indicated that the HCRI was well received by participants and that they highly regarded the inclusion of information related to the latest risks for cancer and the description of the mechanisms by which these factors impact on risk. Personalization of the risk score helped participants to focus on behaviors that they could change. However, dissatisfaction with the HCRI was noted by some participants because exposures they believed to be important were not included (e.g., poverty, toxic waste, air pollution). Evaluation of the impact of the index on intention to change provided preliminary evidence that this may be an effective toll for helping mobilize individuals toward change across a number of risk factors. Further quantitative evaluation of the HCRI is planned.

Characteristics of patients adhering to a hospital's no-smoking policy

OBJECTIVES

The purpose of this paper is to examine the characteristics of smokers who adhere to a hospital smoking ban, compared to those who do not.

DESIGN

The data presented in this paper are baseline and discharge survey data collected among hospitalized smokers.

SETTING

This study was conducted in two teaching hospitals in a northeastern city.

PATIENTS/PARTICIPANTS

The subjects were 358 smokers who participated in a larger smoking intervention trial.

MAIN RESULTS

Seventy-six percent of the subjects reported adhering to the smoke-free policy during their hospital stay. In a multivariate model, demographic factors that predicted adherence included being older, having shorter length of stay, not reporting recreational drug use in the previous 12 months, and not having alcohol-related problems. Smoking history variables that predicted adherence included having had at least 24 h of abstinence in the 7 days prior to hospitalization; self-efficacy variables (e.g., confidence in ability to quit smoking in 1 month and less anticipated difficulty refraining from smoking during hospitalization) also predicted adherence.

CONCLUSIONS

Understanding the factors that predict adherence to health care policies can provide useful information for health promotion interventions in a medical setting. The implications of these findings are discussed.

Factors influencing nutrition education for patients with low literacy skills

Although there has been increasing attention to cancer prevention among low-income and minority populations, only a few nutrition interventions have addressed the special needs of people with low literacy skills. To determine the best provider and the most effective format for a nutrition intervention targeting patients with low literacy skills, we conducted interviews with literacy experts and health care providers and focus groups with members of adult basic education classes. Thirty-five literacy experts and health-center-based physicians, nurses, and nutritionists in Boston, Mass, were interviewed. In addition, 50 volunteer clients from 4 Boston-based adult basic education programs participated in 6 focus groups. Results suggested that health care providers consider nutrition to be a fundamental health education topic, but that its successful inculcation in patients with limited literacy skills is hindered mostly by insufficient provider time. Almost all providers agreed that patients need to be referred to nutritionists for nutrition education. Although most providers and patients acknowledged that patients perceive physicians to be the authorities on health, patients with low literacy skills turned first to family members and friends for health information. These results suggest that effective nutrition interventions must build on patients' social networks; appear in a visually based, interactive format; and be culturally appropriate.

Evaluation of motivationally tailored vs. standard self-help physical activity interventions at the workplace

PURPOSE

This study compares the efficacy of a self-help intervention tailored to the individual's stage of motivational readiness for exercise adoption with a standard self-help exercise promotion intervention.

DESIGN

Interventions were delivered at baseline and 1 month; assessments were collected at baseline and 3 months.

SETTING

Eleven worksites participating in the Working Healthy Research Trial.

SUBJECTS

Participants (n = 1559) were a subsample of employees at participating worksites, individually randomized to one of two treatment conditions.

INTERVENTION

Printed self-help exercise promotion materials either (1) matched to the individual's stage of motivational readiness for exercise adoption (motivationally tailored), or (2) standard materials (standard).

MEASURES

Measures of stage of motivational readiness for exercise and items from the 7-Day Physical Activity Recall.

RESULTS

Among intervention completers (n = 903), chi-square analyses showed that, compared to the standard intervention, those receiving the motivationally tailored intervention were significantly more likely to show increases (37% vs. 27%) and less likely to show either no change (52% vs. 58%) or regression (11% vs. 15%) in stage of motivational readiness. Multivariate analyses of variance showed that changes in stage of motivational readiness were significantly associated with changes in self-reported time spent in exercise.

CONCLUSIONS

This is the first prospective, randomized, controlled trial demonstrating the efficacy of a brief motivationally tailored intervention compared to a standard self-help intervention for exercise adoption. These findings appear to support treatment approaches that tailor interventions to the individual's stage of motivational readiness for exercise adoption.

Predictors of smoking among US college students

OBJECTIVES

This study explored predictors of smoking among a large, representative national sample of students enrolled in American 4-year colleges.

METHODS

A sample of undergraduate students, randomly selected from 140 colleges, was sent a detailed questionnaire that included questions about smoking status.

RESULTS

The 30-day smoking prevalence was 22.3%; 25% of the participants were former smokers. Multivariate analyses suggested that, among college students, men are less likely to smoke than women. In addition, high-risk behaviors (e.g., marijuana use) and lifestyle choices (e.g., nonparticipation in athletics) increased the likelihood of being a smoker.

CONCLUSIONS

This study's findings have important implications for health education and promotion among college populations.

Tobacco control: a brief review of its history and prospects for the future

Smoking prevalence among American adults is at its lowest point in the last 30 years, and there is unprecedented popular support for tobacco control measures. The financial resources to carry on the battle for tobacco control are still heavily stacked in favor of the industry, which by current estimates is worth $45 billion, including $6 billion spent each year on advertising and promotion alone. Nonetheless, industry executives must realize that, even if they can win individual battles, they are losing the war. This article has discussed key events in the history of tobacco control, as well as some of the most innovative strategies currently being used for tobacco control. Although it is important that tobacco control efforts be disseminated widely and through novel channels, the challenge facing public health advocates in the next several decades will be to anticipate the industry's response to key initiatives, as well as to launch organized and strategic counterattacks against efforts to dissuade acceptance of such initiatives. The history of tobacco control demonstrates that public health advocacy resources should be strategically focused in precisely the areas in which the industry feels most vulnerable (e.g., nicotine addiction, regulation of nicotine, environmental tobacco smoke), rather than in areas in which the industry maintains a vocal presence for the purposes of public relations (e.g., youth access). Through its lobbying efforts and financial clout, the tobacco industry has played a key role in the development of public health policy. Although it is no secret that the tobacco industry regularly makes campaign contributions to both Republicans and Democrats, the impact of these donations on public policy making have only recently begun to be quantified and documented. Moore et al found that the more tobacco money a politician received, the less likely he or she was to support tobacco control legislation. Similar distortional effects of tobacco money have been demonstrated at the state level. The political expenditure of 12 tobacco firms increased 10-fold in California after the implementation of Proposition 99 in California--from $790,050 in the 1985-1986 election, to $7,615,091 in the 1991-1992 election. In an analysis of the behavior of the California legislature between 1991 and 1992, a statistically significant relationship was found between members' receipt of tobacco money and their likelihood of opposing tobacco control measures. Tobacco control advocates as well as health professionals in general have an important role to play in holding their legislators accountable for developing public health policy that reflects the concerns of their constituencies, not of the tobacco lobby. Public health advocates should pay particular attention to the recent regulations placed on cigarettes as a key tobacco control strategy for the next several decades. For the first time in the history of the United States, a President has introduced legislation that will allow a governmental agency to regulate tobacco. The FDA has faced relentless attacks by the tobacco industry, and it will continue to be a target. Public health advocates and health care providers have a critical role to play in the FDA's efforts to bring this issue to fruition. If the public health community fails to support this initiative and create an active and forceful opposition to the industry's efforts to derail it, it is likely that the impact on tobacco control efforts will be resounding and far-reaching.

Cognitive-behavioral mediators of changing multiple behaviors: smoking and a sedentary lifestyle

BACKGROUND

A significant percentage of the U.S. population has multiple poor health behaviors. Understanding the relationship among these behavioral risk factors is important for designing effective multiple risk factor interventions. While there is some evidence suggesting that participation in physical exercise may have a positive impact on smoking cessation, there is much to be learned about the relationships between cognitive-behavioral (self-efficacy, decisional-balance) and motivational mechanisms (stage of change) which have been shown to mediate changes in both exercise and smoking behavior.

METHODS

The sample comprised 332 smokers employed at two workplaces-a government agency and a medical center-recruited as part of a larger worksite health promotion project and who completed questionnaires on their smoking and exercise behaviors.

RESULTS

The results revealed significant relationships between smoking variables and exercise variables. Smokers who rated as important the positive benefits of smoking also rated as important the costs associated with increased physical activity. Similarly, the negative consequences of smoking were significantly associated with the positive benefits of physical activity. Self-efficacy for one behavior was significantly associated with self-efficacy for the other. Significant differences by exercise and smoking stage of change were found on the cross-behavior sets of variables (self-efficacy, pros, cons). Smokers who were contemplating a more active lifestyle reported the negative consequences of smoking to be significantly more important to them than smokers who were not considering adoption of a more active lifestyle. Smokers who were exercising regularly reported significantly more confidence in their ability to refrain from smoking than smokers not exercising regularly. Finally, smokers preparing for quitting reported less confidence in their ability to exercise than smokers who had already taken action to change their smoking behavior.

CONCLUSIONS

The cognitive mechanisms associated with changes in smoking behavior are related to the cognitive variables which have been shown to predict changes in exercise behavior. Significant relationships in mediating mechanisms including decisional balance and self-efficacy between smoking and exercise provide preliminary information on how change in one risk behavior may relate to change in another. These associations have implications for future intervention research and for methods research on multiple risk factors interactions.

Respiratory response to cigarette smoking among adolescent smokers: a pilot study

BACKGROUND

Because cigarette smoking affects the respiratory system earlier than many other systems of the human body, an attempt was made to identify objective and subjective respiratory problems among adolescent smokers.

METHODS

Two studies based on a pulmonary function test (PFT), respiratory symptom assessment, and other smoking-related variables were undertaken. Study 1 involved cigarette smokers (N = 18, 22% males, mean age 18.7 years) from a freshman college class who participated in an acute smoking experiment that involved performing a PFT before and after smoking a single cigarette. Study 2 was performed on a combined group of vocational-technical high school students and freshman college students (N = 44, 48% males, mean age 17.8 years) where PFT parameters, respiratory symptoms, and smoking-related health vulnerability were assessed among smokers vs nonsmokers.

RESULTS

In Study 1, the average reduction across PFT parameters was 4.4% and the mean estimated lung age increased from 27.15 to 29.84 years. In Study 2, a consistent trend toward reduction of PFT values among smokers vs nonsmokers was observed; the mean forced expiratory volume in 1 sec/forced vital capacity ratio (90.51% vs 94.59%), peak expiratory flow rate (80.32% vs 92.06%), and flow rate of 50% of forced vital capacity (88.39% vs 102.81%) differed significantly. Significant differences in respiratory symptoms were also observed among smokers vs nonsmokers.

CONCLUSIONS

The beginning of respiratory health disorders can be identified among adolescent smokers. These findings might provide important clues on how to improve outcomes from health care provider-based adolescent smoking cessation counseling.

Use of a 24-hour recall diary to assess exposure to environmental tobacco smoke

Methods to assess exposure to environmental tobacco smoke need to be valid and relatively easy to use. We therefore explored the use of a 24-h environmental tobacco smoke exposure-recall diary by comparing data from the 24-h diary with questionnaire responses and levels of salivary cotinine--a biochemical marker of environmental tobacco smoke exposure. A total of 875 nonsmokers at five Rhode Island worksites participated in the study. Twenty-five percent of the participants lived with smokers, and 96% had regular exposure to environmental tobacco smoke at work. Individuals who lived with smokers reported more exposures in the 24-h diary, both outside of work and during work hours, compared with those who had no smokers in their household. The correlation between saliva cotinine concentrations and the exposures recorded in the diary was weak (r = .10). Brief instruments for assessment of environmental tobacco smoke should be viewed cautiously, and use of this 24-h recall diary is not recommended.

Distribution of smokers by stage in three representative samples

OBJECTIVES

A key variable for the design of individual and public health interventions for smoking cessation is Stage of Change, a variable which employs past behavior and behavioral intention to characterize an individual's readiness to change. Reactively recruited samples distort estimates of the stage distribution in the population because such samples attract a disproportionate number of late-stage participants. Three representative samples are described which provide accurate estimates of the stage distribution in the population. These samples are of adequate size to permit within-sample comparisons with respect to sex, age, Hispanic or non-Hispanic origin, race, and education level. The implications of using stage distribution as a tool for planning intervention is discussed.

METHOD

The first sample of 4,144 smokers was from the state of Rhode Island and involved a random-digit-dial survey. The second sample of 9,534 smokers was from the state of California and involved a stratified random-digit-dial survey. The third sample of 4,785 smokers was from a total of 114 worksites located in four different geographic locations.

RESULTS

The stage distributions were approximately identical across the three samples, with approximately 40% of the sample in Precontemplation, 40% in Contemplation, and 20% in Preparation. The stage distribution was generally stable across age groups with the exception of the 65 years and older group. Education level did affect the stage distribution with the proportion of the sample in Precontemplation decreasing as education level increased. In all three samples, minor differences in stage distribution were related to Hispanic origin and race, but the pattern was not consistent across the samples.

CONCLUSIONS

The pattern of stage distribution has important implications for the design of interventions. Existing interventions are most appropriate for the Preparation stage, but the majority of the three samples were in the first two stages, resulting in a likely mismatch between the smoker and the intervention. The stability of distribution across age suggests that interventions that are appropriately matched to stage can be applied across all age groups. The differences found with respect to education, Hispanic origin, and race can serve as a guide to the tailoring of intervention materials.

Dietary intake and exposure to environmental tobacco smoke in a worksite population

OBJECTIVES

Nonsmokers who live with smokers have poorer dietary habits than those who live in nonsmoking households. This relationship may be due to shared lifestyle patterns by spouses and family members. However, in order to fully understand the nature of this relationship, it is also important to examine the association between diet and exposure to environmental tobacco smoke (ETS) at the workplace. Further, blue collar workers' patterns of exposure to ETS both at work and at home have not been studied. The goal of this study is to examine the dietary intake of manufacturing workers as it relates to exposure to ETS at work and at home.

METHODS

The Working Well Trial surveyed 10,833 nonsmokers about a variety of health behaviors, including smoking, dietary behaviors, and ETS exposure.

RESULTS

Nonsmokers who had ETS exposure in their household had significantly lower intake of all target micronutrients, compared to those without household exposure. Exposure to ETS at the workplace was associated with lower intakes of vitamin C and fruits and vegetables, but not the other micronutrients examined.

CONCLUSIONS

Exposure to ETS was associated with poorer dietary habits. Household exposure was a stronger predictor of intake than was workplace exposure. Because of the antagonistic effects of many components of a healthful diet in relation to the harmful effects of tobacco smoke, these findings have relevance larger than either ETS exposure or diet considered singly.

Smoking at home: the impact of smoking cessation on nonsmokers' exposure to environmental tobacco smoke

Nonsmokers who live with smokers are at increased risk for chronic disease. This study evaluated the impact of eliminating smoking in the home on nonsmokers' environmental tobacco smoke (ETS) exposure. Nonsmokers participated in measurements of their ETS exposure before and after the smoker in their home quit smoking. A matched comparison group of nonsmokers from nonsmoking homes was also included. ETS exposure was assessed using passive nicotine monitors, an exposure diary, and a questionnaire. Nonsmokers from smoking homes had significantly higher exposure to ETS than those from nonsmoking homes. There was a 60% reduction in nicotine levels following smoking cessation by the household smoker. However, there were still detectable levels of nicotine measured at posttest. These results have important implications for individual risk reduction and public health policy.

Smoking at home: the impact of smoking cessation on nonsmokers' exposure to environmental tobacco smoke

Nonsmokers who live with smokers are at increased risk for chronic disease. This study evaluated the impact of eliminating smoking in the home on nonsmokers' environmental tobacco smoke (ETS) exposure. Nonsmokers participated in measurements of their ETS exposure before and after the smoker in their home quit smoking. A matched comparison group of nonsmokers from nonsmoking homes was also included. ETS exposure was assessed using passive nicotine monitors, an exposure diary, and a questionnaire. Nonsmokers from smoking homes had significantly higher exposure to ETS than those from nonsmoking homes. There was a 60% reduction in nicotine levels following smoking cessation by the household smoker. However, there were still detectable levels of nicotine measured at posttest. These results have important implications for individual risk reduction and public health policy.

Smoking interventions for patients with cancer: guidelines for nursing practice

PURPOSE/OBJECTIVES

To identify strategies for oncology nurses to assist patients with cancer in modifying their smoking behaviors.

DATA SOURCES

Published research articles, conference proceedings, Surgeon General Reports, and book chapters.

DATA SYNTHESIS

Cigarette smoking is associated with a variety of cancers, and persistent smoking following a cancer diagnosis contributes to increased morbidity and mortality. Smoking cessation affords numerous health benefits to patients with cancer, including improved respiratory functioning, increased activity tolerance, and a personal sense of accomplishment. To date, few smoking interventions have targeted patients with cancer.

CONCLUSIONS

Oncology nurses can become more actively involved in effective smoking interventions by incorporating current research findings and theoretical models of behavior change into daily practice.

NURSING IMPLICATIONS

Oncology nurses can more effectively help their patients who smoke by assessing smoking status and patients' readiness to quit; providing brief, supportive messages consistently over time; offering or referring patients to appropriate resources; and providing continued follow-up.

Mechanisms in multiple risk factor interventions: smoking, physical activity, and dietary fat intake among manufacturing workers. Working Well Research Group

BACKGROUND

Individuals who have multiple poor health behaviors account for a disproportionately large percentage of the preventable U.S. health care cost burden. Understanding the relationships between multiple risk factors is important for the design of both individual and public health interventions. There have been few efforts to examine the co-occurrence of psychosocial and motivational mechanisms that mediate smoking, dietary fat intake, and physical activity in a defined population of blue collar workers.

METHODS

The sample comprised 1,559 manufacturing workers who participated in a self-help physical activity intervention and who completed a computerized assessment battery about their smoking, dietary fat intake, physical activity, and demographic characteristics.

RESULTS

Twenty-six percent of the sample were smokers, 51% did not exercise regularly, and 35% consumed more than an estimated 40% of calories per day from fat. Almost half of the sample was in the later stages of readiness for physical activity and dietary fat intake, compared with only 3% for smoking. Only 12% of the smokers had smoking as their only risk factor. Smokers were significantly more likely to engage in poor dietary and physical activity behaviors, compared with nonsmokers. The relationship among smoking status and the other risk factors was apparent both in terms of dietary fat and physical activity behaviors, as well as mediators such as motivation for change. Lower dietary fat intake was associated with an absence of the other two risk factors.

CONCLUSIONS

The results suggest that there are important mediating mechanisms both within and among workers with one or more risk factors. Smokers are a particularly important target for health promotion interventions, and it may be possible to make initial contact with them through other health programs at the worksite. The role of other lifestyle changes as a gateway to smoking cessation has not yet been explored, but may have potential for reaching smokers who are very low in their motivational readiness to change. The implications of these findings for research and the design of multiple risk factor interventions are discussed.

Recruitment of work sites to a health promotion research trial. Implications for generalizability

The characteristics of companies that either accepted or declined participation in a 5-year randomized trial of a multirisk factor health promotion intervention were compared to investigate potential limitations on the generalizability of research findings. A representative sample of 151 manufacturing work sites in the northeast was recruited to participate. Sixty-four of the companies were determined to be eligible and 10 others, which refused to have an administrator interviewed, were presumed to be eligible. Of this group, 27 companies agreed to participate. Work force demographics, shift structure, and prior history of health promotion offerings were not significantly different in the two groups. However, participating companies employed fewer workers and had a more favorable financial outlook than did companies that declined to participate. Implications of these findings for research on work site health promotion are discussed.