C. Tracy Orleans

Effect of restrictions on smoking at home, at school, and in public places on teenage smoking: cross sectional study

Abstract Objective: To determine the relation between extent of restrictions on smoking at home, at school, and in public places and smoking uptake and smoking prevalence among school students. Design: Cross sectional survey with merged records of extent of restrictions on smoking in public places. Setting: United States. Participants: 17 287 high school students. Main outcome measures: Five point scale of smoking uptake; 30 day smoking prevalence. Results: More restrictive arrangements on smoking at home were associated with a greater likelihood of being in an earlier stage of smoking uptake (P<0.05) and a lower 30 day prevalence (odds ratio 0.79 (95% confidence interval 0.67 to 0.91), P<0.001). These findings applied even when parents were smokers. More pervasive restrictions on smoking in public places were associated with a higher probability of being in a earlier stage of smoking uptake (P<0.05) and lower 30 day prevalence (0.91 (0.83 to 0.99), P=0.03). School smoking bans were related to a greater likelihood of being in an earlier stage of smoking uptake (0.89 (0.85 to 0.99), P<0.05) and lower prevalence (0.86 (0.77 to 0.94), P<0.001) only when the ban was strongly enforced, as measured by instances when teenagers perceived that most or all students obeyed the rule. Conclusions: These findings suggest that restrictions on smoking at home, more extensive bans on smoking in public places, and enforced bans on smoking at school may reduce teenage smoking.

Does the Chronic Care Model Serve Also as a Template for Improving Prevention

Practical models of ways to enhance service delivery are sorely needed to help close the gap between research and practice. An evidenced-based model of chronic-illness management is shown to apply equally to preventive interventions. Successful examples of prevention programs in cancer screening and counseling for health behavior change illustrate the utility of the model for prevention and across different types of health care organizations. Although there are some important differences between interventions required for chronic disease management and prevention, there are a greater number of common factors. They share the need to alter reactive acute-care-oriented practice to accommodate the proactive, planned, patient-oriented longitudinal care required for both prevention and chronic care.

Predicting smoking cessation with self-reported measures of nicotine dependence: FTQ, FTND, and HSI

In two independent studies, we explored the usefulness of three self-report measures of tobacco dependence--the Fagerström Tolerance Questionnaire (FTQ), the Fagerström Test for Nicotine Dependence (FTND), and the Heavy Smoking Index (HSI). The FTND is a revised version of the FTQ. The HSI is identical to a two-question subset of the FTND. Study 1 involved 932 participants in a seven-session, five-week, group smoking cessation program, and it looked at the ability of these self-report tests to predict expired air carbon monoxide (i.e., heaviness of smoking) at beginning of treatment and cessation at end of treatment. Study 2 involved 1877 participants in a self-help smoking cessation program, and it looked at the prediction of cessation at 16-month follow-up. All tests made statistically reliable predictions of smoking cessation, but generally accounted for little variance (about 1%). In Study 1, the test scores were associated positively with carbon monoxide levels. The shorter (six vs. eight questions), more reliable FTND is to be preferred to the FTQ; and the HSI (two questions) works as well as the FTND. Evidence is presented that suggests that samples of high-scoring smokers will not be well differentiated from the mid-range to the high-end of the scores.

Evidence-based behavioral medicine: What is it and how do we achieve it?

The goal of evidence-based medicine is ultimately to improve patient outcomes and quality of care. Systematic reviews of the available published evidence are required to identify interventions that lead to improvements in behavior, health, and well-being. Authoritative literature reviews depend on the quality of published research and research reports. The Consolidated Standards for Reporting Trials (CONSORT) Statement (www.consort-statement.org) was developed to improve the design and reporting of interventions involving randomized clinical trials (RCTs) in medical journals. We describe the 22 CONSORT guidelines and explain their application to behavioral medicine research and to evidence-based practice. Additional behavioral medicine-specific guidelines (e.g., treatment adherence) are also presented. Use of these guidelines by clinicians, educators, policymakers, and researchers who design, report, and evaluate or review RCTs will strengthen the research itself and accelerate efforts to apply behavioral medicine research to improve the processes and outcomes of behavioral medicine practice.

Integrating individual and public health perspectives for treatment of tobacco dependence under managed health care: a combined stepped-care and matching model.

There is an increasing momentum to integrate prevention into mainstream health care. Three decades of research on tobacco dependence can provide insights into the conceptual, clinical, economic, and service delivery challenges to such an integration. Biological sciences, cognitive-behavioral, clinical treatment outcome, and public health arenas are selectively reviewed. The key conceptual issues are explored relevant to the optimal delivery of quality smoking cessation treatments for the general population of adult smokers at reasonable cost. A comprehensive model for adult smoking cessation treatment is developed. The model consists of an overarching public health approach, focusing on enhancing motivational level from low motivation to quit to high motivation. A common outcome metric of overall impact is proposed to facilitate comparisons between clinical and public health interventions. Smokers are then assessed and triaged into one of three treatment steps of minimal, moderate, and maximal intensity and cost. Smoker individual differences at both the population and individual level are also taken into account as part of a tailoring or matching strategy within and across the stepped interventions. Smoker profiles include sociocultural, nicotine dependence, and comorbidity factors. The result is a hybrid stepped-care matching model. The model serves to illustrate some of the needs and challenges facing future tobacco dependence research and practice. Comparisons are made between tobacco control and other preventive medicine practices in terms of cost per quality adjusted life-year saved. The barriers and opportunities under managed care are explored. The conceptual principles identified here could be used as a guidepost for integrating other preventive medicine programs into the evolving managed health care system.

Self-Help Quit Smoking Interventions: Effects of Self-Help Materials, Social Support Instructions, and Telephone Counseling.

Smokers requesting self-help materials for smoking cessation (N = 2,021) were randomized to receive (a) an experimental self-quitting guide emphasizing nicotine fading and other nonaversive behavioral strategies, (b) the same self-quitting guide with a support guide for the quitters family and friends, (c) self-quitting and support guides along with four brief counselor calls, or (d) a control guide providing motivational and quit tips and referral to locally available guides and programs. Subjects were predominantly moderate to heavy smokers with a history of multiple previous quit attempts and treatments. Control subjects achieved quit rates similar to those of smokers using the experimental quitting guide, with fewer behavioral prequitting strategies and more outside treatments. Social support guides had no effect on perceived support for quitting or on 8- and 16-month quit rates. Telephone counseling increased adherence to the quitting protocol and quit rates.

Diabetes Self-Management: Self-reported recommendations and patterns in a large population

OBJECTIVE Diabetes self-management is the cornerstone of overall diabetes management. Yet many questions concerning self-management remain unanswered. The current study was designed to examine several questions about diabetes self-management: 1) What do individuals report being told to do? 2) What are their self-reported levels and patterns of self-care? 3) Are there differences on self-reported self-management recommendations and levels across various subgroups? RESEARCH DESIGN AND METHODS Mailed surveys were returned by 2,056 individuals (73.4% response rate). Of the total, 13.8% had IDDM and the remainder had NIDDM, with 65% of the NIDDM group using insulin. RESULTS The levels and patterns of self-management were consistent with those found in previous studies, i.e., individuals most regularly followed their prescribed medication regimen and least regularly followed recommendations for lifestyle changes of diet and exercise. There were significant differences on reported self-management recommendations across different subgroups. Comparisons on level of self-management across diabetes type revealed significant differences for diet and glucose testing. Differences were also found on self-management levels for a number of individual characteristics, including age, working status, and type of insurance, along with knowledge of the Diabetes Control and Complications Trial findings. CONCLUSIONS These findings provide important information on perceived self-management recommendations and the specific self-management levels and patterns in individuals with diabetes. The current findings may help health professionals better understand the levels and correlates of diabetes self-management and direct future research.

Incorporating biomarkers of exposure and genetic susceptibility into smoking cessation treatment: effects on smoking-related cognitions, emotions, and behavior change.

In this article the authors report on the short-term impact of incorporating biomarker feedback about exposure and genetic susceptibility into minimal-contact quit-smoking counseling (QSC). Four hundred and twenty-seven smokers were randomized to 1 of 3 treatments: (a) QSC, (b) QSC + exposure biomarker feedback (EBF) about carbon monoxide in exhaled breath, or (b) QSC + EBF + biomarker feedback about genetic susceptibility to lung cancer (SBF). We observed significant immediate positive effects of SBF, compared with EBF and QSC on perceived risk, perceived quitting benefits, and fear arousal. However, at the 2-month follow-up, there were no group differences in quit rates. SBF did lead to significant reductions in the number of cigarettes smoked for smokers who were in the preparation stage. Smokers in the EBF and QSC conditions showed reductions in depressive symptoms by 2 months, but smokers in the SBF condition did not. In the context of QSC, genetic feedback may heighten vulnerability and possibly promote distress, but may not immediately enhance quitting in most smokers.

Helping pregnant smokers quit: meeting the challenge in the next decade

Throughout the past decade, smoking has remained the single most important modifiable cause of poor pregnancy outcome in the USA. It accounts for 20% of low birth weight deliveries, 8% of preterm births, and 5% of all perinatal deaths.1 New studies have found that maternal smoking during pregnancy contributes to sudden infant death syndrome and may cause important changes in fetal brain and nervous system development.2-7 New economic estimates indicate that the direct medical costs of a complicated birth for a smoker are 66% higher than for non-smokers—reflecting the greater severity of complications and the more intensive care required.8 While quitting smoking early in pregnancy is most beneficial, important health benefits accrue from quitting at any time during the pregnancy.1 Moreover, the health hazards and health care burden to women and their family members caused by smoking do not begin or end with pregnancy. Before pregnancy, smoking increases the risk of serious medical complications for women using oral contraceptives and can impair fertility.1 After pregnancy, in addition to adversely affecting womens health, smoking exposes infants and young children to environmental tobacco smoke. This exposure is linked to SIDS, respiratory illnesses, middle ear infections, and decreased lung function.3 4 9 Currently, 27% of US children aged 6 years and under are exposed to tobacco smoke at home,10with the annual direct medical costs of parental smoking estimated at

Accelerating Evidence Reviews and Broadening Evidence Standards to Identify Effective, Promising, and Emerging Policy and Environmental Strategies for Prevention of Childhood Obesity

4.6 billion and loss of life costs estimated at