John G. Spangler

Risk of serious adverse cardiovascular events associated with varenicline: a systematic review and meta-analysis

Background: There have been postmarketing reports of adverse cardiovascular events associated with the use of varenicline, a widely used smoking cessation drug. We conducted a systematic review and meta-analysis of randomized controlled trials to ascertain the serious adverse cardiovascular effects of varenicline compared with placebo among tobacco users. Methods: We searched MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, websites of regulatory authorities and registries of clinical trials, with no date or language restrictions, through September 2010 (updated March 2011) for published and unpublished studies. We selected double-blind randomized controlled trials of at least one week’s duration involving smokers or people who used smokeless tobacco that reported on cardiovascular events (ischemia, arrhythmia, congestive heart failure, sudden death or cardiovascular-related death) as serious adverse events asociated with the use of varenicline. Results: We analyzed data from 14 double-blind randomized controlled trials involving 8216 participants. The trials ranged in duration from 7 to 52 weeks. Varenicline was associated with a significantly increased risk of serious adverse cardiovascular events compared with placebo (1.06% [52/4908] in varenicline group v. 0.82% [27/3308] in placebo group; Peto odds ratio [OR] 1.72, 95% confidence interval [CI] 1.09–2.71; I2 = 0%). The results of various sensitivity analyses were consistent with those of the main analysis, and a funnel plot showed no publication bias. There were too few deaths to allow meaningful comparisons of mortality. Interpretation: Our meta-analysis raises safety concerns about the potential for an increased risk of serious adverse cardiovascular events associated with the use of varenicline among tobacco users.

Are Medical Students Aware of Their Anti-Obesity Bias?

Purpose Anti-obesity prejudices affect the quality of care obese individuals receive. The authors sought to determine the prevalence of weight-related biases among medical students and whether they were aware of their biases. Method Between 2008 and 2011, the authors asked all third-year medical students at Wake Forest School of Medicine to complete the Weight Implicit Association Test (IAT), a validated measure of implicit preferences for “fat” or “thin” individuals. Students also answered a semantic differential item assessing their explicit weight-related preferences. The authors determined students’ awareness of their biases by examining the correlation between students’ explicit preferences and their IAT scores. Results Of 354 medical students, 310 (88%) completed valid surveys and consented to participate. Overall, 33% (101/310) self-reported a significant (“moderate” or “strong”) explicit anti-fat bias. No students self-reported a significant explicit anti-thin bias. According to the IAT scores, over half of students had a significant implicit weight bias: 39% (121/310) had an anti-fat bias and 17% (52/310) an anti-thin bias. Two-thirds of students (67%, 81/121) were unaware of their implicit anti-fat bias. Only male gender predicted an explicit anti-fat bias (odds ratio 3.0, 95% confidence interval 1.8–5.3). No demographic factors were associated with an implicit anti-fat bias. Students’ explicit and implicit biases were not correlated (Pearson r = 0.03, P = .58). Conclusions Over one-third of medical students had a significant implicit anti-fat bias; few were aware of that bias. Accordingly, medical schools’ obesity curricula should address weight-related biases and their potential impact on care.

Obesity Educational Interventions in U.S. Medical Schools: A Systematic Review and Identified Gaps

Background: Obesity is the second leading cause of preventable death in the United States. However, physicians feel poorly trained to address the obesity epidemic. This article examines effective training methods for overweight and obesity intervention in undergraduate medical education. Using indexing terms related to overweight, obesity, and medical student education, we conducted a literature searched PubMed PsycINFO, Cochrane, and ERIC for relevant articles in English. References from articles identified were also reviewed to located additional articles. Summary: We included all studies that incorporated process or outcome evaluations of obesity educational interventions for U.S. medical students. Of an initial 168 citations, 40 abstracts were retrieved; 11 studies were found to be pertinent to medical student obesity education, but only 5 included intervention and evaluation elements. Quality criteria for inclusion consisted of explicit evaluation of the educational methods used. Data extraction identified participants (e.g., year of medical students), interventions, evaluations, and results. These 5 studies successfully used a variety of teaching methods including hands on training, didactic lectures, role–playing, and standardized patient interaction to increase medical students’ knowledge, attitudes, and skills regarding overweight and obesity intervention. Two studies addressed medical student bias toward overweight and obese patients. No studies addressed health disparities in the epidemiology and bias of obesity. Conclusions: Despite the commonly cited “obesity epidemic,” there are very few published studies that report the effectiveness of medical school obesity educational programs. Gaps still exist within undergraduate medical education including specific training that addresses obesity and long-term studies showing that such training is retained.

E-cigarette Availability and Promotion Among Retail Outlets Near College Campuses in Two Southeastern States

INTRODUCTION E-cigarettes are relatively new products that simulate the smoking experience. This descriptive study assessed changes in e-cigarette availability and promotions among retailers in 11 college communities in North Carolina and Virginia during a 1-year period. METHODS During the spring of 2012 and 2013, observers completed assessments in 320 tobacco-selling retailers, including grocery and convenience stores, pharmacies, and tobacco shops. Assessors collected e-cigarette availability, advertising, price, and promotions. RESULTS E-cigarette availability increased among retailers from 24.7% in 2012 to 59.9% in 2013. They were available in the form of disposables and reusable kits and were most frequently available in tobacco shops, convenience stores, and pharmacies. The average price for disposables was

Measuring medical student attitudes and beliefs regarding patients who are obese.

9.70 (SD = 1.07) in 2012 and

Prevalence and predictors of tobacco use among Lumbee Indian women in Robeson County, North Carolina.

9.61 (SD = 2.10) in 2013; the average price for kits was

Marijuana use trajectories and academic outcomes among college students.

39.58 (SD = 15.79) in 2012 and

Smoking status and psychosocial variables in type 1 diabetes mellitus

32.59 (SD = 18.65) in 2013. The presence of interior advertising increased from 12.7% to 50.6% (p < .0001), and the presence of exterior advertising increased from 7.6% to 22.8% (p = .0002). Convenience stores with gas (16.4%-70.4%; p < .0001) and without gas (6.0%-48.4%; p < .0001) had significant increases in the presence of interior advertising. Convenience stores with gas also had a significant increase in the presence of exterior advertising (8.2%-33.3%; p < .0001). Only 3% of retailers offered price promotions. CONCLUSIONS Availability of e-cigarettes, including rechargeable kits and disposables, more than doubled during the study. The presence of interior and exterior advertising also significantly increased. Results underscore the need for further surveillance to understand how these environmental characteristics impact individual exposure and use of e-cigarettes.

Environmental Manganese and Cancer Mortality Rates by County in North Carolina: An Ecological Study

Purpose Research shows obesity bias to undermine the patient–doctor relationship and lead to substandard care. The authors developed and tested an instrument to measure medical students’ attitudes and beliefs about obese patients. Method The authors conducted a literature search to identify validated measures of obesity bias. Because they identified no appropriate scale, they decided to design a novel survey instrument: the Nutrition, Exercise and Weight Management (NEW) Attitudes Scale. An expert panel generated items which focus groups of third-year medical students then discussed. Next, experienced medical educators judged and weighted the remaining revised items. Then, second- and fourth-year medical students completed the scale alongside two previously validated measures of obesity bias, the Anti-Fat Attitudes Questionnaire (AFA) and Beliefs About Obese Persons Scale (BAOP). Third-year students completed the NEW Attitudes Scale before and after a simulated encounter with an obese standardized patient instructor. The authors tested the validity and reliability. Results The final instrument comprised 31 items. A sample of 201 judges rated the items. A sample of 111 second- and fourth-year medical students completed the survey (mean score 24.4, range −37 to 76 out of a possible −118 to 118; higher scores indicate more positive attitudes). Pearson correlations between the NEW Attitudes Scale and AFA and BAOP were, respectively, −0.47 and 0.23. Test–retest reliability was 0.89. Students scored 27% higher after completing the standardized patient–instructor encounter (P < .001). Conclusion The NEW Attitudes Scale has good validity and reliability and may be used in future studies.

Hypertension, hyperlipidemia, and abdominal obesity and the development of microalbuminuria in patients with non-insulin-dependent diabetes mellitus.

Tobacco use among some Native American tribes is high compared to the overall US population. Little is known, however, about tobacco use among Native Americans in North Carolina, a state with strong economic ties to tobacco. To assess the epidemiology of tobacco use in this population, data from the North Carolina Native American Cervical Cancer Project was reviewed. Nine hundred eighty-two Lumbee Indian women in Robeson County provided general demographic information as well as information on cancer risk knowledge, attitudes and behaviors during the 5-year study. Women were selected from the community using a random sample of 5200 persons from the tribal roll of approximately 40,000 persons. 20.6% of women were current smokeless tobacco users, while 23.7% were current smokers. Demographic and social support predictors were unique for the different types of tobacco use. Cigarette smoking was associated with younger age, higher education, excellent or good self-reported health, having a recent physical exam, separated or divorced marital status, low church participation, and alcohol consumption. Conversely, use of smokeless tobacco was associated with older age, lower education level, fair or poor self-reported health, widowed marital status, and having a high number of friends. These data show a high prevalence of smokeless tobacco use among women in this population, and a contrast in the predictors of tobacco use by source. Intervention programs for tobacco use cessation should be sensitive to these differences.