Primary care physician management, referral, and relations with specialists concerning patients at risk for cancer due to family history

BACKGROUND

Risk stratification based on family history is a feature of screening guidelines for a number of cancers and referral guidelines for genetic counseling/testing for cancer risk.

AIMS

Our aim was to describe primary care physician perceptions of their role in managing cancer risk based on family history.

METHODS

Structured interviews were conducted by a medical anthropologist with primary care physicians in 3 settings in 2 north-eastern states. Transcripts were systematically analyzed by a research team to identify major themes expressed by participants.

RESULTS

Forty interviews were conducted from May 2003 through May 2006. Physicians provided a diversity of views on roles in management of cancer risk based on family history, management practices and patient responses to risk information. They also provided a wide range of perspectives on criteria used for referral to specialists, types of specialists referred to and expected management roles for referred patients.

CONCLUSION

Some primary care physicians appeared to make effective use of family history information for cancer risk management, but many in this sample did not. Increased focus on efficient assessment tools based on recognized guidelines, accessible guides to management options, and patient education and decision aids may be useful directions to facilitate broader use of family history information for cancer risk management.

Potentially modifiable influences on cancer family history-taking among primary care physicians in Vermont and Massachusetts

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Background. Taking a complete family history is key in identifying individuals at increased risk for cancer. The objectives of this study were to test hypothesized relationships between potentially modifiable factors and family history-taking by primary care physicians. Methods. Primary care physicians (family medicine, internal medicine, gynecology) were surveyed by mail in Vermont, urban and suburban Boston (n=880) using comprehensive rosters from employers or state-wide networks, with a response rate of 70%. Measures of family history-taking quality and factors that may influence this behavior were developed systematically and validated using factor analysis methods. The primary outcome variable was either extent of history-taking or age of cancer diagnoses. These dependent variables were regressed on scales measuring physician perceptions of the advantages and disadvantages of history-taking, confidence in taking cancer family histories, supportive resources, and knowledge of management for patients at high risk for breast and colon cancer; relevant factors controlled in these multiple regressions included type and location of practice. Results. Most physician perception factors hypothesized to influence quality of history taking were found to be significantly associated in the analysis. The strongest predictor of extent of family history-taking was perceived disadvantages of taking a cancer family history (p<.001). Reports of supportive resources ((p<.01); perceived advantages (p=.02); and confidence (p=.02) were also associated with this behavior. Gathering age of cancer diagnoses was significantly associated with perceived advantages, supportive resources and confidence (all p<.0001). Knowledge of high risk management was not associated with quality of family history-taking in either analysis. Conclusions. Potentially modifiable resource and perception factors were significantly associated with quality of family history in a large and diverse sample of primary care physicians. Improving family history quality for identification of high risk individuals among primary care providers will need to address multiple factors.

No significant financial relationships to disclose.

Cost effectiveness of a community based research project to help women quit smoking

OBJECTIVE

To estimate the cost effectiveness of a four year, multifaceted, community based research project shown previously to help women quit smoking.

DESIGN

A quasi-experimental matched control design.

SETTING

Two counties in Vermont and two in New Hampshire, USA.

SUBJECTS

Women aged 18-64 years.

METHODS

Costs were the grant related expenditures converted to 2002 US dollars. Survey results at the end of the intervention were used to estimate the numbers of never smokers, former smokers, light smokers, and heavy smokers in the intervention and comparison counties, and 1986 life tables for populations of US women categorised by smoking status to estimate the gain in life expectancy.

MAIN OUTCOME MEASURES

Cost effectiveness ratios, as dollars per life-year saved, for the intervention only and for total grant costs (intervention, evaluation and indirect costs).

RESULTS

The cost effectiveness ratio for the intervention, in 2002 US dollars per life-year saved, discounted at 3%, was 1156 dollars (90% confidence interval (CI) 567 dollars to infinity), and for the total grant, 4022 dollars (90% CI 1973 dollars to infinity). When discounted at 5%, these ratios were 1922 dollars (90% CI 1024 dollars to 15,647 dollars), and 6683 dollars (90% CI 3555 dollars to 54,422 dollars), respectively.

CONCLUSION

The cost effectiveness ratios of this research project are economically attractive, and are comparable with other smoking cessation interventions for women. These observations should encourage further research and dissemination of community based interventions to reduce smoking.

Psychosocial factors associated with the public's willingness to pay for genetic testing for cancer risk: a structural equations model

An adaptation of Andersen's behavioral model of health services utilization is used to examine the psychosocial and socio-demographic factors that directly and indirectly influence the likelihood of undergoing genetic susceptibility testing for cancer, and the amount of money that individuals would be willing to pay out-of-pocket for such a test. Apart from willingness and likelihood, the model also included perceived benefits and barriers, perceived susceptibility, dispositional optimism, information seeking, family history of cancer, socioeconomic status (SES), and age, and explained 30.3% of the variation in willingness. We found as hypothesized that likelihood of undergoing such tests was central to understanding willingness to pay. Being aware of genetic susceptibility testing for cancer, and talking and seeking information about it was directly associated with an increased chance of being willing to pay more, independent of other indirect associations (effects). Interventions targeting those with a family history of cancer and those with a higher SES should generate more awareness about the potential positive and negative consequences to one's family of testing, and the interface between family history of cancer and perceived susceptibility. Interventions should also motivate people to talk and seek more information about genetic testing for cancer risk to enable them take well-informed decisions.

Free nicotine patches plus proactive telephone peer support to help low-income women stop smoking

BACKGROUND

This study tested the impact of free nicotine patches plus proactive telephone peer support to help low-income women stop smoking.

METHODS

A total of 214 Medicaid-eligible women smokers of childbearing age were randomized to receive free nicotine patches through the mail or free nicotine patches through the mail plus the provision of proactive support by telephone from a woman ex-smoker for up to 3 months. Assessments were conducted by telephone at baseline, 10 days, and 3 and 6 months after enrollment.

RESULTS

At the 3-month follow-up, significantly more women in the patch plus proactive telephone support condition were abstinent (42%) compared to the patch only condition (28%) (P = 0.03). Similarly, more women in the experimental condition were abstinent at both the 10-day and 3-month assessments (32 v 19%, P = 0.02). However, differences were not found at the 6-month follow-up, suggesting that the addition of proactive telephone peer support enhanced short-term, but not long-term cessation.

CONCLUSIONS

This is the first study to demonstrate a beneficial effect for the addition of proactive telephone support as an adjunct to free nicotine replacement in a low-income population.

Helping women quit smoking: results of a community intervention program

OBJECTIVES

This intervention was implemented to reduce the prevalence of cigarette smoking among women.

METHODS

We used community organization approaches to create coalitions and task forces to develop and implement a multicomponent intervention in 2 counties in Vermont and New Hampshire, with a special focus on providing support to help women quit smoking. Evaluation was by pre-intervention and post-intervention random-digit-dialed telephone surveys in the intervention counties and the 2 matched comparison counties.

RESULTS

In the intervention counties, compared with the comparison counties, the odds of a woman being a smoker after 4 years of program activities were 0.88 (95% confidence interval = 0.78, 1.00) (P = .02, 1-tailed); women smokers' perceptions of community norms about women smoking were significantly more negative (P = .002, 1-tailed); and the quit rate in the past 5 years was significantly greater (25.4% vs 21.4%; P = .02, 1-tailed). Quit rates were significantly higher in the intervention counties among younger women (aged 18 to 44 years); among women with household annual incomes of $25,000 or less; and among heavier smokers (those who smoked 25 or more cigarettes daily).

CONCLUSIONS

In these rural counties, community participation in planning and implementing interventions was accompanied by favorable changes in women's smoking behavior.

The role of health professionals in a community-based program to help women quit smoking

BACKGROUND

Health professionals are credible sources of smoking cessation advice. This study describes changes in health professionals' reported provision of smoking cessation counseling activities for women during a community health education project that took place in two intervention counties (I) and compares these to reports from health professionals in two similar comparison counties (C).

METHODS

Specific smoking cessation activities reported by physicians (I n = 73, C n = 73), dentists (I n = 51, C n = 46), dental hygienists (I n = 38, C n = 44), family planning and WIC (Special Supplemental Food Program for Women, Infants and Children) counselors (I n = 14 C n = 16), and community mental health counselors (I n = 57, C n = 23) were assessed by mailed surveys at baseline, after 4 years of countywide interventions, and 2 years later.

RESULTS

Compared with health professionals in the comparison counties, significant increases in smoking cessation training (P < 0.01) and in reported referral of women to stop smoking groups, support groups, and one-to-one support were noted for physicians, family planning, and WIC counselors (P < 0.001); in training and referral to stop smoking groups and support groups by dentists and dental hygienists (P < 0.05); and in referral to support groups by community mental health counselors (P < 0.05). Significant increases in setting quit dates (P < 0.05) and providing self-help materials (P < 0.01) were also noted for family planning and WIC counselors. These effects were no longer demonstrable 2 years after external support for the countywide interventions was withdrawn.

CONCLUSIONS

We suggest that an important aspect of facilitating consistent smoking cessation advice and counseling from health professionals in the future will be the provision of a broader range of regularly available smoking cessation support systems within communities than is generally available at this time in the United States.

Likelihood of undergoing genetic testing for cancer risk: a population-based study

BACKGROUND

Studies on public perceptions of genetic susceptibility testing for cancer risks are few and tend to focus on specific cancer risks of higher-risk populations, ignoring the general population and their perceived risk of getting any cancers. This study develops and tests a psychosocial model of the proximal and distal influences on likelihood of undergoing genetic susceptibility testing for cancer risk among a population-based sample.

METHODS

The sample consisted of 622 adults aged 18-75 interviewed by telephone. The survey instrument included measures derived from the Health Belief Model and adaptations of existing measures from the literature. Data were analyzed using structural equation modeling techniques.

RESULTS

The model suggested independent main effects for perceived benefits, perceived barriers, perceived susceptibility, and pessimism while simultaneously accounting for the effects of age, socioeconomic status, family history of cancer, and awareness of the existence of genetic susceptibility testing for cancer risk. The model explained 34% of the variance in likelihood.

CONCLUSIONS

While perceived benefits, perceived barriers, perceived susceptibility, and pessimism may directly impact likelihood, they may also mediate the effects of age, socioeconomic status, family history of cancer, and awareness of cancer genetic susceptibility testing, on likelihood.

Community-based promotion of breast screening using small group education

Small Group Education (SGE) to promote breast cancer screening was implemented in a community-wide program. Based on diffusion of innovations theory, SGE initially was directed toward women at higher occupation and education levels and then progressively shifted toward more vulnerable populations of women at risk of not getting screening. During the four-year intervention, 116 volunteers led SGE presentations, with 8,184 women participating in 740 groups at work sites, organizations, residences, and churches. High participation in SGE and positive participant responses suggest that delivery of SGE using a social diffusion model was an effective method for reaching women throughout the community.

Three-year prospective adherence to three breast cancer screening modalities

BACKGROUND

This study prospectively examined rates of adherence to mammography, clinical breast examination (CBE), and breast self-examination (BSE) in a cohort of women over 3 years to determine whether participation in BSE influenced participation in the other two screening modalities.

METHODS

Women ages 51 and older (n = 450) who attended a small group educational session to learn BSE and to hear about CBE and mammography guidelines were assessed annually by telephone for 3 consecutive years to determine their subsequent breast cancer screening behavior.

RESULTS

Annual CBE and mammography screening are highly positively associated. Regular performance of BSE has a modest positive association with both CBE and mammography adherence over time.

CONCLUSIONS

Women who perform BSE regularly over time may be more likely to adhere to the other breast cancer screening guidelines.

Estimated gains in birth weight associated with reductions in smoking during pregnancy

OBJECTIVE

To compare the estimated effect on birth weight of reductions in maternal cigarette consumption and urinary cotinine during pregnancy.

STUDY DESIGN

An observational study of 641 women with complete data on cigarette consumption, urinary cotinine and infant birth weight. Correlation and regression analyses were used to examine relationships between birth weight, cigarette consumption and urinary cotinine at first and last prenatal visits.

RESULTS

Correlations of cigarette consumption and urinary cotinine with infant birth weight were -.23 and -.30 (first visit) and -.26 and -.31 (last visit); all P values were < .001. The regression equation relating urinary cotinine concentrations at first and last visits to infant birth weight explained a significantly larger proportion of the variability in birth weight than the equation relating cigarette consumption at these visits to infant birth weight, 11% vs. 7%, P = .04. Among continuing smokers, both equations predicted gains in birth weight in association with reductions in cigarette consumption, but quitting smoking before the first visit was associated with the most weight gain. As compared to the average infant birth weight of a woman who smoked 20 cigarettes per day throughout pregnancy, the estimated gain in birth weight would be 105 g if she cut down by 10 cigarettes per day after the first visit, 210 g if she quit after this visit and 310 g if she quit before the first visit.

CONCLUSION

For women still smoking at their first prenatal visit, infant birth weight is already compromised, but subsequent reductions in cigarette consumption are associated with gains in birth weight. For women who cannot quit smoking, these reductions need to be substantial if increases in birth weight of > 100 g are to be achieved.

Smoking relapse prevention during pregnancy. A trial of coordinated advice from physicians and individual counseling

INTRODUCTION

Our objective was to examine the efficacy of physicians' advice and referral to individual counseling in preventing relapse to smoking among women who were smokers early in pregnancy, but quit prior to their first prenatal visit.

DESIGN

A randomized controlled trial of prompted physician's advice and individual relapse prevention counseling during pregnancy compared to usual physician advice. Smoking status was assessed by self-report, exhaled carbon monoxide, and urinary cotinine during pregnancy and by self-report 1 year postpartum.

RESULTS

There were no significant differences in relapse rates between the intervention and usual-care groups during pregnancy, nor at 1 year postpartum. Relapse rates were 23% in both groups at the 36-week visit, and 32% and 22%, respectively, 1 year postpartum. Younger age, higher motivation to resume smoking, and higher levels of exhaled carbon monoxide at the first prenatal visit were predictive of relapse to smoking during pregnancy. With the conservative assumption that all those lost to follow-up relapsed, the combined 1-year postpartum relapse rate, 51%, was 17 percentage points lower than we observed in an earlier relapse prevention trial, and 15 percentage points lower than that observed nationally a decade earlier.

CONCLUSION

Prompting physicians to provide supportive advice combined with referral to individual relapse prevention counseling did not reduce smoking relapse rates during pregnancy, or postpartum. However, the level of attention paid to smoking by physicians in both intervention and usual-care groups during pregnancy may have contributed to the relatively low relapse rates seen 1-year postpartum.

Reducing smoking during pregnancy and postpartum: physician's advice supported by individual counseling

BACKGROUND

Physicians' advice to help pregnant women quit smoking during prenatal care has had mixed results. Training and prompting physicians to provide consistent advice and referral to on-site support might improve cessation rates.

METHODS

Pregnant women who smoked were randomly assigned to receive structured advice from their physician and referral to individual behavior change counseling during prenatal care or to receive brief advice to stop smoking and a quit smoking booklet at their first visit. Smoking status was measured by self-report, exhaled carbon monoxide, and urinary cotinine.

RESULTS

Compared with usual care, greater proportions of intervention group women reported not smoking at the 36th-week visit (14% vs 10%) and at 1 year postpartum (18% vs 11%), but these differences were not significant. However, significantly greater proportions of intervention group women reported either not smoking or reducing their cigarette consumption by 50% or more at their second visit (43% vs 29%, P = 0.02), at their 36th-week visit (40% vs 25%, P < 0.01), and at 1 year postpartum (26% vs 14%, P = 0.02).

CONCLUSIONS

Physician training on how to gain a pregnant smoker's commitment to change her smoking behavior, an office prompt system, and individualized smoking behavior change counseling show promise in reducing smoking during pregnancy and postpartum, but practical methods to assist pregnant smokers between regular prenatal visits, as they attempt to quit, need to be developed.

Predictors of state legislators' intentions to vote for cigarette tax increases

BACKGROUND

This study analyzed influences on state legislators' decisions about cigarette tax increase votes using a research strategy based on political science and social-psychological models.

METHODS

Legislators from three states representing a spectrum of tobacco interests participated in personal interviews concerned with tobacco control legislation (n = 444). Measures of potential predictors of voting intention were based on the consensus model of legislative decision-making and the theory of planned behavior. Multiple logistic regression methods were used to identify social-psychological and other predictors of intention to vote for cigarette tax increases.

RESULTS

General attitudes and norms concerning cigarette tax increases predicted legislators' intention to vote for cigarette tax increases. More specific predictors included perceptions of public health impact and retail sales impact of cigarette tax increases. Constituent pressure was the strongest perceived social influence. Political party and state also were strong predictors of intention. Results were consistent with related research based on political science models.

CONCLUSIONS

Legislators' votes on cigarette tax increases may be influenced by their perceptions of positive and negative outcomes of a cigarette tax increase and by perceived constituent pressures. This research model provides useful insights for theory and practice and should be refined in future tobacco control research.

Assessment of self-reward strategies for maintenance of breast self-examination

This study examined the relative impact of different self-reward strategies on maintenance of breast self-examination (BSE) practice among 1649 women trained to do BSE. Training groups were randomized into four conditions: (a) self-reward instructions and materials delivered at the end of the BSE training session; (b) self-reward suggestions delivered through the mail each month, contingent upon the BSE performance; (c) external monetary rewards and self-reward suggestions delivered through the mail each month on an intermittent schedule, contingent upon BSE practice; and (d) a no-reward control condition. Follow-up assessments 12 months following training revealed a pattern of evidence in support of the benefits of external monetary rewards and self-reward prompts on BSE frequency and quality; however, it is likely that the value of that condition lies in the external reward component.

State legislators' intentions to vote and subsequent votes on tobacco control legislation

The predictive validity of state legislators' behavioral intentions in relation to their votes on tobacco control legislation was assessed by using the theory of planned behavior (I. Ajzen, 1991). Intentions to vote for cigarette tax increases were measured through interviews in the summer of 1994. A bill containing cigarette tax increases was considered about 8 months later. Votes were compared with intentions and were found to be consistent for 78% of these legislators (N = 120). Multiple logistic regression analyses showed a strong independent relationship between intentions and voting and a similar effect of political party; results suggested but did not confirm that votes were predicted by interactions between intentions and perceived control. Legislator surveys that use this conceptual model can provide results relevant to understanding tobacco policy development.

Exhaled carbon monoxide and urinary cotinine as measures of smoking in pregnancy

We examined the relationships among self-reported cigarette consumption, exhaled carbon monoxide, and urinary cotinine/creatinine ratio in pregnant women. Information on these measures of smoking was collected at first and 36th week prenatal visits. Correlations between cigarette consumption and exhaled carbon monoxide were .65 at the first visit and .70 at the 36th-week visit. For urinary cotinine/creatinine ratio, the correlations were .61 and .65, respectively, at these visits. Correlations with change in cigarette consumption between the two visits were .37 for change in carbon monoxide and .33 for change in urinary cotinine/creatinine ratio. Urinary cotinine/creatinine ratio had slightly higher overall agreement with self-reported smoking status and was less likely to misclassify smokers than carbon monoxide. We conclude that urinary cotinine/creatinine ratio is the more accurate measure for validating smoking status among pregnant women, but exhaled carbon monoxide is the better measure of cigarette consumption and of changes in consumption.

A mass media programme to prevent smoking among adolescents: costs and cost effectiveness

OBJECTIVE

To examine costs and cost-effectiveness ratios of a four-year mass media programme previously shown to prevent the onset of smoking among adolescents.

DESIGN

A matched control design.

SETTING

Two cities in Montana, one in New York and one in Vermont, USA.

SUBJECTS

Students in grades 10-12 (ages 15-18).

INTERVENTION

A four-year mass media campaign to prevent the onset of smoking.

MAIN OUTCOME MEASURES

Cost per student potentially exposed to the mass media campaign; cost per student smoker potentially averted; and cost per life-year gained. Cost estimates were also made for a similar campaign that would be broadcast nationally in the United States.

RESULTS

In 1996 dollars, the cost of developing and broadcasting the mass media campaign was $759,436, and the cost per student potentially exposed to the campaign (n = 18,600) was $41. The cost per student smoker averted (n = 1023) was $754 (95% confidence interval (CI) = $531-$1296). The cost per life-year gained discounted at 3% over the life expectancy for young adult smokers was $696 (95% CI = $445-$1269). The estimated cost of developing and broadcasting a similar four-year mass media campaign in all 209 American media markets would be approximately $84.5 million, at a cost of $8 per student potentially exposed to a national campaign, $162 per student smoker averted, and $138 (95% CI = $88-$252) per life-year gained.

CONCLUSION

Estimates of the cost-effectiveness ratios of this mass media campaign in preventing the onset of smoking showed it to be economically attractive and to compare favourably with other preventive and therapeutic strategies.

State legislators' attitudes and voting intentions toward tobacco control legislation

OBJECTIVES

This study describes state legislators' knowledge, attitudes, and voting intentions with regard to tobacco-related issues.

METHODS

A cross-sectional survey of state legislators was conducted in North Carolina, Texas, and Vermont in 1994.

RESULTS

Most legislators agreed that secondhand smoke can cause lung cancer in nonsmokers, and a majority believed that smokers are addicted to nicotine. More than 75% stated that they would support a measure to enforce laws preventing tobacco sales to youth. A majority of Texas and Vermont legislators supported an increase in the state cigarette excise tax; 43% of North Carolina legislators would support an increase if revenues were directed toward tobacco farmer diversification.

CONCLUSIONS

State legislators believe tobacco to be addictive, and they support policies to protect youth from tobacco. Support for other legislative measures differs significantly across states.

State legislators' intentions to vote and subsequent votes on tobacco control legislation

The predictive validity of state legislators' behavioral intentions in relation to their votes on tobacco control legislation was assessed by using the theory of planned behavior (I. Ajzen, 1991). Intentions to vote for cigarette tax increases were measured through interviews in the summer of 1994. A bill containing cigarette tax increases was considered about 8 months later. Votes were compared with intentions and were found to be consistent for 78% of these legislators (N = 120). Multiple logistic regression analyses showed a strong independent relationship between intentions and voting and a similar effect of political party; results suggested but did not confirm that votes were predicted by interactions between intentions and perceived control. Legislator surveys that use this conceptual model can provide results relevant to understanding tobacco policy development.

Long-term responses of higher and lower risk youths to smoking prevention interventions

BACKGROUND

Adolescents at risk for cigarette smoking are difficult to reach with conventional interventions but have substantial exposure to the mass media. This study is the first to show that smoking prevention messages presented through the mass media can have large and durable effects on higher risk adolescents.

METHODS

Students in two communities received media and school interventions beginning in grades 5-7; those in matched comparison communities received school interventions. Media interventions were targeted to higher risk youths. School surveys were conducted before and after the interventions, in grades 4-6 and grades 8-10. Two years after interventions ended, when participants were in grades 10-12, school and telephone surveys were conducted to assess smoking status. Survey participants (n = 2,860) were classified at baseline as having higher or lower risk for becoming a smoker.

RESULTS

Smoking prevalence within the higher risk sample was significantly lower for those receiving media-school interventions than for those receiving school interventions only (odds ratio = 0.71). Effects on the lower risk sample were similar in magnitude but marginally significant.

CONCLUSIONS

Mass media and school interventions achieved lower smoking rates among higher risk youngsters 2 years following completion of the interventions. This strategy represents a uniquely effective method for communicating with a high-priority group.

Smoking in pregnancy, exhaled carbon monoxide, and birth weight

OBJECTIVE

To examine the relation of cigarette consumption and exhaled carbon monoxide levels during pregnancy and to assess the effect of these smoking measures on birth weight.

METHODS

Cigarette consumption and exhaled carbon monoxide levels were recorded at the first prenatal visit and the 36-week visit from women who smoked early in pregnancy. Analysis of variance was used to compare birth weights for differing levels of cigarette consumption and exhaled carbon monoxide. Correlation and regression analyses were used to estimate the effects of the smoking measures at both prenatal visits on birth weight.

RESULTS

Cigarette consumption and exhaled carbon monoxide levels at both visits were associated significantly with birth weight. After the first prenatal visit, a reduction in cigarette consumption of at least nine cigarettes per day or in exhaled carbon monoxide of 8 parts per million (ppm) was associated with gains in birth weight of 100 g or more. The proportion of low birth weight (LBW) infants increased significantly with increasing levels of cigarette consumption and with increasing concentrations of exhaled carbon monoxide.

CONCLUSION

Substantial reductions in cigarette consumption or in exhaled carbon monoxide levels after the first prenatal visit are needed to achieve gains in birth weight. Not smoking, or having an exhaled carbon monoxide level less than 5 ppm minimizes the likelihood of having an LBW infant.

Modeling smoking cessation: exploring the use of a videotape to help pregnant women quit smoking

This exploratory study examined the acceptability and efficacy of a videotape modeling smoking cessation as an adjunct to smoking cessation advice delivered during prenatal care. In a randomized controlled trial involving 60 women, we compared the delivery of brief smoking cessation advice and a tipsheet to the same advice and tipsheet plus provision of the videotape. Outcomes included opinions about content and acceptability of the videotape, and smoking behavior change during pregnancy. The most highly endorsed features of the videotape were seeing other women quitting smoking (77%), dealing with stress and bad feelings (69%), talking about what to do with urges to smoke (69%), and discussing ways to get support from families and friends (54%). The reported quit rate in the last month of pregnancy, validated by exhaled carbon monoxide levels, and including women lost to follow-up as smokers, was 19.2% in the intervention group and 0% in the comparison group (p = .02). This study suggests that the use of videotapes modeling smoking behavior change may increase the effectiveness of the assistance in quitting smoking that is generally available in obstetric and family practices or public maternity clinics.

Community education programs to promote mammography participation in rural New York State

BACKGROUND

Rural women are less likely to receive screening mammography at recommended intervals. This study evaluated efforts to promote screening mammography among women in rural communities through community education interventions and low-cost mobile mammography van services.

METHODS

Two matched sets of communities were identified in an isolated rural region. One area received community education programs in addition to the mammography van for 2 years; the second area received only the van services. The educational programs were designed using diagnostic research methods; they included recruitment of opinion leaders to organize small group breast screening education sessions, an information campaign using direct mail, and primary health care provider education.

RESULTS

A household telephone survey conducted 6 months after completion of these programs indicated that mammography utilization and perceived mammography norms were higher among women in the Program area than among women in the Comparison area. Process data were consistent with these findings. Clinical examination and self-examination behaviors were not influenced by the programs.

CONCLUSIONS

This study showed that well-focused educational interventions for rural women can increase utilization of screening mammography when access and cost barriers also are reduced.

State legislators' perceptions of lobbyists and lobbying on tobacco control issues

OBJECTIVE

To determine state legislators' perceptions about health and tobacco lobbyists, their frequency of contact with these lobbyists, and the amount of campaign contributions from health professional organisations and the tobacco industry.

DESIGN

Cross-sectional study.

SUBJECTS

State legislators from North Carolina, Texas, and Vermont (USA), serving in 1994.

MAIN OUTCOME MEASURES

Perceptions about lobbyists representing the tobacco industry, non-profit health organisations, and state medical societies with respect to their credibility, importance as sources of information, and persuasiveness; extent of lobbying activities; campaign contributions from health professional organisations and the tobacco industry.

RESULTS

Almost all legislators reported that medical society and non-profit health organisation lobbyists are credible on tobacco issues and just over half believed that these lobbyists are important sources of information. More legislators said they could be persuaded by medical and health lobbyists than by tobacco lobbyists. Although health professional Political Action Committees (PACs) gave campaign contributions to more state legislators, and gave higher amounts on average, than tobacco PACs, legislators reported less contact with medical society lobbyists than tobacco lobbyists about tobacco issues.

CONCLUSIONS

State legislators have positive attitudes toward lobbyists for non-profit health organisations and state medical societies regarding tobacco issues. These groups may be an underused resource for educating legislators about tobacco control measures.

Using mass media to prevent cigarette smoking among adolescent girls

This article describes the development of a mass media smoking prevention intervention targeted primarily toward adolescent girls at increased risk for smoking and assesses its outcomes. A cohort of 5,458 students was surveyed at baseline in Grades 4-6 and annually for 4 years. Through diagnostic and formative research, media messages were created to appeal especially to girls. Students beginning in Grades 5-7 received the 4-year media intervention and a school program in two communities, while students in two matched communities received the school program alone. Media targeting techniques resulted in high levels of message appeal and exposure consistent with effects on mediating variables and 40% lower weekly smoking at Grades 8-10 for girls receiving the media and school interventions compared to school alone. Smoking behavior effects were maintained at Grades 10-12. These results indicate that mass media interventions targeting specific audience segments can reduce substance use behavior for those segments.

Helping women quit smoking: baseline observations for a community health education project

INTRODUCTION

Our objectives were (1) to examine the relationship between women's intention of stopping smoking in the next month and a broad range of mediating variables and (2) to assess the implications of these relationships for intervention components of a comprehensive community-wide health education program to help women quit smoking.

METHODS

In preparation for the community-wide program to help women quit smoking, baseline data were collected through a random digit dialing telephone survey of 6,324 adult women, 18-64 years of age.

RESULTS

At baseline, smoking prevalence, defined as smoking an average of one or more cigarettes per day, was 25.8% and showed clear relationships with age and income, but most strikingly with education, indicating the need for programs for women of childbearing age with low incomes and fewer years of schooling. Among female smokers, knowledge of the health effects of smoking; motivations toward quitting; confidence in controlling weight, or handling stress, anger or boredom; number of strategies named to cope when upset of angry; number of community smoking cessation resources named; perceptions of support for quitting; and perceptions of norms concerning women smoking varied significantly with level of intention to quit smoking in the next month.

CONCLUSIONS

These relationships provided support for the broad range of health behavior change strategies proposed for this community-based program to help women quit smoking.

Stages of change in smoking during pregnancy in low-income women

This study examined the effects of a smoking cessation intervention on stages of change in 349 low-income, pregnant women. At first prenatal visit, women were randomized into experimental or usual care condition and classified by stage of change: precontemplation, contemplation, preparation, or action. For each stage of change at the first prenatal visit, the stage distributions of the experimental and usual care groups were compared at the second and 36-week prenatal visits. Kruskal-Wallis tests revealed significant differences at the second visit in the stage distributions by condition for subjects who were initially in precontemplation or in preparation. In each case, a greater proportion of experimental than usual care subjects advanced through the stages. The shift was not maintained at the 36-week visit.

Breast screening by African-American women: insights from a household survey and focus groups

This study uses quantitative and qualitative information to examine the relationships between predisposing, reinforcing, and enabling factors from a health education planning model and levels of mammography screening, clinical breast exam (CBE), and breast self-exam (BSE) among African-American women. We analyzed data from a random sample household survey of African-American women in a Florida community (n = 281) and three age-homogenous focus groups from the same population. Two thirds of the random sample and all of the focus group participants had less than a high school education and household incomes below $10,000. Even though both samples of women were likely to have a physician they see regularly, most had never had a mammogram and could not accurately describe more than two major techniques for BSE. Knowing guidelines for mammography, CBE, and BSE (predisposing factors), believing their screening behavior mattered to at least some family members (reinforcing factor), seeing a physician for health care and advice, and having been taught BSE in a physician's office (enabling factors) predicted one form of breast screening behavior or another in multivariate logistic regression analyses. In addition, knowing mammography and BSE guidelines and having been taught BSE in a physician's office were significant predictors of breast-screening behavior for both low- and moderate-income women. Focus-group participants unanimously reported a willingness to listen to physician instructions regarding breast screening and to receive a mammogram if their physician recommended one. Both survey and focus group results emphasize the particular importance of physicians in promoting breast screening among African-American women regardless of their income.

Barriers to condom use among women attending planned parenthood clinics

Assessed condom use, barriers to condom use, oral contraceptive use, partnership status and STD history in 457 15-30 year-old women attending four family planning clinics. Subjects were classified into three condom use groups: Non Users (37%); Current Users (33%); and Past Users (30%). Factor analysis revealed five barriers to condom use: Partner's Perception, Peer's Perception, Pleasure/Intimacy, Communication, and Low Perceived Need. Multivariate analyses revealed significant group differences on only two barrier factors: Pleasure/Intimacy and Low Perceived Need. Low Perceived Need accounted for 13.5% of the variance in condom use. Women with low perceived need to use condoms were more likely to use oral contraceptives.

Smoking relapse prevention counseling during prenatal and early postnatal care

Our objective was to examine the efficacy of the added effect of individualized smoking relapse prevention counseling on obstetricians' and nurse midwives' usual advice during prenatal care. One hundred and seventy-five pregnant women who were smoking early in their pregnancy, but had quit by first prenatal visit, were randomly assigned to receive the usual advice from their obstetrician or nurse midwife, or usual advice plus individual relapse prevention counseling. Smoking status was measured by self-report, by urinary cotinine/creatinine ratio at the 36-week visit, and by self-report at long-term postpartum follow-up. We found that a smaller percentage of women in the intervention group (8.8%) reported smoking at the thirty-sixth-week visit than those in the usual care group (16.9%), a nonsignificant difference. No significant difference in relapse rates during pregnancy was observed based on urinary cotinine/creatinine ratios, but these rates, 29.5% and 27.9% respectively, were substantially higher than those based on self-report. The average number of days abstinent reported by women in the intervention group was significantly longer than that in the usual care group, 199 days versus 166 days respectively (P < .01). Logistic regression analysis indicated that longest time abstaining before first visit, level of belief in smoking's harm to the fetus, and motivation to smoke were independently related to the probability of relapsing to smoking by the 36-week visit. Long-term relapse rates were not significantly different: intervention group, 50.9%, usual care group, 50.0%.(ABSTRACT TRUNCATED AT 250 WORDS)

Measuring community leaders' perceived ownership of health education programs: initial tests of reliability and validity

Development of community ownership is often identified as an important intermediate objective of community health education programs. Community ownership is assumed to be important to program effectiveness and long-term maintenance, but validated measures of this construct have not been available to test this proposition. A measure of community leaders' perceived ownership of health education programs was developed and tested. The Community Ownership Scale identified key functions within a program and asked community leaders to rate the amount of control the leaders themselves, the external sponsoring agency and the local program staff had in each area. The measure was tested with the volunteer leadership of three community health education programs. Predictions about scores were based on the conceptual framework from which the ownership construct was derived. Results of these tests were consistent with predictions, providing evidence for the validity of the measure. Subscale scores showed high levels of internal consistency reliability. This measure could be applied at different stages in the life of a program to monitor the success of efforts to foster community ownership, and to test the relationships between perceived ownership and program effectiveness and maintenance.

Cigarette smoking control strategies of firms with small work forces in two Northeastern States

PURPOSE

Cigarette smoking control strategies of firms with small work forces were assessed and compared with those of larger firms.

DESIGN

A cross-sectional telephone survey was conducted in 1990 among private employers systematically selected from a proprietary database.

SETTING

These firms were located in four counties of two northeastern states.

SUBJECTS

Interviews were conducted with managers of 470 small (< or = 25 employees; n = 262), medium (26-50; n = 87), and larger (> 50; n = 121) firms.

MEASURES

Interviews assessed characteristics of the firms and their cigarette smoking policies and cessation programs.

RESULTS

Small firms differed from larger firms in several areas. They were less likely to have written policies, used fewer methods to communicate their policies, and their policies were consistently less restrictive. Small firms also offered less assistance to employees who wished to quit.

CONCLUSIONS

The less restrictive smoking policies reported here may be relatively ineffective in protecting nonsmokers in small firms. Small firms may encounter difficulties introducing more restrictive smoking policies because of the relative closeness of employee relations, smaller work spaces, and inability to deliver smoking cessation services to employees. Methods should be developed to assist managers of smaller firms to implement stronger smoking policies and to devise ways of making cessation assistance more easily available to their employees.

Individualized smoking cessation counseling during prenatal and early postnatal care

OBJECTIVE

We examined the efficacy of individualized smoking cessation counseling added to obstetricians' and nurse-midwives' advice.

STUDY DESIGN

In a mixed private and publicly supported prenatal clinic 600 pregnant women who smoked were randomly assigned to receive the usual advice from their obstetrician or nurse-midwife or the usual advice plus individualized smoking cessation counseling. Smoking status was measured by self-report and urinary cotinine/creatinine ratios at 36 weeks and by self-report during long-term postpartum follow-up.

RESULTS

Quitting rates during pregnancy were not increased by adding individualized smoking cessation counseling to usual care. At the long-term follow-up, reported quitting rates were significantly greater among intervention group women cared for in the publicly supported clinic than among those receiving the usual care, 14.5% versus 2.5%, p < 0.01.

CONCLUSION

Although adding individual smoking cessation counseling did not increase quitting rates during pregnancy, it should be considered for women in public maternity clinics because of its potential long-term effectiveness.

Comparisons of the smoking cessation counseling activities of six types of health professionals

BACKGROUND

This study was designed to assess and compare the smoking cessation counseling activities of primary care physicians, dentists, dental hygienists, family planning counselors, WIC counselors, and community mental health counselors in four counties in the northeastern United States for planning appropriate education programs.

METHODS

Lists of the health professionals in each of these groups in the four study counties were obtained from state licensing boards, clinic directors, and telephone directories. Surveys were conducted by mail, using a 19-item instrument which could be completed in 2-4 min.

RESULTS

Comparisons among these professional groups showed that physicians, family planning counselors, and WIC counselors felt better prepared to provide cessation advice than did mental health counselors, dentists, and dental hygienists. Physicians, family planning counselors, and WIC counselors also were more active in providing smoking cessation advice to women smokers than were the other three groups. Levels of use of specific counseling activities were generally low. Setting a quit date, arranging for follow-up visits, and referral for further assistance were used for only a minority of women smokers.

CONCLUSIONS

Opportunities for educational interventions that could increase these health professionals' effectiveness were apparent for each of the groups.

Mass media and school interventions for cigarette smoking prevention: effects 2 years after completion

The long-term cigarette smoking prevention effects of mass media and school interventions were assessed. Adolescents in two communities received both mass media and school interventions; those in two matching communities received only school interventions. Surveys of 5458 students were conducted at baseline in grades 4 through 6 and 2 years after the 4-year interventions were completed, when students were in grades 10 through 12. Students exposed to the media-plus-school interventions were found to be at lower risk for weekly smoking (odds ratio = 0.62, 95% confidence interval = 0.49, 0.78) than those receiving school interventions only, indicating that the effects of the combined interventions persisted 2 years after the interventions' completion.

Development of a community breast screening promotion program using baseline data

The process of developing a comprehensive community-based breast screening program for the Breast Screening Program Project is presented in this article. Behavior change theories were used to develop a program effects model which served as the conceptual foundation for a comprehensive breast screening program. This program would enlist professional and lay resources to promote breast screening through public and physician education and through improved access to mammography. Baseline survey data were used to focus program components on educational needs of women ages 40 and older for participating in regular mammography, clinical breast exam, and breast self-exam. The program effects model was also used as an evaluation framework to specify the intermediate changes that will be accomplished to reach a hypothesized 15% increase in screening participation between a study area receiving the program and two comparison areas. Results of this study will be of immediate value to other communities planning breast screening promotion programs.

Acquired immunodeficiency syndrome/human immunodeficiency virus risk behavior among gay men in small cities. Findings of a 16-city national sample

BACKGROUND

Most research on acquired immunodeficiency syndrome has been conducted in several of the country's largest cities, and little is known about the current level of human immunodeficiency virus risk taking among gay men in other geographical areas. The purpose of this study was to determine the frequency of risk behavior practices among gay men in smaller communities.

METHOD

A large sample of men who patronized gay bars in 16 small and moderate-size cities drawn from six states in four different regions of the country was surveyed to determine the frequency of high-risk behavior and factors influencing risk taking. Eighty-five percent of men in all cities' bars completed all survey measures. The community samples were 1991 men; mean age, 31.3 years; mean education, 10.6 years; 90% were white and 10% were of other ethnicities. All participants provided detailed information on their sexual behavior practices over the preceding 2 months and completed measures assessing their perceived peer norms concerning safer sex practices and risk avoidance, intentions to avoid risk, personal risk estimation, acquired immunodeficiency syndrome risk knowledge, perceived threat of acquired immunodeficiency syndrome/human immunodeficiency virus, and serostatus testing history.

RESULTS

High-risk patterns were still common among gay men in these smaller cities; nearly one third of all men had engaged in unprotected anal intercourse an average of eight times in the past 2 months, usually outside monogamous relationships. High-risk behavior was most strongly associated with beliefs that safer sex practices would not be well accepted by peers, weak intentions to use condoms, underestimation of personal vulnerability to the acquired immunodeficiency syndrome, younger age, and higher levels of overall sexual activity. Nine percent of men tested said they were seropositive.

CONCLUSIONS

Growing human immunodeficiency virus prevalence and continued high rates of risk behavior indicate that a new "front line" for human immunodeficiency virus prevention among homosexually active men has shifted to the country's smaller cities. Community prevention efforts in these areas are urgently needed to avert sharp increases in future human immunodeficiency virus infections in this population.

Prevention of cigarette smoking through mass media intervention and school programs

OBJECTIVES

In this study we tested the ability of mass media interventions to enhance the efficacy of school cigarette smoking prevention programs.

METHODS

For 4 years, students in one pair of communities received media interventions and school programs that had common educational objectives. Students in a matched pair of communities received only the school programs. The combined cohort of 5458 students was surveyed at baseline in grades 4, 5, and 6 and was followed up annually for 4 years.

RESULTS

Significant reductions in reported smoking, along with consistent effects on targeted mediating variables, were observed for the media-and-school group. For cigarettes per week the reduction was 41% (2.6 vs 4.4); for smoking cigarettes yesterday the reduction was 34% (8.6% vs 13.1%); and for smoking in the past week the reduction was 35% (12.8% vs 19.8%). No effects were observed for substance use behaviors not targeted by the interventions.

CONCLUSIONS

These results provide evidence that mass media interventions are effective in preventing cigarette smoking when they are carefully targeted at high-risk youths and share educational objectives with school programs.

Training obstetric and family practice residents to give smoking cessation advice during prenatal care

OBJECTIVE

Our objective was to determine the effectiveness of training obstetric and family practice residents to provide smoking cessation advice.

STUDY DESIGN

The effectiveness of the trained residents' advice was assessed from exit interviews of pregnant smokers taking part in a randomized, controlled trial of smoking cessation advice. Exit interview responses were compared by chi 2 analysis.

RESULTS

Training resulted in significant changes in the advice provided by the residents, with greater emphasis on gaining a commitment to smoking behavior change, but not in the average time providing the advice, approximately 3 minutes. Adherence to the protocol was maintained at 80%. Significantly more women who received the brief structured advice agreed to stop smoking (54%) or cut down their cigarette consumption (28%) compared with women in the control group (14% and 6%, respectively), p = 0.0001.

CONCLUSION

The structured advice consistently provided by the trained residents was effective in gaining commitments from pregnant smokers to change their smoking behavior.

Smoking cessation among self-quitters

We examined cessation among 630 smokers who quit abruptly on their own. Continuous, complete abstinence rates were 33% at 2 days, 24% at 7 days, 22% at 14 days, 19% at 1 month, 11% at 3 months, 8% at 6 months postcessation, and 3% at 6 months with biochemical verification. Slipping (smoking an average of less than 1 cigarette/day) was common (9% to 15% of subjects) and was a strong predictor of relapse; however, 23% of long-term abstainers slipped at some point. These results challenge beliefs that most smokers can initially stop smoking and that most relapse occurs later on postcessation.

Family physicians' attitudes about dietary advice

Family physicians in Vermont were surveyed to assess their attitudes and practices concerning the provision of dietary and nutritional advice to their patients. The response rate was 82%. Ninety-six percent of respondents considered that nutrition counseling was their responsibility, and the attitudes and beliefs of most of them concurred with the presently accepted relationships between diet and coronary artery disease. Sixty-five percent of respondents reported making dietary recommendations to less than 40% of their nondiabetic patients under the age of 40. Only 27% of respondents routinely took a dietary history, but those who did were significantly more likely to counsel a larger proportion of their patients than those who did not. Serum cholesterol was reported as being measured in about 35% of adults, and the average level of serum cholesterol at which dietary advice would be given was 237 +/- 15 mg/dL. Most reasons for not giving dietary advice were related to the physician's perception that the patient was not at risk for a diet-related disease. Perceived patient lack of interest and lack of compliance were also important reasons, but lacking time or not being reimbursed were much less frequently cited, although adequate financial reimbursement for giving such advice was considered a moderate or major problem by 45% of family physicians.

Predictors of smoking behavior change 6 and 18 months after individual counseling during periodic health examinations

Predictors of smoking behavior change were examined in a randomized controlled trial of individualized smoking cessation counseling delivered by a smoking cessation counselor during periodic health examination. Self-reports of not smoking at 6 and 18 months and attempts to quit were greater, but not significantly so, in the intervention group compared with the usual care group. There was no difference between the intervention group and the usual care group in reported continuous abstinence. Multivariate analysis showed that longer periods of abstinence in the past and having smoking identified as the main problem were important predictors of subsequent quitting. Having fewer other smokers in the household, stronger intentions to stop smoking in the next month, and being in the intervention group were also significant predictors of abstinence at 6 months, but not at 18 months. Those who had tried to quit by 6 months and 18 months were more likely to be in the intervention group, to have greater motivation to stop smoking, and to have more problems of daily living. Supplementing physician's advice with individualized smoking cessation counseling during health maintenance examinations was associated with a greater short-term quit rate and more quit attempts over 18 months than physician advice alone, but did not influence continuous abstinence from cigarettes over this time.

A community-wide program in breast self-examination training and maintenance

This study reports on the effects of innovative community-wide breast self-examination education approaches in increasing breast self-examination frequency and quality, and ability to detect breast lumps during a 1-year training program and a second-year maintenance program. Four Vermont communities were randomly assigned to receive breast self-examination training plus maintenance, training alone, control (with full measurement), and low-measurement control. Random digit dialing telephone surveys were conducted at baseline and at 1- and 2-year follow-up with a panel of 637 women representing all adult women in the first three communities. The low-measurement control community received only baseline and second-year follow-up surveys with a panel of 238 women. Home interviews to determine breast self-examination palpation skills and lump detection on silicone breast models were conducted in first- and second-year follow-up surveys. Results of the first-year follow-up survey indicated significant increases in breast self-examination frequency, quality, and number of lumps detected for women in communities receiving the training program compared with controls; in the second year, women in the community also receiving breast self-examination maintenance showed greater improvement in reported breast self-examination quality and detected more breast lumps than did women in other communities.

Smoking cessation counseling during periodic health examinations

Periodic health examinations are an excellent opportunity to counsel smokers to quit. The impact of a specialized smoking cessation counselor on the smoking behavior of patients having periodic health examinations was studied in a general internal medicine practice. One hundred fifty-five smokers having periodic health examinations were randomly assigned to a control group who received usual physician advice or an intervention group who received usual physician advice and two counseling sessions with a smoking cessation counselor. The two groups were similar in all demographic variables, smoking-related baseline variables, and baseline levels of motivation and intention to quit smoking. The smoking status of 97% of the subjects was assessed 6 months later. In the intervention group, 46% made quit attempts and 19% quit, compared with 34% and 12%, respectively, in the control group. Intervention-group smokers made more quit attempts (mean +/- SD, 5.0 +/- 2.5 vs 1.8 +/- 0.2) and had a greater reduction in daily cigarette use (8.4 +/- 1.5 vs 3.5 +/- 1.3). Of the 74% of smokers with higher levels of motivation to quit smoking, more intervention-group smokers attempted to quit (70.8% vs 45.5%) and succeeded in quitting at the 6-month follow-up (27.1% vs 10.9%). Periodic health examinations are an excellent opportunity to counsel smokers to quit, especially those smokers with higher levels of motivation to quit smoking.