Turning Community Feedback into a Culturally Responsive Program for American Indian/Alaska Native Commercial Tobacco Users

BACKGROUND

American Indian/Alaska Native (AI/AN) cigarette smoking prevalence is disproportionately high, especially in the northern United States. Tailored quitlines are needed to support AI/AN commercial tobacco users with quitting.

OBJECTIVES

Obtain community feedback by working with trusted AI/AN partners; genuinely incorporate feedback into program design; collaboratively develop and implement culturally relevant quitline services for Minnesota's AI/AN community.

METHODS

Working in partnership, AI/AN community input was gathered, and community partners were engaged to inform the development, training, implementation and monitoring of a tailored program within the existing state quitline.

RESULTS

Findings suggest focusing on the commercial tobacco user/coach relationship, increased cultural understanding and program content adaptations could make quitlines more acceptable for AI/AN commercial tobacco users.

CONCLUSIONS

The development and launch of the AI Quitline demonstrated the feasibility of collaboration among AI/AN organizations and community members, funders and providers to create a culturally relevant cessation service for AI/AN commercial tobacco users.

Engaging Smokeless Tobacco Users in Population-Based Cessation Services: Findings From an Observational Study

Although telephone quitlines are effective for helping smokeless tobacco (ST) users quit, ST users are underrepresented among quitline participants. After ClearWay MinnesotaSM implemented multiple changes to its quitline service (QUITPLAN® Services), utilization increased dramatically, including by ST users. We examined data from Minnesota and Wisconsin to determine whether these changes were unique to Minnesota. Four years of quitline registration data were analyzed for both states. A significant increase in enrollees reporting any ST use was seen in Minnesota after changes were made to services; no change was seen in Wisconsin. A 2-week starter kit of nicotine replacement therapy and the ability to register for services online were popular among Minnesotans reporting ST use. This study suggests that quitline services can be designed to increase participation by ST users.

Online Versus Telephone Registration: Differences in Quitline Participant Characteristics

INTRODUCTION

Although 72% of Internet users have searched for health information, online quitline registration is not universally available. In 2014, QUITPLAN Services (Minnesota's quitline) added options (Individual Services: 2-week nicotine-replacement therapy starter kit, text messaging, e-mail messaging, quit guide) to the existing Helpline (telephone counseling, nicotine-replacement therapy, integrated e-mails and texts, quit guide) and online registration for all programs. Demographic and quit outcome differences by registration mode (online versus telephone) and program type (Individual Services versus Helpline) were examined.

METHODS

A total of 4 years (March 2014-February 2018) of participants' registration and utilization data (N=55,817) were examined. Data were also studied from subsets of participants who completed the outcome evaluations conducted in 2014 (n=1,127) and 2017 (n=872). Select demographic and program use characteristics and quit outcomes were analyzed by registration method and stratified by program type. Associations between registration mode and quit outcomes were examined within program and adjusted for available covariates using 2017 outcome study data. Data were analyzed in 2019.

RESULTS

Overall, 65.8% of participants enrolled online, and 34.2% enrolled by telephone. Helpline participants were more likely to enroll by telephone than Individual Services participants (85.8% vs 25.3%). Younger adults were more likely to enroll online for either program type than older adults (p<0.001). No differences were found in 30-day point prevalence abstinence by registration mode within program after adjusting for covariates.

CONCLUSIONS

Online quitline registration has multiple benefits, including engaging younger tobacco users. Moreover, abstinence rates do not differ. Online registration may be particularly appropriate for nontelephone quitline services. Quitlines may wish to add online registration to capitalize on Internet use.

Projecting the future impact of past accomplishments in tobacco control

BACKGROUND

The benefits to adults who quit smoking increase over time as former smokers live longer, healthier lives. Youth who never smoke will benefit for decades. Thus, the long-term population effects of tobacco prevention and control policies may be substantial. Yet they are rarely quantified in evaluations of state tobacco control programmes.

METHODS

Using a microsimulation model, we predicted the benefits to Minnesotans from 2018 to 2037 of having reduced cigarette smoking prevalence from 1998 to 2017. We first simulated the health and economic harms of tobacco that would have occurred had smoking prevalence stayed at 1997 levels. The harms produced by that scenario were then compared with harms in scenarios with smoking declining at observed rates from 1998 to 2017 and either expected declines from 2018 to 2037 or a greater decline to 5% prevalence in 2037.

RESULTS

With expected smoking prevalence decreases from 2018 to 2037, Minnesotans will experience 12 298 fewer cancers, 72 208 fewer hospitalisations for cardiovascular disease and diabetes, 31 913 fewer respiratory disease hospitalisations, 14 063 fewer smoking-attributable deaths, $10.2 billion less in smoking-attributable medical expenditures and $9.4 billion in productivity gains than if prevalence had stayed at 1997 levels. These gains are two to four times greater than for the previous 20 years, and would be about 15% higher if Minnesota achieves a 5% adult prevalence rate by 2037.

CONCLUSIONS

The tobacco control measures implemented from 1998 to 2017 will produce accelerated benefits during 2018-2037 if modest progress in tobacco prevalence rates is maintained.

Utilizing Reach Ratios to Assess Menthol Cigarette Smoker Enrollment in Quitline Services

INTRODUCTION

Increasing the reach of evidence-based cessation services is a longstanding public health priority, especially for subgroups who may be most at risk. Little research has examined whether quitlines are reaching menthol cigarette smokers who may have increased difficulty quitting compared with nonmenthol cigarette smokers. This study aims to understand whether quitline services are reaching menthol cigarette smokers.

METHODS

The study sample included adult smokers enrolled in Minnesota's quitline program, QUITPLAN Services, between May 2017 and April 2018 (N=10,999). Cigarette smokers were asked about the usual cigarette type (menthol versus nonmenthol). Reach ratios were calculated by dividing the percentage of program enrollees who are menthol smokers by the percentage of Minnesota smokers who are menthol smokers. Differences in demographic, tobacco use, and utilization characteristics between menthol and nonmenthol smokers were assessed using chi-square and t-tests. Analyses were conducted in March 2019.

RESULTS

Among QUITPLAN Services enrollees, 30.7% of smokers reported using menthol cigarettes. The reach ratio was 1.12 (95% CI=0.99, 1.25). Menthol smokers were more likely to be younger, be female, be Black/African American, be Hispanic, and live in an urban area than nonmenthol smokers. Although menthol smokers were more likely than nonmenthol smokers to enroll in text messaging, no other significant differences in service utilization were found.

CONCLUSIONS

The findings suggest that menthol smokers are proportionately represented among quitline enrollees. State quitlines should assess menthol smoking status at intake and allocate resources to reach and better serve menthol smokers.

The 20-year impact of tobacco price and tobacco control expenditure increases in Minnesota, 1998-2017

Introduction

Tobacco control programs and policies reduce tobacco use and prevent health and economic harms. The majority of tobacco control programs and policies in the United States are implemented at local and state levels. Yet the literature on state-level initiatives reports a limited set of outcomes. To facilitate decision-making that is increasingly focused on costs, we provide estimates of a broader set of measures of the impact of tobacco control policy, including smoking prevalence, disease events, deaths, medical costs, productivity and tobacco tax revenues, using the experience of Minnesota as an example.

Methods

Using the HealthPartners Institute’s ModelHealth^™: Tobacco MN microsimulation, we assessed the impact of the stream of tobacco control expenditures and cigarette price increases from 1998 to 2017. We simulated 1.3 million individuals representative of the Minnesota population.

Results

The simulation estimated that increased expenditures on tobacco control above 1997 levels prevented 38,400 cancer, cardiovascular, diabetes and respiratory disease events and 4,100 deaths over 20 years. Increased prices prevented 14,600 additional events and 1,700 additional deaths. Both the net increase in tax revenues and the reduction in medical costs were greater than the additional investments in tobacco control.

Conclusion

Combined, the policies address both short-term and long-term goals to reduce the harms of tobacco by helping adults who wish to quit smoking and deterring youth from starting to smoke. States can pay for initial investments in tobacco control through tax increases and recoup those investments through reduced expenditures on medical care.

Replicating state Quitline innovations to increase reach: findings from three states

BACKGROUND

Reaching tobacco users is a persistent challenge for quitlines. In 2014, ClearWay Minnesota^SM changed its quitline services and media campaign, and observed substantial increases in reach and strong quit outcomes. Oklahoma and Florida implemented the same changes in 2015 and 2016. We examined whether the strategies used in Minnesota could be replicated with similar results.

METHODS

We conducted a cross-sectional observational study of Minnesota's QUITPLAN® Services, the Oklahoma Tobacco Helpline, and Florida's Quit Your Way program. Each program offers free quitline services to their state's residents. For each state, data were compared for 1 year prior to service changes to 1 year after services changed and promotions began. Registration and program utilization data from 21,918 (Minnesota); 64,584 (Oklahoma); and 141,209 (Florida) program enrollees were analyzed. Additionally, outcome study data from 1542 (Minnesota); 3377 (Oklahoma); and 3444 (Florida) program enrollees were analyzed. We examined treatment reach, satisfaction, 24-h quit attempts, 30-day point prevalence abstinence rates, select demographic characteristics, registration mode (post period only), and estimated number of quitters. Data were analyzed using χ² analyses and t-tests.

RESULTS

Treatment reach rates increased by 50.62% in Oklahoma, 66.88% in Florida, and 480.56% in Minnesota. Significant increases in the estimated number of quitters were seen, ranging from + 42.75% to + 435.90%. Statistically significant changes in other variables (satisfaction, 24-h quit attempts, 30-day point prevalence abstinence rates, gender, and race) varied by state. During the post period, participants' method of registration differed. Online enrollment percentages ranged from 19.44% (Oklahoma), to 54.34% (Florida), to 70.80% (Minnesota). In Oklahoma, 71.63% of participants enrolled by phone, while 40.71% of Florida participants and 26.98% of Minnesota participants enrolled by phone. Fax or electronic referrals comprised 8.92% (Oklahoma), 4.95% (Florida), and 2.22% (Minnesota) of program enrollees, respectively.

CONCLUSIONS

Changing quitline services and implementing a new media campaign increased treatment reach and the estimated number of participants who quit smoking in three states. Quitline funders and tobacco control program managers may wish to consider approaches such as these to increase quitline utilization and population health impact.

Changing patterns in E-cigarette use among Minnesota adults between 2014 and 2018

Minnesota has observed declining combustible tobacco use and a large increase in e-cigarette use among youth and young adults. Less is known about adult e-cigarette users' frequency of use, smoking status, use of flavors, and demographic differences. The Minnesota Adult Tobacco Survey (MATS) is a cross-sectional, random digit-dial telephone survey representative of Minnesotans aged 18 and over. MATS measured e-cigarette use in 2014 (N = 9304) and 2018 (N = 6065). In 2018, 6.0% of adult Minnesotans used an e-cigarette in the past 30 days; this was unchanged from 2014 (5.9%). While past 30-day e-cigarette use declined for current smokers (2014: 27.3%; 2018: 16.1% p < 0.001), it increased for never smokers (2014: 1.2%; 2018: 4.4% p < 0.001) and 18-24-year-olds (2014: 12.8%; 2018: 21.9% p = 0.001). Daily e-cigarette use increased from 2014 to 2018 for current smokers (p = 0.001), 25-44-year-olds (p < 0.001), females (p = 0.001), and those with a high-school education (p = 0.006). Among e-cigarette users in 2018, use of flavored e-cigarettes was associated with smoking status (p = 0.041), age (p < 0.001), and using e-cigarettes to quit smoking (p = 0.011). E-cigarettes appeal primarily to younger adults. Of concern are increases in never smokers initiating e-cigarette use, increasing their exposure to nicotine, addiction, and the risk of future combustible tobacco use. Simultaneously, fewer smokers are using e-cigarettes but those who do are using them more frequently. Use of flavored e-cigarettes was common and correlated with interest in quitting combustible cigarettes. These findings can inform recent calls for additional tobacco control policy and programs aimed at reducing e-cigarette use.

Financial incentives and proactive calling for reducing barriers to tobacco treatment among socioeconomically disadvantaged women: A factorial randomized trial

Improved strategies and scalable interventions to engage low-socioeconomic status (SES) smokers in tobacco treatment are needed. We tested an intervention designed to connect low-SES smokers to treatment services, implemented through Minnesota's National Breast and Cervical Cancer Early Detection Program (Sage) in 2017; the trial was designed to last 3 months (July through October). Participants were female smokers who were 250% below the federal poverty level (randomized N = 3723; analyzed N = 3365). Using a factorial design, participants were randomized to six intervention groups consisting of a proactive call (no call vs call) and/or a financial incentive offered for being connected to treatment services ($0 vs $10 vs $20). Simple randomization was conducted using Stata v.13. All individuals received direct mail. Participants and staff were blinded to allocation. The outcome was connection via phone to QUITPLAN Services®, Minnesota's population-based cessation services. Groups that received $10 or $20 incentives had higher odds of treatment engagement compared to the no incentive group [respectively, OR = 1.94; 95% CI (1.19-3.14); OR = 2.18; 95% CI (1.36-3.51)]. Individuals that received proactive calls had higher odds of treatment engagement compared to individuals not called [OR = 1.59; 95% CI (1.11-2.29)]. Economic evaluation revealed that the $10 incentive, no call group had the best cost-benefit ratio compared to the no incentive, no call group. Direct mail with moderate incentives or proactive calling can successfully encourage connections to population-based tobacco treatment services among low-SES smokers. The intervention could be disseminated to similar programs serving low-SES populations. This trial is registered at ClinicalTrials.gov (NCT03760107).

Support person interventions to increase use of quitline services among racially diverse low-income smokers: A pilot study

INTRODUCTION

Social support from nonsmokers may have a role in prompting smokers to use evidence-based cessation treatment. Prior studies found that an intervention for nonsmoking support persons (SPs) was effective for promoting smokers' use of free, state quitline services. This pilot study adapted and assessed feasibility of this intervention for a racially diverse, low-income population.

METHODS

Single group, non-randomized design enrolling SP-smoker dyads with low income status enrolled in one of three study "waves" of 10 pairs each. Participants were recruited using flyers and in-person outreach methods. The SP intervention included a 1-session coaching call and written materials; study waves 2 and 3 also included text messaging and a monetary incentive for smokers who used quitline services. Using content analysis, the intervention was iteratively adapted based on SP feedback. Baseline measures assessed socio-demographics, dyad and tobacco use characteristics. Follow-up assessments were conducted among SPs at 1-month follow-up and among smokers at 3-months follow-up. Feasibility indicators were recruitment, retention, and SP intervention acceptability and adherence. Secondary outcomes were smokers' use of any quitline service verified by quitline staff and 7-day, point prevalence, biochemically verified smoking abstinence at 3 months.

RESULTS

Recruitment of 30 dyads was feasible; in-person recruitment methods were the most successful. SPs who completed follow-up assessments found the intervention acceptable, suggesting only minor content modifications, and they perceived the quitline information as novel. But the study had some feasibility challenges (e.g., SP coaching call completion: 60% and SP study retention: 53%). At 3 months, 2 smokers (7%) had used any quitline service and 13% were biochemically confirmed smoking abstinent.

CONCLUSIONS

This pilot study demonstrated feasibility of recruiting SP-smoker dyads from diverse, low-income communities. While the intervention was well received, its delivery was not feasible in this population. Results suggest that further consumer adaptation of the intervention is needed among both SPs and smokers.

Impact and Effectiveness of a Stand-Alone NRT Starter Kit in a Statewide Tobacco Cessation Program

PURPOSE

To examine 2-week nicotine replacement therapy (NRT) starter kit quit outcomes and predictors and the impact of adding this new service on treatment reach.

DESIGN

Observational study of a 1-year cohort of QUITPLAN Services enrollees using registration and utilization data and follow-up outcome survey data of a subset of enrollees who received NRT starter kits.

SETTING

ClearWay Minnesota's QUITPLAN Services provides a quit line that is available to uninsured and underinsured Minnesotans and NRT starter kits (a free 2-week supply of patches, gum, or lozenges) that are available to all Minnesota tobacco users.

PARTICIPANTS

A total of 15 536 adult QUITPLAN Services enrollees and 818 seven-month follow-up survey NRT starter kit respondents.

MEASURES

Treatment reach for all services and tobacco quit outcomes and predictors for starter kit recipients.

ANALYSIS

Descriptive analyses, χ² analyses, and logistic regression.

RESULTS

Treatment reach increased 3-fold after adding the 2-week NRT starter kit service option to QUITPLAN Services compared to the prior year (1.86% vs 0.59%). Among all participants enrolling in QUITPLAN services during a 1-year period, 83.8% (13 026/15 536) registered for a starter kit. Among starter kit respondents, 25.6% reported being quit for 30 days at the 7-month follow-up. After controlling for other factors, using all NRT and selecting more cessation services predicted quitting.

CONCLUSION

An NRT starter kit brought more tobacco users to QUITPLAN services, demonstrating interest in cessation services separate from phone counseling. The starter kit produced high quit rates, comparable to the quit line in the same time period. Cessation service providers may want to consider introducing starter kits to reach more tobacco users and ultimately improve population health.

Increasing reach by offering choices: Results from an innovative model for statewide services for smoking cessation

Although state quitlines provide free telephone counseling and often include nicotine replacement therapy (NRT), reach remains limited (1-2% in most states). More needs to be done to engage all smokers in the quitting process. A possible strategy is to offer choices of cessation services through quitlines and to reduce registration barriers. In March 2014, ClearWay Minnesota^SM implemented a new model for QUITPLAN® Services, the state's population-wide cessation services. Tobacco users could choose the QUITPLAN® Helpline or one or more Individual QUITPLAN® Services (NRT starter kit, text messaging, email program, or quit guide). The program website was redesigned, online enrollment was added, and a new advertising campaign was created and launched. In 2014-2015, we evaluated whether these changes increased reach. We also assessed quit attempts, quit outcomes, predictors of 30-day abstinence, and average cost per quit via a seven-month follow-up survey. Between March 2014-February 2015, 15,861 unique tobacco users registered, which was a 169% increase over calendar year 2013. The majority of participants made a quit attempt (83.7%). Thirty-day point prevalence abstinence rates (responder rates) were 26.1% for QUITPLAN Services overall, 29.6% for the QUITPLAN Helpline, and 25.5% for Individual QUITPLAN Services. Several variables predicted quit outcomes, including receiving only one call from the Helpline and using both the Helpline and the NRT starter kit. Providing greater choice of cessation services and reducing registration barriers have the potential to engage more tobacco users, foster more quit attempts, and ultimately lead to long-term cessation and reductions in prevalence.

Seizing an opportunity: increasing use of cessation services following a tobacco tax increase

Background

Tobacco tax increases are associated with increases in quitline calls and reductions in smoking prevalence. In 2013, ClearWay Minnesota^SM conducted a six-week media campaign promoting QUITPLAN® Services (QUITPLAN Helpline and quitplan.com) to leverage the state’s tax increase. The purpose of this study was to ascertain the association of the tax increase and media campaign on call volumes, web visits, and enrollments in QUITPLAN Services.

Methods

In this observational study, call volume, web visits, enrollments, and participant characteristics were analyzed for the periods June–August 2012 and June–August 2013. Enrollment data and information about media campaigns were analyzed using multivariate regression analysis to determine the association of the tax increase on QUITPLAN Services while controlling for media.

Results

There was a 160% increase in total combined calls and web visits, and an 81% increase in enrollments in QUITPLAN Services. Helpline call volumes and enrollments declined back to prior year levels approximately six weeks after the tax increase. Visits to and enrollments in quitplan.com also declined, but increased again in mid-August. The tax increase and media explained over 70% of variation in enrollments in the QUITPLAN Helpline, with media explaining 34% of the variance and the tax increase explaining an additional 36.1% of this variance. However, media explained 64% of the variance in quitplan.com enrollments, and the tax increase explained an additional 7.6% of this variance.

Conclusions

Since tax increases occur infrequently, these policy changes must be fully leveraged as quickly as possible to help reduce prevalence.

Facilitators of health systems change for tobacco dependence treatment: a qualitative study of stakeholders' perceptions

Background

Health systems play key roles in identifying tobacco users and providing evidence-based care to help them quit. Health systems change – changes to health care processes, policies and financing – has potential to build capacity within these systems to address tobacco use. In 2010, ClearWay Minnesota^SM piloted a health systems change funding initiative, providing resources and technical assistance to four health care systems. This paper presents findings from a process evaluation, describing key stakeholders’ views on whether changes to how health systems treat tobacco use resulted from this initiative and what may have facilitated those changes.

Methods

A process evaluation was conducted by an independent evaluation firm. A qualitative case study approach provided understanding of systems change efforts. Interviews were conducted with key informants representing the health systems, funder and technical assistance providers. Core documents were reviewed and compared to thematic analysis from the interviews. Results were triangulated with existing literature to check for convergence or divergence. A cross-case analysis of the findings was conducted in which themes were compared and contrasted.

Results

All systems created and implemented well-defined written tobacco use screening, documentation and treatment referral protocols for every patient at every visit. Three implemented systematic follow-up procedures for patients referred to treatment, and three also implemented changes to electronic health records systems to facilitate screening, referral and reporting. Fax referral to quitline services was implemented or enhanced by two systems. Elements that facilitated successful systems changes included capitalizing on environmental changes, ensuring participation and support at all organizational levels, using technology, establishing ongoing training and continuous quality improvement mechanisms and leveraging external funding and technical assistance.

Conclusions

This evaluation demonstrates that health systems can implement substantial changes to facilitate routine treatment of tobacco dependence in a relatively short timeframe. Implementing best practices like these, including increased emphasis on the implementation and use of electronic health record systems and healthcare quality measures, is increasingly important given the changing health care environment. Lessons learned from this project can be resources for states and health systems likely to implement similar systems changes.

Enhancing tobacco quitline effectiveness: identifying a superior pharmacotherapy adjuvant

INTRODUCTION

Telephone tobacco quitlines are effective and are widely used, with more than 500,000 U.S. callers in 2010. This study investigated the clinical effectiveness and cost-effectiveness of 3 different quitline enhancements: combination nicotine replacement therapy (NRT), longer duration of NRT, and counseling to increase NRT adherence.

METHODS

In this study, 987 quitline callers were randomized to a combination of quitline treatments in a 2 × 2 × 2 factorial design: NRT duration (2 vs. 6 weeks), NRT type (nicotine patch only vs. patch plus nicotine gum), and standard 4-call counseling (SC) versus SC plus medication adherence counseling (MAC). The primary outcome was 7-day point-prevalence abstinence (PPA) at 6 months postquit in intention-to-treat (ITT) analyses.

RESULTS

Combination NRT for 6 weeks yielded the highest 6-month PPA rate (51.6%) compared with 2 weeks of nicotine patch (38.4%), odds ratios [OR] = 1.71 (95% confidence interval [CI]:1.20-2.45). A similar result was found for 2 weeks of combination NRT (48.2%), OR = 1.49 (95% CI: 1.04-2.14) but not for 6 weeks of nicotine patch alone (46.2%), OR = 1.38 (95% CI: 0.96-1.97). The MAC intervention effect was nonsignificant. Cost analyses showed that the 2-week combination NRT group had the lowest cost per quit ($442 vs. $464 for 2-week patch only, $505 for 6-week patch only, and $675 for 6-week combination NRT).

CONCLUSIONS

Combination NRT for 2 or 6 weeks increased 6-month abstinence rates by 10% and 13%, respectively, over rates produced by 2 weeks of nicotine patch when offered with quitline counseling. A 10% improvement would potentially yield an additional 50,000 quitters annually, assuming 500,000 callers to U.S. quitlines per year.

Minnesota's smokefree policies: impact on cessation program participants

BACKGROUND

Smokefree policies are enacted to protect individuals from secondhand smoke; however, these laws may have broader cessation effects.

PURPOSE

This study investigated the relationship between Minnesota's local and statewide smokefree policies and quitting outcomes among cessation program enrollees.

METHODS

Data were collected from 2006 to 2008 from two groups of participants (n=1644 pre-statewide law; n=1273 post-statewide law) and analyzed in 2009. Website enrollees were surveyed by Internet or telephone 6 months post-enrollment. Others were surveyed by telephone 7 months post-enrollment.

RESULTS

Those who enrolled in a cessation program after the statewide smokefree law were more likely to quit (p<0.05, relative risk [RR]=1.15) and were predicted to achieve a 30-day abstinence rate 4.1 percentage points greater than that achieved by those who quit pre-statewide law (30.9% vs 26.8%, respectively). Participants who quit post-statewide law were less likely to relapse and were predicted to have a relapse rate 6.4 percentage points below those who quit pre-statewide law (p<0.05, RR=0.87). Each additional year residing in or adjacent to a county with a local smokefree ordinance in place, up until the time of the statewide law, reduced the likelihood of achieving abstinence post-statewide law (p<0.001, RR=0.92) and increased the likelihood of relapse and the predicted relapse rate (p<0.05, RR=1.05).

CONCLUSIONS

Abstinence and relapse rates for those enrolling in cessation programs appeared more favorable after the implementation of Minnesota's statewide smokefree law, suggesting that smokefree policies may have a small but beneficial impact on cessation outcomes. Previous exposure to local smokefree ordinances may lessen this effect.

Experience of smokers and recent quitters with smokefree regulations and quitting

BACKGROUND

Bans on smoking in public areas have increased as knowledge of secondhand smoke dangers has grown. Restrictions on smoking in public areas may lead to less smoking and increased quitting.

PURPOSE

This study examines the experiences of smokers and recent quitters with local smokefree regulations to better understand the possible mechanisms by which smokefree regulations affect individual tobacco users' patterns of tobacco consumption and quitting.

METHODS

Fifteen in-depth interviews and thirteen focus groups were conducted with tobacco users and recent quitters formerly enrolled in cessation programs provided by ClearWay Minnesota(SM). Data were collected 3 months after smokefree legislation was adopted in the Minneapolis/St. Paul metropolitan area in 2006, and were stratified by tobacco use status and strength of regulation. Essential themes were extracted using NVivo 8 software in 2011.

RESULTS

Study participants reported that smokefree legislation forced them to confront their addiction. They experienced apprehension, frustration, and panic anticipating smoking restrictions. This motivated some to attempt to quit, whereas others felt punished by and angry at government intrusion. Both current and former tobacco users felt smokefree regulations contributed to stigmatizing smokers. They also reported smokefree legislation reduced the temptation to smoke. The physical absence of cigarette smoke in bars and restaurants appeared to support quit attempts. The inconvenience of smoking outside was reported to have a similar effect.

CONCLUSIONS

Essential mechanisms by which bans influenced patterns of tobacco use and quitting include confronting addiction, temptation, inconvenience, and social norms. These findings highlight the success of tobacco control advocates in denormalizing tobacco use, and suggest that some tobacco users may be internalizing negative messages about tobacco.

Increasing consumer demand among Medicaid enrollees for tobacco dependence treatment: the Wisconsin "Medicaid covers it" campaign

PURPOSE

Smoking prevalence among Medicaid enrollees is higher than among the general population, but use of evidence-based cessation treatment is low. We evaluated whether a communications campaign improved cessation treatment utilization.

DESIGN

Quasi-experimental.

SETTING

Wisconsin.

SUBJECTS

Enrollees in the Wisconsin Family Medicaid program. The average monthly enrollment during the study period was approximately 170,000 individuals.

INTERVENTION

Print materials for clinicians and consumers distributed to 13 health maintenance organizations (HMOs) serving Wisconsin Medicaid HMO enrollees.

MEASURES

Wisconsin Medicaid pharmacy claims data for smoking cessation medications were analyzed before and after a targeted communications campaign. HMO enrollees were the intervention group. Fee-for-service enrollees were a quasi-experimental comparison group. Quit Line utilization data were also analyzed.

ANALYSIS

Pharmacotherapy claims and number of registered Quit Line callers were compared precampaign and postcampaign.

RESULTS

Precampaign, cessation pharmacotherapy claims declined for the intervention group and increased slightly for the comparison group (t  =  2.29, p  =  .03). Postcampaign, claims increased in both groups. However, the rate of increase in the intervention group was significantly greater than in the comparison group (t  =  -2.2, p  =  .04). A statistically significant increase was also seen in the average monthly number of Medicaid enrollees that registered for Quit Line services postcampaign compared to precampaign (F [1,22]  =  7.19, p  =  .01).

CONCLUSION

This natural experiment demonstrated statistically significant improvements in both pharmacotherapy claims and Quit Line registrations among Medicaid enrollees. These findings may help inform other states' efforts to improve cessation treatment utilization.

State-level factors influencing tobacco cessation quitline spending in 2008

Tobacco cessation quitlines are an effective population-based smoking cessation treatment. However, quitline funding varies widely. Analyzing state-level factors may help explain these differences. We used data from the North American Quitline Consortium's 2008 survey of state quitlines and U.S. Census estimates to calculate per capita spending on quitline services. Publicly available data sources were used to identify demographic, tobacco use, tobacco control spending, and political and economic climate variables for the analysis. Linear regression analyses were used to identify potential predictors of per capita quitline services budgets in 2008. States with a greater percentage of their population with at least a high school degree, and states that spent more per capita on tobacco control programs overall, spent more per capita on quitline services (p > 0.05). In multivariate analysis, only per capita tobacco control expenditures was statistically significant (β=0.73, p =0.00, 95%CI 0.11-0.19). It appears that per capita tobacco control expenditures is the most consistent predictor of state per capita quitline expenditures. Additional research into whether and how state-level factors influence quitline funding levels is needed to allow advocates and policy-makers to understand better how to advocate for ongoing support of these population-based services.

Closing tobacco-related disparities: Using community organizations to increase consumer demand

BACKGROUND

Individuals living in poverty are more likely to smoke, and they suffer disproportionately from tobacco use. Strategies used to deliver tobacco-cessation interventions often fail to reach smokers living in poverty. Providing tobacco interventions to smokers when they present to community organizations is a potential strategy, but the acceptability and effectiveness of such interventions is unknown.

METHODS

In this 2007 pilot study, 295 smokers seeking emergency assistance from the Salvation Army in Wisconsin were randomly assigned to either a very brief (30-second) smoking intervention condition or to a control no-intervention condition. All participants completed a follow-up survey at the end of their visit assessing their satisfaction with the community agency, interest in quitting, and motivation to quit.

RESULTS

This brief intervention increased the likelihood that smokers would seek help when they decided to quit (61% vs 44%, p<0.05) but did not affect intention to quit in the next 6 months or perceived difficulty of quitting. The intervention was well received by both participants and Salvation Army staff.

CONCLUSIONS

Smokers in this pilot study found it acceptable to have their smoking addressed when seeking services from a community agency. Such interventions may need to be more intense than the one used in this study in order to achieve the goal of increased motivation to quit. Community agencies should consider including brief tobacco-dependence interventions as a secondary mission to improve their clients' health.

Creating a perfect storm to increase consumer demand for Wisconsin's Tobacco Quitline

BACKGROUND

Telephone quitlines are a clinically proven and cost-effective population-wide tobacco-dependence treatment, and this option is now available in all 50 states. Yet, only 1% of the smoking population accesses these services annually. This report describes a series of policy, programmatic, and communication initiatives recently implemented in Wisconsin that resulted in a dramatic increase in consumer demand for the Wisconsin Tobacco Quitline (WTQL).

INTERVENTION

In 2007, the Wisconsin legislature voted to increase the state cigarette excise tax rate by $1.00, from $0.77/pack to $1.77/pack effective January 1, 2008. In preparation for the tax increase, the Wisconsin Tobacco Prevention and Control Program, the University of Wisconsin Center for Tobacco Research and Intervention, which manages the WTQL, and the state's quitline service provider, Free & Clear, Inc., collaborated to enhance quitline knowledge, availability, and services with the goal of increasing consumer demand for services. The enhancements included for the first time, a free 2-week supply of over-the-counter nicotine replacement medication for tobacco users who agreed to receive multi-session quitline counseling. A successful statewide earned media campaign intensified the impact of these activities, which were timed to coincide with temporal smoking-cessation behavioral patterns (i.e., New Year's resolutions).

RESULTS

As a result, the WTQL fielded a record 27,000 calls during the first 3 months of 2008, reaching nearly 3% of adult Wisconsin smokers.

CONCLUSIONS

This experience demonstrates that consumer demand for quitline services can be markedly enhanced through policy and communication initiatives to increase the population reach of this evidence-based treatment.

Changes in tobacco quitlines in the United States, 2005-2006

INTRODUCTION

Telephone quitlines are an effective way to provide evidence-based tobacco dependence treatment services at the population level. Information about what services quitlines offer and how those services are used may improve their reach to the smoking population.

METHODS

The North American Quitline Consortium surveyed state quitlines in 2005 and 2006 to get information about quitline services, funding, and use. We report changes between 2005 and 2006.

RESULTS

By 2006, all 50 states, the District of Columbia, and Puerto Rico had quitlines, and annual mean reach was approximately 1% of US adult smokers (aged 18 years or older). Significant increases were seen in mean quitline reach, mean per capita funding for quitline services, and provision of free cessation medications; otherwise, few changes were seen in quitline services.

CONCLUSION

Quitlines have the potential to serve a large percentage of smokers. Between 2005 and 2006, gains in the number, reach, and per capita funding for quitline services in the United States were seen. Although this represents progress, further research and investment to optimize quitline service delivery and reach are required for quitlines to fulfill their potential of improving the health of the American population.

Tobacco cessation quitline spending in 2005 and 2006: what state-level factors matter?

Tobacco cessation telephone quitlines are an effective population-wide strategy for smoking cessation, but funding for this service varies widely. State-level factors may explain this difference. Data from the 2005 and 2006 North American Quitline Consortium surveys and from publicly available sources were analyzed to identify factors that predict higher levels of per capita quitline funding. The best-fitting multivariate model comprised higher per capita tobacco control funding (2005 p = 0.004, 2006 p=0.000), not securitizing Master Settlement Agreement payments (2005 p = 0.008, 2006 p=0.01), and liberal political ideology (2005 p = 0.002, 2006 p=0.002). Select state-level factors appear to have influenced per capita quitline services funding. These findings can help inform advocates and policymakers as they advocate for quitlines and tobacco control funding.

The role of health care systems in increased tobacco cessation

Health care delivery systems are critical components of tobacco cessation efforts. This review summarizes recent evidence in support of the health care system recommendations in the 2000 U.S. Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence. Measurable progress in addressing tobacco use through the health care system is summarized, including accountabilities for addressing tobacco in national health care reporting systems, increases in reported advice to quit smoking from health care providers, and wider availability of insurance coverage for tobacco cessation treatments. Despite progress, significant gaps remain between what is possible and what is done by health care systems to impact tobacco cessation. A four-point public policy agenda is outlined to help close these gaps.

Health system changes to facilitate the delivery of tobacco-dependence treatment

In 1996, the Agency for Health Care Policy and Research (AHCPR, now AHRQ, the Agency for Healthcare Research and Quality) released the first federal clinical practice guideline for smoking cessation that was updated in 2000 by the United States Public Health Service (USPHS). The innovative guideline identified six evidence-based strategies for healthcare systems to facilitate the institutionalization of tobacco dependence treatment so that smokers received evidence-based treatments as a routine part of health care. A growing body of evidence demonstrates the importance of systems approaches. This paper discusses the evidence for the systems-level strategies outlined in the guidelines, as well as future directions and needed systems-level research. Promising strategies include: (1) clinical systems organized to cue assessment of smoking status and assistance to smokers, (2) leveraging clinical information systems to provide performance feedback, (3) providing full insurance coverage for evidence-based cessation treatment, and (4) including tobacco-cessation treatment as a measured standard of care by national accreditation organizations. These systems-level approaches increase the likelihood that tobacco use is addressed systematically in the healthcare delivery system. Further research to optimize the effectiveness and adoption of these strategies will help ensure that patients receive evidence-based interventions that foster tobacco-use cessation.

Do state characteristics matter? State level factors related to tobacco cessation quitlines

BACKGROUND

Quitline services are an effective population-wide tobacco cessation strategy adopted widely in the United States as part of state comprehensive tobacco control efforts. Despite widespread evidence supporting quitlines' effectiveness, many states lack sufficient financial resources to adequately fund and promote this service. Efforts to augment state tobacco control efforts might be fostered by greater knowledge of state level factors associated with the funding and implementation of those efforts.

METHODS

We analysed data from the 2004 North American Quitline Consortium survey and from publicly available sources to identify state level factors related to quitline implementation and funding. Factors included in the analyses were state demographic characteristics, tobacco use variables, state tobacco control spending, and economic and political climate variables. Univariate and multivariate regression analyses were conducted.

RESULTS

The best fitting multivariate model that significantly predicted the presence or absence of a state quitline included only cigarette excise tax rate (p = 0.020). In terms of funding levels, states with high rates of cigarette consumption (p = 0.047) and with higher per capita expenditures for tobacco control programmes (p = 0 .0.004) were most likely to spend more on per capita operations budget for quitlines.

CONCLUSION

State level factors appear to play a part in whether states had established quitlines by mid-2004 and the amount of per capita quitline funding.

Corticotropin releasing hormone--a GPCR drug target

Corticotrophin Releasing Hormone (CRH) is a primary hormone in the fight or flight response targeting a membrane bound G-protein coupled receptor (GPCR). Many people worldwide stand to benefit by the development of CRH agonists and antagonists for the treatment of anxiety and depression, with additional therapeutic targets including Alzheimer's, pain and the prevention of premature birth: so why the delay in development? In this review, we will discuss not only CRH, related proteins, receptors and ligands, but some of the obstacles that have arisen, as well as strategies being pursued to overcome these problems in the pursuit of this GPCR targeted therapeutic. Several key proteins influence the complex and intrinsic regulation of CRH, including its receptors (CRHR), of which 3 types have been categorised, CRHR(1), CRHR(2), CRHR(3), each containing active and inactive splice variants. Additionally, the CRH binding protein (CRHBP) is believed to moderate the effects of CRH at the receptor, whether it is as a molecular mop, or a delivery vessel, or both, is still being investigated. Homology based receptor modelling is a technique that has only recently become available with the crystallisation of bovine rhodopsin (a GPCR), [1] and the application of this technique to the CRH receptors is still in the early stages of development. Therefore, the medicinal chemist has previously had to rely on ligand-based strategies, specifically, the development of pharmacophores. Thus, an extensive number of both CRH peptide analogues and small ligands that show nanomolar antagonism have been developed with SAR libraries being integral to the iterative drug design process.

Control of HIV Through the Inhibition of HIV-1 Integrase: A Medicinal Chemistry Perspective

This article reviews the current status of classes of HIV-1 integrase enzyme inhibitors. These classes include peptide-based inhibitors, natural products, polyhydroxylated aromatics, diketo acids, naphthyridines, and sulfonated compounds including sulfonic acids. Discussions of structure activity relationships are presented and include the current overview of the structure-based model, suitable for the further design and development. To date, the advances in the medicinal chemistry of HIV-1 integrase inhibitors have relied mostly on ligand-based designs leading to most displaying similar binding interactions within the active site or at the dimer interface. This paves the way for single enzyme mutations rendering entire compound classes inactive and thus, the requirement for second and third generation inhibitors with novel modes of binding is apparent. To facilitate future structure-based drug design efforts, a model of the biologically relevant structure of the HIV-1 integrase enzyme, a dimer of dimers has also been discussed.

Organization, financing, promotion, and cost of U.S. quitlines, 2004

BACKGROUND

Quitlines have been established as an effective, evidence-based, population-wide strategy to deliver smoking-cessation treatment, and are now available in most states across America. However, little is known about the organization, financing, promotion, and cost of state quitlines.

METHODS

In 2004, the North American Quitline Consortium surveyed the 50 states and Washington DC to obtain information about state quitlines. Data were analyzed in fall 2005 through spring 2006. Analyses of these data are reported in this paper.

RESULTS

Analyses were limited to the 38 states that reported having a quitline in 2004. State governments funded most (89.5%) quitlines. Median state quitline operating budgets in 2004 were 500,000 dollars; this translates into a modest annual median operating cost of 0.14 dollar per capita or 0.85 dollar per adult smoker. A lesser amount was spent for quitline promotion. Quitline services varied, with 97.4% of respondents providing mailed self-help resources, 89.5% providing proactive telephone counseling, and 89.2% providing referrals to other services. Many quitlines provide services in languages other than English. Only 21.1% of quitlines reported providing cessation medication at no cost. Promotional strategies varied widely.

CONCLUSION

A large majority of U.S. smokers live in states with tobacco quitlines, which provide cessation treatment at a remarkably modest per capita cost. There is a great deal of congruence in services and promotional strategies among states. Further research is required to determine how external factors such as the federal National Network of Tobacco Cessation Quitlines funding for state quitlines and the availability of a national portal number (1-800-QUITNOW), both implemented in 2004, affect state quitlines. Additional research to evaluate the cost effectiveness of quitline services is also warranted.

Increasing uncoupling protein-2 in pancreatic beta cells does not alter glucose-induced insulin secretion but decreases production of reactive oxygen species

AIMS/HYPOTHESIS

Levels of uncoupling protein-2 (UCP2) are regulated in the pancreatic beta cells and an increase in the protein level has been associated with mitochondrial uncoupling and alteration in glucose-stimulated insulin secretion. However, it is not clear whether an increase in uncoupling protein-2 per se induces mitochondrial uncoupling and affects ATP generation and insulin secretion.

MATERIALS AND METHODS

Transgenic mice with beta cell-specific overexpression of the human UCP2 gene and INS-1 cells with doxycycline-inducible overproduction of the protein were generated and the consequences of increased levels of UCP2 on glucose-induced insulin secretion and on parameters reflecting mitochondrial uncoupling were determined.

RESULTS

In transgenic mice, an increase in beta cell UCP2 protein concentration did not significantly modify plasma glucose and insulin levels. Glucose-induced insulin secretion and elevation in the ATP/ADP ratio were unaltered by an increase in UCP2 level. In INS-1 cells, a similar increase in UCP2 level did not modify glucose-induced insulin secretion, cytosolic ATP and ATP/ADP ratio, or glucose oxidation. Increased levels of UCP2 did not modify the mitochondrial membrane potential and oxygen consumption. Increased UCP2 levels decreased cytokine-induced production of reactive oxygen species.

CONCLUSION/INTERPRETATION

The results obtained in transgenic mice and in the beta cell line do not support the hypothesis that an increase in UCP2 protein per se uncouples the mitochondria and decreases glucose-induced insulin secretion. In contrast, the observation that increased UCP2 levels decrease cytokine-induced production of reactive oxygen species indicates a potential protective effect of the protein on beta cells, as observed in other cell types.

Fax to quit: a model for delivery of tobacco cessation services to Wisconsin residents

Research has shown that proactive tobacco cessation quitlines are effective in increasing quit rates 4-fold, compared to quitting with no counseling support. In Wisconsin, the state-funded Wisconsin Tobacco Quit Line has documented a quit rate of 22%, with an estimated 6700 individuals quitting as a result of receiving Quit Line services. Since its launch in 2001, the Wisconsin Tobacco Quit Line has assisted more than 36,000 callers. Until recently, quitline call volume has been highly dependent on paid media campaigns-an expensive, episodic, and often politically difficult strategy to fund at the state level. To foster and sustain quitline use and assist health care professionals in helping their patients successfully quit, the University of Wisconsin Center for Tobacco Research and Intervention (UW-CTRI) developed the "Fax to Quit" program in March 2003. The model involves close collaboration between UW-CTRI and health care delivery systems who train their staff and integrate a quitline referral system into their regular delivery of health care for smokers who are interested in having the quitline contact them. This paper examines the extent to which this approach has been adopted by health care providers in Wisconsin. The potential is for this to become a key component of an integrated tobacco dependence treatment.

Preventing 3 million premature deaths and helping 5 million smokers quit: a national action plan for tobacco cessation

In August 2002, the Subcommittee on Cessation of the Interagency Committee on Smoking and Health (ICSH) was charged with developing recommendations to substantially increase rates of tobacco cessation in the United States. The subcommittee's report, A National Action Plan for Tobacco Cessation, outlines 10 recommendations for reducing premature morbidity and mortality by helping millions of Americans stop using tobacco. The plan includes both evidence-based, population-wide strategies designed to promote cessation (e.g., a national quitline network) and a Smokers' Health Fund to finance the programs (through a 2 US dollar per pack excise tax increase). The subcommittee report was presented to the ICSH (February 11, 2003), which unanimously endorsed sending it to Secretary Thompson for his consideration. In this article, we summarize the national action plan.

E-MSD: an integrated data resource for bioinformatics

The Macromolecular Structure Database (MSD) group (http://www.ebi.ac.uk/msd/) continues to enhance the quality and consistency of macromolecular structure data in the Protein Data Bank (PDB) and to work towards the integration of various bioinformatics data resources. We have implemented a simple form-based interface that allows users to query the MSD directly. The MSD 'atlas pages' show all of the information in the MSD for a particular PDB entry. The group has designed new search interfaces aimed at specific areas of interest, such as the environment of ligands and the secondary structures of proteins. We have also implemented a novel search interface that begins to integrate separate MSD search services in a single graphical tool. We have worked closely with collaborators to build a new visualization tool that can present both structure and sequence data in a unified interface, and this data viewer is now used throughout the MSD services for the visualization and presentation of search results. Examples showcasing the functionality and power of these tools are available from tutorial webpages (http://www. ebi.ac.uk/msd-srv/docs/roadshow_tutorial/).

The prevention of preterm labour -- corticotropin releasing hormone type 1 receptors as a target for drug design and development

The role of the corticotropin releasing hormone in the onset of labour and the subsequent medicinal chemistry implications of CRH antagonists for the prevention of premature birth, and identification of the CRH type 1 receptor as the target for this drug design, are reviewed here.

E-MSD: the European Bioinformatics Institute Macromolecular Structure Database

The E-MSD macromolecular structure relational database (http://www.ebi.ac.uk/msd) is designed to be a single access point for protein and nucleic acid structures and related information. The database is derived from Protein Data Bank (PDB) entries. Relational database technologies are used in a comprehensive cleaning procedure to ensure data uniformity across the whole archive. The search database contains an extensive set of derived properties, goodness-of-fit indicators, and links to other EBI databases including InterPro, GO, and SWISS-PROT, together with links to SCOP, CATH, PFAM and PROSITE. A generic search interface is available, coupled with a fast secondary structure domain search tool.

A rural mental health research agenda: defining context and setting priorities

This article provides a brief overview of research perspectives on rural mental health services and suggests the importance of building an agenda to bring coherence to studies in this area. The need for sound theory and methodology to guide research is emphasized. The importance of better conceptualization of the rural context as a focus of research is addressed, and 14 propositions concerning issues the authors think will advance rural research are presented. This article is intended to stimulate discussion about a research agenda that will lead to better understanding of rural needs for mental health services as well as more responsive service models.

Changes in smooth muscle cell pH during hypoxic pulmonary vasoconstriction: a possible role for ion transporters

Hypoxic pulmonary vasoconstriction (HPV) occurs in smooth muscle cells (SMC) from small pulmonary arteries (SPA) and is accompanied by increases in free cytoplasmic calcium ([Ca2+]i) and cytoplasmic pH (pHi). SMC from large pulmonary arteries (LPA) relax during hypoxia, and [Ca2+]i and pHi decrease. Increases in pHi and [Ca2+]i in cat SPA SMC during hypoxia and the augmentation of hypoxic pulmonary vasoconstriction by alkalosis seen in isolated arteries and lungs suggest that cellular mechanisms, which regulate inward and outward movement of Ca2+ and H+, may participate in the generation of HPV. SMC transport systems that regulate pHi include the Na+ - H+ transporter which regulates intracellular Na+ and H+ and aids in recovery from acid loads, and the Na+ -dependent and Na+ -independent Cl-/HCO3- transporters which regulate intracellular chloride. The Na+ -dependent Cl-/HCO3- transporter also aids in recovery from acidosis in the presence of CO2 and HCO3-. The Na+ -independent Cl-/HCO3- transporter aids in recovery from cellular alkalosis. The Na+ - H+ transporter was present in SMC from SPA and LPA of the cat, but it seemed to have little if any role in regulating pHi in the presence of CO2 and HCO3-. Inhibiting the Cl-/HCO3- transporters reversed the normal direction of pHi change during hypoxia, suggesting a role for these transporters in the hypoxic response. Future studies to determine the interaction between pHi, [Ca2+]i and HPV should ascertain whether pHi and [Ca2+]i changes are linked and how they may interact to promote or inhibit SMC contraction.

Comparison of two inversion techniques of a semi-analytical model for the determination of lake water constituents using imaging spectrometry data

In this study, two different inversion techniques for the determination of chlorophyll-a in water were compared by a sensitivity analysis: (i) a matrix inversion method, and (ii) a curve-fitting routine. Adding white noise to the reflectance spectrum led to clearly better results for the curve-fitting routine. If, however, the atmospheric parameter visibility was not exactly known, both methods behaved similarly well. The analyses implied that the performance depended on the quality of the input spectra, the knowledge of model parameters, and also on the inversion methods, even if they were based on the same semi-analytical model. Of course, not only the uncertainties of model parameters had to be considered for the testing of the performance, but also other factors, such as processing time, implementation of the inversion algorithm, number of relevant parameters, and the application of the method to different times and different lakes.

Ion exchange activity in pulmonary artery smooth muscle cells: the response to hypoxia

The purposes of this study were to determine 1) the presence of the major ion transport activities that regulate cytoplasmic pH (pH(c)) in cat pulmonary artery smooth muscle cells, i.e., Na+/H+ and the Na+-dependent and -independent Cl-/HCO3- exchange, 2) whether pH(c) changes in cells from small (SPAs) and large (LPAs) pulmonary arteries during hypoxia, and 3) whether changes in pH(c) are due to changes in the balance of exchange activities. Exchange activities as defined by physiological maneuvers rather than molecular identity were ascertained with fluorescence microscopy to document changes in the ratio of the pH(c) indicator 2',7'-bis-(2-carboxyethyl)-5-(and-6)-carboxyfluorescein. Steady-state pH(c) was higher in LPA than in SPA normoxic smooth muscle cells. SPAs and LPAs possessed all three transport activities; in HCO3- containing normoxic solutions, Cl-/HCO3- exchange rather than Na+/H+ exchange set the level of pH(c); in HCO3- containing hypoxic solutions, pH(c) increased in SPA and decreased in LPA cells; altering the baseline pH(c) of a cell type to that of the other did not change the direction of the pH(c) response during hypoxia. The absence of Na+ prevented hypoxia-induced alkalinization in SPA cells; in both cell types, inhibiting the Cl-/HCO3- exchange activities reversed the normal direction of pH(c) changes during hypoxia.

Corticotropin releasing hormone: therapeutic implications and medicinal chemistry developments

Corticotropin releasing hormone (CRH, sometimes known as CRF) is an endogenous 41 amino acid peptide that has been implicated in the onset of pregnancy, the 'fight or flight' response, in addition to a large number of physiological disorders. Recently, medicinal chemists have developed a number of potent and selective compounds that show promise in a vast array of therapeutic uses. Herein we review the current status of research.

Development of computational and graphical tools for analysis of movement and flexibility in large molecules

We developed a computer program for the calculation and display of the difference distance matrices (DDMs) of macromolecules that has the ability to compare multiple structures simultaneously. To demonstrate its use, a data set of atoms for superimposition of the HIV-1 reverse transcriptase enzyme was defined using the coordinates for the 21 available crystal structures of this enzyme and its complexes. The DDM technique for superimposition data set generation allows selection of atoms that are invariant in all structures, is free from user bias, and represents the most accurate and precise method of producing such subsets. Comparison of this technique was made against other published methods of generating superimposition data sets, and it was found that significant differences in magnitude and trends of atom movements are observed depending on which data set was used.

Pharmacophore development for corticotropin-releasing hormone: new insights into inhibitor activity

Corticotropin-releasing hormone (CRH) is an endogenous 41-amino acid peptide involved in a wide ranging series of systems including the brain, the coordination of the body's overall response to stress, and more recently as a crucial initiator in the onset of labor, also known as the placental clock. Although more physiological data on CRH is emerging shedding more light on the processes involved and their integration, the mode of action of the hormone and the postulated binding site(s) remain unknown. Recently, a number of small-molecular-weight ligands have emerged as potent antagonists but, as therapeutics, suffer from a lack of solubility. Additionally, despite a number of exhaustively large patents, the lack of structural diversity with these antagonists has enabled little scope for comprehensive and wide ranging studies into the structure of the binding sites of this hormone. As part of a program investigating new, structurally diverse antagonists and agonists of CRH, we have developed a preliminary pharmacophore based on the known small-molecular-weight ligands as an initial step in our program. This pharmacophore was validated by comparison with some of the compounds we postulated to be active.

Converting the unconverted: the effect of inclination and opportunity to discount health-related fear appeals

Two experiments indicated that the conventional wisdom for designing fear appeals, higher fear arousal, and a consequences-recommendations ordering, was more persuasive for adherents, or those who were already following the advocated recommendations. Instead, lowering the level of fear arousal and reversing the order of the consequences and recommendations were more effective for persuading the unconverted. The unconverted were more persuaded by the latter message format because it reduced the level of message discounting. Specifically, unconverted participants who received either a low fear appeal or recommendations preceding consequences perceived themselves to be more susceptible, perceived the consequences as more severe, regarded the recommendations as more efficacious, believed they were more able to follow the recommendations, and were less likely to refute the message claims.

Docking experiments in the flexible non-nucleoside inhibitor binding pocket of HIV-1 reverse transcriptase

Docking experiments were undertaken using a number of published crystal structures of HIV-1 reverse transcriptase complexes with various non-nucleoside inhibitors. The docking method was validated by successfully docking each ligand, in the conformation found in the crystal structure of the complex with the enzyme, back into its binding pocket in the right orientation and position. Each ligand was then subjected to conformational searching and a database of unique low-energy conformations of all ligands established. Docking this database into each of the reverse transcriptase binding pockets showed that all inhibitors could be fitted into each different pocket, without alteration of the pocket geometry. This contradicts findings from earlier docking investigations and implies that the conformation of the binding pocket in each different complex is conserved sufficiently to allow particular uniform ligand binding modes. The inhibitor conformations selected by this docking process are mostly the same as the one the ligand adopts in its own pocket and the selected conformations and orientations exhibit an impressive degree of similarity in the arrangement of their steric and electronic features. A correlation has also been observed between inhibitor flexibility and tightness of fit into the pockets with the more flexible inhibitors achieving a tighter fit and thus fewer favourable orientations upon docking.

Deposition of macromolecular structures

Macromolecular structures are being determined at an increasing rate, and are of interest to a wide diversity of researchers. Depositing a macromolecular structure with the Protein Data Bank makes it readily available to the community. Accuracy, consistency and machine-readability of the data are essential, as are clear indications of quality, and sufficient information to allow non-experimentalists to interpret the data. Good-quality depositions are necessary to allow this to be achieved. The PDB's AutoDep system allows deposition and some preliminary automatic checking to take place at multiple sites, prior to full processing and release of the structure by the PDB. However, depositing a structure currently requires the manual entry of a large amount of information at the time of deposition. The data-harvesting approach will allow much more information to be deposited, without placing an additional burden on the depositor. Deposition-ready files will be generated automatically during the course of a structure-determination experiment. The additional information will allow improved validation procedures to be applied to the structures, and the data to be made more useful to the wider scientific community.

Intrinsic tone and distensibility of in vitro and in situ cat pulmonary arteries

This study was designed to determine the in vitro and in situ diameter vs pressure relationship of 200- to 1,200-microns diameter pulmonary arteries in the cat. Diameter vs pressure relationships of these arteries were obtained using two methods, microscopic observation of in vitro cannulated and pressurized arteries and X-ray angiography of in situ arteries. Both in vitro and in situ arteries were studied first under normal conditions and then after reducing tone with Ca(2+)-free solution (in vitro) or papaverine (in situ). In vitro arteries commonly increased their tone in response to elevated transmural pressure, and in some cases, the diameter actually decreased as pressure increased. This behavior was not observed in the in situ arteries. The major difference between in vitro and in situ arteries was that when the in vitro arteries were relaxed, the slope of the diameter vs pressure curves increased, whereas the slope was not altered significantly by relaxation of the in situ arteries. This difference is emphasized by the increased distensibility with relaxation of the in vitro arteries but the decreased distensibility with relaxation of the in situ arteries. The results of this study suggest that, at least in the cat, small pulmonary arteries possess a mechanism that is dormant in the in situ environment within the normal lung. However, the potential for pressure-induced constriction may be unmasked by changing the vessel history and/or environment. Extrapolating results obtained from in vitro pulmonary arteries to the in situ situation should therefore be done with caution. Studies directed at what factors contribute to differences in the responses of in vitro and in situ arteries might help in understanding pulmonary vascular pathophysiology.

L-arginine-related responses to pressure and vasoactive agents in monocrotaline-treated rat pulmonary arteries

To determine whether altered NO production contributes to attenuated distensibility (alpha), vasoreactivity, and acetylcholine (ACh) dilation in pulmonary arteries from monocrotaline (MCT)-treated rats (J.A. Madden, P.A. Keller, R. M. Effrosa, C. Sequitte, J.S. Choy, and A.D. Hacker. J. Appl. Physiol. 76: 1589-1593, 1994), intralobar and sidebranch arteries from rats 21 days after MCT treatment were cannulated and pressurized and their diameter changes in response to KCl, norepinephrine, angiotensin II, and pressure were measured in the presence of N omega-nitro-L-arginine (NLA) and L-arginine. NLA treatment decreased MCT artery diameters more than normal arteries (P < 0.05) and abolished ACh dilation in both. Agonist responses were greater in normal but not MCT arteries. The alpha increased in NLA-treated normal (P < 0.05) but not MCT arteries. After L-arginine, normal and MCT arteries returned to control diameters and dilated to ACh. Agonist responses returned to control in normal but not MCT arteries. Normal but not MCT arteries dilated in calcium-free solution (P < 0.05). These results suggest that pulmonary arteries from rats with MCT-induced pulmonary hypertension produce more NO than do pulmonary arteries; inhibiting NO does not increase contractility; and decreased vasoreactivity and alpha values are not due to smooth muscle cell tone but may be due to abnormal vascular remodeling.