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To examine baseline characteristics and biochemically verified 1-, 4-, and 6-month tobacco quit rates among college students enrolled in a Quit and Win cessation trial, comparing those who concurrently smoke both hookah and cigarettes with those who deny hookah use.Analyses were conducted on data from 1217 college students enrolled in a Quit and Win tobacco cessation randomized clinical trial from 2010-2012. Multivariable logistic regression (MLR) analyses examined group differences in baseline characteristics and cotinine verified 30-day abstinence at 1, 4, and 6-month follow-up, adjusting for baseline covariates.Participants smoked 11.5(±8.1) cigarettes per day on 28.5(±3.8) days/month, and 22% smoked hookah in the past 30days. Hookah smokers (n=270) were more likely to be male (p0.0001), younger (p0.0001), report more binge drinking (p0.0001) and score higher on impulsivity (p0.001). MLR results indicate that hookah users, when compared to non-users, had a 36% decrease in odds of self-reported 30-day abstinence at 4-months (OR=0.64, 95% CI=0.45-0.93, p=0.02) and a 63% decrease in odds in biochemically verified continuous abstinence at 6-months (OR=0.37, CI=0.14-0.99, p=0.05).College cigarette smokers who concurrently use hookah display several health risk factors and demonstrate lower short and long-term tobacco abstinence rates.

To examine factors associated with perceiving different types of pictorial cigarette health warning labels as most effective in motivating smokers to quit or preventing smoking initiation among college students.We administered an online survey to 24,055 students attending six Southeast colleges in Fall, 2010. We obtained complete data for the current analyses from 2600.Current smoking prevalence was 23.5%. The largest majority (78.6%) consistently rated gruesome images as most effective, 19.5% rated testimonial images as most effective, and only a small proportion rated either standard (1.6%) or human suffering images (0.3%) as most effective. Subsequent analyses focused on differences between those endorsing gruesome images or testimonials as most effective. Factors related to ranking testimonials versus gruesome images as most effective included being female (p0.01), White (p0.01), and nonsmokers (p=0.04), lower perceived smoking prevalence (p0.01), and greater receptivity to laws/restrictions around smoking (p0.01) and tobacco marketing (p=0.01). Among smokers, factors related to ranking testimonials as most effective versus gruesome images included being female (p=0.03), being White (p=0.03), higher autonomous motivation (p=0.03), and greater extrinsic self-efficacy (p=0.02).Understanding factors related to perceived effectiveness of different pictorial warnings among subpopulations should inform health warning labels released by the FDA.

Objectives To determine the efficacy of providing online cessation intervention for college smokers. Methods This is a two-group randomized controlled trial. The intervention group received $10 weekly incentives to visit an online college life magazine that provided personalized smoking cessation messages and peer email support. Evaluation assessments occurred at baseline and 8, 20, and 30 weeks after enrollment. The primary outcome is self-reported 30-day abstinence at week 30. Carbon monoxide (CO) breath testing was performed for participants reporting 30-day abstinence at week 30. Results Five-hundred and seventeen college smokers at the University of Minnesota were enrolled via internet health screening (control = 260, intervention = 257) in the fall of 2004. Intervention participants completed an average of 18.9 (SD 2.5) of 20 weekly website visits over the course of the study. The rate of 30-day abstinence at week 30 was higher for the intervention compared to the control group (41% vs. 23%, p

To describe the design, implementation, baseline data, and feasibility of establishing a disease management program for smoking cessation in rural primary care.The study is a randomized clinical trial evaluating a disease management program for smoking cessation. The intervention combined pharmacotherapy, telephone counseling, and physician feedback, and repeated intervention over two years. The program began in 2004 and was implemented in 50 primary care clinics across the State of Kansas.Of eligible patients, 73% were interested in study participation. 750 enrolled participants were predominantly Caucasian, female, employed, and averaged 47.2 years of age (SD=13.1). In addition to smoking, 427 (57%) had at least one additional major risk factor for cardiovascular disease (diabetes, hypertension, high cholesterol, heart disease or stroke). Participants smoked on average 23.7 (SD=10.4) cigarettes per day, were contemplating (61%) or preparing to quit (30%), were highly motivated and confident of their ability to quit smoking, and reported seeing their physicians multiple times in the past twelve months (Median=3.50; Mean=5.48; SD=6.58).Initial findings demonstrate the willingness of patients to enroll in a two-year disease management program to address nicotine dependence, even among patients not ready to make a quit attempt. These findings support the feasibility of identifying and enrolling rural smokers within the primary care setting.

Background. The goal of this study is to better understand factors related to physician treatment of tobacco as a chronic medical condition. Methods. In the fall of 2000, we conducted a mail survey of primary care physicians in a large mid-western health plan. The response rate was 61% (750/1235). The survey assessed physician attitude, perceived clinic support, training, and self-reported tobacco treatment practices. Results. Twenty-nine percent of physicians reported incomplete or minimal care. Thirty-nine percent reported providing assistance without follow-up, while 21% reported providing follow-up to tobacco users making quit attempts. Only 12% of physicians reported assistance and follow-up for all tobacco users. Controlling for differences in physician and clinic characteristics, more positive physician attitudes decreased incomplete or minimal care (OR = 4.62 most positive tertile vs. least positive, P < 0.001) but did not increase follow-up activities. Higher perceived clinic support increased follow-up care (OR = 2.69, highest tertile vs. lowest, P < 0.001). Physician training was associated with increased provision of ongoing care (OR = 1.88 per additional hour of training, P < 0.001). Conclusions. Physician attitudes, clinic support, and training are related to different steps in the adoption of more complete tobacco use treatment. These findings support the need for multifaceted approaches to improve tobacco treatment as a chronic medical condition.

Objectives. Identification of individual characteristics that predict successful smoking cessation treatment has been limited to studies with mostly white participants. This study identifies factors that predict successful quitting among African-Americans participating in a smoking cessation trial. Methods. Twenty-one baseline variables were analyzed as potential predictors from a double-blind placebo-controlled, randomized trial that used bupropion SR for smoking cessation among 600 African-American smokers. Chi-square tests, two sample t tests, and multiple logistic regression procedures were employed to identify predictors of 7-day abstinence among the 535 participants who completed the 7-week medication phase. Results. Univariate predictors of cessation were receiving bupropion (P < 0.0001), not smoking menthol cigarettes (P = 0.0062), smoking after 30 min of waking (P < 0.0001), older age (P = 0.0085), smoking fewer cigarettes per day (P = 0.0038), and lower cotinine levels (P = 0.0002). Logistic regression identified three significant independent predictors. Participants who received bupropion treatment were more than twice as likely to quit smoking at the end of treatment compared to participants who received placebo (OR = 2.62; 95% CI = 1.77–3.88, P < 0.0001), while smoking within 30 min of waking (OR = 0.40; 95% CI = 0.25–0.62, P < 0.0001) and higher salivary cotinine levels at baseline (OR = 0.799; 95% CI = 0.629–0.922, P < 0.0001) reduced the likelihood of quitting. Conclusions. This is the first report identifying predictors of smoking cessation among African-Americans participating in a clinical trial. Results indicate that, aside from bupropion treatment, various indicators of addiction were the strongest predictors. While this is similar to findings among white smokers, thresholds of addiction may need to be adjusted for African-American smoking patterns. Additional studies focused on diverse populations are needed to improve treatment approaches and to identify population-specific factors that are important for treatment-matching approaches.

Background. This study documented the frequency and correlates of directly observed physicians' counseling on dietary habits and exercise in private medical practices. Methods. Trained medical students observed physician, office, and patient characteristics in 4344 patient visits in 38 nonmetropolitan primary care physician offices. Results. Counseling rates ranged from 0% in some offices to 55% in others. Physicians counseled patients on dietary habits in 25% of visits and exercise in 20% of visits. Physicians counseled new patients 30% more often than established ones (P < 0.05). Dietary counseling was associated with having dietary and exercise brochures in the office (P < 0.05). When counseling occurred, physicians (rather than patients) initiated both dietary and exercise counseling 61% of the time. Counseling for dietary habits was associated with counseling for exercise (P < 0.05); some physicians may be more likely to give preventive counseling. Counseling was not associated with physicians' age, years in practice, or number of patients per week. Conclusion. Physician counseled patients in 20–25% of visits, and this was not affected by physician characteristics. Results suggest that physician counseling protocols and other office prompts should be developed and promoted. Strategies targeting both physician and the health care system may improve the consistency of physician preventive counseling practices.

Background The effectiveness of smoking cessation interventions may be influenced by a variety of patient characteristics, including level of nicotine addiction and readiness to change. We conducted this study to examine the relationship between these characteristics and the frequency of physician-initiated smoking cessation interventions. Methods We identified smokers seen during office visits to 1 of 38 primary care physicians in rural Kansas. Trained students observed the frequency and nature of doctor–patient discussions related to tobacco. Telephone surveys were conducted with these patients 1 to 3 days after the office visit. Results We completed observations and telephone surveys on 259 smokers. Tobacco-related discussions occurred during 66% of doctor–patient encounters. Although discussions overall were unrelated to a patient’s readiness to quit, specific assistance with smoking cessation was offered less often to precontemplators (15%) than to contemplators (31%) or those preparing to quit (37%) (P < 0.05). While bupropion was discussed with 23% of smokers, nicotine replacement therapy was discussed with 12% and was unrelated to markers of nicotine addiction. Conclusions Current efforts to promote smoking cessation are only marginally related to patient characteristics. Doctors are missing many opportunities to effectively intervene with patients who are contemplating smoking cessation or preparing to quit.

Objectives. The purpose of the study was to determine associations between having a regular source of health care, advice from a physician to quit smoking, and smoking-related behaviors among African American smokers. Methods. A secondary analysis was conducted on data obtained from an intervention study with a posttest assessment of the effectiveness of smoking status as a vital sign. The setting was an adult walk-in clinic at a large inner-city hospital and 879 African American adult current smokers were examined. Results. Among African American smokers, there was an association between having a regular source of health care and planning to quit smoking within the next 30 days (OR = 1.46; 95% CI: 1.04–2.05), receiving physician advice to quit (OR = 1.46; 95% CI: 1.02–2.10), and smoking ≤10 cigarettes a day (OR = 1.42; 95% CI: 1.00–2.03). Conclusions. African American current smokers with a regular source of health care were further along the quitting process than those without a regular source of health care. Our findings indicate a potential benefit of complementing programs that increase physician cessation advice rates with policies that increase rates of health insurance and the likelihood that individuals have a regular source of health care.

Tobacco use remains the leading cause of preventable death in the United States. Although comprehensive tobacco control has a number of essential components, support for cessation services can yield the largest short-term public health benefit. While effective treatments for tobacco dependence do exist, they are not currently available to many of the tobacco users who want and need them. Finding cost-effective, science-based strategies for reducing tobacco dependence in the United States should be a national priority.Late in 1997 a group of experts in the science of tobacco control was convened by the Center for the Advancement of Health to develop recommendations regarding the use of federal funds for treating tobacco dependence. These recommendations were prepared based on the priority of the actions and the estimated cost and effort required to implement them. Following the Master Settlement Agreement in 1998, the recommendations were adapted to address the needs of state policy makers.Effective treatments for tobacco dependence do exist; however, our nation currently lacks the capacity to deliver these services to the many millions who require them. There is a compelling need for funding from a variety of sources to create this capacity.The priority must be to develop the systems, competencies, and resources needed to deliver, and to monitor the delivery of, evidence-based treatments to tobacco users. Treatment must be delivered in an integrated manner, consistent with the needs of tobacco users. Additionally, financial barriers to treatment must be reduced, and consistent, high-quality treatment services must be ensured for all tobacco users who seek them.

Background. Many studies on cessation interventions and self-quitting have been conducted, but few have focused on African Americans. The purpose of this review was to critically evaluate the available studies and make recommendations for future research. Methods. Articles published from 1988 to 1998 were collected using Medline and other data bases, as well as personal communication. Studies were divided into two categories: evaluations of specific cessation interventions and examinations of self-quit behaviors and related factors. Studies were tabulated using author/year, study design/sample size, variables/results, and comments. Results. In the intervention studies, church-based programs may provide an effective location for cessation interventions, but the studies to date did not demonstrate unequivocal effectiveness. In clinic programs, there do not appear to be any interventions that are particularly effective. In community-based interventions, there were no differences for African and Caucasian Americans. With regard to self-quitting, sociodemographic variables were similarly related to cessation as in the general population, as were smoking history variables. All other categories did not contain enough information for firm conclusions to be drawn. Conclusions. There are some interventions that appear to be useful, but little information is available on self-quitting. More research is needed on the natural history of quitting, on the social norms for smoking among African American groups, and on the conceptual dimensions of race in the context of this research.

Background. This paper describes a natural, prospective, open-label study designed to evaluate the impact of free nicotine patches with minimal support for smoking cessation. Methods. Surveys were administered to 223 participants who received nicotine patches from the American Lung Association. All participants received a 6-week supply of 15-mg/16-h transdermal nicotine patches, a self-help book Freedom from Smoking , and information about area smoking cessation classes. Follow-up telephone surveys were administered 6 weeks after the patches were distributed. Abstinence was measured through self-report exclusively. Results. The overall quit rate at 6-weeks was 21% (47/223). Among nonquitters, the mean number of cigarettes smoked per day dropped from 25 at baseline to 14 at 6 weeks. There was a significant difference in the average number of patches used by quitters and nonquitters (26 versus 11, P Conclusions. Nicotine patches with minimal support can be effective in smoking cessation and smoking reduction. The availability of patches may have motivated participants to quit. Efforts to increase access to and use of nicotine patches may result in increased attempts to quit and successful quitting.

Background.Smoking is the single most preventable cause of premature mortality in the United States. In 13 double-blind, controlled trials, the nicotine transdermal patch has been demonstrated to be an effective aid to quitting smoking, even after 6 months of follow-up. Because physicians and payers may consider the cost of the patch to be prohibitive, we examine the cost-effectiveness of the nicotine patch as an adjunct to brief physician counseling during routine office visits. Methods.We estimate the effectiveness of both patch use with brief counseling and counseling alone from meta-analysis of clinical trials. Benefits are measured in terms of years of life gained by those who quit, discounted at 5%. Costs include physician time and patch prescriptions. The incremental cost-effectiveness is quantified as cost per additional year of life saved when patch plus counseling is compared with brief physician counseling alone. Results.Depending on age the average costs per year of life saved range from $965 to $1,585 for men and from $1,634 to $2,360 for women. Incremental costs per year of life saved range from $1,796 to $2,949 for men and from $3,040 to $4,391 for women. Conclusion.The nicotine patch is cost-effective and less costly per year of life saved than other widely accepted medical practices. Physicians and third-party payers should recommend the nicotine patch to patients who wish to stop smoking.

Background. This study of 1025 adolescent nonsmokers aged 11–19 years examined level of interest and factors associated with reported willingness to help someone stop smoking. Methods. Data were collected from a survey distributed primarily in the schools at four geographic and ethnically diverse study sites. Results. A total of 692 adolescents identified someone close to them who smokes whom they thought should quit. Of these, 90% reported that they would be willing to help this person stop smoking. Multivariate predictors of willingness to help were female gender, less difficulty reading English, and greater level of comfort with talking to the smoker about their smoking. The smoker that the adolescents were willing to help was most often a parent or same age friend. Conclusions. If this strong interest among adolescents could be tapped, engaging teens as support persons could be a novel public health approach to reaching parents, adolescents, and other smokers in the population.

Background . The goal of this study was to examine mammography facility characteristics and explore how such characteristics may impact repeat mammography use. Methods . Mammography facility characteristics were obtained through a mailed a 21-item survey to Kansas mammography facilities. Medicare mammography claims were used to calculate facility-specific repeat mammography rates. Administrative data included female Kansas beneficiaries aged 65 years and older ( N = 39,035) with a baseline mammogram during 1999. Beneficiaries with a mammography claim 12–18 months after their baseline mammogram were deemed to have had a repeat mammogram. Results . Completed surveys were received from 90% ( N = 79) of the 97 facilities serving >10 beneficiaries. Most facilities were in rural communities (58%), had an on-site radiologist (58%), and mailed mammography reminders to patients (63%). Extended hours of operation and the acceptance of self-referrals were uncommon (33% and 37%, respectively). Few facilities employed a quality improvement team (33%) or measured annual patient return rates (18%), but many measured patient satisfaction (57%). Of the beneficiaries, 61% had a repeat mammogram during the subsequent 12–18 months (range, 0% to 84%). Facilities notifying primary care providers of patients due for mammograms had higher repeat mammography rates. Multiple regression analyses found that higher repeat mammography rates were associated with facilities that accepted self-referrals, measured patient satisfaction, were in urban areas, and served a larger proportion of white beneficiaries. Conclusion . Mammography facility characteristics and repeat mammography rates vary widely. Although modifiable facility characteristics that may influence repeat mammography need additional study, results from this study indicate that mammography facilities are an opportunistic arena for quality improvement endeavors.

Background. Fecal occult blood testing (FOBT) can reduce colorectal cancer (CRC) mortality. Unfortunately, CRC screening is underutilized. Sociocultural mediators of FOBT adherence have not been extensively studied in lower income, minority populations. This study prospectively studied FOBT return in a low-income, multiethnic population. Methods. Participants ( N = 298), aged ≥40 years, were surveyed and given FOBT kits with instructions. Those not returning kits within 30 days received a reminder telephone call. Bivariate and multivariate analyses assessed predictors of FOBT card return at 90 days. Results. Participants (median age = 48) were predominately African American (69%), without private insurance (88%), and of low income. The largest group of participants preferred FOBT alone (46%), followed by whatever my doctor recommends (19%), endoscopy + annual FOBT (16%), endoscopy alone (14%), and no screening (5%). In multivariate analyses, FOBT return was predicted by age (OR = 1.05) and lack of reported FOBT barriers (OR = 3.81). Among those ≥50 and not up-to-date with screening, FOBT return was predicted by cancer fatalism (OR = 0.83). FOBT barriers were associated with age (OR = 0.96), less than high school education (OR = 2.05), and less physician trust (OR = 2.12). Endoscopy barriers were associated with age (OR = 0.93), less physician trust (OR = 1.95), and female gender (OR = 3.45). Conclusions. Younger individuals and those with less education, less trust in health care providers, and more fatalistic beliefs are at risk for CRC screening non-adherence. Strategies addressing common misconceptions should improve CRC screening rates in low-income, multiethnic populations.

Purpose. The aim of this study was to examine utilization of and trends in fecal occult blood testing (FOBT) among beneficiaries since Medicare began FOBT coverage on January 1, 1998. Methods. We identified Kansas Medicare beneficiaries ages 65–79. Using Medicare claims, we determined which beneficiaries received FOBT during 1998–1999. We examined demographic variables associated with FOBT and rate changes over time. We linked beneficiaries to primary care practices (PCPs) and examined FOBT variations among 483 PCPs. Results. FOBT use remained unchanged during the study period. Of the 215,322 beneficiaries, 11% received at least one FOBT in 1998 and 11% in 1999; 18% had at least one test during the 2-year period, but only 4% had a test during both years. Caucasians and females had the highest FOBT rates. Although FOBT rates among PCPs ranged from 0 to 71%, only 19% of the practice rates exceeded 10%. Conclusions. Few beneficiaries obtain annual FOBT and little change in rates has occurred since Medicare reimbursement began. Although FOBT rates vary widely between PCPs, most either do not provide FOBT or do not bill Medicare for FOBT. The FOBT claims rate is much lower than reported in patient surveys and may indicate that Medicare should reexamine its reimbursement policy.