Tobacco harm reduction: what do the experts think?

OBJECTIVE: To assess experts' opinions about the future of, and potential to improve individual and public health through "tobacco harm reduction" (THR), the use of novel nicotine containing products purporting to reduce the health risks from cigarette smoking. DESIGN: Semi-structured telephone interviews on nine topic areas, with qualitative content analysis of coded transcripts. PARTICIPANTS: 29 professionals with expertise related to tobacco and interest in THR, including prominent tobacco control advocates (7), pharmaceutical (3) and tobacco industry scientists/officials (5), non-industry scientists (12), and Congressional staff (2). RESULTS: Respondents agreed that harm reduction is at minimum theoretically plausible, that characteristics of "good" and "bad" THR products can be identified, that government regulation is essential but not likely in the foreseeable future, and that additional scientific data are very much needed. However, there was no consensus on specifics, such as preferred regulatory strategies or examples of ideal THR products. Disagreement was seen not only across but also within respondent categories. Mistrust of key stakeholders-for example, tobacco control advocates distrust of tobacco industry scientists and vice versa-was pervasive, and cited frequently as a barrier to regulation and collaboration. CONCLUSIONS: Continued dialogue and debate are essential as we enter a new and uncertain era of products purporting to reduce tobacco produced harm. Experts have concluded that effective government regulation is crucial to minimising the risks associated with THR and maximising potential benefits.

Smoking on the rise among young adults: implications for research and policy.

This paper investigates hypotheses regarding the cause of the recent apparent increase in young adult smoking, compares trends in smoking among young adults with trends in the use of other substances, and considers the implications for youth tobacco control research and policy. Time series analyses of national data suggest that the recent observed increase in smoking among young adults is primarily an artefact of the almost simultaneous increase in smoking among high school students. In addition, however, it also appears that there have been real changes in smoking patterns among young adults. While many questions remain regarding recent trends in tobacco and other drug use among adolescents and young adults, what is known leads to a clarion call for increased intervention and policy action for the prevention and control of tobacco use among young adults in the USA.

The Detroit Community-Academic Urban Research Center: development, implementation, and evaluation.

There is increasing research evidence that stressors in the social and physical environment (e.g., poverty, inadequate housing, air pollution, and racism) are associated with poor health outcomes. Given the complex set of determinants of health status, the disproportionate burden of disease experienced within marginalized communities, and the limited effectiveness of traditional prevention research, particularly within communities of color, there have been growing calls for more comprehensive and participatory approaches to public health research and practice. The purpose of this article is to describe and analyze the process of establishing, implementing, and evaluating the Detroit Community-Academic Urban Research Center (URC), a community-based participatory research (CBPR) partnership involving community-based organizations, a local health department, academia, and an integrated health care system. Lessons learned and recommendations for creating effective CBPR partnerships are presented.

Women's Health Alliance Intervention Study: increasing community breast and cervical cancer screening.

The Women's Health Alliance Intervention Study is a quasi-experimental intervention designed to test if county-based coalitions can increase breast and cervical cancer screening compliance among women aged 40 years and older living in rural communities. A number of interventions were designed and implemented by coalitions in four counties in north-central Wisconsin during a 2-year period. Four control counties in southwestern Wisconsin were identified for comparison. Judging from the results of this study, community-based intervention efforts can increase breast and cervical cancer screening compliance significantly among women living in rural communities.

Correlates of surgical treatment type for women with noninvasive and invasive breast cancer.

There is concern that breast-conserving surgery is underused in some breast cancer patient subpopulations, including women with ductal carcinoma in situ (DCIS), an early-stage form of the disease. We conducted a population-based study to identify correlates of surgical treatment type and patient satisfaction, comparing women with DCIS and those with invasive disease. We used telephone interview and mailed survey of 183 women recently diagnosed with breast cancer (oversampling for women with DCIS), identified from the Metropolitan Detroit Cancer Surveillance System (response rate 71.2%). Overall, 52.5% of study subjects received a mastectomy (48.9%, 45.8%, and 73.5% of women with DCIS, local disease, and regional disease, respectively, p < 0.05). One third of women did not perceive that they were given a choice between surgical types, and an additional one third of women received a surgeon recommendation, most of whom received the treatment recommended. Patient attitudes, such as concerns about the clinical benefits and risks of specific surgery options, were important correlates of treatment choice but did not vary by stage of disease. Knowledge about differences in clinical benefits and risks between surgery options was low. Finally, satisfaction with the decision-making process was significantly lower in women who did not perceive a choice between surgery options. Correlates of breast cancer surgery type appeared to be similar for women with DCIS and invasive breast cancer, with surgeons playing a dominant role in the process. Results also suggested that the decision-making process may be as important for patient satisfaction as the treatment chosen.

Can communities and academia work together on public health research? Evaluation results from a community-based participatory research partnership in Detroit.

This article reports the results of a formative evaluation of the first 4 years of the Detroit Community-Academic Urban Research Center (URC), a community-based participatory research partnership that was founded in 1995 with core funding from the Centers for Disease Control and Prevention (CDC). Several organizations are members of this partnership, including a university, six community-based organizations, a city health department, a health care system, and CDC. The Detroit URC is a strong partnership that has accomplished many of its goals, including the receipt of over $11 million in funding for 12 community-based participatory research projects during its initial 4 years. Detroit URC Board members identified a number of facilitating factors for their growth and achievements, such as (1) developing a sound infrastructure and set of processes for making decisions and working together, (2) building trust among partners, (3) garnering committed and active leadership from community partners, and (4) receiving support from CDC. Board members also identified a number of ongoing challenges, including organizational constraints, time pressures, and balancing community interests in interventions and academic research needs. Overall, the Detroit URC represents a partnership approach to identifying community health concerns and implementing potential solutions.

Socioeconomic disparities in health change in a longitudinal study of US adults: the role of health-risk behaviors.

This study investigated the hypothesis that socioeconomic differences in health status change can largely be explained by the higher prevalence of individual health-risk behaviors among those of lower socioeconomic position. Data were from the Americans' Changing Lives study, a longitudinal survey of 3,617 adults representative of the US non-institutionalized population in 1986. The authors examined associations between income and education in 1986, and physical functioning and self-rated health in 1994, adjusted for baseline health status, using a multinomial logistic regression framework that considered mortality and survey nonresponse as competing risks. Covariates included age, sex, race, cigarette smoking, alcohol consumption, physical activity, and Body Mass Index. Both income and education were strong predictors of poor health outcomes. The four health-risk behaviors under study statistically explained only a modest portion of the socioeconomic differences in health at follow-up. For example, after adjustment for baseline health status, those in the lowest income group at baseline had odds of moderate/severe functional impairment in 1994 of 2.11 (95% C.I.: 1.40, 3.20) in an unadjusted model and 1.89 (95% C.I.: 1.23, 2.89) in a model adjusted for health-risk behaviors. The results suggest that the higher prevalence of major health-risk behaviors among those in lower socioeconomic strata is not the dominant mediating mechanism that can explain socioeconomic disparities in health status among US adults.

Excess mortality among urban residents: how much, for whom, and why?

OBJECTIVES: The goals of this study were to estimate prospective mortality risks of city residence, specify how these risks vary by population subgroup, and explore possible explanations. METHODS: Data were derived from a probability sample of 3617 adults in the coterminous United States and analyzed via cross-tabular and Cox proportional hazards methods. RESULTS: After adjustment for baseline sociodemographic and health variables, city residents had a mortality hazard rate ratio of 1.62 (95% confidence interval [CI] = 1.21, 2.18) relative to rural/small-town residents; suburbanites had an intermediate but not significantly elevated hazard rate ratio. This urban mortality risk was significant among men (hazard rate ratio: 2.25), especially non-Black men, but not among women. Among Black men, and to some degree Black women, suburban residence carried the greatest risk. All risks were most evident for those younger than 65 years. CONCLUSIONS: The mortality risk of city residence, at least among men, rivals that of major psychosocial risk factors such as race, low income, smoking, and social isolation and merits comparable attention in research and policy.

Mass screening in low-income populations: the challenges of securing diagnostic and treatment services in a national cancer screening program.

Funding for many mass screening programs for low-income and uninsured populations provides resources for screening tests, yet only rarely does it provide coverage for necessary follow-up diagnostic and treatment services. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP), a federally funded initiative that provides cancer screening to low-income uninsured and underinsured women, covers some diagnostic follow-up tests and no treatment services. We conducted in-depth case studies of seven state programs participating in the NBCCEDP to investigate the strategies and approaches being used to secure diagnostic and treatment services. The results suggest that the program relies on a patchwork of resources--at state and local levels--to provide diagnostic and treatment services. This includes a number of components of local safety nets, all of which are unstable and have uncertain futures. Public health disease-screening initiatives need to reconsider the feasibility of continued reliance on case-by-case appeals to the local safety net for diagnostic follow-up and treatment services.

Measurement error in prenatal care utilization: evidence of attenuation bias in the estimation of impact on birth weight.

OBJECTIVE: Errors in the measurement of the timing and number of prenatal care visits may produce downward bias in estimates of the impact of prenatal care use on birth outcomes. This paper examines the extent of attenuation bias from measurement error in the estimation of the effect of prenatal care use on birth weight. METHODS: Data were analyzed from the 1980 National Natality Survey, a nationally representative sample of live births with information on prenatal care utilization from three sources: birth certificates, medical provider surveys, and maternal surveys. The extent of attenuation bias in estimates of the impact of different measures of prenatal care use on birth weight was examined by comparing estimates robust to measurement error (including instrumental variables) with ordinary least squares results. RESULTS: There is considerable disagreement in measures of prenatal care across the three data sources, with correlations in the utilization measures computed from different sources around 0.5. The results also show evidence of attenuation bias from measurement error in estimates of the impact of prenatal care on birth weight for both White and Black mothers. Attenuation bias was least severe for information from the birth certificate report of prenatal care. CONCLUSIONS: Because of measurement error, previous studies may have underestimated the effect of prenatal care utilization on birth weight. Corrected estimates, however, do not suggest that prenatal care is a major predictor of birth weight. In addition, part of what previous analyses have interpreted as adverse selection bias may in fact be attenuation bias due to measurement error.

Biotechnical use of polymerase chain reaction for microbiological analysis of biological samples.

Since its introduction in the mid-80s, polymerase chain reaction (PCR) technology has been recognised as a rapid, sensitive and specific molecular diagnostic tool for the analysis of micro-organisms in clinical, environmental and food samples. Although this technique can be extremely effective with pure solutions of nucleic acids, it's sensitivity may be reduced dramatically when applied directly to biological samples. This review describes PCR technology as a microbial detection method, PCR inhibitors in biological samples and various sample preparation techniques that can be used to facilitate PCR detection, by either separating the micro-organisms from PCR inhibitors and/or by concentrating the micro-organisms to detectable concentrations. Parts of this review are updated and based on a doctoral thesis by Lantz [1] and on a review discussing methods to overcome PCR inhibition in foods [2].

Maternal smoking and adverse birth outcomes among singletons and twins.

OBJECTIVES: This study assessed the effects of maternal smoking on birth outcomes among singletons and twins. METHODS: An algorithm was developed to link twins with their siblings in the 1995 Perinatal Mortality Data Set. A random-effects logistic regression model was then used to estimate the association between maternal smoking and several adverse outcomes for a random sample of singletons and for all twins with available maternal smoking information. RESULTS: The algorithm successfully linked sibling pairs for 91% of the twin sample. Maternal smoking was associated with a significantly increased risk of low birthweight, very low birthweight, and gestation of less than 33 weeks for both singletons and twins and with an increased risk of gestation of less than 38 weeks, infant mortality, and placental abruption for singletons. Among smokers, negative impacts on the risk of low birthweight, very low birthweight, and extreme premature delivery were significantly higher for women carrying twins. CONCLUSIONS: Some of the negative effects of smoking on low birthweight and preterm delivery are greater for twins than for singletons. Women carrying twins should be warned that smoking increases their already high risk of serious infant health problems.

Investing in youth tobacco control: a review of smoking prevention and control strategies.

OBJECTIVE: To provide a comprehensive review of interventions and policies aimed at reducing youth cigarette smoking in the United States, including strategies that have undergone evaluation and emerging innovations that have not yet been assessed for efficacy. DATA SOURCES: Medline literature searches, books, reports, electronic list servers, and interviews with tobacco control advocates. DATA SYNTHESIS: Interventions and policy approaches that have been assessed or evaluated were categorised using a typology with seven categories (school based, community interventions, mass media/public education, advertising restrictions, youth access restrictions, tobacco excise taxes, and direct restrictions on smoking). Novel and largely untested interventions were described using nine categories. CONCLUSIONS: Youth smoking prevention and control efforts have had mixed results. However, this review suggests a number of prevention strategies that are promising, especially if conducted in a coordinated way to take advantage of potential synergies across interventions. Several types of strategies warrant additional attention and evaluation, including aggressive media campaigns, teen smoking cessation programmes, social environment changes, community interventions, and increasing cigarette prices. A significant proportion of the resources obtained from the recent settlement between 46 US states and the tobacco industry should be devoted to expanding, improving and evaluating "youth centred" tobacco prevention and control activities.

Prenatal interphase detection by FISH of a sex chromosome mosaicism when cytogenetics reports a pseudomosaicism.

We report the detection of a sex chromosome mosaicism (XY/XXY/XYY) by prenatal interphase FISH (fluorescence in situ hybridization) originally identified as a pseudomosaicism involving 47,XXY cells present in a routine 46,XY cytogenetic analysis. After a fetal demise, interphase FISH identified the sex chromosome mosaicism in all tissues examined while cytogenetic analysis revealed only a normal male cell line. After prolonged exposure to colcemid, cytogenetic analysis identified the 47,XXY cell line. This confirmed the presence of the mosaicism and suggested that the abnormal cell line(s) may have been growth disadvantaged. This in turn may have accounted for the intra-uterine fetal demise. The identification by FISH and the role of growth-disadvantaged cell lines may provide a unique insight into chromosomally normal fetal demises.

Strategies for follow-up and treatment services in state breast and cervical cancer screening programs.

This report describes strategies used to provide diagnostic follow-up and treatment services to low-income women screened through the National Breast and Cervical Cancer Early Detection Program.

Evaluation of an extended diagnostic PCR assay for detection and verification of the common causes of bacterial meningitis in CSF and other biological samples.

A seminested polymerase chain reaction (PCR)-based diagnostic assay was evaluated for detection and verification of Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, Steptococcus agalactiae and Listeria monocytogenes in cerebrospinal fluid (CSF) and other biological samples. A general bacterial amplicon from the 16S rRNA gene was amplified in a first step, and species-specific regions in a second. The detection level was 4 fg DNA/reaction, corresponding to about one bacterial genome per reaction tube. Sample preparations (Dynabeads DNA DIRECT kit) were assayed from 140 bacterial strains suspended in saline. In CSF the detection level for bacteria was 10(3)CFU ml-1for N. meningitidis, H. influenzae and S. pneumoniae, 10(4)CFU ml-1for Escherichia coli and 10(5)CFU ml-1for S. agalactiae and L. monocytogenes. The detection levels for these bacteria were the same in the other tested biological samples, like blood with or without culture media. Clinical CSF samples were evaluated from 71 patients with proven bacterial meningitis, as were 61 CSF samples from individuals without bacterial meningitis. The diagnostic sensitivity of the assay in detecting bacteria in general was 0.97, and for the specific species in the clinical CSF samples 0.87-0.94. The specificity was 1.0 for detecting bacteria in general. Some cross-reactions were noted within the streptococcus group. The PCR results were verified by banding patterns of Hae III digested PCR products.

Maternal substance abuse and infant health: policy options across the life course.

Maternal substance abuse is a significant contributor to infant morbidity and mortality. The setting of prenatal care has long been the focus of interventions and policies to prevent these adverse outcomes. However, substance abuse programs and policies that are designed for women who are not yet pregnant can have a significant impact upon this problem. Thus it is essential to view the female life course from a broader perspective in order to consider the full range of policy options for reducing the infant mortality and morbidity caused by maternal substance abuse. This framework also allows comparisons across and between substances and offers new directions for policy development.