A Prospective, Observational, Multicenter Study Assessing Adherence to Interferon Beta-1b Therapy and Patient Satisfaction Using the BETACONNECT Auto-Injector.

INTRODUCTION: It is important to achieve good persistence and adherence to disease-modifying therapies (DMTs) to achieve the best outcomes in chronic diseases such as multiple sclerosis (MS). The BETACONNECT device is an electronic auto-injector for the DMT interferon beta-1b (Betaseron), designed to improve patients' injection experience and to monitor adherence. This observational study aimed to assess patient adherence to and persistence with interferon beta-1b therapy as well as patient-reported satisfaction in a US population. METHODS: A prospective, observational, multicenter study was conducted in 146 adult patients with relapsing-remitting MS or clinically isolated syndrome, newly prescribed or currently established on interferon beta-1b therapy and naïve to the BETACONNECT device, and followed up during a 6-month observation period. RESULTS: Among the 91 patients who completed the study, the overall mean adherence rate was 82.5%, with 65.9% of patients adherent for at least 80% for the duration of the 6-month period. At 6 months, 98.9% of patients had less than a 60-day gap in therapy. Of the 115 patients who provided satisfaction data, 90.5% of patients were either very satisfied or satisfied with the BETACONNECT device. CONCLUSION: This study shows that the BETACONNECT device was associated with high adherence to interferon beta-1b therapy in patients with MS. Patients also reported high degrees of satisfaction with the device. Therefore, this may be a viable delivery option to help with adherence and persistence, potentially leading to improved clinical outcomes.

Factors Shaping the Lived Experience of Resettlement for Former Refugees in Regional Australia.

Refugees experience traumatic life events with impacts amplified in regional and rural areas due to barriers accessing services. This study examined the factors influencing the lived experience of resettlement for former refugees in regional Launceston, Australia, including environmental, social, and health-related factors. Qualitative interviews and focus groups were conducted with adult and youth community members from Burma, Bhutan, Sierra Leone, Afghanistan, Iran, and Sudan, and essential service providers (n = 31). Thematic analysis revealed four factors as primarily influencing resettlement: English language proficiency; employment, education and housing environments and opportunities; health status and service access; and broader social factors and experiences. Participants suggested strategies to overcome barriers associated with these factors and improve overall quality of life throughout resettlement. These included flexible English language program delivery and employment support, including industry-specific language courses; the provision of interpreters; community events fostering cultural sharing, inclusivity and promoting well-being; and routine inclusion of nondiscriminatory, culturally sensitive, trauma-informed practices throughout a former refugee's environment, including within education, employment, housing and service settings.

The mental health of former refugees in regional Australia: A qualitative study.

OBJECTIVE: To examine the resettlement experiences of former refugees living in regional Australia, focusing on mental health and mental health and support services, including barriers to access. DESIGN: A phenomenological approach utilising a combination of six qualitative, semi-structured, face-to-face focus groups (n = 24) and seven individual interviews. Data were analysed thematically using NVivo 10 software. SETTING: Launceston, Tasmania. PARTICIPANTS: Adult and youth former refugees from Afghanistan, Bhutan, Burma, Sierra Leone, Sudan and Iran, and essential service providers, residing in Launceston. MAIN OUTCOME MEASURES: Participants were asked about experiences of resettlement and mental health. RESULTS: Participants reported that their mental health had improved since resettlement; however, major stressors impacted mental health and resettlement included employment and housing access and mastering the English language. Past experiences continued to impact current functioning, with trauma commonly experienced intergenerationally through parenting and attachment and ongoing trauma and feelings of guilt and responsibility experienced with families left behind. Participants noted barriers to accessing services: (a) Language difficulties including lack of interpreters; and (b) lack of culturally sensitive and trauma-informed practices. Discrimination was experienced through the inconsistent provision of interpreters and lack of due consideration of cultural and religious differences. The use of children as interpreters enhanced a number of risk including miscommunication of medical information, exposure to age-inappropriate information and the resulting increased risk of trauma for the child. CONCLUSION: Culturally sensitive, trauma-informed and discrimination-free practices should be employed across services, where Western-views surrounding this medical model are not imposed, cultural differences are respected, and timely access to interpreters was provided.

Six-Month Use of Droxidopa for Neurogenic Orthostatic Hypotension.

BACKGROUND: Droxidopa is approved for adult patients with symptomatic neurogenic orthostatic hypotension (nOH); there is limited information regarding effects on symptoms, outcomes, and quality of life (QOL) beyond two weeks of treatment. OBJECTIVE: Examine the real-world experience of patients taking droxidopa after six months of treatment. METHODS: This non-interventional, US-based, prospective cohort study utilized a pharmacy hub, identifying patients who recently started droxidopa for nOH treatment. Questionnaires for fall frequency and other patient-reported outcomes (PROs) were completed at baseline and one, three, and six months following droxidopa initiation. RESULTS: 179 enrolled patients completed baseline surveys. Droxidopa continuation rates were high at months one, three, and six (87%, 79%, and 75%, respectively). From baseline to month one, there was significant reduction in the proportion of patients reporting falling at least once (54.1% vs. 43.0%; P = 0.0039), with similar observations at month three (52.9% vs. 44.5%; P = 0.0588) and month six (51.4% vs. 40.0%; P = 0.0339). Significant improvements from baseline to month one were observed and maintained at months three and six for most PROs, including the Orthostatic Hypotension Symptom Assessment Item 1, Short Falls Efficacy Scale-International, Sheehan Disability Scale, Physical Component of the 8-item Short-Form Health Survey, and Patient Health Questionnaire-9. CONCLUSIONS: In this non-interventional prospective study, fewer nOH patients reported falling after one, three, and six months of droxidopa treatment. Further, improvements reported in nOH symptoms, physical function, and QOL measures were maintained for six months following treatment initiation. Results from randomized clinical trials are required to validate the findings.

How to use visual methods to promote health among adolescents: A qualitative study of school nursing.

AIMS AND OBJECTIVES: Public health nurses attended a 3-day course to learn the use of visual methods in health dialogue with adolescents. The aim of this study was to explore how to use visual methods to promote health among adolescents in a school nursing context. BACKGROUND: Photovoice is a visualising technique that enables adolescents to participate in health promotion projects in a school setting. Photovoice also enhances work of public health nurses and other health professionals. DESIGN: This was a qualitative action research study. We developed and conducted a course in visual methods and used data from focus group discussions in combination with participant observations involving public health nurses working in school health services. METHODS: We conducted focus group interviews (n = 40) using separate semi-structured discussion guides before and after a course in visual methods. The interviews were audio recorded and transcribed verbatim, and we documented the workshops (n = 8) through field notes. We collected the data from January-October 2016. Data were analysed and coded into themes and subthemes using systematic text condensation. We reported the study in accordance with the COREQ checklist. FINDINGS: Public health nurses found photovoice useful in school nursing. The use of images offered pupils an active role in dialogues and more control in defining the topics and presenting their stories. When nurses allowed adolescents to bring images into conversations, they discovered new insights into public health promotion. The public health nurses pointed out the benefits and challenges of using new methods in practice. CONCLUSION: Public health nurses considered photovoice to be useful in health promotion and other public health issues. Involving pupils in bringing images to conversations offered them an active role and voice in health promotion. RELEVANCE TO CLINICAL PRACTICE: We recommend the use of photovoice and visual technologies (e.g., smartphones) in health promotion activities for adolescents.

Concerns and Treatment Satisfaction in Patients Being Treated With Azelaic Acid Foam for Rosacea

Objective: To describe patient characteristics, concerns, side effects, treatment satisfaction, and quality of life (QoL) of rosacea patients currently being treated with monotherapy azelaic acid foam based on patient-reported data. Methods: The study utilized a non-interventional, prospective, observational design. Patients were recruited in the United States and were eligible if the following criteria were met: diagnosed with rosacea by a medical professional, ≥18 years of age, currently receiving monotherapy with azelaic acid foam, and able to provide informed consent. Patients using other topical treatments for rosacea during enrollment were excluded. An online tool administered a survey of 3 questionnaires including the Rosacea Treatment Preference Questionnaire, Treatment Satisfaction with Medicines Questionnaire (SATMED-Q), and Dermatology Life Quality Index (DLQI). The survey collected demographics, clinical characteristics, treatment history, adverse events, and patient-reported outcomes related to treatment with azelaic acid foam and QoL with rosacea. Results: 54 patients met eligibility criteria. Participants were primarily female (90.7%), ranging from 26 to 63 years of age. The most common subtypes reported were erythematotelangiectatic and papulopustular (74.1% each) with 59.3% of participants reporting mild symptoms (16.7% "absent"; 24.1% "moderate") in the 4 weeks before enrollment. The majority reported no concerns (74.1%) with their treatment. The biggest concern was cost (11.1%), with a mean importance score (IS) on a 10-point scale of 9.3. A majority (77.8%) of patients reported no side effects. Side effects reported included dryness (13%; IS: 5.3), stinging (7.4%, IS: 2.5), itching (5.6%; IS: 4.7), or burning (3.7%; IS: 7.0). Global satisfaction (SATMED-Q) mean score was 79.0 and treatment effectiveness mean score was 70.8. QoL impact of rosacea was minimal (mean DLQI score: 2.35). In regression models, increasing dryness was significantly associated with worsening outcomes in SATMED-Q and DLQI. Conclusions: Patient characteristics of the study population closely mirror the distribution of rosacea by gender and subtype as in previous estimates. Findings indicate minimal patient concerns with azelaic acid foam and primarily pertained to cost. Patient-reported side effects were rare. Minor patient-reported side effects and concerns do not appear to affect rosacea-related QoL and medication satisfaction. Compared to a previously conducted study of similar design with patients using metronidazole gel and metronidazole cream, more patients in the current study reported no concerns with their treatment, while the number of patients reporting no side effects, as well as mean SATMED-Q and DLQI scores, were similar. Further research is necessary to directly compare the results of these 2 studies. J Drugs Dermatol. 2019;18(4):381-386.

Ethical challenges experienced by public health nurses related to adolescents' use of visual technologies.

BACKGROUND: Visual technologies are central to youth culture and are often the preferred communication means of adolescents. Although these tools can be beneficial in fostering relations, adolescents' use of visual technologies and social media also raises ethical concerns. AIMS: We explored how school public health nurses identify and resolve the ethical challenges involved in the use of visual technologies in health dialogues with adolescents. RESEARCH DESIGN: This is a qualitative study utilizing data from focus group discussions. PARTICIPANTS AND RESEARCH CONTEXT: We conducted focus group discussions using two semi-structured discussion guides with seven groups of public health nurses (n = 40) working in Norwegian school health services. The data were collected during January and October 2016. Discussions were audio recorded, transcribed, and coded into themes and subthemes using systematic text condensation. ETHICAL CONSIDERATIONS: The leader of the public health nursing service who agreed to provide access for the study and the Norwegian Center for Research Data that reviewed and approved the study. All participants gave informed consent. FINDINGS: In adolescents' use of visual materials with public health nurses, ethical concerns were raised regarding suicide ideations, socially unacceptable content, violation of privacy, and presentations of possible child neglect. The nurses utilized their professional knowledge and experience when identifying and navigating these ethical dilemmas; they resolved ethical uncertainties through peer discussion and collaboration with fellow nurses and other professionals. DISCUSSION: We discussed the findings in light of Annemarie Mol's interpretation of the ethics of care. Mol expands the notion of ethical care to include the action of technologies. CONCLUSION: Although the increasing use of visual technologies offered benefits, school nurses faced ethical challenges in health dialogues with adolescents. To address and navigate these ethical issues, they relied on their experience and caring practices based on their professional ethics. Uncertainties were resolved through peer dialogue and guidance.

Remote Monitoring of Automated Peritoneal Dialysis Patients: Assessing Clinical and Economic Value.

BACKGROUND: For chronic kidney disease patients who progress to end-stage renal disease, survival is dependent on renal replacement therapy in the form of kidney transplantation or chronic dialysis. Peritoneal dialysis (PD), which can be performed at home, is both more convenient and less costly than hemodialysis that requires three 4-h visits per week to the dialysis facility and complicated equipment. Remote therapy management (RTM), technologies that collect medical information and transmit it to healthcare providers for patient management, has the potential to improve the outcomes of patients receiving automated peritoneal dialysis (APD) at home. OBJECTIVE: Estimate through a simulation study the potential impact of RTM on APD patients use of healthcare resources and costs in the United States, Germany, and Italy. METHODS: Twelve APD patient profiles were developed to reflect potential clinical scenarios of APD therapy. Two versions of each profile were created to simulate healthcare resource use, one assuming use of RTM and one with no RTM. Eleven APD teams (one nephrologist, one nurse) estimated resources that would be used. RESULTS: Results from U.S., German, and Italian clinicians found that RTM could avoid use of 59, 49, and 16 resources over the 12 profiles, respectively. Estimated reduced utilization across the three countries ranged from one to two hospitalizations, one to four home visits, two to five emergency room visits, and four to eight unplanned clinic visits. Total savings across all scenarios were $23,364 in the United States, $11,477 in Germany, and $7,088 in Italy. CONCLUSION: In a simulated environment, early intervention enabled by RTM reduced healthcare resource utilization and associated costs.

The economic burden of lung cancer and mesothelioma due to occupational and para-occupational asbestos exposure.

OBJECTIVES: To estimate the economic burden of lung cancer and mesothelioma due to occupational and para-occupational asbestos exposure in Canada. METHODS: We estimate the lifetime cost of newly diagnosed lung cancer and mesothelioma cases associated with occupational and para-occupational asbestos exposure for calendar year 2011 based on the societal perspective. The key cost components considered are healthcare costs, productivity and output costs, and quality of life costs. RESULTS: There were 427 cases of newly diagnosed mesothelioma cases and 1904 lung cancer cases attributable to asbestos exposure in 2011 for a total of 2331 cases. Our estimate of the economic burden is $C831 million in direct and indirect costs for newly identified cases of mesothelioma and lung cancer and $C1.5 billion in quality of life costs based on a value of $C100 000 per quality-adjusted life year. This amounts to $C356 429 and $C652 369 per case, respectively. CONCLUSIONS: The economic burden of lung cancer and mesothelioma associated with occupational and para-occupational asbestos exposure is substantial. The estimate identified is for 2331 newly diagnosed, occupational and para-occupational exposure cases in 2011, so it is only a portion of the burden of existing cases in that year. Our findings provide important information for policy decision makers for priority setting, in particular the merits of banning the mining of asbestos and use of products containing asbestos in countries where they are still allowed and also the merits of asbestos removal in older buildings with asbestos insulation.

Visual methods in health dialogues: A qualitative study of public health nurse practice in schools.

AIMS: We aimed to explore how using visual methods might improve or complicate the dynamics of the health dialogue between public health nurses (PHNs) and school pupils. This was done from the perspective of PHNs, specifically examining how they understood their role and practice as a PHN and the application of visual methods in this practice. BACKGROUND: The health dialogue is a method used by PHNs in school nursing in Norway. In this practice, there can be communicative barriers between pupils and PHNs. Investigating how PHNs understand their professional practice can lead to ways of addressing these communicative barriers, which can affect pupil satisfaction and achievement of health-related behaviours in the school context. Specifically, the use of visual methods by PHNs may address these communicative barriers. DESIGN: The research design was qualitative, using focus groups combined with visual methods. METHODS: We conducted focus group interviews using a semi-structured discussion guide and visual methods with five groups of PHNs (n = 31) working in northern Norwegian school health services. The data were collected during January and February 2016. Discussions were audio recorded, transcribed and coded into themes and sub-themes using systematic text condensation and drawings were analysed using interpretive engagement, a method of visual analysis. FINDINGS: Drawings and focus group discussions showed that PHNs perceived their professional practice as primarily a relational praxis. The PHNs used a variety of visual methods as part of the health dialogue with school pupils. This active use of visualization worked to build and strengthen relations when words were inadequate and served to enhance the flexible and relational practice employed by the PHNs. CONCLUSIONS: PHNs used different kinds of visualization methods to establish relations with school pupils, especially when verbalization by the pupils was difficult. PHNs were aware of both the benefits and challenges of using visualization with school pupils in health education. We recommend the use of visual methods in schools because they are useful for PHNs, other health professionals and teachers working with children and young people in developing relations, particularly where verbal communication may be a challenge.

Maximising students' use of purpose-built shade in secondary schools: quantitative and qualitative results of a built-environment intervention.

A trial installing shade sails at secondary schools found increased students' use of newly shaded areas, but relatively low use overall. We examined site features and weather related to use of these shaded areas. Tables with seats and temperatures ≥27°C increased student use of shaded areas, presence of grass decreased use. Focus groups at eight schools suggest students were unaware of changes to their habitual use of favoured locations. Results infer careful selection of locations for built-shade and provision of tables with seats will assist in maximising student use and investments in shade sails.

Making news: the appearance of tobacco control organizations in newspaper coverage of tobacco control issues.

PURPOSE: To characterize the presence of advocacy groups in media coverage about tobacco issues. DESIGN: A content analysis of tobacco-related newspaper articles. SETTING: Australia. SAMPLE: All 12 national and state capital daily newspapers published in Australia between 2004 and 2007. MEASURES: We coded each article for explicit mentions of any of 16 major national or state tobacco control advocacy groups; for the article type, prominence, and topic; for the tone of the event; and for the author's opinion. ANALYSIS: A series of 2 × 2 χ(2) analyses assessed the extent to which advocacy groups were more or less likely to be mentioned in articles of each type, prominence, topic, event impact, and opinion orientation. RESULTS: Of the 4387 tobacco-related articles published over this period, 22% mentioned an advocacy group. There was a greater-than-expected proportion of advocacy groups mentioned in news articles with very high prominence (44%; χ(2) [1, N = 3118] = 27.4, p < .001), high prominence (34%; χ(2) [1, N = 3118] = 10.9, p < .001), and medium prominence (30%; χ(2) [1, N = 3118] = 7.3, p = .007), and in articles covering events with mixed (30%; χ(2) [1, N = 4387] = 10.0, p = .002) or positive (24%; χ(2) [1, N = 4387] = 26.1, p < .001) implications for tobacco control. CONCLUSIONS: Australian tobacco control advocacy groups have a reasonable presence within the news discourse on tobacco control issues and so are likely to contribute to generating and shaping this discourse, particularly in relation to evolving and controversial issues.

How do friends influence smoking uptake? Findings from qualitative interviews with identical twins.

The smoking behavior of friends is a major risk factor for adolescent smoking uptake. To explore the social context of smoking experimentation and consolidation with a particular focus on friends, the authors interviewed both members of 14 young adult identical twin pairs who were discordant for smoking. The different smoking status of twins was connected to their different friendship groups and development of different identities. Smoking respondents gravitated to the behaviors and images of the peer group who smoked. Many nonsmokers felt strong pressure from their peers not to smoke and spoke about how the images conveyed by smoking were inconsistent with their peer group's image. Adolescents and young adults are aware of the messages that smoking can convey to others and exploit these images to construct a social identity.

Portrayal of tanning, clothing fashion and shade use in Australian women's magazines, 1987-2005.

To examine modelling of outcomes relevant to sun protection in Australian women's magazines, content analysis was performed on 538 spring and summer issues of popular women's magazines from 1987 to 2005. A total of 4949 full-colour images of Caucasian females were coded for depth of tan, extent of clothing cover, use of shade and setting. Logistic regression using robust standard errors to adjust for clustering on magazine was used to assess the relationship between these outcomes and year, setting and model's physical characteristics. Most models portrayed outdoors did not wear hats (89%) and were not in shade (87%). Between 1987 and 2005, the proportion of models depicted wearing hats decreased and the proportion of models portrayed with moderate to dark tans declined and then later increased. Younger women were more likely to be portrayed with a darker tan and more of their body exposed. Models with more susceptible phenotypes (paler hair and eye colour) were less likely to be depicted with a darker tan. Darker tans and poor sun-protective behaviour were most common among models depicted at beaches/pools. Implicit messages about sun protection in popular Australian women's magazines contradict public health messages concerning skin cancer prevention.

"Stay away from them until you're old enough to make a decision": tobacco company testimony about youth smoking initiation.

OBJECTIVE: To determine common themes used by US tobacco industry witnesses pertaining to youth smoking initiation during litigation in the United States. METHODS: Qualitative thematic analysis of transcripts from 29 tobacco litigation cases dating from 1992 to 2002. RESULTS: Youth smoking is portrayed by the tobacco industry as a source of great concern to them. Youth smoking prevention programmes developed by US tobacco companies are supposedly intended to delay decision-making about smoking until age 18, when individuals are then seen to be of an age where they are able to "choose to smoke". Tobacco industry media campaigns, youth access, community and school-based programmes are predicated on peer influence, parental factors, and commercial access being the primary influences on youth smoking uptake, rather than tobacco marketing, inaccurate risk appraisal, price and other factors known to influence youth smoking. Despite substantial financial investment in tobacco industry programmes, their witnesses were able to describe only weak evaluation methods, being preoccupied with measures of message comprehension, programme reach and uptake, and the associated costs of their efforts, rather than any evaluation designed to assess effects on youth smoking behaviour. CONCLUSION: Stated concerns about youth smoking and youth smoking prevention programmes are put forward in litigation as evidence that the tobacco industry is "serious" about tackling youth smoking, and serve as a primary strategy to improve the tobacco industry's public image. The tobacco industry's evaluation of the effectiveness of their youth smoking prevention programmes is demonstrably insufficient under current public health evaluation standards. Public health and welfare agencies should avoid engagement with tobacco industry-sponsored programmes.

Australian letters to the editor on tobacco: triggers, rhetoric, and claims of legitimate voice.

News coverage of tobacco issues influences both individual behavior change and policy progression. Thus, media advocacy is increasingly recognized as important for promoting public health. Letters to the editor (LTE) are a basic form of media advocacy, serving to demonstrate community sentiment on a given issue. Such letters are yet to receive systematic analytic consideration. The authors conducted an ethnographic content analysis of LTE on tobacco issues from a sample of 11 Australian daily newspapers over a 3-year period (2001 to 2003, N=361). They argue that letters are artifacts of active engagement in a public debate and note that various stakeholders adopt similar strategies to pursue their objectives. They illustrate how identifying personal and collective identities is crucial in the assertion of legitimacy of voice in LTEs. Better understanding is needed of both the particular issues that spark public engagement, and the salient rhetoric employed by advocates of disparate positions.

Impact of news of celebrity illness on breast cancer screening: Kylie Minogue's breast cancer diagnosis.

OBJECTIVES: To describe the main media narratives in the reportage of singer Kylie Minogue's illness with breast cancer; and to assess the impact of this coverage on bookings for screening for breast cancer by mammography in four Australian states. SETTING: Government sponsored BreastScreen programs in Queensland, Victoria, Tasmania and Western Australia. MAIN OUTCOME MEASURES: Narratives on breast cancer in television news programs 17-27 May 2005; initial and re-screening bookings for mammograms. PARTICIPANTS: Women aged > or = 40 years who booked for mammograms in BreastScreen programs in the 19 weeks before, the 2 weeks during, and the 6 weeks after the publicity. RESULTS: There was a 20-fold increase in news coverage of breast cancer, which emphasised that young women do get breast cancer and that early detection was critical. Overall screening bookings rose 40% in the 2 weeks of the publicity, with a 101% increase in non-screened women in the eligible age-group 40-69 years. Six weeks after the publicity, bookings remained more than a third higher in non-screened women. CONCLUSIONS: News coverage of Kylie Minogue's breast cancer diagnosis caused an unprecedented increase in bookings for mammography. Health advocates should develop anticipatory strategies for responding to news coverage of celebrity illness.

Individual versus corporate responsibility for smoking-related illness: Australian press coverage of the Rolah McCabe trial.

This paper provides a thematic frame analysis of Australian newspaper reporting of the outcome and implications of the trial of Rolah McCabe versus British American Tobacco Australasia (BATA). In this trial, a Melbourne woman was awarded A$700,000 damages for smoking-attributable lung cancer when the defendant, BATA, had its case dismissed due to document destruction. In 60 commentaries from Australian national or capital city newspapers between 12 April and 9 May 2002, a total of 79 instances of eight tobacco-related frames were identified. Overall, 43% of the 79 instances were positive for tobacco control, 46% were negative for tobacco control and 11% were neutral. The most common frame that was negative for tobacco control (in 35% of articles) was the conception that smokers exert 'free will' in deciding to smoke and should therefore be personally responsible for their smoking and any disease that arises as a result of it. A related, but less commonly employed frame (in 18% of articles) was the expressed fear of a 'slippery slope' of litigation, which portrayed smoking as similar to eating fast food or other 'vices'. The most common frame that was positive for tobacco control (in 35% of articles) was the notion that the tobacco industry was 'evil' and, to a lesser extent, that the government should 'do more' to control smoking (15% of articles). These findings provide a sobering public health challenge to improve public communication efforts about the powerful forces that conspire to induce people to start smoking and keep them smoking for decades, despite a strong desire to quit. There is a need to fund public education programs and quit smoking services more adequately to address the complex education task of understanding the nature of addiction to tobacco and the enormity of the health risk.