Home and workplace smoking bans in Italy, Ireland, Sweden, France and the Czech Republic.

The purpose of this study was to report predictors and prevalence of home and workplace smoking bans in five European countries. We conducted a population-based telephone survey of 4,977 females, ascertaining factors associated with smoking bans. Odds ratios and 95% confidence intervals were derived using unconditional logistic regression. A complete home smoking ban was reported by 59.5% of French, 63.5% of Irish, 61.3% of Italian, 74.4% of Czech and 87.0% of Swedish females. Home smoking bans were associated with younger age and being bothered by secondhand smoke, and among smokers, inversely associated with greater tobacco dependence. Among nonsmokers, bans were also related to believing smoking is harmful (OR 1.20, 95% CI 1.11-1.30) and having parents who smoke (OR 0.62, 95% CI 0.52-0.73). Workplace bans were reported by 92.6% of French, 96.5% of Irish, 77.9% of Italian, 79.1% of Czech and 88.1% of Swedish females. Workplace smoking bans were reported less often among those in technical positions (OR 0.64, 95% CI 0.50-0.82) and among skilled workers (OR 0.53, 95% CI 0.32-0.88) than among professional workers. Workplace smoking bans are in place for most workers in these countries. Having a home smoking ban was based on smoking behaviour, demographics, beliefs and personal preference.

Youth smoking prevention and tobacco industry revenue.

OBJECTIVES: Epidemiological surveys make it clear that youth smoking contributes to both current and future tobacco industry revenue: over 80% of adult smokers reportedly began smoking before age 18. This paper estimates annual and lifetime revenue from youth smoking, and highlights the association between declines in youth smoking and declines in tobacco industry revenue. MAIN OUTCOME MEASURES: This paper reports the amount of tobacco industry revenue generated by youth smoking at two points in time (1997 and 2002), and describes the distribution of youth generated tobacco income among the major tobacco companies. The authors project the amount of tobacco industry revenue that will be generated by members of two cohorts (the high school senior classes of 1997 and 2002) over the course of their lifetimes. RESULTS: In 1997, youth consumed 890 million cigarette packs, generating $737 million in annual industry revenue. By 2002, consumption dropped to 541 million packs and revenue increased to nearly $1.2 billion. Fifty eight per cent of youth generated revenue goes to Philip Morris USA, 18% to Lorillard, and 12% to RJ Reynolds. The authors project that, over the course of their lives, the 1997 high school senior class will smoke 12.4 billion packs of cigarettes, generating $27.3 billion in revenue. The 2002 high school senior class is projected to smoke 10.4 billion packs, generating $22.9 billion in revenue over the course of their lives. CONCLUSIONS: Cigarette price increases from 1997 to 2002 have resulted in greater revenue for the tobacco industry, despite declines in youth smoking prevalence. However, in the absence of further cigarette price increases, declines in youth smoking are projected to lead ultimately to a loss of approximately $4 billion in future tobacco industry revenue from a single high school cohort.

Who's afraid of the truth?

The November 1998 Master Settlement Agreement between tobacco manufacturers and state attorneys general significantly restricted the marketing of tobacco products, made possible markedly expanded tobacco control programs in the states, and provided for the creation of a new foundation whose primary purpose is to combat tobacco use in the United States. This commentary describes the American Legacy Foundation, with particular emphasis on one of its efforts--the "truth" Campaign, a countermarketing effort to reduce smoking among youths. The "truth" Campaign has been well received by the public and is expected to be [corrected] effective in reducing smoking among youths. The only negative reaction to the campaign has been, predictably, from the tobacco industry.

Women and tobacco: with the master settlement agreement, we've come a long way, baby!

This commentary provides a brief overview of the impact tobacco has on the health of women. Tobacco control activities that reduce the number of young people who start smoking, reduce exposure to environmental tobacco smoke, and increase the ability of Americans to successfully quit have the capacity to markedly reduce the toll of tobacco. The efforts can be greatly enhanced by the unprecedented opportunity the master settlement agreement (MSA) between the state attorneys general and the tobacco industry presents for directing resources to those policies and programs that are most effective in stemming tobacco use. The relentless increase in tobacco marketing reaching teens and ethnic minority women makes ever more urgent our concerted efforts to confront those policy initiatives that can ensure the MSA is adhered to fully.

The adolescent years: an academic-community partnership in Harlem comes of age.

Much has been written about the potential benefits in health promotion that are possible through partnerships between academic institutions and community-based organizations, but little practical advice has been provided on how to sustain these relationships when the original grant funds have been exhausted. Here we document our experiences in Harlem, New York City, a community with grave social, structural, and physical environmental inequities, and describe the successes and failings of a partnership now in its "adolescence" between researchers at the Joseph L. Mailman School of Public Health of Columbia University and community activists at West Harlem Environmental Action (WE ACT).

Creating training opportunities for public health practitioners.

In response to several reports issued by the federal government and private foundations on the under-training of public health practitioners, Joseph L. Mailman School of Public Health of Columbia University (SPH) and the New York City Department of Health (NYC DOH) initiated the Public Health Scholars program (SPH-PHS) to make degree-level public health training available to NYC DOH employees. Public Health Scholars receive a 50% tuition scholarship and enroll part-time while working full-time at NYC DOH. Sixteen scholars have enrolled during the past three years. The SPH-PHS program is considered a success by both SPH and NYC DOH. This article details the history of the collaboration between the two agencies and the structure of the program and provides a critical analysis of the SPH-PHS program based on interviews with 16 scholars. It also examines the cost and benefit to other schools of public health of implementing such a program.

Safer sex strategies for women: the hierarchical model in methadone treatment clinics.

Women clients of a methadone maintenance treatment clinic were targeted for an intervention aimed to reduce unsafe sex. The hierarchical model was the basis of the single intervention session, tested among 63 volunteers. This model requires the educator to discuss and demonstrate a full range of barriers that women might use for protection, ranking these in the order of their known efficacy. The model stresses that no one should go without protection. Two objections, both untested, have been voiced against the model. One is that, because of its complexity, women will have difficulty comprehending the message. The second is that, by demonstrating alternative strategies to the male condom, the educator is offering women a way out from persisting with the male condom, so that instead they will use an easier, but less effective, method of protection. The present research aimed at testing both objections in a high-risk and disadvantaged group of women. By comparing before and after performance on a knowledge test, it was established that, at least among these women, the complex message was well understood. By comparing baseline and follow-up reports of barriers used by sexually active women before and after intervention, a reduction in reports of unsafe sexual encounters was demonstrated. The reduction could be attributed directly to adoption of the female condom. Although some women who had used male condoms previously adopted the female condom, most of those who did so had not used the male condom previously. Since neither theoretical objection to the hierarchical model is sustained in this population, fresh weight is given to emphasizing choice of barriers, especially to women who are at high risk and relatively disempowered. As experience with the female condom grows and its unfamiliarity decreases, it would seem appropriate to encourage women who do not succeed with the male condom to try to use the female condom, over which they have more control.

Effects of ZDV-based patient education on intentions toward ZDV use, HIV testing and reproduction among a US cohort of women.

This study examined the immediate effects of exposure to a patient education brochure concerning the risks and benefits of zidovudine (ZDV) therapy during pregnancy to reduce perinatal HIV transmission (protocol ACTG 076) on related knowledge, behavioural intentions and attitudes of women with and at-risk for HIV-infection. Self-reports were collected from 653 women of childbearing age from community family planning clinics and hospital-based HIV centres in 19 sites from nine US cities between May and November 1995. The intervention was a nine-page patient education brochure in Spanish, Creole and English versions, evently presenting the pros and cons of ZDV therapy to reduce perinatal HIV-transmission. Brochure exposure increased knowledge (p < 0.001) for all but one scale concerning ZDV resistance and increased the likelihood of women reporting intentions to take ZDV during pregnancy (p < 0.001) and to believe ZDV reduced transmission (p < 0.001). Brochure exposure had differential effects for some subpopulations. Intentions to have or terminate current or future pregnancies, knowledge about ZDV and attitudes toward ZDV varied mostly by ethnicity/race, language preference and HIV status. Pregnancy status, age, education and having an HIV-positive child had less impact on the brochure's effect, while income had no impact.

A decision analysis of mandatory compared with voluntary HIV testing in pregnant women.

BACKGROUND: The benefit of antiretroviral therapy in reducing maternal-fetal transmission of HIV during pregnancy has caused a public policy debate about the relative benefits of mandatory HIV screening and voluntary HIV screening in pregnant women. OBJECTIVE: To evaluate the benefits and risks of mandatory compared with voluntary HIV testing of pregnant women to help guide research and policy. DESIGN: A decision analysis that incorporated the following variables: acceptance and benefit of prenatal care, acceptance and benefit of zidovudine therapy in HIV-infected women, prevalence of HIV infection, and mandatory compared with voluntary HIV testing. MEASUREMENTS: The threshold deterrence rate (defined as the percentage of women who, if deterred from seeking prenatal care because of a mandatory HIV testing policy, would offset the benefit of zidovudine in reducing vertical HIV transmission) and the difference between a policy of mandatory testing and a policy of voluntary testing in the absolute number of HIV-infected infants or dead infants. RESULTS: Voluntary HIV testing was preferred over a broad range of values in the model. At baseline, the threshold deterrence rate was 0.4%. At a deterrence rate of 0.5%, the number of infants (n = 167) spared HIV infection annually in the United States under a mandatory HIV testing policy would be lower than the number of perinatal deaths (n = 189) caused by lack of prenatal care. CONCLUSIONS: The most important variables in the model were voluntary HIV testing, the deterrence rate associated with mandatory testing compared with voluntary testing, and the prevalence of HIV infection in women of child-bearing age. At high levels of acceptance of voluntary HIV testing, the benefits of a policy of mandatory testing are minimal and may create the potential harms of avoiding prenatal care to avoid mandatory testing.

Directly observed therapy and treatment completion for tuberculosis in the United States: is universal supervised therapy necessary?

OBJECTIVES: This study examined the relationship between directly observed therapy and treatment completion rates in the years before and after infusion of federal funding for tuberculosis (TB) control in 1993. METHODS: An ecological study of estimated directly observed therapy rates and 12-month treatment completion rates from 1990 through 1994 was undertaken for TB control programs in all 25 cities and counties across the nation with 100 or more incident TB cases in any year from 1990 to 1993. Three cohorts were formed: high treatment completion, intermediate completion, and low completion. RESULTS: In 1990, the median 12-month treatment completion rate was 80% for the entire study population, with a median estimated directly observed therapy rate of 16.8%. By 1994, those rates had increased to 87% and 49.4%, respectively, and increases were shown in all 3 cohorts. CONCLUSIONS: Directly observed therapy has had a marked impact on treatment completion rates in jurisdictions with historically low rates. But TB treatment completion rates of more than 90% can be attained with directly observed therapy rates far lower than those proposed by advocates of universal supervised therapy.

Delivering HIV/AIDS services: the professional care provider speaks out.

BACKGROUND: This study evaluates the stresses and satisfactions experienced by health care and social service providers working in HIV/AIDS service agencies in New York City. This study was part of the Ryan White Title I Evaluation in New York City. METHODS: This study is based on semi-structured interviews with 86 randomly sampled providers from a representative sample of 29 HIV/AIDS service agencies. Personal interviews were completed with a cross section of AIDS care providers. All staff interviewed were audiotaped to facilitate data analysis. Staff discussed their frustrations and their personal satisfaction at working in AIDS care. In addition, all staff completed the Maslach Burnout Inventory (MBI) to facilitate a structured comparison of their levels of burnout. RESULTS: Using the three subscales of the MBI, we found that interviewed AIDS care providers experienced lower than expected levels of burnout. Compared to national norms, health care and social service providers showed above-average levels of personal accomplishment, below-average levels of depersonalization, and average levels of emotional exhaustion. Interview transcripts were analyzed focusing on three broad themes: unique stressors of HIV/AIDS services, positive aspects of HIV/AIDS services, and effective provider supports. The study confirms that HIV/AIDS care providers feel a high level of personal commitment to working with HIV-positive clients. Personal commitment to HIV-positive clients may blunt some of the stresses associated with HIV/AIDS care.

The impact of patient education about the effect of zidovudine on HIV perinatal transmission: knowledge gain, attitudes, and behavioral intent among women with and at risk of HIV.

The termination of the perinatal HIV transmission trial, ACTG 076, by the Data Safety and Monitoring Board in February 1994 because of the efficacy of zidovudine (ZDV) in substantially reducing maternal-infant HIV transmission has created a considerable need for efficacious patient education approaches and materials for women with and at risk of HIV infection. Complexities surrounding patients' decisions to use ZDV in accordance with the treatment arm protocol of this study must be communicated to women, especially the consequences for both themselves and their potential children. In March 1994, a public-private partnership was formed to develop and test the impact of patient education information on 076 and to explore cultural differences in decision-making surrounding ZDV use during pregnancy. Objectives were (1) to develop an efficacious patient informational booklet on the results of ACTG 076 and (2) to determine the differential attitudes and behavioral intentions of women toward taking AZT during pregnancy. A multi-disciplinary group of providers and researchers developed the patient education booklet and field-tested it in five New York City area sites. Subjects were a multiethnic group of women of childbearing age who were predominantly HIV-positive or at risk of HIV infection (n = 120). This 076 education resulted in a substantial increase in intention to use ZDV to reduce perinatal transmission despite full disclosure of the unknowns (P < .001). There were differences in knowledge acquired between racial/ethnic groups, which must be viewed cautiously since the study did not assess socioeconomic status adequately. Attitudes toward ZDV (P < .05), trust in health care providers (P < .03), and opinions on whether testing should be voluntary (P < .02) also varied by race/ethnicity. Medical Subject Headings (MeSH): perinatal transmission, AIDS education, pregnancy, HIV, ACTG 076.

Stabilizing the HIV/AIDS workforce: lessons from the New York City experience.

The Ryan White Title I Personnel Needs Study described here is an evaluation of the human resource needs of HIV/AIDS service agencies in New York City. The research presented here was conducted in collaboration with researchers from the Medical and Health Research Association and the New York City Department of Health and the Planning and Evaluation Committee of the New York City HIV Health and Human Services Planning Council. The assessment is divided into two components. The first component is a survey of 100 key informants from HIV/ AIDS service agencies. The second component is a detailed staffing survey of 70 personnel directors of HIV/AIDS service agencies. HIV/AIDS service directors perceived staff recruitment as a more difficult process than staff retention, regardless of agency type. Vacancy rates at the surveyed agencies varied by professional category; they were especially high in the category of nurse practitioners (13%) and outreach/education workers (15%). Agencies stressed that incentives that would positively affect recruitment and retention should be tailored to address the concerns of varied health care and social service professionals. In addition, agencies were not routinely able to provide some incentives deemed effective such as higher salaries, housing subsidies, and smaller caseloads. To reduce recruitment and retention problems, agency informants recommended a variety of incentive programs including malpractice insurance for physicians, flexible hours for full-time employees (including case managers, nurses, physician's assistants), smaller caseloads, and a decrease in the proportion of staff time devoted to direct client contact. Overall health care trends including truncated federal budgets, state Medicaid cutbacks, and the rapid conversion to managed care all affect the quality of patient care and of the work setting for health care and social service providers serving persons with AIDS. Medical Subject Headings (MeSH): AIDS, health personnel, employment supported, employee workload, staff attitude.

A balancing act: the tension between case-finding and primary prevention strategies in New York State's voluntary HIV counseling and testing program in women's health care settings.

This study sought (1) to identify factors that influence women's willingness to accept voluntary HIV counseling and testing at New York State Family Planning Programs (FPPs) and Prenatal Care Assistance Programs (PCAPs) and (2) to evaluate the effectiveness of such a voluntary counseling and testing program. Telephone interviews elicited organizational-level data from 136 agencies; a combination of telephone and face-to-face interviews was used to gather provider data from 98 HIV counselors; and client data were gathered from 354 women in face-to-face interviews at counseling sites. Slightly fewer than 60% of women agreed to be counseled, and, of those, under half consented to an HIV test at the counseling site. Approximately two thirds of the women who were tested returned for their results and posttest counseling. Clients' recall of pretest counseling content was relatively poor. Bivariate and regression analyses suggest that client, provider, and organizational factors are all associated with rates of pretest counseling and testing. The current voluntary counseling and testing program is achieving only moderate success. Although a substantial number of clients accept HIV counseling, many women remain reluctant to consent to HIV testing, and many who accept testing do not return for their results. Moreover, among those who receive pretest counseling, many do not recall important informational content, which suggests variation may exist in the quality of counseling or that one-time HIV counseling interventions are insufficient to communicate complex information. Medical Subject Headings (MeSH): AIDS, HIV serodiagnosis, women's health, patient education.

The effect of video interventions on improving knowledge and treatment compliance in the sexually transmitted disease clinic setting. Lesson for HIV health education.

Eight intervention studies investigating patient education and treatment adherence in the sexually transmitted disease (STD) clinic setting are reviewed. Across the eight studies selected for analysis, meta-analytic procedures were applied to compare the impact of educational and prevention approaches. The effect of video was compared with that of other modes of health education on: 1) knowledge and attitudes about STDs and condoms and 2) treatment compliance, as measured by return for test of cure, drug compliance, premature resumption of sexual activity, and condom coupon redemption rates. The largest effects were those for video on knowledge and attitudes about STDs and condoms, followed by the effects of other non-video interventions on STD knowledge. Lower effects were found among video and non-video interventions targeting treatment compliance outcomes. These results are consistent with prior prevention studies that have demonstrated difficulty in achieving behavior change.

Controlling AIDS in Cuba. The logic of quarantine.

PIP: Cuba has initiated a program to control Acquired Immune Deficiency Syndrome (AIDS) that is designed to limit the spread of infection with the human immunodeficiency virus (HIV) by implementing compulsory elements of the public health tradition. Widespread screening for HIV infection began 3 years ago, and persons identified as infected have been sent to a sanatorium located in a Havana suburb. The program also reflects concern over the marked increase in prevalence of sexually transmitted diseases. Educational effects in Cuba stress that AIDS is not a disease exclusively of homosexuals and can affect any individual. Condoms are recommended for protection. In contrast to virtually every other nation, Cuba has not made education the key focus of its anti-AIDS strategy. Education is relegated to a marginal role. Key to the policy is identifying infected individuals and bringing them under medical control. Cuba's HIV surveillance program has been carried out with use of an enzyme-linked immunosorbent assay (ELISA), Western blot assay, and antigen tests that have been developed domestically. The director of the Cuban AIDS Investigations Laboratory reports that nearly 3 million Cubans have been tested. It is estimated that among the 7 low-infection groups tested in Cuba, between 21 and 53 persons may have been inaccurately considered positive as a result of testing. Cuban authorities have expressed much interest in obtaining commercially available HIV screening kits -- both ELISA and Western blot assays -- as a standard against which to measure their own test. Despite the inevitability of continued viral transmission, Cuba's policy of a modified quarantine certainly will limit the toll of HIV infection markedly yet comes at a great price. For other nations, the imperatives of prevention, however important, are not the only values to be considered in the battle against AIDS.^ieng