The ID effect on youth access to cigarettes.

OBJECTIVE: To estimate the effect on cigarette sales rates when minors present identification (ID). DESIGN: Controlled experiment in which minors attempting to purchase cigarettes either carried a valid photo ID (documenting they were minors) or carried no ID, and were instructed to show the ID or admit having no ID if the clerk requested proof of age. SETTING: Census of retail stores in six urban and suburban Colorado counties. SUBJECTS: Retail cigarette clerks, uninformed of the study. MAIN OUTCOME MEASURES: Relative risk (RR) of cigarette sale to a minor when ID was requested and presented versus requested but not presented. RESULTS: When clerks requested ID, sales were more than six times as frequent if minors presented ID than if they did not (12.2% v 2.0%, RR 6.2, p < 0.0001). The relative risk remained substantially unchanged under adjustment for demographic and circumstantial covariates. CONCLUSIONS: Presentation of photo ID in compliance checks increases illegal cigarette sales to minors. The impact may vary among states or locales and depends strongly on how often clerks request proof of age. Clerk training and responsible cigarette sales practices should include age calculations from photo ID. Programmes relying on investigative purchase attempts to estimate actual rates of cigarette sales to minors should ascertain and replicate local ID presenting behaviours that minors typically use during genuine attempts to buy cigarettes.

Smoking during pregnancy and breast cancer risk in very young women (United States).

OBJECTIVE: To evaluate the association of smoking during a woman's first pregnancy, a period of pronounced growth and differentiation of mammary tissue, and her subsequent breast cancer risk. METHODS: In this matched case-control study, we used linked birth certificate and tumor registry data from the New York State Health Department. Cases were 319 women aged 26-45 who were diagnosed with breast cancer in New York State between 1989 and 1995 and who completed a first pregnancy in New York State after 1987 at least one year prior to diagnosis of cancer. Controls were 768 primiparous women matched to cases on county of residence and delivery date. Information on prenatal smoking and other factors characterizing the woman's first pregnancy was obtained from the pregnancy record of each subject, and the association of these factors to breast cancer risk was assessed using conditional logistic regression. RESULTS: Smoking during pregnancy was associated with increased risk for breast cancer (crude OR = 2.7, 95% confidence interval (CI): 1.1-6.3). Adjustment for maternal age, subject age, race, and education strengthened this association (OR = 4.8, CI 1.6-14.6). CONCLUSIONS: These findings suggest that cigarette smoking during a woman's first pregnancy may increase her risk for early-onset breast cancer.

Patient age and cancer treatment decisions. Patient and physician views.

PURPOSE: The purpose of this study was to examine patient and physician factors influencing the decision to use adjuvant chemotherapy for stage III colon cancer in elderly persons. DESCRIPTION OF STUDY: A cross-sectional mailed population-based survey of patients 65 years of age and older who had undergone surgical resection of stage III colon cancer in Colorado between August 1995 and December 1997 were identified by the statewide cancer registry (n = 276) and their treating physicians (n = 232). A questionnaire about the determinants of colon cancer treatment decisions was mailed to all patients for whom physician permission was granted (n = 119). A similar questionnaire was sent to treating physicians. RESULTS: Ninety-two physicians (internal medicine 23%; family medicine 12%; surgery 37%; and oncology 24%) and 67 patients (mean age 75.8 years; 55% women) completed surveys. Fifty-four (80.6%) of the patients had received adjuvant chemotherapy. The major determinants of receiving adjuvant chemotherapy were having seen an oncologist (P = .003), being younger (P = .003), and being married (P = .021). After controlling for other potential influences, only having seen an oncologist (odds ratio 8.0; confidence interval 1.5-43.1) remained significantly associated with the receipt of chemotherapy. Physicians were more likely than patients to rank comorbid conditions (39.1% versus 3.0%, respectively; P < .001) and the medical literature (20.7% versus 4.5%, respectively; P = .004) as important factors in making treatment decisions, while patients were more likely than physicians to rank physician opinion (73.1% versus 26.1%, respectively; P = .001), family preference (31.3% versus 9.8%, respectively; P = .001), and family burden (10.4% versus 2.2%, respectively; P = .038). CLINICAL IMPLICATIONS: In this elderly population, patient age is not recognized by patients or physicians as affecting the decision to use adjuvant chemotherapy. Other biologic and social factors are important, however, and the perspectives of physicians and patients differ regarding their relative importance.

Preeclampsia and breast cancer risk.

Breast cancer is associated with endogenous hormone levels, but the exact relation and underlying mechanisms remain unclear. Data from several recent epidemiologic studies suggest that a woman who experiences preeclampsia in her own pregnancy, or who was herself born to a preeclamptic pregnancy, is at reduced risk for breast cancer later in life. This paper reviews the evidence for a connection between preeclampsia and breast cancer risk, and discusses the hormonal mechanisms that might explain this association. Preeclampsia is characterized by reduced levels of estrogens and insulin-like growth factor-1, and by elevated levels of progesterone, androgens, human chorionic gonadotropin, IGF-1 binding protein, corticotropin-releasing factor, cortisol, and insulin. These factors may act both individually and synergistically to decrease breast cancer risk. The occurrence of preeclampsia during a woman's pregnancy may reflect an underlying hormonal profile that both predisposes her to preeclampsia and reduces her risk for breast cancer. In addition, the major hormonal alterations associated with preeclampsia during gestation may have lasting effects on subsequent breast cancer risk. Finally, the hormonal and nutritional environment of the womb, for which preeclampsia is a marker, may play an important role in programming lifelong risk for breast cancer in the female offspring.

A woman's own birth weight and gestational age predict her later risk of developing preeclampsia, a precursor of chronic disease.

Preeclampsia is a major complication of pregnancy and a predictor of future chronic disease. We investigated the hypothesis that a woman's own weight and gestational age as a newborn influence her risk of developing preeclampsia later in life. This case-control study used linked computerized birth registry data from the Colorado Department of Public Health and Environment. The study subjects were women ages 12-20 who were born in Colorado after 1974, each of whom delivered a live infant in Colorado between 1990 and 1995. Cases were subjects with a report of eclampsia and/or preeclampsia on the 1990-1995 birth records (N = 345). Controls were randomly selected from subjects with uncomplicated pregnancies who were frequency matched to cases by year of delivery (N = 3,995). Records from each subject's pregnancy (1990-1995) were then linked to those from her own birth (1975-1983). Birth weight and gestational age, as recorded on the subject's birth records, were independently associated with the risk of developing preeclampsia after adjustment for age, parity, race/ethnicity, and other risk factors. The risk of preeclampsia decreased with increasing gestational age in a dose-dependent fashion; relative to mothers born post-term, adjusted odds ratios for preeclampsia ranged from 3.62 [95% confidence interval (95% CI) = 1.27-10.28] for mothers born at less than 34 weeks gestational age to 1.45 (95% CI = 0.85-2.45) for those born at term. Relative to women who were born at 8.5 lb or more, those born in the lowest weight category (under 4.5 lb) appeared at greatest risk for preeclampsia (odds ratio = 5.16; 95% CI = 1.24-21.51), although no directional trend was apparent. These findings suggest that women born small or premature may be at increased risk of developing preeclampsia as teenagers or young adults.

Serum folate and chronic disease risk: findings from a cohort of United States adults.

BACKGROUND: Previous studies have suggested that folate may provide protection against various chronic conditions. METHODS: We examined the effect of serum folate concentration on mortality and chronic disease incidence in a nationally representative sample of 3059 adults of the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study who were first examined from 1971 through 1975 and who were followed for about 19 years through 1992. Proportional hazards regression was used to estimate hazard ratios for the lowest quintile of serum folate compared with the highest quintile for selected causes of death and disease incidence. RESULTS: The hazards ratio for all-cause mortality was 1.18 (95% CI: 0.91-1.52); for mortality for diseases of the circulatory system, 1.31 (95% CI: 0.82-2.12); and for cancer mortality, 0.99 (95% CI: 0.46-2.11). The hazard ratio for incidence of diseases of the circulatory system was 1.04 (95% CI: 0.86-1.26); and for cancer incidence, 1.00 (95% CI: 0.61-1.66). The hazards ratio for all-cause mortality was 1.26 (95% CI: 1.01-1.57) for participants with a serum folate of <9.3 nmol/l compared with other participants. CONCLUSIONS: Low levels of serum folate may be associated with mortality from all-causes and cardiovascular disease. However, the study lacked power to adequately examine the association between folate and disease-specific endpoints. Additional studies, using serum and other measures of folate nutritional status, are needed to examine the relationship between folate nutrition and other more specifically defined health outcomes.

The validity of self-reports of past body weights by U.S. adults.

Past weight or patterns of weight change may be more important to chronic disease risk than current weight. Self-reports, however, are often the only source of information about past body weight. To date, very few studies have examined factors affecting the validity of self-reported past body weight. We examined the validity of self-reported past body weights of 1,931 U.S. adults who were participants in the First National Health and Nutrition Examination Survey (1971-1975) and were interviewed again in the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study (1982-1984). We compared the body weight measured during the initial examination (1971-1975) with the recalled 1971-1975 body weight reported during the follow-up interview (1982-1984). Recalled past weight was strongly correlated with previously measured weight (r = 0.73 for men, and r = 0.74 for women). Men overestimated their past body weight, whereas women underestimated their past weight. Although 39% of men and 41% of women estimated their past weight within 5 pounds, approximately 17% of women and 10% of men underestimated their past weight more than 15 pounds. Accuracy of reporting was influenced by sex, race, current body mass index, and the amount of weight gained over the 10 years following the initial examination. These factors should be considered when using recalled weight in epidemiologic studies.

Dietary glutathione intake and the risk of oral and pharyngeal cancer.

Glutathione, a tripeptide found in a variety of foods, may function as an anticarcinogen by acting as an antioxidant and by binding with cellular mutagens. The association between dietary glutathione intake and risk of oral and pharyngeal cancer was investigated using data from 1,830 white participants (855 cases and 975 controls) in a population-based case-control study conducted in New Jersey; metropolitan Atlanta, Georgia; Los Angeles County, California; and Santa Clara and San Mateo counties, south of San Francisco-Oakland, California, during 1984-1985. The estimated relative risk of cancer among people with the highest quartile of glutathione intake from all sources was 0.5 (95% confidence interval 0.3-0.7). When analyzed by dietary source, however, glutathione intakes derived from all vegetables and from meat were not related to risk of cancer. Only glutathione derived from fruit and from vegetables commonly consumed raw was associated with reduced oral cancer risk. Relative to the lowest level of combined intake of fruit and of fruit-derived glutathione, risk of cancer decreased slightly with increasing intake of fruit glutathione. This analysis was limited, however, by the small numbers of subjects with extreme combinations of intakes. Further studies are needed to distinguish the potential effect of glutathione from that of fruit and raw vegetables per se or from the influence of other constituents in these foods.

Dietary glutathione intake in humans and the relationship between intake and plasma total glutathione level.

Glutathione may function as an anticarcinogen by acting as an antioxidant or by binding with cellular mutagens. Orally administered glutathione increases plasma glutathione levels, and plasma glutathione is also synthesized in the liver. To investigate the associations between glutathione intake and plasma glutathione level, we compared dietary intake estimates from food frequency questionnaire data and measured concentrations of plasma total glutathione and other serum antioxidants in 69 white men and women. Daily glutathione intake ranged from 13.0 to 109.9 mg (mean 34.8 mg). Fruits and vegetables were found to contribute over 50% of usual dietary glutathione intake, whereas meats contributed less than 25%. Small negative correlations were observed between dietary and plasma glutathione and, although they were usually not statistically significant, they were generally consistent by different time periods of dietary intake assessment. Adjustment for sex, age, caloric intake, and dietary intake of the sulfur-containing amino acids methionine and cystine did not alter the observed associations. The correlations appeared to be modified, however, by serum vitamin C concentration, with little or no association between dietary and plasma glutathione among those with lower levels of serum vitamin C and stronger negative correlations among those with higher serum vitamin C levels. These findings indicate that factors regulating plasma glutathione concentration are complex and not simply related to dietary glutathione intake or supply of precursor amino acids.

Weight control practices of U.S. adolescents and adults.

OBJECTIVE: To estimate the prevalence of various weight-loss practices in U.S. adolescents and adults. DESIGN: The Youth Risk Behavior Survey, a self-administered survey of a random sample of high school students in 1990 and the Behavioral Risk Factor Surveillance System, a random-digit dial survey in 1989. SETTING: Thirty-eight states and the District of Columbia. PARTICIPANTS: High school students (n = 11,467) and adults 18 years and older (n = 60,861). RESULTS: Among high school students, 44% of female students and 15% of male students reported that they were trying to lose weight. An additional 26% of female students and 15% of male students reported that they were trying to keep from gaining more weight. Students reported that they had used the following weight control methods in the 7 days preceding the survey: exercise (51% of female students and 30% of male students); skipping meals (49% and 18%, respectively); taking diet pills (4% and 2%, respectively); and vomiting (3% and 1%, respectively). Among adults, 38% of women and 24% of men reported that they were trying to lose weight, whereas 28% of each sex reported that they were trying to maintain their weight. CONCLUSIONS: Attempts to lose or maintain weight are very prevalent among both adolescents and adults, especially among females.

Weight loss and subsequent death in a cohort of U.S. adults.

OBJECTIVE: Because we previously found that weight loss was associated with increased risk for death in all but very overweight men in a cohort of U.S. adults, we undertook a new analysis to determine whether inadequate control for preexisting illness or cigarette smoking contributed to this association. DESIGN: Cohort study. SETTING: The first National Health and Nutrition Examination Survey (NHANES I, 1971 to 1975) collected information on maximum lifetime weight and measured current weight on a probability sample of U.S. adults. The NHANES I Epidemiologic Follow-up Study determined the vital status of participants through 1987. PARTICIPANTS: Men (n = 2453) and women (n = 2739) who were 45 to 74 years old at the time of the NHANES I examination. RESULTS: The effect of excluding persons who died within the first 5 and first 8 years after baseline was examined to limit the influence of weight loss due to preexisting illness. For women, extension of the exclusionary period weakened the association between weight loss and increased risk for death from noncardiovascular disease. However, excluding death for as much as 8 years after baseline did not affect the strong association between weight loss and increased risk for death from cardiovascular disease among men and women with maximum body mass indexes between 26 and 29 (relative risks of up to 2.1 and 3.6 for men and women, respectively, after excluding deaths in the first 8 years). Results were not substantially altered by limiting the analysis to persons who never smoked. CONCLUSIONS: Preexisting illness may influence the association between weight loss and death principally through deaths from noncardiovascular disease. For some persons, weight loss is associated with an increased risk for death, even after excluding deaths occurring in the first 8 years.

Diet, smoking, and alcohol in cancer of the larynx: a case-control study.

A case-control study among white men in western New York was conducted from 1975 through 1985 to examine diet and other risk factors for laryngeal cancer. Incident pathologically confirmed cases (250) and age- and neighborhood-matched controls (250) were interviewed to determine usual diet and lifetime use of tobacco and alcohol. Cigarettes were strongly associated with risk; pipes and cigars were not. Beer and hard liquor but not wine were associated with increased risk. Dietary fat and carotenoids were related to risk in opposite ways. The upper quartile odds ratio for dietary fat was 2.40 [95% confidence interval 1.26, 4.55], and the upper quartile odds ratio for carotenoids was 0.51 (0.26, 1.01). There was effect modification by smoking. Carotenoids were most negatively associated with risk among the lightest smokers, whereas dietary fat was most positively associated with risk among the heaviest smokers. Total calories, protein, and retinol were associated with increased risk; there was no relationship between laryngeal cancer and vitamin C, vitamin E, carbohydrate, or dietary fiber. This study again demonstrates the strong association between tobacco and alcohol and laryngeal cancer and also suggests that diets low in carotenoids and high in fat may increase risk.

Lag time between stress events and risk of recurrent episodes of inflammatory bowel disease.

We followed a cohort of 124 subjects with a history of inflammatory bowel disease to ascertain risk estimates for clinically active disease associated with exposure to recent stress events. We calculated risk estimates for three lag models (-1, 0, + 1 month). The data indicated a strong association between stress exposures and new clinical episodes of disease (RR = 2.9, 95% Cl: 2.0-4.1), most apparent in the immediate period (lag = 0). Risk estimates were also elevated for extended episodes of disease in subjects under stress compared with unexposed subjects. These results underscore the importance of monitoring stress exposures in prevention and treatment of recurrent disease.

Relevance of major stress events as an indicator of disease activity prevalence in inflammatory bowel disease.

The impact of psychological stress in recurrence of inflammatory bowel disease (IBD) is unclear. Why some patients with ulcerative colitis (UC) or Crohn's disease (CD) have unrelenting relapses whereas other IBD patients experience long periods of quiescent disease remains an enigma. The authors examined the risk of exposure to major stress events in clinical episodes of IBD. They followed up on 124 persons in a prospective study that monitored behavioral and biological characteristics for a period of 6 months. Stress-exposed subjects demonstrated increased risk of clinical episodes of disease when compared with unexposed subjects (RR = 2.6, 95% CI: 1.3-4.9). Elevated effect measures were highest for the domain of health-related stress (RR = 3.8, 95% CI: 1.5-9.9). In the multiple regression analysis, major stress events remained the most significant indicator of disease activity in the presence of the covariables considered. Only 7% of the variation in disease activity was uniquely attributed to stress. Baseline activity was the other notable indicator of subsequent disease activity in the study sample. All variables considered together explained 52% of the variance observed and implicated factors of potential clinical importance in monitoring recurrence of the disease.

Methodological issues in nutrition surveillance: the CDC experience.

Nutrition surveillance systems serve to provide state- and locality-specific data that are useful for the management of public health nutrition programs. Current systems, such as the Pediatric and Pregnancy Nutrition Surveillance Systems coordinated by the Centers for Disease Control (CDC), collect program-based data focused on nutrition problems in infants, children, and pregnant women. These systems provide highly useful information, but also present significant methodological challenges relating to representativeness, quality control, and indicator sensitivity/specificity. As the importance of nutritional risk factors for chronic disease is increasingly recognized, the concept of nutrition surveillance must be expanded beyond maternal and child nutrition to include nutrition-related behaviors and risk factors in adolescents and adults. The Behavioral Risk Factor Surveillance System (BRFSS), coordinated by CDC, collects telephone survey data that include information on nutrition-related issues such as overweight, weight-loss practices, and cholesterol screening. In addition, a school-based surveillance system is being established by CDC in coordination with state education agencies to assess adolescent health behaviors, including nutrition. The operation of these nutrition surveillance systems presents significant methodological issues that must be considered in interpreting and using the data for public health purposes.

Cigarette smoking and risk of clinical relapse in patients with Crohn's disease.

Risk of clinical relapse among cigarette smokers and nonsmokers was examined in a cohort of 74 adult Crohn's disease (CD) patients who were identified and followed at monthly intervals for six months. We measured clinical activity by a weighted symptom index used previously. Relapse at any point during the study was defined by the index score exceeding 150. Approximately 50% of nonsmokers experienced clinical relapse during the study period. Current smokers experienced a relapse risk 1.6 times that of nonsmokers (P less than .01). The risk estimates correspond to mean overall clinical activity scores of 142 +/- 34 for smokers compared to 119 +/- 26 for nonsmokers. Adjustment for confounding effects did not substantially alter the association shown between cigarette use and clinical relapse. We observed no increase in the likelihood of relapse among former smokers. The statistically significant finding that current smoking increases the risk of relapse for CD patients is of clinical importance, given the high prevalence of smoking (42%) among CD patients in this sample.

Vasoactive intestinal peptide as a laboratory supplement to clinical activity index in inflammatory bowel disease.

Circulating levels of vasoactive intestinal peptide (VIP) in plasma were measured in gauging activity in inflammatory bowel disease (IBD). One hundred-fifteen adult IBD patients were studied cross-sectionally and prospectively, 48 with ulcerative colitis (UC) and 67 with Crohn's disease (CD). Sequential samples of plasma were assayed for VIP by specific radioimmunoassay. Sixty males and 55 females, ranging in age from 22 to 76 years were studied over six months. The results revealed a strong, positive association between VIP levels and clinical activity, both at baseline (r = 0.38, P less than 0.001) and follow-up (r = .41, P less than 0.001). The ability of the VIP immunoassay to gauge clinical activity was also evaluated where VIP concentrations above 30 pg/ml were defined as abnormal. At baseline, sensitivity (specificity) was found to be 81% (55%). The predictive value of a positive (negative) test was 57% (80%). These estimates did not differ at follow-up. Examination of paired plasma samples from intermittently active patients revealed nearly twofold increases (P less than 0.05) in VIP concentration during active periods of disease. The data suggest that plasma VIP levels may be a valuable laboratory parameter in gauging activity in inflammatory bowel disease.