Merchandising of cigarettes in San Francisco pharmacies: 27 years later.

OBJECTIVE: To estimate changes since 1976 in the proportion of San Francisco pharmacies that sell cigarettes and to characterise the advertising of cigarettes and the merchandising of non-prescription nicotine replacement therapy (NRT) products in these retail establishments. METHODS AND SETTING: 100 randomly selected San Francisco pharmacies were visited in 2003. Pharmacies were characterised based on the sale of cigarettes, advertising for cigarettes, and the merchandising of non-prescription NRT products. RESULTS: In 2003, 61% of pharmacies sold cigarettes, a significant decrease compared to 89% of pharmacies selling cigarettes in 1976 (p < 0.001); 84% of pharmacies selling cigarettes also displayed cigarette advertising. Non-prescription NRT products were stocked by 78% of pharmacies, and in 55% of pharmacies selling cigarettes, the NRT products were stocked immediately adjacent to the cigarettes. CONCLUSIONS: Since 1976, there has been a decline in the overall proportion of pharmacies in San Francisco that sell cigarettes yet most pharmacies, particularly traditional chain pharmacies, continue to merchandise the primary known risk factor for death in the USA.

Nicotine dependence, withdrawal symptoms, and adolescents' readiness to quit smoking.

The purpose of this study was to characterize nicotine dependence and nicotine withdrawal symptoms among adolescent smokers and to investigate associations between these key factors and adolescents' readiness to quit smoking. A total of 5624 high school students participated in a school-based survey. Of 1111 adolescents who were current or former smokers, the following stage-of-change distribution for smoking cessation was observed: precontemplation, 52.5%; contemplation, 16.0%; preparation, 7.5%; action, 13.2%; and maintenance, 10.8%. Among current smokers, 18.1% were substantially dependent on nicotine, 45.2% had moderate dependence, and 36.7% had no dependence. Higher proportions of current smokers than successful quitters reported withdrawal symptoms with their most recent quit attempts. Precontemplators exhibited significantly higher mean nicotine dependence scores than did students in the contemplation or preparation stages (F(2,837) = 12.03; p < 0.0001). A similar trend was observed for withdrawal-symptom scores across the stages of change. The nicotine dependence and withdrawal-symptom scores were significantly correlated (r = 0.44, p < 0.001). Nicotine dependence and nicotine withdrawal appear to interfere with adolescents' abilities and readiness to quit smoking, suggesting a potential role for nicotine replacement therapy in the treatment of tobacco use and dependence among adolescents.

D2 dopamine receptor gene polymorphisms among African-Americans and Mexican-Americans: a lung cancer case-control study.

Recent research suggests that variant alleles (A1 and B1) of the DRD2 gene play a role in determining smoking status. However, no studies have evaluated these variant alleles in African-Americans and Mexican-Americans. The primary objective of this study, therefore, was to test the hypothesis that ever smokers in these ethnic groups are more likely than never smokers to have the DRD2 alleles associated with tobacco use (A1 and B1). Furthermore, because of a predicted higher prevalence of smokers in a family because of the patterns of inheritance of the genotypes associated with tobacco use, we also anticipated that individuals with these at-risk DRD2 alleles would be more likely to have a family history of smoking-related cancers. Because other inherited genetic variants may interact with smoking on cancer risk, we also hypothesized that this association might differ between cancer patients and control subjects. PCR was used to perform genotyping on peripheral WBC DNA from 140 lung cancer patients (43 Mexican-Americans and 97 African-Americans) and 222 age-, sex-, and ethnicity-matched controls (111 Mexican-Americans and 111 African-Americans). A personal family history was obtained from each participant. There were no statistically significant differences in the distribution of the DRD2 genotypes between cases and controls, although the frequency of the B1 genotype significantly differed by ethnicity (P = 0.002 for controls and P = 0.001 for cases). The DRD2 genotypes and smoking status showed a correlation among Mexican-American controls, although not among African-American controls. The cigarette pack-years in control subjects for the two ethnic groups combined were 30.8, 21.9, and 18.6 for the A1A1, A1A2, and A2A2 genotypes and 36.5, 20.8, and 18.5 for the B1B1, B1B2, and B2B2 genotypes, respectively. Similar trends were found for the number of cigarettes smoked per day among control subjects. From the standpoint of polymorphisms, however, there was a borderline significantly increased (3.6 times greater) frequency of smoking-related cancers among the first-degree relatives of case subjects with an A1 allele than among those without an A1 allele. There was also an elevated (1.8 times greater) frequency of smoking-related cancer among first-degree relatives of case subjects with a B1 allele compared with patients without a B1 allele, but this finding was not statistically significant. This phenomenon was not observed among control subjects. We noted a trend toward interaction of DRD2 A1 genotypes and case status for increased risk of smoking-related cancer among first-degree relatives. These findings suggest that the variant DRD2 genotypes are associated with a greater likelihood to smoke and a greater smoking intensity, as well as with a familial aggregation of smoking-related cancers. However, a large study is needed to confirm this finding.

Validation of the modified Fagerström tolerance questionnaire with salivary cotinine among adolescents.

This study was conducted to gain evidence of validity for a nicotine dependence measure for adolescent smokers. We hypothesized that the individual item responses and the total Fagerström Tolerance Questionnaire (FTQ) score would be positively correlated with cotinine values. We examined the relationship between a seven-item modified FTQ and saliva continine among 131 adolescent volunteers in a smoking cessation program. As anticipated, the total FTQ score was related to saliva cotinine (r = .40, p < .01), as were six of the seven individual FTQ items (p < .05). Our findings provide preliminary evidence that the modified FTQ scale is valid and applicable to adolescent smokers.

Perceived benefits of and barriers to participation in a phase I/II colon cancer chemoprevention trial.

METHOD: A questionnaire was administered to 42 subjects completing a one-year cancer chemoprevention trial (response rate = 69%, n = 29). The questionnaire assessed subjects' 1) previous study participation, 2) perceived benefits/barriers of participation, 3) likelihood of participating in future trials, 4) willingness to pay out-of-pocket expenses for trial participation, and 5) interest in post-trial continuation of the drug. RESULTS: The most highly rated benefits of trial participation were the possibility of reducing one's chance of getting cancer and the possibility of preventing others from getting cancer in the future. Barriers considered to be the most troublesome were billing problems and having colonoscopies done. Only 29% would have joined the trial had they been required to pay for trial-related costs. CONCLUSION: Results of this study may be used to educate potential participants about the benefits of/barriers to trial participation. Additionally, by learning from the experiences of trial participants, investigators can improve the execution of clinical trials, increasing participant satisfaction.

Eating orientation, postcessation weight gain, and continued abstinence among female smokers receiving an unsolicited smoking cessation intervention.

Predictors of weight gain following smoking cessation were assessed among 1,219 female smokers enrolled in a health maintenance organization. Women randomized to the treatment group received a cessation intervention without regard to their interest in quitting smoking. It was hypothesized that cessation would result in subsequent weight gain and postcessation weight gain would be associated with scores on a modified Restraint Scale, the Disinhibition Scale, and a scale assessing tendency to eat during periods of negative affect. Persons who abstained from smoking over the 18-month study gained more weight than did intermittent smokers and continuous smokers, and among 762 women who reported at least 1 on-study attempt to quit smoking, 36% gained weight. Weight gain was associated with disinhibited eating and negative affect eating but not with restrained eating. Weight gain also was associated with continued abstinence from smoking.

Cigarette smoking in a multiethnic population of youth: methods and baseline findings.

BACKGROUND: To expand upon recent research studies that have identified dramatic ethnic differences in adolescent cigarette smoking, this study was designed to characterize smoking among a multiethnic population of adolescents and to identify significant factors that may protect against smoking initiation. METHODS: During the first 2 years, this mixed cross-sectional, longitudinal study recruited and collected baseline data from a volunteer sample of 1,441 Houston-area public school students in the 5th, 8th, or 12th grade. A wide range of new and established predictors of smoking behavior was assessed, and their associations with ever smoking and susceptibility to smoking were assessed within ethnicity (white, N = 537; African-American, N = 454; and Hispanic, N = 297). RESULTS: Consistent with previous studies, white students smoked in substantially higher proportions than African-American students, with Hispanic adolescents in-between. Simultaneously adjusting for other variables, the odds of ever smoking (OR = 0.47, P < 0.01) and susceptibility to smoking (OR = 0.64, P < 0.01) were significantly lower among African-American adolescents when compared with whites; odds ratios for Hispanics and whites did not differ. Across all three ethnicities, the most important predictor of both ever smoking and susceptibility to smoking was the smoking status of the three best friends. Several ethnicity-specific variables also were identified. CONCLUSIONS: In concordance with previous investigations, cigarette smoking prevalence differs by ethnicity, and the factors associated with ever smoking and susceptibility to smoking differ among white, African-American, and Hispanic adolescents. The results of this study may be used to develop theory-based, culturally appropriate smoking intervention programs for adolescents.

Case-control study of the D2 dopamine receptor gene and smoking status in lung cancer patients.

BACKGROUND: Interindividual differences in the structure and expression of the dopamine receptor genes affect dopamine availability and may be the genetic basis for variation in vulnerability to tobacco smoking. In this study, prevalences of polymorphisms in the TaqIA allele (A1 and A2) and the TaqIB allele (B1 and B2) of the D2 dopamine receptor gene in 157 lung cancer case patients and 126 control subjects were determined to assess whether individuals homozygous or heterozygous for the less common A1 and B1 alleles are more vulnerable to nicotine addiction. METHODS: Case and control subjects were accrued from an ongoing epidemiologic study. Blood samples were collected from them and subjected to molecular genetic analyses. Subjects were interviewed to obtain relevant information. Current and former smokers were administered a questionnaire to quantify their addiction to nicotine. RESULTS: The combined B1B2 genotypes appeared to be more prevalent in ever smokers than in never smokers among case patients (30.3% versus 13.3%; two-sided P = .233) and among control subjects (30.9% and 0%; two-sided P = .02); statistically significant differences were not observed among those with A1 genotypes. Statistically significant correlations between the presence of the A1 and B1 alleles were observed (r = .73 for case subjects and r = .76 for control subjects; two-sided P<.001). Individuals with rarer genotypes reported having been substantially younger at the time of smoking initiation (statistically significant for both A1 and B1) and having attempted to quit smoking fewer times (statistically significant for only A1). CONCLUSION: Variant alleles of the D2 dopamine receptor gene may play a role in determining nicotine addiction, although the associations between the at-risk genotypes and measures of nicotine addiction were not entirely consistent.

Worksite health and safety climate: scale development and effects of a health promotion intervention.

BACKGROUND: Environmental influences on health and health behavior have an important place in research on worksite health promotion. We tested the validity and internal consistency of a new measure of organizational health and safety climate that was used in a large randomized trial of a worksite cancer prevention program (the Working Well Trial). The resulting scales then were applied to assess intervention effects. METHODS: This study uses data from a subset of 40 worksites in the Working Well Trial. Employees at 20 natural gas pipeline worksite and 20 rural electrical cooperatives completed a cross-sectional questionnaire at baseline and 3-year follow-up. RESULTS: A factor analysis of this self-report instrument produced a two-factor solution. The resulting health and safety climate scales had good internal consistency (Cronbach's alpha = 0.74 and 0.82, respectively) and concurrent validity. The health climate scale was correlated more highly with organizational measures that were indicative of a supportive health climate than those indicating supportive safety climate, while the reverse was true of the safety climate scale. Changes in health climate were associated with the number of smoking and smokeless tobacco programs offered at the worksites at the time of the 3-year follow-up (r = 0.46 and 0.42, respectively). The scales were not correlated with most employee health behaviors. The health climate scores increased at intervention worksites, compared with scores at control worksites (F[1,36] = 7.57, P = 0.009). CONCLUSIONS: The health and safety climate scales developed for this study provide useful instruments for measuring organizational change related to worksite health promotion activities. The Working Well Intervention resulted in a significant improvement in worksite health climate.

Identifying and recruiting healthy control subjects from a managed care organization: a methodology for molecular epidemiological case-control studies of cancer.

Case-control studies with stringent matching criteria require large pools of healthy subjects from which to select matched controls. This paper describes a successful method of identifying a large pool of potential control subjects to participate in two molecular epidemiological case-control studies of lung cancer, each enrolling 400 case subjects and 400 control subjects. These studies are not population based, and the study base is not well-defined. Therefore, potential control subjects are being identified and recruited through 20 area clinic sites of a large multispecialty health maintenance organization. Because the research focus is driven by genetic hypotheses and we are controlling for multiple smoking-related variables, representativeness is of lesser concern. To identify potential control subjects, a one-page questionnaire is distributed to patients in the waiting room to assess contact information as well as data relevant to the case-control matching process. An average of 2,228 questionnaires are returned monthly toward a target pool of 40,000; of these, 59% of the respondents fulfill eligibility criteria as a control subject for one of the studies and are not averse to being contacted in the future for the purpose of research. When compared to former smokers and never smokers, current smokers in the control population were least likely to refuse further contact. A collaborative arrangement with a managed care organization offers a feasible mechanism through which researchers can access a large, ethnically diverse population of potential control subjects.

Outcomes of a placebo run-in period in a head and neck cancer chemoprevention trial.

This study describes the outcomes of an eight-week placebo run-in period in a head and neck cancer chemoprevention trial. Of 391 former cancer patients who entered the run-in over the first two years of the trial, 91% were randomized. Pill counts showed that adherence rates ranged from 0% to 120% (mean 96%, SD = 15%). The trial did not randomize subjects who were no longer interested in trial participation (n = 20), who did not return within 10 weeks of enrollment date (n = 3), or who did not achieve a drug adherence level of at least 75% (n = 9). Three subjects were not randomized for other reasons. Univariate predictors of run-in outcome (randomized or not randomized) included ethnicity, education level, cancer site, cancer stage, and Karnofsky performance score. Multivariate analyses resulted in a logistic model with Karnofsky performance and education level as significant predictors of randomization. Persons with a Karnofsky score of 100 had 2.3 higher odds of randomization (95% CI = 1.1, 4.9) than persons with compromised Karnofsky scores, and persons with more than a high school education had 2.1 higher odds of randomization (95% CI = 1.0, 4.9) than persons with less education. These results suggest that the use of a run-in period may compromise the external validity of randomized prevention trials. More research is needed to understand further the behavioral factors underlying the observed differences so that prevention researchers can develop effective interventions for facilitating trial participation, especially in under-represented, trial-eligible groups. Investigators should expand the objectives of a run-in period to (1) evaluate why eligible persons refuse trial enrollment or fail to be randomized at the end of the run-in and (2) use the run-in period for a systematic evaluation of levels and costs of intervention strategies designed to promote trial enrollment and adherence.

A descriptive study of the role of the oncology nurse practitioner.

PURPOSE/OBJECTIVES: To describe the characteristics and activities of nurse practitioners (NP) with a focus in oncology. DESIGN: Descriptive. SAMPLE: 129 NPs employed in an oncology setting who completed on NP program and were functioning in the NP role. METHODS: Subjects completed an eight-page, self-administered questionnaire comprised of fixed-choice and open-ended questions. MAIN RESEARCH VARIABLES: Demographics, employment settings, populations served, advanced practice subroles, clinical functions, practice privileges, reimbursement issues, job descriptions, performance appraisals, job satisfaction, and facilitators/barriers to role implementation. FINDINGS: The majority of oncology NPs (ONPs) were located in the eastern United States in university-affiliated hospitals. The most common patient population served by the respondents was adults in the medical oncology outpatient setting. More than three-quarters of the respondents worked from protocols, almost two-thirds performed procedures traditionally performed by physicians, and approximately half had prescriptive authority. Few NP respondents reported that they obtained direct reimbursement for their services from third-party payors. Physicians were cited as the most facilitative of the NP role, and administrators were cited as the most frequent barrier. The vast majority of the respondents were satisfied with their roles. IMPLICATIONS FOR NURSING PRACTICE: The NP role in oncology is established and expanding. The scope of practice and more detailed characterization of the role is an area for future research. Data on the effectiveness of ONPs, particularly regarding cost-effectiveness, quality of care, and patient satisfaction, are needed to maintain their viability within the healthcare system.

Readiness for change: implications for patient care.

The strategic position of pharmacists within the community allows frequent interactions with many patients, thus making pharmacists potentially valuable resources for assisting patients in making behavioral changes regarding adherence to treatment. The Transtheoretical Model is a behavior-change model that provides a functional approach through which pharmacists can help patients to reach specific behavioral goals. The model is described and stage-specific examples of patient-pharmacist dialogue are provided to show how the model may be used to promote progression through the stages.

Telephone-guided placement and removal of nicotine monitors for the assessment of passive exposure to environmental tobacco smoke.

The aim of this study was to determine the feasibility of telephone-guided placement of nicotine air sampling monitors in homes of women with infants. A monitor was mailed to homes in which the mother, her partner, or both were smokers, and a research assistant telephoned the woman and guided her through proper placement of the monitor according to a standard protocol. To assess the success of the guided placement, research assistants visited the homes of 50 women at the end of the two-week air-sampling period. The placement was determined to be correct if the monitor was positioned at least 1 ft from windows, more than 1 ft from the nearest corner of the room, and more than 2 ft from ashtrays. We had a 94% success rate for monitor placement in our study population, and our cost assessment showed that guided placement and removal cost approximately one-tenth the amount of methods requiring research assistants to conduct placements onsite. These results suggest that telephone-guided placement of monitors is an acceptable, inexpensive alternative to onsite placement by research assistants.

Promoting smoking cessation among cancer patients: a behavioral model.

The smoking cessation clinical practice guideline recently published by the Agency for Health Care Policy and Research (AHCPR) summarizes current knowledge on smoking cessation treatments. Among its recommendations, the guideline encourages physicians to motivate patients who indicate that they are not yet ready to quit smoking. Because medical training typically emphasizes pharmacologic rather than behavioral treatment, we believe that physicians caring for cancer patients may benefit from more extensive instruction in motivating patients to quit smoking. This article describes how a contemporary theoretical approach, the transtheoretical model of change, can be used to promote behavioral change. Multiple studies, primarily in the field of smoking cessation, provide strong empiric support for use of this model in clinical practice. The model consists of five stages of smoking cessation that describe different levels of readiness to quit: precontemplation, contemplation, preparation, action, and maintenance. A diagnostic tool is presented, and specific smoking cessation counseling strategies are suggested for each stage of change. Implications for the use of the model by physicians who counsel and treat smokers are discussed.

Participants' perceptions of a phase I colon cancer chemoprevention trial.

To assess participants' perceptions of a phase I colon cancer chemoprevention trial using a calcium intervention, questionnaires were mailed to trial participants at the conclusion of the study. Responses to questionnaire items reported here include (1) perceived benefits and barriers of participation, (2) interest in participating in future trials, (3) willingness to pay trial expenses out of pocket, and (4) posttrial continuation of the calcium regimen. The study found that the most highly rated trial benefit was the perception of potential colon cancer prevention; the trial barrier reported to be the most troublesome was inappropriate or mistaken billing for study visits. Three fourths of the subjects expressed an interest in future trials of the same duration. For trials of longer duration, this percentage decreased to 66%. Approximately half did not object to participation in future trials involving placebos, and just over one third indicated that they would either definitely (8%) or probably (27%) have joined the calcium trial even if they had to pay some study expenses out of pocket. Over 90% indicated they would continue taking the calcium pills if calcium is shown to be effective. The level of perceived benefits was positively associated with reported interest in participating in future trials of the same and longer durations, and the level of reported difficulty with trial pills and procedures was inversely related to interest in future placebo-controlled trials. The results of this study, in conjunction with results of prospective studies of trial participation, may be applied in future chemoprevention trials to facilitate recruitment, reduce attrition, and promote positive trial experiences for participants by emphasizing frequently reported benefits and minimizing frequently reported barriers.

Pharmacy applications of the transtheoretical model in smoking cessation.

The transtheoretical model for intentional behavior change is described, and pharmacists' use of the model in smoking-cessation interventions is discussed. This model combines elements of theories used in psychotherapy and behavior modification. In the model are five stages (precontemplation, contemplation, preparation, action, and maintenance) that describe when behavior change occurs. To be most effective, a health care provider's interventions should match the patient's stage of change. The model also includes 10 cognitive and behavioral processes that describe how change occurs while a person is moving among the stages. The processes (social liberation, dramatic relief, helping relationships, consciousness-raising, environmental reevaluation, reinforcement management, self-reevaluation, stimulus control, counterconditioning, and self-liberation) define change in terms of the coping strategies used. Before intervening, the pharmacist needs to ask questions about the patient's behavior that will identify the stage. If smokers in the precontemplation stage are receiving medications for chronic diseases, pharmacists can make them aware of the negative effects of smoking on their specific conditions. People in the contemplation stage are open to education about smoking and health, and those in the preparation stage are ready to set goals and choose methods for cessation. Smokers in the action stage are attempting to quit. Pharmacists can offer support, reinforcement, and guidance to people in the action and maintenance stages. Pharmacists can use the transtheoretical model to categorize patients by their stage of change and then devise and deliver appropriate and individualized interventions.