Short term patterns of early smoking acquisition.

OBJECTIVE: To describe short term patterns of smoking acquisition exhibited by adolescent smokers. DESIGN: Interview records from the prospective development and assessment of nicotine dependence in youth study were examined retrospectively. Interviews were conducted three times per year over 30 months. SUBJECTS: 164 students in grades 7-9 (ages 12-15 years, 86 girls, 78 boys) who had used cigarettes at least twice. MAIN OUTCOME MEASURES: A continuous timeline of smoking activity, beginning with the subject's first use of tobacco and continuing through follow up, was translated into six patterns--abstinent, sporadic, occasional, daily, escalating, and intermittent. Outcome measures were the proportion of subjects starting/ending in each pattern, and the number of transitions per subject between patterns. RESULTS: There was a general but discontinuous progression from infrequent to more frequent use, with many interspersed periods of not smoking. Escalation to daily smoking was common after the development of dependence symptoms, but was rare among those who did not have symptoms. After the appearance of symptoms, both transitions to heavier daily smoking and attempts at cessation increased. CONCLUSIONS: Movement to heavier, more frequent smoking is generally unidirectional, although many youths attempt to quit one or more times. The appearance of any symptom of dependence altered the subsequent pattern of smoking behaviour. Future investigators might consider using more frequent data points and a continuous timeline to track smoking behaviour.

Development of symptoms of tobacco dependence in youths: 30 month follow up data from the DANDY study.

OBJECTIVE: To determine if there is a minimum duration, frequency or quantity of tobacco use required to develop symptoms of dependence. DESIGN AND SETTING: A retrospective/prospective longitudinal study of the natural history of tobacco dependence employing individual interviews conducted three times annually in two urban school systems over 30 months. Detailed histories of tobacco use were obtained including dates, duration, frequency, quantity, patterns of use, types of tobacco, and symptoms of dependence. PARTICIPANTS: A cohort of 679 seventh grade students (age 12-13 years). MAIN OUTCOME MEASURES: The report of any of 11 symptoms of dependence. RESULTS: Among 332 subjects who had used tobacco, 40% reported symptoms, with a median latency from the onset of monthly smoking of 21 days for girls and 183 days for boys. The median frequency of use at the onset of symptoms was two cigarettes, one day per week. The report of one or more symptoms predicted continued smoking through the end of follow up (odds ratio (OR) 44, 95% confidence interval (CI) 17 to 114, p < 0.001). CONCLUSIONS: Symptoms of tobacco dependence commonly develop rapidly after the onset of intermittent smoking, although individuals differ widely in this regard. Girls tend to develop symptoms faster. There does not appear to be a minimum nicotine dose or duration of use as a prerequisite for symptoms to appear. The development of a single symptom strongly predicted continued use, supporting the theory that the loss of autonomy over tobacco use begins with the first symptom of dependence.

Is the standard compliance check protocol a valid measure of the accessibility of tobacco to underage smokers?

OBJECTIVE: To determine if the standard compliance check protocol is a valid measure of the experience of underage smokers when purchasing tobacco in unfamiliar communities. SETTING: 160 tobacco outlets in eight Massachusetts communities where underage tobacco sales laws are vigorously enforced. PROCEDURE: Completed purchase rates were compared between underage smokers who behaved normally and inexperienced non-smoking youths who were not allowed to lie or present proof of age (ID). RESULTS: The "smoker protocol" increased the likelihood of a sale nearly sixfold over that for the non-smokers (odds ratio (OR) 5.7, 95% confidence interval (CI) 1.5 to 22). When the youths presented an ID with an underage birth date, the odds of a completed sale increased dramatically (OR 27, 95% CI 3.4 to 212). Clerks judged to be under 21 years of age were seven times more likely to make an illegal sale (OR 7.6, 95% CI 2.4 to 24.0). CONCLUSIONS: Commonly used compliance check protocols are too artificial to reflect accurately the experience of underage smokers. The validity of compliance checks might be improved by having youths present ID, and by employing either tobacco users, or non-tobacco users who are sufficiently experienced to mimic the self confidence exhibited by tobacco users in this situation. Consideration should be given to prohibiting the sale of tobacco by individuals under 21 years of age.

The effect of a global multiculturalism track on cultural competence of preclinical medical students.

BACKGROUND: We evaluated the effect of an elective (the Global Multiculturalism Track), including international and domestic immersion experiences, on the cultural competence of preclinical medical students. METHODS: A self-assessment instrument was used to measure cultural competence, and it was administered to Track participants and nonparticipating class cohorts at the beginning and the end of the preclinical years. RESULTS: Track participants (n=26) had a higher level of cultural competence both at the beginning and at the end of the program. At the end of their second year, students participating in the Track had, for the first time, greater knowledge of certain aspects of local cultures, more tolerance of people of other cultures not speaking English, and more comfort with patients of these cultures, compared with non-Track participants. CONCLUSIONS: The results are based on a small sample size, but the suggestion that a multiculturalism track could provide a model for development of cultural competence warrants further research.

What is the potential cost-effectiveness of enforcing a prohibition on the sale of tobacco to minors?

BACKGROUND: Enforcement programs to halt the sale of tobacco to youths have been implemented across the United States. The potential cost-effectiveness of enforcement was evaluated under a range of assumptions regarding cost and impact. METHODS: An enforcement model was constructed incorporating quarterly inspections of all tobacco vendors. The cost of discounted years of life saved was calculated using reported values regarding cost and a range of assumptions regarding the impact on youth tobacco use. RESULTS: Inspecting an estimated 543,000 tobacco outlets would cost up to $190 million annually. Costs range from $44 to $8,200 per year of life saved depending on the discount rate and assumptions regarding cost, and efficacy. To compete in cost-effectiveness with implementing smoking cessation guidelines, enforcement would have to produce a 5% reduction in adolescent smoking at a cost of no more than $250 per vendor. CONCLUSION: At this level of cost and effectiveness an enforcement program could save 10 times as many lives as the same amount spent on mammography or screening for colorectal carcinoma. A one-cent per pack cigarette tax could fully fund enforcement. Enforcement of tobacco sales laws deserves further study as one component of a multifaceted approach to tobacco use prevention.

Initial symptoms of nicotine dependence in adolescents.

OBJECTIVES: It has been assumed that nicotine dependence has a slow onset and occurs only after prolonged daily use of tobacco. A cohort of young adolescents was followed to determine when the first symptoms of nicotine dependence occur with respect to the duration and frequency of tobacco use. DESIGN: A cohort of 681 seventh grade students (age 12-13 years) from seven schools in two small cities in central Massachusetts was followed over one year. Detailed information regarding tobacco use was obtained in individual confidential interviews conducted in school three times over the year. The latency time to the onset of symptoms of nicotine dependence was measured from the time a subject first smoked at a frequency of at least once per month. RESULTS: 22% of the 95 subjects who had initiated occasional smoking reported a symptom of nicotine dependence within four weeks of initiating monthly smoking. One or more symptoms were reported by 60 (63%) of these 95 subjects. Of the 60 symptomatic subjects, 62% had reported experiencing their first symptom before smoking daily or began smoking daily only upon experiencing their first symptom. DISCUSSION: The first symptoms of nicotine dependence can appear within days to weeks of the onset of occasional use, often before the onset of daily smoking. The existence of three groups of individuals-rapid onset, slower onset, and resistant-distinguishable from one another by their susceptibility to nicotine dependence, is postulated.

Determinants of counseling in primary care pediatric practice: physician attitudes about time, money, and health issues.

OBJECTIVES: To assess pediatrician goals and practice in preventive counseling, and to use social learning theory to examine physician attitudes about preventive health issues, time, and reimbursement to explain physician counseling behavior. DESIGN: Random sample survey of American Academy of Pediatrics fellows. PARTICIPANTS: A total of 1620 pediatricians were surveyed with a return rate of 72%. The 556 pediatricians who had finished training and who currently performed child health supervision were included. METHODS: Pediatricians were asked about their goals in 6 areas of health supervision: biomedical issues, development, behavior, family functioning, safety education, and supportive interpersonal interaction. They were also asked about the prevalence of counseling, importance of specific topics, their self-efficacy, outcome expectation in these areas, and their concerns about time and reimbursement for preventive counseling. RESULTS: Assurance of physical health and normal development were the most important goals of child health supervision among the pediatricians surveyed. Goals involving behavioral, family, and safety issues were less important and less likely to be addressed in practice. Most did not regularly discuss family stress, substance abuse, gun safety, and television. In these areas, physicians had less confidence they could provide guidance and lower expectation that they could prevent problems. Only 17% felt that they receive adequate reimbursement for preventive counseling. Most have adequate time (53%) and receive adequate respect (57%) for their preventive efforts. Physicians who were more concerned about time for preventive counseling reported less overall counseling (r = -0.28, P<.001). Concern about reimbursement was not associated with reported counseling. Multiple regression analysis found that the primary predictors of physician counseling were an issue's importance, a physician's perceived self-efficacy, and perceived effectiveness of counseling, while concerns about time and reimbursement were secondary. CONCLUSIONS: Physician goals in child health supervision were primarily biomedical, with psychosocial and safety issues of lesser importance. Concern about time for preventive counseling was associated with less reported counseling. Physician attitudes regarding the importance of a health issue and their confidence and effectiveness in counseling were more predictive of physician practice than their attitudes about time and reimbursement for preventive care.

Assessing mothers' attitudes about the physician's role in child health promotion.

OBJECTIVE: This study assessed maternal attitudes about the physician's role in child health promotion. METHODS: Home interviews were conducted with 200 Massachusetts mothers (with one child age 2 to 3 years) enrolled in a health maintenance organization. RESULTS: Mothers chose growth and nutrition, physical development, and illness as the most important topics and felt that providers have the ability to prevent problems and to help. Psychosocial and safety issues were less important, although mothers felt susceptible to these issues and believed they greatly affected children's health. CONCLUSIONS: On all issues, mothers believed physicians were more effective in helping families after, not before, problems arose. The Health Belief Model provided insight into attitudes and possible interventions.

Expectations, goals, and perceived effectiveness of child health supervision: a study of mothers in a pediatric practice.

The purpose of the study was to assess parent expectations and goals in child health supervision and variability by socioeconomic status (SES), family size, social support, and pediatrician. Home interviews were conducted with mothers and their pediatricians were surveyed. Two hundred mothers with at least one child age 2-3 years who see one of five pediatricians in a staff model health maintenance organization were asked to participate. Mothers' and pediatricians' goals in the following seven areas of health supervision were assessed: biomedical, development, behavior, family functioning, safety education, and interpersonal and system interaction. Mothers stated physicians were their main source of parenting information. Assurance of physical health and normal development were more important than discussion of behavioral, family, or safety issues. Mothers of low SES were more likely to feel that physical aspects of health should be the focus and were less interested in psychosocial issues. Physicians stressed interpersonal, safety, and behavioral goals more than mothers. Individual physician responses did not predict the responses of mothers in their practice. Our data suggest either that mothers do not feel that psychosocial and safety issues are the highest priorities in health supervision or that physicians are not effectively reaching mothers on these issues.

Youth access to tobacco: the effects of age, gender, vending machine locks, and "it's the law" programs.

OBJECTIVES: This study evaluated the influence of age, gender, vending machine lockout devices, and tobacco industry-sponsored voluntary compliance programs ("It's the Law" programs) on underage youths' ability to purchase tobacco. METHODS: Twelve youths made 480 attempts to purchase tobacco in Massachusetts from over-the-counter retailers and vending machines with and without remote control lockout devices. Half the vendors were participating in It's the Law programs. RESULTS: In communities with no requirements for lockout devices, illegal sales were far more likely from vending machines than from over-the-counter sources (odds ratio [OR] = 5.9, 95% confidence interval [CI] = 3.3, 10.3). Locks on vending machines made them equivalent to over-the-counter sources in terms of illegal sales to youths. Vendors participating in It's the Law programs were as likely to make illegal sales as nonparticipants (OR = 0.87, 95% CI = 0.57, 1.35). Girls and youths 16 years of age and older were more successful at purchasing tobacco. CONCLUSIONS: The It's the Law programs are ineffective in preventing illegal sales. While locks made vending machines equivalent to over-the-counter sources in their compliance with the law, they are not a substitute for law enforcement.

Confidentiality in health care. A survey of knowledge, perceptions, and attitudes among high school students.

OBJECTIVE: To assess adolescent knowledge, perceptions, and attitudes about health care confidentiality. DESIGN: Anonymous self-report survey with 64 items addressing confidentiality issues in health care. SETTING: Rural, suburban, and urban high schools in central Massachusetts. PARTICIPANTS: Students in ninth through 12th grades from three schools. RESULTS: A total of 1295 students (87%) completed the survey: 58% had health concerns that they wished to keep private from their parents, and 69% from friends and classmates; 25% reported that they would forgo health care in some situations if their parents might find out. There were differences in response by gender, race, and school. About one third were aware of a right to confidentiality for specific health issues. Of those with a regular source of care, 86% would go to their regular physician for a physical illness, while only 57% would go there for questions about pregnancy, the acquired immunodeficiency syndrome, or substance abuse that they wished to keep private. Sixty-eight percent had concerns about the privacy of a school health center. CONCLUSIONS: A majority of adolescents have concerns they wish to keep confidential and a striking percentage report they would not seek health services because of these concerns. Interventions to address confidentiality issues are thus crucial to effective adolescent health care.

Functional benefits following coronary artery bypass graft surgery.

While some studies of patients who undergo cardiac surgery have included such outcome measures as amounts of symptom reduction and rates of resumption of employment, little attention has been focused on the extent to which these patients have experienced the simple, yet very important, broad range of functional benefits that might be anticipated by clinicians to result from operation. The present report seeks to document the extent of improvement that does exist in terms of physical, sexual, and social-role functioning. In a cohort of 340 patients (age, 32 to 69 years) studied before and six months after coronary artery bypass operation, improvements were noted in each of three dimensions of functional benefit: physical functioning (fewer total activity restrictions or incapacitated days per month), sexual functioning (through increased energy and desire and decreased pain and worry), and role functions (ability to work, social participation, and pursuit of hobbies). Further improvements might be anticipated with additional months of recovery.

Physical, psychologic, social, and economic outcomes after cardiac valve surgery.

Eighty-nine patients receiving cardiac valve replacement or surgery consisting of valve replacement and coronary artery bypass grafts in four teaching hospitals were studied before surgery and again six months after surgery. More than 60 indicators of the quality of life were assessed. The majority of persons showed improvement in physical function, emotional states, and social activity. Of those with exertional angina or dyspnea before surgery, about two thirds were completely relieved at six months after surgery. There was a substantial reduction in number (from 31 to seven) of persons with five or more days of disability per month due to cardiac symptoms. The majority remained the same in their usual level of physical activity, most psychological traits, and attitudes and social support networks. Most previously employed persons returned to work. Improvements in the conditions of patients who had valve surgery closely paralleled those of patients who had undergone coronary artery bypass surgery in the same hospitals.

Coronary artery bypass surgery. Physical, psychological, social, and economic outcomes six months later.

To evaluate the benefits of coronary artery bypass graft (CABG) surgery, we interviewed and tested 318 patients (268 men and 50 women) younger than age 70 before and six months after elective CABG at four university medical centers. Biomedical, psychoneurological, physical function, role function, occupational, social, family, sexual, emotional, and attitudinal variables were assessed. Quantitative comparisons showed improvement on many factors. Angina was completely relieved for 69% to 85% of persons, depending on whether it had been induced by exertion or other events. Disability days were reduced more than 80%. Seventy-five percent of employed persons had returned to work. Anxiety, depression, fatigue, and sleep problems declined. Vigor and well-being scores rose significantly. When losses were expected (eg, psychoneurological function, marital adjustment), they generally were not found. For none of the more than 60 outcome variables was widespread serious worsening found. The findings suggest that the great majority of patients are able to resume normal economic and social functioning within six months after CABG.

Correlates of angina pectoris among men awaiting coronary by-pass surgery.

Biomedical, behavioral, and psychological correlates of angina pectoris were identified in 204 men awaiting coronary artery by-pass graft surgery. Angina was rated by use of a precoded series of interview questions. Four circumstances of anginal symptoms were investigated: exertional, emotional, post-prandial, and while resting or sleeping. These were uncorrelated with one another, except for exertional and post-prandial. Two-thirds of these patients experienced angina less often than daily in the most recent unrestricted month. Severity of coronary artery obstruction was not positively associated with frequency or severity of any type of angina, and were primarily behavioral and psychological. Disturbances of sleep, physical inactivity, history of cigarette smoking, distressed response to life crises, life dissatisfactions, hostility, use of propranolol, duration of cardiac illness, and age were among the predictors in the multiple regression equations. These results from selected by-pass candidates may apply more directly to such persons than to unselected community residents reporting angina symptoms. The findings suggest the need for greater focus on sources of variability in myocardial oxygen supply and demand in understanding the dynamics of angina episodes.

Predictors of employment status after cardiac surgery.

Preoperative predictors of postoperative employment status were studied in 228 patients (aged 25 to 64 years) who underwent cardiac surgery. Of the 150 patients working in the year before surgery, 73% returned within six months. Of those not so employed, 18% started working. Patients who expected preoperatively to return to work did so at an 82% rate compared with 39% of the others. This was a strong predictor in the multiple regression analysis. Educational level and family income were stronger predictors than occupation or level of physical exertion required. Rates of return were higher in patients with less severe angina and less fatigue preoperatively, but did not differ significantly by sex, surgical procedure, or duration of illness. Seven variables predicted work status correctly for 86% of persons. These results suggest that determinants of return to work are largely present before surgery and that patients' attitudes and expectations play an important role.

Neuropsychological dysfunction following elective cardiac operation. II. A six-month reassessment.

Three neuropsychological tests were administered to 245 men and women, ages 25 to 69 years, before and 6 months after coronary bypass and cardiac valve operations to provide current information regarding the incidence of long-term postoperative decrements in neuropsychological function and the factors associated with them. Biographical, psychological and medical-surgical data were studied together with changes on the Trail Making Test from the Halstead-Reitan Battery, and Visual Reproduction (VR) and Logical Memory tests, both from the Wechsler Memory Scale (WMS). Although 28% of this group showed a deterioration in one or more test scores at a 9 day postoperative examination as compared to their preoperative scores, over 80% of these patients had returned to normal range by 6 months. Similarly, the majority of the 19% of patients showing a significant decrease in one or more of four scores at 6 months had incurred their performance decrements subsequent to the 9 day examination. Hence it seems inappropriate to attribute these latter dysfunctions to the surgical epidose per se, as others have reported. Only 5% of patients showed consistent postoperative test score deterioration both at 9 days and 6 months. Decrements of function at 6 months appear to be associated with total estimated blood loss greater than 3,000 ml and administration of propranolol during the operation plus several postoperative factors including higher levels of fatigue, depression, and worries related to the operation and the recovery process. These findings underscore the need for clinicians and investigators studying neuropsychological dysfunction following cardiac operations to take concurrent emotional and physical states into account, and to make repeated measures well separated in time, before interpreting the presence or absence of residual neuropsychological problems.

Neuropsychological dysfunction following elective cardiac operation. I. Early assessment.

Two neuropsychological tests were administered to 227 men and women, ages 25 to 69 years, before and after coronary bypass and cardiac valve operations to provide current information regarding the incidence of postoperative decrements in neuropsychological dysfunction and the factors associated with them. Biographical, psychological, and medical-surgical data were studied together with changes in scores on the Trail Making Tests and the Visual Reproduction (VR) Test of the Wechsler Memory Scale (WMS). Postoperative decrements greater than one standard deviation were observed in each of the four scores derived from these testings for 11% to 17% of the patients. Yet 70% of all patients remained within one standard deviation of original performance on all four scores. Among the preoperative correlates of significantly reduced test performance were age greater than 60 years, end-diastolic pressure greater than 30 mm Hg, moderate to severely enlarged heart size on preoperative x-ray film, and use of propranolol or chlordiazepoxide hydrochloride. Significant perioperative correlates included measure of duration of operation (such as total time of operation greater than 7 hours, time on the pump greater than 2 hours, and aortic cross-clamp time greater than 2 hours), total estimate of blood loss greater than 2,000 ml, hypotension, difficult intubation, and insertion of an intra-aortic balloon. Postoperative factors significantly associated with declines in test scores included electrolyte (Na+, K+, Cl-) abnormalities, longer stay in the intensive care unit, bizarre behavior or disorientation, and depression score. These findings suggest that those patients with more precarious heart function, a more protracted operation, and/or increased metabolic disturbances are especially prone to neuropsychological dysfunction following cardiac operations.