[Show abstract][Hide abstract] ABSTRACT: To report findings of a nationwide project that examined nursing homes' tobacco policies for residents.
A random selection procedure was used to sample nursing homes proportional to the geographic distribution of nursing homes in the United States. Rubrics were developed to objectively describe and compare policies.
Policies were obtained from 4 types of facilities: (1) facilities that allow smoking indoors and outdoors (I/O-SFs), (2) facilities that allow residents to smoke outdoors only (O-SFs), (3) facilities that do not allow residents to smoke indoors or out of doors (NSFs), and (4) facilities in transition (TFs) from a smoking facility to an NSF.
Rubrics used to score policies had common categories: administrative/authority issues, notification, resident smoking, safety, cessation assistance/encouragement, and smoking areas. Criteria within each category varied to reflect the smoking regulations of each type of facility (eg, policies of facilities that do not allow smoking indoors were not examined for inclusion of issues related to ventilation).
Facilities' policies from geographically diverse facilities are described. Across all facilities, mean percentages reflecting policies' overall comprehensiveness were low, and when examining specific components of the policies, few areas were consistently addressed across facilities.
Considerable gaps were found in written policies regarding smoking. Although nursing homes may in fact have practices that are more extensive than their policies portray, creating policies that guide practice can assist these long-term care facilities to promote an environment that aligns with their goals and desired practices to protect the health of residents and staff.
Journal of the American Medical Directors Association 06/2009; 10(4):258-63. DOI:10.1016/j.jamda.2008.11.004 · 4.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Dominican Republic, a tobacco growing country, has significant tobacco use and exposure. Published research on DR tobacco use, attitudes/beliefs is limited as are tobacco control and intervention programs.
Six economically disadvantaged DR communities (2 urban, 2 peri-urban, 2 rural) were randomized to community-based tobacco intervention vs. control conditions. Serial Rapid Assessment Procedures provided a baseline (formative data) and post-implementation qualitative snapshot of community attitudes and perspectives on tobacco use. Interdisciplinary mixed gendered teams conducted observations and interviews over a 2-week period in 2003 and 2006 in each community. Each period included over 150 individuals including tobacco users, former users and non-users and key leaders and community members. Changes occurred across all communities: greater awareness of risks of passive smoking, increasing view of tobacco use as a viceand more private smoking. The few social smokers considered themselves non-smokers. Additionally new ways of using tobacco were discovered. Chewing tobacco appeared to be increasing among young adults. Intervention communities had more individuals engaged in quitting, greater awareness of anti-tobacco messages, and heightened sense of costs and health risks associated with tobacco use. Health care providers (intervention communities) were more likely to refer smokers to local and community resources.
Overall, attitudes and awareness regarding tobacco changed over time in both intervention and control communities, with greater change in former. The absence of a culture of quitting, noted in 2003, was obvious only in the control communities in 2006. These qualitative findings guided ongoing development of interventions and to increase the viability of sustainability.
136st APHA Annual Meeting and Exposition 2008; 10/2008
[Show abstract][Hide abstract] ABSTRACT: The current ethical structure for collaborative international health research stems largely from developed countries' standards of proper ethical practices. The result is that ethical committees in developing countries are required to adhere to standards that might impose practices that conflict with local culture and unintended interpretations of ethics, treatments, and research. This paper presents a case example of a joint international research project that successfully established inclusive ethical review processes as well as other groundwork and components necessary for the conduct of human behavior research and research capacity building in the host country.
[Show abstract][Hide abstract] ABSTRACT: The Dominican Republic is a tobacco-growing country, and tobacco control efforts there have been virtually nonexistent. This study provides a first systematic surveillance of tobacco use in six economically disadvantaged Dominican Republic communities (two small urban, two peri-urban, two rural; half were tobacco growing). Approximately 175 households were randomly selected in each community (total N = 1,048), and an adult household member reported on household demographics and resources (e.g., electricity), tobacco use and health conditions of household members, and household policies on tobacco use. Poverty and unemployment were high in all communities, and significant gaps in access to basic resources such as electricity, running water, telephones/cell phones, and secondary education were present. Exposure to tobacco smoke was high, with 38.4% of households reporting at least one tobacco user, and 75.5% allowing smoking in the home. Overall, 22.5% reported using tobacco, with commercial cigarettes (58.0%) or self-rolled cigarettes (20.1%) the most commonly used types. Considerable variability in prevalence and type of use was found across communities. Overall, tobacco use was higher in males, illiterate groups, those aged 45 or older, rural dwellers, and tobacco-growing communities. Based on reported health conditions, tobacco attributable risks, and World Health Organization mortality data, it is estimated that at least 2,254 lives could potentially be saved each year in the Dominican Republic with tobacco cessation. Although it is expected that the reported prevalence of tobacco use and health conditions represent underestimates, these figures provide a starting point for understanding tobacco use and its prevalence in the Dominican Republic.
[Show abstract][Hide abstract] ABSTRACT: Background: Factors that influence maternal smoking during pregnancy and its effects on the physical, behavioral and cognitive development of children are well analyzed/researched in the developed world. As the tobacco epidemic expands to include low to middle income countries, additional research is warranted to understand tobacco attitudes and practices among their populations.
Methods: Two surveys were conducted. The Community Survey, included 1052 community members from 6 disenfranchised communities in the DR (2 rural; 2 peri-urban; 2 urban). The Smoker Cohort Survey included 659 smokers randomly selected from households with multiple adult smokers.
Results: Preliminary analyses of the community survey indicated that 92.9% of interviewed females had been pregnant; of these 22.0% reported smoking during a prior or current pregnancy; 45.7% reported being advised by a health care provider to quit during pregnancy; 33.9% stopped smoking because of pregnancy and 77.2% reported frequent exposure to Secondhand Smoke. In the Smoker Cohort, 42.49% were female and 93.0% had experienced a pregnancy; 88.4% reported smoking daily and 72.1% smoked their first cigarette within the first 30 minutes of waking-up; 76.6% had made a serious attempt to quit. Data will be presented on tobacco use and SHS exposure during pregnancy for both the community sample and the smokers' cohort.
Conclusions: While smoking among men is often the first priority in tobacco control initiatives, these data indicate that smoking among women is a significant problem that should not be overlooked. Data obtained clearly support the need for tobacco intervention with a focus targeting pregnant females.
135st APHA Annual Meeting and Exposition 2007; 11/2007
[Show abstract][Hide abstract] ABSTRACT: Using community partnership models to tailor evidence based smoking cessation interventions to local culture positively affected awareness and health care provider behavior. Both quantitative and qualitative formative baseline data informed the tailoring. This clinical trial compared three intervention and three control communities in the Dominican Republic. All were economically disadvantaged and matched on rural/urban and tobacco growing status. Interventions, based on evidence from other countries, included 1) community awareness raising (tobacco use risks, cessation benefits/resources (radio spots, community talks, health fairs, posters/printed materials, community partnerships) and 2) community cessation initiatives (training local Tobacco Cessation Specialists (TCS) and clinics/hospitals, and training health care providers (HCP) in brief interventions (3As model) with referral to TCS. The post intervention measure occurred approximately one year after intervention roll out. Preliminary data suggest changes in intervention vs. control communities, based on household surveillance data (N= 1105 yr1, 1092 yr2), community surveys (N=526 yr1, 525 yr2), and smoker cohort surveys (N=257 yr1, 255 yr2). Data were collected by trained local data collectors. In intervention communities, awareness about tobacco use and cessation resources increased (83% to 91%). Tobacco use prevalence decreased (21% to 17%), and former tobacco users increased (5.8% to 9.5%). Smokers reported HCPs asking about smoking increased (49% to 68%); HCP advising to quit increased from 53-65%. Tailoring evidence-based tobacco control interventions demonstrated encouraging results. In-depth understanding of the target population and overall community landscape, working from a community-participatory perspective, and implementation flexibility may increase the likelihood of such interventions becoming sustainable community resources.
135st APHA Annual Meeting and Exposition 2007; 11/2007
[Show abstract][Hide abstract] ABSTRACT: Tobacco dependence, responsible for approximately 4 million annual deaths worldwide, is considered to be a "pediatric disease." The smoking epidemic is spreading rapidly in developing countries. Factors contributing to youth smoking in developing countries include cultural traditions, tobacco's easy accessibility and moderate pricing, peer and family influences, and tobacco companies' advertisements and promotional activities. Secondhand tobacco smoke exposure is a substantial problem that causes increased rates of pneumonia, otitis media, asthma, and other short- and long-term pediatric conditions. Parental tobacco use results in children's deprivation of essential needs such as nutrition and education. In this article we review contemporary evidence with respect to the etiology of nicotine dependence among youth, the forms of youth tobacco products worldwide, global youth tobacco-control efforts to date, medical education efforts, and child health care clinicians' special role in youth tobacco-control strategies. In addition, we provide a review of currently available funding opportunities for development and implementation of youth tobacco-control programs.
[Show abstract][Hide abstract] ABSTRACT: To conduct formative research on the landscape of tobacco use to guide survey and subsequent intervention development in the Dominican Republic (DR).
Rapid Assessment Procedures, systematic qualitative methods (participant-observations, in-depth interviewing, focus groups) using bilingual mixed age and gendered teams from the United States and DR.
Over 160 adults (men and women), ages 18 to 90 years, current, former and never smokers, community members and leaders from six underserved, economically disadvantaged DR communities.
Key domains: tobacco use patterns and attitudes; factors affecting smoking initiation, continuation, quitting; perceived risks/benefits/effects of smoking; and awareness/effects of advertising/regulations.
Perceptions of prevalence varied widely. While "everybody" smokes, smokers or ex-smokers were sometimes difficult to find. Knowledge of health risks was limited to the newly mandated statement "Fumar es prejudicial para la salud" [Smoking is harmful to your health]. Smokers started due to parents, peers, learned lifestyle, fashion or as something to do. Smoking served as an escape, relaxation or diversion. Quit attempts relied on personal will, primarily for religious or medical reasons. Social smoking (custom or habit) (< 10 cigarettes per day) was viewed as a lifestyle choice rather than a vice or addiction. Out of respect, smokers selected where they smoked and around whom. Health care providers typically were reactive relative to tobacco cessation, focusing on individuals with smoking related conditions. Tobacco advertising was virtually ubiquitous. Anti-tobacco messages were effectively absent. Cultures of smoking and not smoking coexisted absent a culture of quitting.
Systematic qualitative methods provided pertinent information about tobacco attitudes and use to guide subsequent project steps. Integrating qualitative then quantitative research can be replicated in similar countries that lack empirical data on the cultural dimensions of tobacco use.
[Show abstract][Hide abstract] ABSTRACT: Preventive services guidelines recommend screening all adolescents for diet habits, physical activity and growth, counseling underweight teens about body image and dieting patterns, and counseling overweight or obese teens about dietary habits and exercise. In this study, we assess whether adolescents at risk for overweight or for eating disorders have discussed recommended diet and nutrition topics with their physicians.
We surveyed 14-18-year-old adolescents who had been seen for well care in primary care pediatric and family medicine practices. Adolescents self-reported their weight, height, body image, dieting habits, and issues they had discussed with their clinicians. Body mass index (BMI) was used to define those "at risk for an eating disorder" (< 5% BMI), "at risk of becoming overweight" (85%-95% BMI), and "overweight" (> 95% BMI).
A total of 8384 adolescents completed surveys (72% completion rate). Nearly one-third of adolescents were "at risk" or overweight. Females were less likely to be overweight than males (9.4% vs. 15.7%; p < .001). Although 26.4% were attempting to lose weight, only 12.2% of all teens were actually overweight. Exercise and restricting intake were the preferred methods of weight loss. Physicians routinely discussed adolescents' weight during visits, and were more likely to discuss it with those "at risk" (p < .001). Body image was more often discussed with girls than with boys (52% vs. 44.6%, p < .001) and with those at risk (51.6% vs. 45.5%; p < .001). Discussion of healthy eating and weight loss occurred more often with adolescents "at risk" for becoming overweight (p < .001).
Many adolescents are at risk for being overweight or are currently overweight, confirming the importance of clinicians discussing diet and nutrition health topics with all teens. Many adolescents also misclassify their body image, and hence perceive their body image to be different from their actual BMI; clinicians should discuss body image with all adolescents, not just those at risk for eating disorders. Better interventions are needed to promote healthy nutrition and physical activity to all adolescents.
Journal of Adolescent Health 05/2006; 38(5):608.e1-6. DOI:10.1016/j.jadohealth.2005.06.009 · 3.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Physician office settings play an important role in tobacco cessation intervention. However, few tobacco cessation trials are conducted at these sites, in part because of the many challenges associated with recruiting community physician offices into research. The present study identified and implemented strategies for recruiting physician offices into a randomized clinical trial of tobacco screening and cessation interventions with adolescent patients. A total of 30 community physicians participated in focus groups to elicit their perceptions of facilitators of and barriers to initial engagement of physician practices and the subsequent enrollment of the practices in long-term research projects. Physicians identified facilitators such as (a) the involvement of office staff in the recruitment process and (b) on-site presentations of the study's background and aims. Some of the barriers identified were time commitment concerns and the lack of incentives in exchange for participation. These focus group findings were then integrated with theory-based and empirically driven recruitment strategies for a 12-month randomized tobacco intervention trial with adolescent patients. Of 185 office practices approached to participate (screened from a pool of 273 practices), 103 agreed to on-site presentations of the study. Subsequently, almost all of the practices (101) that received the presentation agreed to enroll in the study. Conclusions are that (a) recruitment is a multicomponent process, (b) the processes of communication, engagement, and enrollment must be carefully planned and implemented to achieve maximal results, and (c) the development of effective strategies for recruiting health care provider practices presents an important infrastructure for testing adolescent smoking cessation interventions.
[Show abstract][Hide abstract] ABSTRACT: Purpose – To provide a rationale regarding the importance of physician behavior change counseling. To describe the double helix behavior change curriculum at the University of Rochester (UR). To provide initial evidence that the curriculum is effective. Design/methodology/approach – Evidence that physician use of the 5A's model is effective in changing important patient health behaviors is summarized. The behavior change curriculum is described. Initial evidence assessing knowledge, attitudes and skills for behavior change counseling is reviewed. Findings – Physicians will be better prepared to intervene to improve their patients quality and quantity of life if they consistently counsel patients using a brief standard model (the 5A's) that integrates biological, psychological, and social aspects of disease and treatment. Past efforts in the UR's curriculum have demonstrated that students adopt broader “biopsychosocial values” when the curriculum supports their learning needs. Initial evidence demonstrates that double helix curriculum students learn this model well and are able to provide the counseling in a patient-centered style. Research limitations/implications – These results are limited by the observational design, and the reliance on student self-reports and standardized patient observations of student behavior rather than change in patient behavior. Practical implications – Strong evidence exists that physicians can be effective in providing behavior change counseling. Additional research is called for to create, implement, and fully evaluate behavior change counseling curricula for medical students. Originality/value – An example of a behavior change curriculum is provided for medical educators, and initial evidence of its effectiveness is provided.
Health Education 04/2005; 105(2):142-153. DOI:10.1108/09654280510584580
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to provide a first assessment of (a) long-term care staffs' prevalence of and attitudes toward giving smoking cessation advice to residents and (b) predictors of advice giving. Results of a survey (N = 115) found that 54.8% of licensed nurses and 34.6% of nursing assistants reported ever advising. Advising was associated with job classification and believing that residents' problem lists should include smoking. Not advising was associated with believing advice is the physicians' responsibility. Staff somewhat endorsed risks of smoking and benefits of cessation for residents, smoking as a right and pleasure, and that some residents cannot make decisions about smoking. Staff moderately endorsed safety concerns: 36% wanted policy changes. Lack of institutional support and perceived residents' cessation disinterest were key barriers. The findings suggest that staff may be missing intervention opportunities and that institutional support of advising cessation may facilitate maintenance and improvement of nursing home residents' health.
[Show abstract][Hide abstract] ABSTRACT: A survey of 230 physicians assessed Public Health Service (PHS) guideline-based smoking cessation screening and assistance to patients aged 50 and older. The 5A model (Ask, Advise, Assess, Assist, Arrange) was examined. Strong adherence to guidelines was reported. Those familiar with guidelines handed out materials more frequently than those less familiar. Advice was provided as often as to younger smokers and was 'strong and personalised'. Assisting was focused on behaviour rather than pharmacotherapy or programmes. High rates of advice occurred in three smoking-related disease groups, but lower rates were found in patients with cancer. Facilitators of guideline-based behaviour were health related. Barriers included patient resistance and other pressing health concerns. Physicians more familiar with the PHS guidelines for cessation were more likely to personalise advice and to assist by providing cessation materials. Increased familiarity with the guidelines can be an important first step to changing clinical behaviour with mid-life and older smokers.
[Show abstract][Hide abstract] ABSTRACT: Quitlines provide a model for the translation of research findings to public health application. Quitlines are currently in operation in more than half of US states, in Canada, and in multiple countries globally. Overall, when implemented correctly, quitlines have been shown to be efficacious and effective. Multiple quitline models are in use, but there is no evidence on the relative effectiveness of one over the other. Differences have been demonstrated for the efficacy of quitlines for specific applications, with the strongest evidence base for application as a primary intervention or as follow-up for hospitalized patients and particularly for cardiac patients. The evidence base for both reactive and proactive services is reviewed, and future directions to continue to advance the field are discussed.
The American Journal of the Medical Sciences 11/2003; 326(4):201-5. DOI:10.1097/00000441-200310000-00010 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper highlights the increasing level of collaboration, resource sharing, and consensus building in youth tobacco control taking place in the United States. Better knowledge of current research, activities, and collaborations in this area will help in the planning of activities and the rational allocation of funds for tobacco control programs, research, advocacy, and the counter-advertising activities. We defined three general classifications for organizations that had national youth tobacco control activities: Government centers and institutes, government organizations, and bridging organizations. We asked national experts in our own organization and all other included organizations to suggest additional groups for inclusion. After gathering available public information on each organization from Web sites and printed materials, we than solicited additional information by personal communication with individuals in leadership positions for youth tobacco control within each group. We developed a uniform framework to present a clear picture of each group in the areas of institutional conception, general goals, youth tobacco control research, and youth tobacco control activities. The tables provide a helpful reference guide presenting the institutional conception, goals, funding for research, activities, and Web sites for the institutions and organizations discussed here. Many groups have current youth tobacco control priorities in the United States. This synthesis of current research, funding sources, programmatic activities, and collaborations in the United States will be a valuable resource for clinicians, tobacco control advocates, researchers, and program planners.
[Show abstract][Hide abstract] ABSTRACT: Tobacco use is a serious pediatric health issue as dependence begins during childhood or adolescence in the majority of tobacco users. Primary care settings provide tremendous opportunities for delivering tobacco treatment to young tobacco users. Although evidence-based practice guidelines for treating nicotine dependence in youths are not yet available, professional organizations and the current clinical practice guideline for adults provide recommendations based on expert opinion. This article reports on the current tobacco treatment practices of pediatric and family practice clinicians, discusses similarities and differences between adolescent and adult tobacco use, summarizes research efforts to date and current cutting-edge research that may ultimately help to inform and guide clinicians, and presents existing recommendations regarding treating tobacco use in youths. Finally, recommendations are made for the primary care clinician, professional organizations, and health care systems and policies. Pediatricians and other clinicians can and should play an important role in treating tobacco dependence in youths.
[Show abstract][Hide abstract] ABSTRACT: To provide recommendations that will build a better foundation for research on youth smoking cessation.
The Youth Tobacco Collaborative Cessation panel evaluated youth tobacco cessation literature and convened meetings to reach consensus.
Methodological issues include design, recruitment and retention, follow-up, measurement, and youth vernacular. Research gaps include youth characteristics, theoretical approaches, delivery settings, and type of provider. Thirteen key research components for reporting are addressed.
Given the dearth of studies on youth smoking cessation, scientifically rigorous studies need to be conducted with attention to methodological issues, research gaps, and reporting of key research components.
American journal of health behavior 02/2003; 27 Suppl 2:S170-84. · 1.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A workgroup formed by the Society for Research on Nicotine and Tobacco reviewed the literature on abstinence measures used in trials of smoking cessation interventions. We recommend that trials report multiple measures of abstinence. However, at a minimum we recommend that trial: (a) report prolonged abstinence (i.e., sustained abstinence after an initial period in which smoking is not counted as a failure) as the preferred measure, plus point prevalence as a secondary measure; (b) use 7 consecutive days of smoking or smoking on > or = 1 day of 2 consecutive weeks to define treatment failure; (c) include non-cigarette tobacco use, but not nicotine medications in definitions of failure; and (d) report results from survival analysis to describe outcomes more fully. Trials of smokers willing to set a quit date should tie all follow-ups to the quit date and report 6- and/or 12-month abstinence rates. For these trials, we recommend an initial 2-week grace period for prolonged abstinence definitions; however, the period may vary, depending on the presumed mechanism of the treatment. Trials of smokers who may not be currently trying to quit should tie follow-up to the initiation of the intervention and should report a prolonged abstinence measure of > or = 6-month duration and point prevalence rates at 6- and 12-month follow-ups. The grace period for these trials will depend on the time necessary for treatment dissemination, which will vary depending on the treatment, setting, and population. Trials that use short-term follow-ups (< or = 3 months) to demonstrate possible efficacy should report a prolonged abstinence measure of > or = 4 weeks. We again recommend a 2-week grace period; however, that period can vary.
[Show abstract][Hide abstract] ABSTRACT: In the absence of empirical literature from the resident perspective, this study provided a first assessment of smoking history, knowledge of the risks of smoking, the risks of environmental tobacco exposure, and the benefits of quitting among older (age 50+) nursing home unit residents, as well as readiness to quit, barriers to quitting, frequency of cessation advice by healthcare givers, and quit-attempt history of residents who smoke. Subjects were 25 smokers and 70 non-smokers housed on long-term nursing home units in a county hospital. Results indicated that smoking status for the majority of residents was similar to when they were admitted, although smokers smoked fewer cigarettes (M = 11.6, SD = 9.2) than prior to admission (M = 18.6, SD = 11.8). Smokers were less likely than non-smokers to agree that smoking is harmful to their health. Both smokers and non-smokers were not well informed of the dangers of passive smoke exposure. The majority of smokers were in precontemplation (no interest in quitting within the next 6 months). Fewer than half of residents who smoked reported receiving cessation advice from physicians (40%) or nurses (36%), and no in-house cessation programs were available. These results suggest gaps in knowledge and resources for smoking cessation in this setting and an opportunity for intervention. This study begins to build an evidence base from the residents' perspective that can be used by healthcare providers, administrators, and policy makers in addressing smoking in the nursing home.