Physical therapy vs internet-based exercise training for patients with knee osteoarthritis: results of a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of physical therapy (PT, evidence-based approach) and internet-based exercise training (IBET), each vs a wait list (WL) control, among individuals with knee osteoarthritis (OA). DESIGN: Randomized controlled trial of 350 participants with symptomatic knee OA, allocated to standard PT, IBET and WL control in a 2:2:1 ratio, respectively. The PT group received up to eight individual visits within 4 months. The IBET program provided tailored exercises, video demonstrations, and guidance on progression. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC, range 0 [no problems]-96 [extreme problems]), assessed at baseline, 4 months (primary time point) and 12 months. General linear mixed effects modeling compared changes in WOMAC among study groups, with superiority hypotheses testing differences between each intervention group and WL and non-inferiority hypotheses comparing IBET with PT. RESULTS: At 4-months, improvements in WOMAC score did not differ significantly for either the IBET or PT group compared with WL (IBET: -2.70, 95% Confidence Interval (CI) = -6.24, 0.85, P = 0.14; PT: -3.36, 95% (CI) = -6.84, 0.12, P = 0.06). Similarly, at 12-months mean differences compared to WL were not statistically significant for either group (IBET: -2.63, 95% CI = -6.37, 1.11, P = 0.17; PT: -1.59, 95% CI = -5.26, 2.08, P = 0.39). IBET was non-inferior to PT at both time points. CONCLUSIONS: Improvements in WOMAC score following IBET and PT did not differ significantly from the WL group. Additional research is needed to examine strategies for maximizing benefits of exercise-based interventions for patients with knee OA. TRIAL REGISTRATION: NCT02312713.

Evaluate, assess, treat: development and evaluation of the EAT framework to increase effective communication regarding sensitive oral-systemic health issues.

Oral healthcare providers are likely to encounter a number of sensitive oral/systemic health issues whilst interacting with patients. The purpose of the current study was to develop and evaluate a framework aimed at oral healthcare providers to engage in active secondary prevention of eating disorders (i.e. early detection of oral manifestations of disordered eating behaviours, patient approach and communication, patient-specific oral treatment, and referral to care) for patients presenting with signs of disordered eating behaviours. The EAT Framework was developed based on the Brief Motivational Interviewing (B-MI) conceptual framework and comprises three continuous steps: Evaluating, Assessing, and Treating. Using a group-randomized control design, 11 dental hygiene (DH) and seven dental (D) classes from eight institutions were randomized to either the intervention or control conditions. Both groups completed pre- and post-intervention assessments. Hierarchical linear models were conducted to measure the effects of the intervention whilst controlling for baseline levels. Statistically significant improvements from pre- to post-intervention were observed in the Intervention group compared with the Control group on knowledge of eating disorders and oral findings, skills-based knowledge, and self-efficacy (all P < 0.01). Effect sizes ranged from 0.57 to 0.95. No statistically significant differences in outcomes were observed by type of student. Although the EAT Framework was developed as part of a larger study on secondary prevention of eating disorders, the procedures and skills presented can be applied to other sensitive oral/systemic health issues. Because the EAT Framework was developed by translating B-MI principles and procedures, the framework can be easily adopted as a non-confrontational method for patient communication.

Smokeless tobacco use among professional baseball players: survey results, 1998 to 2003.

OBJECTIVE: The use of smokeless tobacco (ST) (snuff and chewing tobacco) has long been associated with baseball in the USA. This article reviews six years of survey data from major and minor league baseball players to evaluate trends in tobacco use and quitting patterns over time in order to gain insight into the effects of past interventions and to document continued intervention needs. METHOD: Surveys were distributed by athletic trainers to major and minor league professional baseball players during spring training session in the six years from 1998 to 2003. The surveys were anonymous and identified only by team, level of league, and other self reported demographic data. RESULTS: ST use among professional baseball players remains much higher than among young males in the general population, and use is most prevalent among white non-Hispanic players. There was a significant decrease in ST use among minor league players from 1998 to 2003, with seven day self reported use declining from 31.7% in 1998 to 24.8% in 2003. No significant year to year changes were observed for major league players. Major league players' self reported past week use rates, estimated at 35.9% in 1998 and at 36% in 2003, were consistently higher than those of minor league players. Self reported prevalence of past month cigarette and cigar smoking was much lower than ST use for both major and minor league players. CONCLUSIONS: Six years of survey data confirm a continuing high use of ST among professional baseball players. Results suggest that the effects of the broad spectrum ST control efforts launched over the past decade may have been stronger among minor than major league players. Stronger policy interventions at the major league level and multi-level efforts, including programmes to increase the use of effective quitting aids and assistance, at both levels of play are needed. Future research is needed to further clarify changes in ST practices among professional players and set policy intervention directions.

Pediatric office-based smoking intervention: impact on maternal smoking and relapse.

OBJECTIVE: To determine the impact of a brief smoking intervention delivered by pediatricians in the context of usual well baby office visits on postnatal maternal smoking and relapse. SETTING: Forty-nine private pediatric practices including 128 practitioners. DESIGN: Randomization of pediatric practices into minimal and extended intervention sites with all enrolled mothers of newborns within a practice receiving the same level of intervention. INTERVENTION: Smoking mothers in minimal condition received a hospital packet containing written information about passive smoking and a letter advising them to quit. Those in extended condition received the hospital packet plus oral and written advice at usual well baby visits: 2 weeks, 2, 4, and 6 months. MEASUREMENTS: Smoking and relapse rates at 6 months postpartum, demographics associated with smoking status, attitudes, and knowledge in regard to passive smoking, and recall surveys of mothers in regard to receiving advice or written materials. RESULTS: Two-thousand nine-hundred-one mothers of newborns were enrolled in the study. Those in the extended condition had higher quit rates (5.9% vs 2.7%, P < .01) and lower relapse rates (45% vs 55%, P < .01) than those in the minimal condition. Mothers' educational status and the presence of a smoking partner in the home were the major demographic variables associated with smoking status at enrollment and at follow-up. Compared with smokers in the minimal condition, those in extended at 6 months postpartum had significantly better attitudes and knowledge regarding passive smoking and allowed less smoking in the home. Mothers attending extended practices reported much higher rates of receiving oral advice and written materials than those in the minimal condition. CONCLUSIONS: A brief program can lead to major increases in the willingness of pediatricians to deliver smoking advice. A 1- to 2-minute intervention delivered in the context of usual well baby care can have a positive impact on maternal smoking and especially upon relapse prevention. A recent smoking history should be obtained from all mothers of newborns so that interventions can be aimed at both cessation and relapse prevention.

Maternal smoking cessation and relapse prevention during health care visits.

BACKGROUND: Although effects of maternal smoking during pregnancy could be alleviated if women quit early in pregnancy, most do not. Relapse rates among quitters are high. OBJECTIVE: To test the effects of a low-intensity, smoking-cessation/relapse-prevention intervention delivered by clinic staff and providers and based on stages-of-change constructs of the transtheoretical model and brief motivational interviewing techniques. METHODS: A quasi-experimental prospective cohort design employed in obstetric, in-patient, and pediatric care delivery settings of a large health maintenance organization in Portland, Oregon. Subjects were pregnant smokers registered for their first prenatal visit. Primary outcome measures were sustained (self-reported) quit rates during pregnancy and smoking abstinence between 6 and 12 months after delivery. RESULTS: Regression analyses found statistically significant improvement for intervention women in sustained pregnancy quit rates (OR=2.7, CI=1. 2-5.7) and on smoking abstinence between 6 and 12 months after delivery (OR=2.4, CI=1.1-5.3). CONCLUSIONS: While these outcomes are based on self-report only, they emerged despite variable delivery of the intervention across clinics and represent clinically meaningful improvements in rates of nonsmoking. The intervention supports women who want to quit smoking during pregnancy and improves the likelihood of their remaining nonsmokers for the long term.

Evaluation of a dental office tobacco cessation program: effects on smokeless tobacco use.

We describe a randomized trial designed to evaluate the effectiveness of a smokeless tobacco cessation intervention delivered by dental hygienists as part of a patient's regularly scheduled cleaning visit. Seventy-five practices were randomized to continue their usual care (n=25; 239 smokeless tobacco using patients enrolled) or to receive training to provide a tobacco cessation intervention (n=50; 394 smokeless tobacco using patients enrolled). Patient reports indicated that the training program was successful in getting hygienists to implement the intervention. The intervention produced a strong effect on sustained quitting for smokeless tobacco users but had no impact on secondary outcomes, including unsuccessful quit attempts, future intent to quit using smokeless tobacco, and change in readiness to quit using. Frequency of smokeless tobacco use and receipt of specific components of the intervention, including the video and written materials, predicted sustained cessation. Since this intervention was delivered by dental hygienists as part of a patient's regularly scheduled cleaning visit, it is easily disseminable.

Health behavior, quality of work life, and organizational effectiveness in the lumber industry.

A major incentive for work-site health promotion activities has been the promise of increased company profitability. Some critics have challenged the economic argument based on distal outcomes such as increased employee longevity and less morbidity later in life. The purpose of this study was to examine the relationships between employee health behavior, quality of work life, and proximal organizationally valued outcomes. Data were collected from a stratified random sample of employees working at Pacific Lumber Company (N = 146), the largest single-site lumber mill in California. Although employee sleep patterns predicted health care utilization and psychological well-being, for the most part employee health behaviors were not strong predictors of proximal organizational effectiveness factors. However, quality-of-work-life factors significantly predicted organizational commitment, absenteeism, and tardiness frequency. The findings suggest the value of improving the system of work in which employees are embedded as part of comprehensive work-site health promotion efforts.

Sampling bias due to consent procedures with adolescents.

Positive consent was solicited from parents of 604 seventh grade students in four middle schools. Three hundred and fifty eight (59%) returned consents and completed a questionnaire under " bogus pipeline" conditions with saliva and air samples. Two weeks later both students with consent and those without were administered a second questionnaire without physiological measures. Comparison between consent and nonconsent students show significant differences in the smoking of cigarettes and marijuana, but no difference in the use of alcohol. Additional significant differences were found in exposure to smoking models, and level of education of both parents. The bias shown on significant dependent variables may adversely effect the generalizability of results of studies of adolescent drug use that depend upon positive parental consent.

Chewing tobacco use by adolescents: prevalence and relation to cigarette smoking.

The prevalence of teenage smokeless tobacco use and its relation to cigarette smoking was studied. Nine percent of 7th grade boys and 20% of 9th and 10th grade boys reported daily use. There was very little regular chewing among girls although about 20% reported having tried it. There was a strong association between smoking and chewing among 7th graders but only a weak association among 9th and 10th graders. Boys who chew tended to have friends who chew and/or smoke. The data suggested that chewing is affected by peer social influence processes in a manner similar to smoking.

Measuring dependence in smokeless tobacco users.

Two scales based on the Fagerstrom Tolerance Questionnaire were developed to measure dependence in smokeless tobacco users. The total score for both scales correlated positively with saliva cotinine levels in subjects, and several individual items produced equally positive correlations. Regression analyses yielded two subsets of three items from each scale that predicted cotinine level. Reports of using smokeless tobacco within 30 min of waking served as a predictor in both models. For the purposes of measuring smokeless tobacco dependence, attention should be given to individual items correlated with saliva cotinine levels that could be used to determine the direction of cessation efforts. Future research should also develop additional items specific to the use of snuff or chewing tobacco and eliminate questions not contributing to the overall scale.

Evaluating two self-help interventions for smokeless tobacco cessation.

The need for effective, low-cost self-help treatment methods for smokeless tobacco (ST) addiction becomes more evident as rates of product use and associated morbidities increase. This study evaluated two self-help methods for ST cessation. One hundred ninety-eight ST users were randomized into two conditions: half received the LifeSign, a credit card-sized computer designed for gradual ST cessation, and half received the Enough Snuff self-help manual and a video. Subjects in both conditions received telephone support for their quit effort. The study was conducted entirely through phone and mail, allowing delivery of the intervention to both rural and urban users. Self-reported rates of sustained abstinence (no tobacco use at two months and six months) were 24.5% for the manual/video condition, and 18.4%, for the LifeSign condition.

Who enrolls in a self-help cessation program for smokeless tobacco?

To further our understanding of the representativeness of the smokeless tobacco (SLT) user recruited to various treatment settings, and to suggest gaps in services available to SLT users, we first compared participants who enrolled in a self-help cessation program with two samples of nontreatment-seeking SLT users: SLT users identified through a random digit dialing (RDD) survey, and SLT users who came to 1 of 75 dental practices for a routine cleaning visit. We found that those in the self-help SLT cessation program were older, more educated, more likely to have made a serious quit attempt, and used more SLT weekly than those who did not seek treatment. Secondly, we compared SLT users seeking treatment in three different treatment settings varying in accessibility and intensity: self-help study participants, SLT users enrolled in a clinic-based study, and callers to the California Help Line for SLT cessation. Participants differed across the three studies on demographics, some measures of dependence, and history of SLT use.

The organizational implications of smokeless tobacco use in the lumber mill industry.

Although much is known about the characteristics of employees who smoke cigarettes, very little is known about workers who use smokeless tobacco. The current study was designed to understand the characteristics of smokeless tobacco users in relation to their performance at work and compare them with smokers and former tobacco users. Data were collected via interviews and questionnaires from a random sample of employees working at Pacific Lumber Company (N = 146), the largest single-site lumber mill in California. A total of 63 smokeless tobacco users (21 of whom also smoked cigarettes), 43 cigarette smokers, and 40 employees who had successfully quit using tobacco (34 of whom previously used cigarettes only) provided information about their health behavior, quality of work life, and performance at work. Analyses revealed that smokeless tobacco users reported less healthful sleep patterns, drank alcohol more often, were intoxicated more often, reported less job satisfaction and organizational commitment, and reported that both chewers and smokers do not work as hard and take more breaks than do tobacco-free employees (quitters). Specific differences among chewers-only, smokers-only, smokers-and-chewers, and quitters are presented. Results suggest the organizational value of developing worksite cessation programs for smokeless tobacco users.

Tobacco cessation interventions in health care settings: rationale, model, outcomes.

Health care settings provide opportunities to reach populations of tobacco users with personalized cessation assistance. We describe a model for doing so which emphasizes a team approach, minimizes the burden on clinicians, and uses brief counseling by allied professionals, videos, written materials, and telephone calls to augment clinician advice. The model has been implemented in several diverse settings including outpatient, inpatient, and dental clinic managed care; fee-for-service dentistry and pediatric practices; and planned parenthood clinics. Data from several randomized trials support the effectiveness of the approach. The brief, low-intensity interventions derived from the model appear to be sustainable on a routine basis in many settings.

Biochemical validation of smoking status: pros, cons, and data from four low-intensity intervention trials.

Biochemical validation of smoking status has long been considered essential, but recent reports have questioned its utility in certain kinds of field trials. We describe efforts to biochemically validate self-reports of smoking cessation from participants in four large-scale randomized trials in outpatient clinics, hospitals, worksites, and dental clinics. These studies included over 5,000 adults smokers who participated in the population-based low-intensity intervention evaluations. At a 1-year follow-up, 798 subjects reported no tobacco use. We attempted to verify these reports using saliva continine/carbon monoxide validation procedures. Overall, there was a moderately high nonparticipation rate (27%), a low disconfirmation rate (4%), and a high self-reported relapse rate (12%) in the interval between survey and biochemical validation. There were no differences between intervention and control conditions on any of the above variables. Longer durations of self-reported abstinence were strongly related to increased probability of biochemical confirmation. Differences in results across projects were related to how biochemical validation was conducted. These results, as well as statistical power considerations, raise questions about whether biochemical validation procedures are practical, informative, or cost-effective in such population-based, low-intensity intervention research.

Psychosocial factors in the use of smokeless tobacco and their implications for P.L. 99-252.

This article briefly reviews the prevalence of smokeless tobacco use by males in the United States, the relationship of smokeless tobacco use to cigarette use, and patterns of use that include dosage, topography, products, and function of use. The primary focus of the article is to describe the concurrent and predictive factors associated with onset, use, and cessation of smokeless tobacco. The implications of P.L. 99-252, the Comprehensive Smokeless Tobacco Act of 1986, are discussed in the context of what is known about the psychosocial variables associated with the use of smokeless tobacco.

Smokeless tobacco habits and oral mucosal lesions in dental patients.

As part of a smokeless tobacco (ST) intervention study, we collected data on tobacco use habits and oral health for 245 male ST users aged 15 to 77. The study sample was identified during routine dental office visits and represents a relatively diverse population of patients. Oral health data collection included grading the clinical appearance of oral mucosal lesions using Greer and Poulson's classification system, as well as identifying and recording the primary anatomic location of ST placement. Results show that 78.6 percent of ST users had observable oral lesions, 23.6 percent of which were in the most clinically advanced category (degree III). Of the lesions noted, 85 percent were in the same location the patient identified as his primary area of smokeless tobacco placement. In a comparison sample of 223 non-ST-users with the same age distribution, only 6.3 percent had observable lesions. A multiple logistic regression model for ST users showed that lesion presence and severity were most significantly related to current frequency of ST use.

Relationship between tobacco use and self-reported oral hygiene habits.

A sample of 34,897 dental patients completed written surveys assessing their tobacco use, frequency of brushing and flossing and perception of oral health problems. Brushing two times per day was reported by 73.5 percent of the patients and flossing one time per day by 35.6 percent. Tobacco users brushed and, particularly, flossed much less frequently than did nonusers. Compliance with daily flossing regimens was particularly low among smokeless tobacco users. Tobacco users also reported more oral health problems.

Using the hygiene visit to deliver a tobacco cessation program: results of a randomized clinical trial.

To examine the effectiveness of advising patients who use tobacco to quit, the authors conducted a randomized clinical trial to test a brief office-based intervention with all tobacco users in 75 fee-for-service dental practices in Oregon. The authors found that the dental hygienist-delivered intervention was effective in getting smokeless tobacco users to quit at three and 12 months and to sustain abstinence at both three and 12 months. They found that the program was not effective for cigarette smokers. The authors discuss the public health implications of program dissemination and widespread program adoption.

Smokeless tobacco cessation.

Smokeless tobacco use is increasing in the United States, especially among young men, but there are few resources to assist users in quitting their use of moist snuff or chewing tobacco. This article reviews some unique aspects of smokeless tobacco use and provides a systematic four-step clinical plan for providing cessation. The authors provide clear suggestions, measures, and aids for getting the user ready to quit, planning their quit, quitting, and staying quit. The procedures and measures have been validated in randomized clinical trials and provide empirical support for the recommended cessation procedures. Finally, a review of brief cessation interventions in the context of health care is provided.