A mixed methods feasibility study of nicotine-assisted smoking reduction programmes delivered by community pharmacists - The RedPharm study.

BACKGROUND: Pivotal trials have established that, among people who have no immediate intention to quit smoking, nicotine replacement therapy (NRT) helps people reduce and eventually stop smoking. The prime aim of this trial was to investigate the feasibility of implementing such a programme in community pharmacies. In addition, we investigated the effectiveness of providing behavioural support compared with self-help methods and of shorter compared with standard length reduction programmes. METHODS: Pharmacists were trained to deliver a smoking reduction programme and opportunistically invite people to participate in the programme. In a 2 × 2 factorial design, eligible volunteers were randomised to either receive in-person behavioural support or a self-help booklet. In both cases, participants were supported to set targets to reduce their smoking and use behavioural techniques to assist reduction. In addition, participants were randomised to cut down and stop over 4 weeks or over 16 weeks, but in either case continue NRT for up to nine months. We assessed uptake and adherence to the programme and smoking cessation four weeks and six months after a quit day and reduction in the three months following programme end and incorporated a qualitative processes assessment. RESULTS: Only 68 of the planned 160 smokers could be recruited. Pharmacists were deterred by the bureaucracy of trial enrolment and that many smokers did not return for further support. Pharmacists sometimes subverted the randomisation or provided support to participants in the self-help arm. Smokers stayed in the programme for an average of 6 weeks rather than the 9 months envisaged. Rates of follow-up declined to around 20% of participants by 12 months. There was insufficient evidence to assess whether support or speed of reduction enhanced cessation or reduction but cessation and reduction were less common overall than in the pivotal trials for licensing NRT for this indication. CONCLUSIONS: This programme of smoking reduction and the trial design to assess its effectiveness proved unpopular to potential participants and pharmacists. As a result, the trial produced no evidence on the effectiveness of behavioural support or speed or smoking reduction. A trial of this programme in this context is unfeasible. TRIAL REGISTRATION: ISRCTN 54805841 . Registered 18 March 2010.

Give It Up For Baby: outcomes and factors influencing uptake of a pilot smoking cessation incentive scheme for pregnant women.

BACKGROUND: The use of incentives to promote smoking cessation is a promising technique for increasing the effectiveness of interventions. This study evaluated the smoking cessation outcomes and factors associated with success for pregnant smokers who registered with a pilot incentivised smoking cessation scheme in a Scottish health board area (NHS Tayside). METHODS: All pregnant smokers who engaged with the scheme between March 2007 and December 2009 were included in the outcome evaluation which used routinely collected data. Data utilised included: the Scottish National Smoking Cessation Dataset; weekly and periodic carbon monoxide (CO) breath tests; status of smoking cessation quit attempts; and amount of incentive paid. Process evaluation incorporated in-depth interviews with a cross-sectional sample of service users, stratified according to level of engagement. RESULTS: Quit rates for those registering with Give It Up For Baby were 54% at 4 weeks, 32% at 12 weeks and 17% at 3 months post partum (all data validated by CO breath test). Among the population of women identified as smoking at first booking over a one year period, 20.1% engaged with Give It Up For Baby, with 7.8% of pregnant smokers quit at 4 weeks. Pregnant smokers from more affluent areas were more successful with their quit attempt. The process evaluation indicates financial incentives can encourage attendance at routine advisory sessions where they are seen to form part of a wider reward structure, but work less well with those on lowest incomes who demonstrate high reliance on the financial reward. CONCLUSIONS: Uptake of Give It Up For Baby by the target population was higher than for all other health board areas offering specialist or equivalent cessation services in Scotland. Quit successes also compared favorably with other specialist interventions, adding to evidence of the benefits of incentives in this setting. The process evaluation helped to explain variations in retention and quit rates achieved by the scheme.This study describes a series of positive outcomes achieved through the use of incentives to promote smoking cessation amongst pregnant smokers.

A randomised trial of nicotine assisted reduction to stop in pharmacies - the RedPharm study.

BACKGROUND: Public policy and clinical treatment in tobacco addiction in the UK has focused on cessation: an abrupt attempt to stop all cigarettes. However, recent evidence suggests that allowing more gradual withdrawal from tobacco or even permanent partial substitution by nicotine replacement therapy (NRT) could lead to net benefits to public health. No jurisdiction has introduced smoking reduction programmes in normal clinical care and the best methods for their implementation is uncertain. Community pharmacists offering smoking cessation services in the UK are ideally placed to implement reduction programmes.This pilot study aims therefore to examine the feasibility of implementing smoking reduction programme in pharmacies, and also to see if behavioural support and a longer treatment affect the success rate for cessation. DESIGN AND METHODS: This is a 2 × 2 randomised factorial trial of behavioural support versus no support and short versus standard length reduction programme. The pharmacists will recruit 16 patients per pharmacy, 160 smokers altogether. Pharmacists will randomise each participant by sealed envelopes. In a standard supported programme, the pharmacist will give support for 34 weeks, inviting participants to set a treatment goal and providing advice on how to reduce cigarette use. Participants in the short programme will be given the same advice on how to reduce but will reduce smoking over four weeks. Participants in the no support arms will be given a leaflet that describes the reduction programmes in 4-week and 34-week format. All participants are encouraged to use of NRT to support the reduction. These processes will be measured by recording the number of recruited smokers; percentage of those who reduce and sustain their consumption to at least 50% of baseline value, and the proportion of people who attain 4 weeks abstinence and 6 months abstinence. Interviews will assess smokers' and pharmacists' views on the way the programme ran. DISCUSSION: This is a pilot study to assess the feasibility of offering smoking reduction programme within pharmacies that offer naturalistic setting to show population benefit from these programmes. Findings from this trial will inform the development of evidence-based treatment for smokers who want to reduce and best approaches to engage reluctant quitters onto the programme. TRIAL REGISTRATION: Current Controlled Trials ISRCTN 2010-019259-24.

Assessment of alcohol problems using AUDIT in a prison setting: more than an 'aye or no' question.

BACKGROUND: Alcohol problems are a major UK and international public health issue. The prevalence of alcohol problems is markedly higher among prisoners than the general population. However, studies suggest alcohol problems among prisoners are under-detected, under-recorded and under-treated. Identifying offenders with alcohol problems is fundamental to providing high quality healthcare. This paper reports use of the AUDIT screening tool to assess alcohol problems among prisoners. METHODS: Universal screening was undertaken over ten weeks with all entrants to one male Scottish prison using the AUDIT standardised screening tool and supplementary contextual questions. The questionnaire was administered by trained prison officers during routine admission procedures. Overall 259 anonymised completed questionnaires were analysed. RESULTS: AUDIT scores showed a high prevalence of alcohol problems with 73% of prisoner scores indicating an alcohol use disorder (8+), including 36% having scores indicating 'possible dependence' (20-40). AUDIT scores indicating 'possible dependence' were most apparent among 18-24 and 40-64 year-olds (40% and 56% respectively). However, individual questions showed important differences, with younger drinkers less likely to demonstrate habitual and addictive behaviours than the older age group. Disparity between high levels of harmful/hazardous/dependent drinking and low levels of 'treatment' emerged (only 27% of prisoners with scores indicating 'possible dependence' reported being 'in treatment'). Self-reported associations between drinking alcohol and the index crime were identified among two-fifths of respondents, rising to half of those reporting violent crimes. CONCLUSIONS: To our knowledge, this is the first study to identify differing behaviours and needs among prisoners with high AUDIT score ranges, through additional analysis of individual questions. The study has identified high prevalence of alcohol use, varied problem behaviours, and links across drinking, crime and recidivism, supporting the argument for more extensive provision of alcohol-focused interventions in prisons. These should be carefully targeted based on initial screening and assessment, responsive, and include care pathways linking prisoners to community services. Finally, findings confirm the value and feasibility of routine use of the AUDIT screening tool in prison settings, to considerably enhance practice in the detection and understanding of alcohol problems, improving on current more limited questioning (e.g. 'yes or no' questions).

"It makes you feel so full of life" LiveWell, a feasibility study of a personalised lifestyle programme for colorectal cancer survivors.

GOALS: The acceptability and feasibility of a 3-month personalised lifestyle (diet, exercise and weight management) intervention in overweight adults who had completed curative treatment for colorectal cancer were assessed by qualitative interviews, quality-of-life questionnaires and subjective and objective measures of diet and activity. MAIN RESULTS: Over a 4-month period, 28 of 37 (75%) patients met the inclusion criteria and 20 (71%) of the eligible patients agreed to participate in the study and 18 (90%) completed the 3-month study. Reported adherence related to tailored advice, personalised feedback and family support. Reported barriers included time following surgery, fatigue, having a stoma or chronic diarrhoea and conflicting advice from clinicians. A weight change of -1.2 (+/-4.4) kg was achieved overall and -4.1 (+/-3.7) kg in the ten who had lost weight. CONCLUSIONS: Colorectal cancer survivors will participate in a lifestyle change initiative. Interventions should be personalised to suit abilities, provide feedback on personal goals and encourage social support. Intervention timing and attaining greater support from clinicians should be explored prior to the development of an efficacy trial.

Responding to change: how did bar workers adapt to the smoke-free legislation in Scotland?

In recent years a number of countries have implemented comprehensive smoking bans to protect workers from adverse effects of exposure to second-hand smoke. It is also well known that many key stakeholders working in hospitality settings are themselves smokers. This paper reports the findings of a longitudinal qualitative study conducted with bar workers following the implementation of smoke-free legislation in Scotland. It examines the effects of smoking prevalence and status on support for smoke-free legislation, and its impact on business and working practices as well as bar workers' smoking behaviour both in and outside of the workplace. The results highlight a need for targeted assistance for businesses serving disadvantaged communities both to adapt commercially to the legislation and to provide cessation support to workers who smoke.

Public health or social impacts? A qualitative analysis of attitudes toward the smoke-free legislation in Scotland.

INTRODUCTION: Introduction of smoke-free legislation presents a unique opportunity to study how population-level interventions can challenge existing smoking norms. Our study examined support and opposition to the Scottish legislation and ascertained the relative importance of social and health factors in shaping attitudes among bar customers. METHODS: Repeat (pre-/post-legislation) recorded and transcribed semistructured interviews with customers (n = 67/62) of eight community bars in contrasting settings were conducted, and data were analyzed thematically. RESULTS: While the legislation was marketed primarily in terms of gains to public and individual health, supportive and opposing responses to the legislation tended to be framed around libertarian and practical factors. Attitudes tended to be stable across both waves of data collection. DISCUSSION: It is concluded that reasons for smoking were not challenged by promotion of the legislation. In addition to a focus on health gains, social marketing of smoke-free legislation and initiatives may therefore benefit from a stronger focus on social and contextual effects of such policies.

A qualitative analysis of compliance with smoke-free legislation in community bars in Scotland: implications for public health.

AIM: To explore compliance with the smoke-free legislation within a cross-section of community bars in Scotland. DESIGN: Ethnographic case study combining unobtrusive observation and in-depth interviews conducted pre- and post-introduction. SETTING: Eight Scottish community bars in three contrasting study communities. PARTICIPANTS: Ten bar proprietors, 16 bar workers and 44 customers. Measurements Observations and participant reports of compliance over the first 12 months of the smoking ban. FINDINGS: All eight study bars endeavoured to enforce the ban, but with varying enthusiasm. Compliance varied, with violations more prevalent in those bars serving deprived communities. Most violations occurred in peripheral areas and generally went unchallenged. Six bars reported some form of complicit behaviour with staff and customers smoking together, either in the entrance area or during 'lock-ins' when access to the bar was restricted to regular customers. Three factors were particularly important to explaining variance between bars: smoking norms, management competency and management attitudes towards the ban. The first and last were related to social disadvantage. CONCLUSIONS: Official data provide only a crude assessment of compliance in licensed premises. Data from this study offer a detailed picture of the nature and levels of compliance, and suggest a need for more sophisticated surveillance methods, greater enforcement and use of prosecutions where merited, and targeted support for bars serving deprived communities to help ensure that the major gains already achieved are retained and built upon. It is also suggested that acceptance of the smoke-free legislation could be enhanced by complementary initiatives targeting support to smokers in deprived communities. Those planning to introduce smoke-free legislation need to set in place these measures in advance in order to realize the benefits of full compliance.

Financial incentives for smoking cessation in pregnancy: randomised controlled trial.

OBJECTIVE: To assess the efficacy of a financial incentive added to routine specialist pregnancy stop smoking services versus routine care to help pregnant smokers quit. DESIGN: Phase II therapeutic exploratory single centre, individually randomised controlled parallel group superiority trial. SETTING: One large health board area with a materially deprived, inner city population in the west of Scotland, United Kingdom. PARTICIPANTS: 612 self reported pregnant smokers in NHS Greater Glasgow and Clyde who were English speaking, at least 16 years of age, less than 24 weeks pregnant, and had an exhaled carbon monoxide breath test result of 7 ppm or more. 306 women were randomised to incentives and 306 to control. INTERVENTIONS: The control group received routine care, which was the offer of a face to face appointment to discuss smoking and cessation and, for those who attended and set a quit date, the offer of free nicotine replacement therapy for 10 weeks provided by pharmacy services, and four, weekly support phone calls. The intervention group received routine care plus the offer of up to £400 of shopping vouchers: £50 for attending a face to face appointment and setting a quit date; then another £50 if at four weeks' post-quit date exhaled carbon monoxide confirmed quitting; a further £100 was provided for continued validated abstinence of exhaled carbon monoxide after 12 weeks; a final £200 voucher was provided for validated abstinence of exhaled carbon monoxide at 34-38 weeks' gestation. MAIN OUTCOME MEASURE: The primary outcome was cotinine verified cessation at 34-38 weeks' gestation through saliva (<14.2 ng/mL) or urine (<44.7 ng/mL). Secondary outcomes included birth weight, engagement, and self reported quit at four weeks. RESULTS: Recruitment was extended from 12 to 15 months to achieve the target sample size. Follow-up continued until September 2013. Of the 306 women randomised, three controls opted out soon after enrolment; these women did not want their data to be used, leaving 306 intervention and 303 control group participants in the intention to treat analysis. No harms of financial incentives were documented. Significantly more smokers in the incentives group than control group stopped smoking: 69 (22.5%) versus 26 (8.6%). The relative risk of not smoking at the end of pregnancy was 2.63 (95% confidence interval 1.73 to 4.01) P<0.001. The absolute risk difference was 14.0% (95% confidence interval 8.2% to 19.7%). The number needed to treat (where financial incentives need to be offered to achieve one extra quitter in late pregnancy) was 7.2 (95% confidence interval 5.1 to 12.2). The mean birth weight was 3140 g (SD 600 g) in the incentives group and 3120 (SD 590) g in the control group (P=0.67). CONCLUSION: This phase II randomised controlled trial provides substantial evidence for the efficacy of incentives for smoking cessation in pregnancy; as this was only a single centre trial, incentives should now be tested in different types of pregnancy cessation services and in different parts of the United Kingdom. TRIAL REGISTRATION: Current Controlled Trials ISRCTN87508788.

Barriers and facilitators to a criminal justice tobacco control coordinator: an innovative approach to supporting smoking cessation among offenders.

AIMS: To examine the barriers and facilitators to effective operation of a regional tobacco control coordinator working within and across criminal justice and public health, whose goal was to raise tobacco control awareness and support the development of smoking cessation treatment for offenders. DESIGN: A reflexive, mixed-methods case study approach using in-depth interviews, project reports and observation of advisory board meetings. SETTING: The coordinator worked with prisons, probation and police custody, where there are high levels of social disadvantage and smoking. PARTICIPANTS: Interviews (n = 34) at different stages of project with the coordinator, project advisers and local stakeholders from criminal justice and public health. MEASUREMENTS: Analysis of facilitators and barriers and the coordinator role from different perspectives. FINDINGS: Readiness to develop cessation services was a critical predictor of different criminal justice settings' engagement with the coordinator role. The coordinator enhanced cessation service delivery in individual prisons where there was a requirement and infrastructure in place to provide such services. In police custody, where there was no central guidance or pre-existing requirements, efforts to establish smoking cessation on the local agenda proved ineffective. In probation settings, the coordinator documented examples of good practice and supported brief intervention training. Variability in willingness to engage limited the project's ability to create joined-up working across criminal justice settings. CONCLUSIONS: In the English criminal justice system, the prison service appears to provide a favourable context for development of smoking cessation support and a means of accessing hard-to-reach groups. Other criminal justice settings, most specifically police custody, appear less responsive to such activity. A coordinator role can improve smoking cessation support in the prison setting, and develop local improvements in tobacco control interventions in other settings such as probation, but as configured here, does not have the capacity to effect change across the criminal justice system.

The cessation in pregnancy incentives trial (CPIT): study protocol for a randomized controlled trial.

BACKGROUND: Seventy percent of women in Scotland have at least one baby, making pregnancy an opportunity to help most young women quit smoking before their own health is irreparably compromised. By quitting during pregnancy their infants will be protected from miscarriage and still birth as well as low birth weight, asthma, attention deficit disorder and adult cardiovascular disease. In the UK, the NICE guidelines: 'How to stop smoking in pregnancy and following childbirth' (June 2010) highlighted that little evidence exists in the literature to confirm the efficacy of financial incentives to help pregnant smokers to quit. Its first research recommendation was to determine: Within a UK context, are incentives an acceptable, effective and cost-effective way to help pregnant women who smoke to quit? DESIGN AND METHODS: This study is a phase II exploratory individually randomized controlled trial comparing standard care for pregnant smokers with standard care plus the additional offer of financial voucher incentives to engage with specialist cessation services and/or to quit smoking during pregnancy.Participants (n = 600) will be pregnant smokers identified at maternity booking who, when contacted by specialist cessation services, agree to having their details passed to the NHS Smokefree Pregnancy Study Helpline to discuss the trial. The NHS Smokefree Pregnancy Study Helpline will be responsible for telephone consent and follow-up in late pregnancy. The primary outcome will be self reported smoking in late pregnancy verified by cotinine measurement. An economic evaluation will refine cost data collection and assess potential cost-effectiveness while qualitative research interviews with clients and health professionals will assess the level of acceptance of this form of incentive payment. The research questions are: What is the likely therapeutic efficacy? Are incentives potentially cost-effective? Is individual randomization an efficient trial design without introducing outcome bias? Can incentives be introduced in a way that is feasible and acceptable? DISCUSSION: This phase II trial will establish a workable design to reduce the risks associated with a future definitive phase III multicenter randomized controlled trial and establish a framework to assess the costs and benefits of financial incentives to help pregnant smokers to quit. TRIAL REGISTRATION: Current Controlled Trials ISRCTN87508788.

Smoking prevalence and smoking cessation services for pregnant women in Scotland.

BACKGROUND: Over 20% of women smoke throughout pregnancy despite the known risks to mother and child. Engagement in face-to-face support is a good measure of service reach. The Scottish Government has set a target that by 2010 8% of smokers will have quit via NHS cessation services. At present less than 4% stop during pregnancy. We aimed to establish a denominator for pregnant smokers in Scotland and describe the proportion who are referred to specialist services, engage in one-to-one counselling, set a quit date and quit 4 weeks later. METHODS: This was a descriptive epidemiological study using routinely collected data supplemented by questionnaire information from specialist pregnancy cessation services. RESULTS: 13266 of 52370 (25%) pregnant women reported being current smokers at maternity booking and 3133/13266 (24%) were referred to specialist cessation services in 2005/6. Two main types of specialist smoking cessation support for pregnant women were in place in Scotland. The first involved identification using self-report and carbon monoxide breath test for all pregnant women with routine referral (1936/3352, 58% referred) to clinic based support (386, 11.5% engaged). 370 (11%) women set a quit date and 116 (3.5%) had quit 4 weeks later. The second involved identification by self report and referral of women who wanted help (1195/2776, 43% referred) for home based support (377/1954, 19% engaged). 409(15%) smokers set a quit date and 119 (4.3%) had quit 4 weeks later. Cost of home-based support was greater. In Scotland only 265/8062 (3.2%) pregnant smokers identified at maternity booking, living in areas with recognised specialist or good generic services, quit smoking during 2006. CONCLUSIONS: In Scotland, a small proportion of pregnant smokers are supported to stop. Poor outcomes are a product of current limitations to each step of service provision--identification, referral, engagement and treatment. Many smokers are not asked about smoking at maternity booking or provide false information. Carbon monoxide breath testing can bypass this difficulty. Identified smokers may not be referred but an opt-out referral policy can remove this barrier. Engagement at home allowed a greater proportion to set a quit date and quit, but costs were higher.

Developmental regulation of an adhesin gene during cellular morphogenesis in the fungal pathogen Candida albicans.

Candida albicans expresses specific virulence traits that promote disease establishment and progression. These traits include morphological transitions between yeast and hyphal growth forms that are thought to contribute to dissemination and invasion and cell surface adhesins that promote attachment to the host. Here, we describe the regulation of the adhesin gene ALS3, which is expressed specifically during hyphal development in C. albicans. Using a combination of reporter constructs and regulatory mutants, we show that this regulation is mediated by multiple factors at the transcriptional level. The analysis of ALS3 promoter deletions revealed that this promoter contains two activation regions: one is essential for activation during hyphal development, while the second increases the amplitude of this activation. Further deletion analyses using the Renilla reniformis luciferase reporter delineate the essential activation region between positions -471 and -321 of the promoter. Further 5' or 3' deletions block activation. ALS3 transcription is repressed mainly by Nrg1 and Tup1, but Rfg1 contributes to this repression. Efg1, Tec1, and Bcr1 are essential for the transcriptional activation of ALS3, with Tec1 mediating its effects indirectly through Bcr1 rather than through the putative Tec1 sites in the ALS3 promoter. ALS3 transcription is not affected by Cph2, but Cph1 contributes to full ALS3 activation. The data suggest that multiple morphogenetic signaling pathways operate through the promoter of this adhesin gene to mediate its developmental regulation in this major fungal pathogen.

Global role of the protein kinase Gcn2 in the human pathogen Candida albicans.

The pathogen Candida albicans responds to amino acid starvation by activating pseudohyphal development and the expression of amino acid biosynthetic genes (GCN response). In Saccharomyces cerevisiae, the GCN response is dependent on Gcn2, which regulates the translation of the transcription factor Gcn4. Therefore, we examined the role of Gcn2 in C. albicans by using molecular, cellular, and genomic approaches. We show that C. albicans GCN2 encodes an eIF2alpha kinase, like its S. cerevisiae homologue. However, GCN4 appears to be regulated mainly at the transcriptional level in C. albicans. Furthermore, the inactivation of C. albicans Gcn2 only partially attenuates growth under amino acid starvation conditions and resistance to the histidine analogue 3-aminotriazole. Our comparison of the Gcn4 and Gcn2 regulons by transcript profiling reinforces the view that Gcn2 contributes to, but is not essential for, the activation of general amino acid control in C. albicans.

Gcn4 co-ordinates morphogenetic and metabolic responses to amino acid starvation in Candida albicans.

Candida albicans is a major fungal pathogen of humans. It regulates its morphology in response to various environmental signals, but many of these signals are poorly defined. We show that amino acid starvation induces filamentous growth in C.albicans. Also, starvation for a single amino acid (histidine) induces CaHIS4, CaHIS7, CaARO4, CaLYS1 and CaLYS2 gene expression in a manner reminiscent of the GCN response in Saccharomyces cerevisiae. These morphogenetic and GCN-like responses are both dependent upon CaGcn4, which is a functional homologue of S.cerevisiae Gcn4. Like ScGcn4, CaGcn4 activates the transcription of amino acid biosynthetic genes via the GCRE element, and CaGcn4 confers resistance to the histidine analogue, 3-aminotriazole. CaGcn4 interacts with the Ras-cAMP pathway to promote filamentous growth, but the GCN-like response is not dependent upon morphogenetic signalling. CaGcn4 acts as a global regulator in C.albicans, co-ordinating both metabolic and morphogenetic responses to amino acid starvation.

Msn2- and Msn4-like transcription factors play no obvious roles in the stress responses of the fungal pathogen Candida albicans.

In Saccharomyces cerevisiae, the (C2H2)2 zinc finger transcription factors Msn2 and Msn4 play central roles in responses to a range of stresses by activating gene transcription via the stress response element (STRE; CCCCT). The pathogen Candida albicans displays stress responses that are thought to help it survive adverse environmental conditions encountered within its human host. However, these responses differ from those in S. cerevisiae, and hence we predicted that the roles of Msn2- and Msn4-like proteins might have been functionally reassigned in C. albicans. C. albicans has two such proteins: CaMsn4 and Mnl1 (for Msn2- and Msn4-like). CaMSN4, but not MNL1, weakly complemented the inability of an S. cerevisiae msn2 msn4 mutant to activate a STRE-lacZ reporter. Also, the disruption of CaMsn4 and Mnl1 had no discernible effect upon the resistance of C. albicans to heat, osmotic, ethanol, nutrient, oxidative, or heavy-metal stress or upon the stress-activated transcriptome in C. albicans. Furthermore, although Cap1-dependent activation of a Yap response element-luciferase reporter was observed, a STRE reporter was not activated in response to stresses in C. albicans. Ectopic expression of CaMsn4 or Mnl1 did not affect the cellular or molecular responses of C. albicans to stress. Under the conditions tested, the putative activation and DNA binding domains of CaMsn4 did not appear to be functional. These data suggest that CaMsn4 and Mnl1 do not contribute significantly to stress responses in C. albicans. The data are consistent with the idea that stress signaling in this fungus has diverged significantly from that in budding yeast.