Current Postlaunch Implementation of State Mandates of Newborn Screening for Critical Congenital Heart Disease by Pulse Oximetry in U.S. States and Hospitals.

OBJECTIVE: Our objective was to gauge adherence to nationally endorsed protocols in implementation of pulse oximetry (POx) screening for critical congenital heart disease (CCHD) in infants after mandate by all states and to assess associated characteristics. STUDY DESIGN: Between March and October 2019, an online questionnaire was administered to nurse supervisors who oversee personnel conducting POx screening. The questionnaire used eight questions regarding performance and interpretation of screening protocols to measure policy consistency, which is adherence to nationally endorsed protocols for POx screening developed by professional medical societies. Multilevel linear regression models evaluated associations between policy consistency and characteristics of hospitals and individuals, state of hospital location, early versus late mandate adopters, and state reporting requirements. RESULTS: Responses from 189 nurse supervisors spanning 38 states were analyzed. Only 17% received maximum points indicating full policy consistency, and 24% selected all four options for potential hypoxia that require a repeat screen. Notably, 33% did not recognize ≤90% SpO2 as an immediate failed screen and 31% responded that an infant with SpO2 of 89% in one extremity will be rescreened by nurses in an hour rather than receiving an immediate physician referral. Lower policy consistency was associated with lack of state reporting mandates (beta = -1.23 p = 0.01) and early adoption by states (beta = -1.01, p < 0.01). CONCLUSION: When presented with SpO2 screening values on a questionnaire, a low percentage of nurse supervisors selected responses that demonstrated adherence to nationally endorsed protocols for CCHD screening. Most notably, almost one-third of respondents did not recognize ≤90% SpO2 as a failed screen that requires immediate physician follow-up. In addition, states without reporting mandates and early adopter states were associated with low policy consistency. Implementing state reporting requirements might increase policy consistency, but some inconsistency may be the result of unique protocols in early adopter states that differ from nationally endorsed protocols. KEY POINTS: · Low adherence to nationally endorsed protocols.. · Inconsistent physician follow-up to hypoxia.. · Reporting improved consistency with national policy..

The Relationships of Expectancies With E-cigarette Use Among Hospitalized Smokers: A Prospective Longitudinal Study.

Background: Expectancies demonstrate cross-sectional associations with e-cigarette use, but the prospective relationships between expectancies and e-cigarette use are unknown. This study examined the longitudinal associations of expectancies with e-cigarette use among hospitalized tobacco cigarette smokers. Methods: E-cigarette expectancies (e-cigarette-specific Brief Smoking Consequences Questionnaire-Adult [BSCQ-A]), tobacco cigarette expectancies (tobacco-specific BSCQ-A), and number of days used e-cigarettes in the past 30 days were assessed at baseline hospitalization, 6-months post-hospitalization, and 12-months post-hospitalization among 978 hospitalized tobacco cigarette smokers. Expectancy difference scores (e-cigarette-specific expectancies minus tobacco-specific expectancies) were computed for each of the 10 BSCQ-A scales. Cross-lagged panel models tested the relationships between expectancy difference scores and number of days used e-cigarettes in the past 30 days for each of the 10 BSCQ-A scales. Results: Though some models revealed partial associations between expectancies and e-cigarette use, only one yielded results consistent with hypotheses. Greater e-cigarette use at baseline predicted greater expectancies that e-cigarettes taste pleasant as compared to tobacco cigarettes at 6 months, which then predicted greater e-cigarette use at 12 months. To a lesser degree greater expectancies that e-cigarettes taste pleasant as compared to tobacco cigarettes at baseline predicted greater e-cigarette use at 6 months, which then predicted greater expectancies that e-cigarettes taste pleasant as compared to tobacco cigarettes at 12 months. Conclusions: Expectancies that e-cigarettes provide similar or more pleasant taste sensations as compared to tobacco cigarettes may be both a cause and consequence of e-cigarette use. Focusing on the taste experience may prove most effective in modifying e-cigarette use behavior. Implications: The current study offers the first longitudinal examination of expectancies and e-cigarette use. Results suggest expectancies that e-cigarettes provide similar or more pleasant taste sensations relative to tobacco cigarettes are both a cause and consequence of e-cigarette use. Efforts that focus on the e-cigarette taste experience may prove most effective in modifying e-cigarette use behavior.

On Some Practical Considerations Regarding Community-Based Participatory Research for Addressing Cancer Health Disparities.

There is a consensus about the benefits of community-based participatory research and the important role it can play in reducing cancer health disparities. Although every community-based participatory research project is unique in many ways, several fundamental issues deserve consideration. We discuss issues concerning community representation, possible tensions within community-based participatory research (CBPR) projects, and staffing CBPR projects. Flexibility, open-mindedness, transparency, and above all, caring, are characteristics that best ensure successful and rewarding outcomes.

The Relationship of Religiosity, Spirituality, Substance Abuse, and Depression Among Black Men Who Have Sex with Men (MSM).

HIV infection rates continue to disproportionately affect Black men who have sex with men (Black MSM) compared to other groups. Research has shown that higher rates of substance use and higher levels of depression are positively correlated with higher sexual risk behavior, and little research has examined relationships between high levels of religiosity and spirituality prevalent in Black culture and issues of substance use and depression among Black MSM. This study did just that and found a relationship between religiosity, spirituality, and risk behavior. These relationships suggest that future HIV prevention models might incorporate religiosity and spirituality to increase the efficacy of risk reduction interventions for Black MSM.

The Relationship Between HIV Risk, High-Risk Behavior, Religiosity, and Spirituality Among Black Men Who Have Sex with Men (MSM): An Exploratory Study.

Blacks in the USA, including black men who have sex with men (MSM), tend to have stronger religious and spiritual affiliations compared with other racial/ethnic populations. HIV and STD incidence rates continue to rise among Black MSM. Using data from the CDC Brothers y Hermanos (ByHS) project, this study examined correlations between high-risk behavior, e.g., substance use and high-risk sexual behavior (e.g., condom use history, unprotected sexual intercourse, HIV infection status, and STD infection status) religiosity, spirituality, age, among Black MSM (N = 1141). This exploratory study examined whether religiosity and spirituality were associated with high-risk behavior and high-risk sexual behavior among Black MSM. Religiosity and spirituality indices were compiled from the ByHS data. The religiosity index was significantly associated with HIV infection and use of cocaine, crack, and poppers as well as marginally associated with ecstasy use. Spirituality was significantly associated with HIV infection status, STD infection status, alcohol use, and crack use. Given these relationships, current and future HIV prevention models targeting Black MSM should consider the potential importance of the roles of religiosity and spirituality in the lives of Black MSM to increase the efficacy of risk reduction interventions.

Predictors of colorectal cancer surveillance among survivors of childhood cancer treated with radiation: a report from the Childhood Cancer Survivor Study.

BACKGROUND: Childhood cancer survivors treated with radiotherapy to a field including the colon or rectum have an elevated risk of developing radiation-induced colorectal cancer (CRC). The Children's Oncology Group recommends colonoscopy every 5 years beginning at age 35 years for at-risk survivors. METHODS: Analyses included 702 five-year survivors (Childhood Cancer Survivor Study) aged ≥36 years who received ≥30 gray of abdominal, pelvic, or spinal radiotherapy. Multivariate generalized linear models were used to calculate relative risks (RR) with 95% confidence intervals (95% CI) for adherence to the Children's Oncology Group's CRC surveillance recommendations. RESULTS: With a median age of 43 years (range, 36-58 years), 29.5% of the survivors (207 of 702 survivors) met surveillance recommendations. In multivariate analyses, age ≥50 years versus age 36 to 49 years (RR, 2.6; 95% CI, 2.0-3.4), reporting a routine cancer follow-up visit within 1 year before the study (RR, 1.5; 95% CI, 1.0-2.2), reporting ≥10 physician visits within the past year versus 0 to 9 visits (RR, 1.4; 95% CI, 1.1-1.7), and discussing future cancer risk with a physician at the time of the most recent follow-up visit (RR, 1.4; 95% CI, 1.1-1.7) were found to be associated with adherence to CRC surveillance recommendations. CONCLUSIONS: Greater than 70% of survivors at an increased risk of CRC were not screened as recommended. Regular physician contact and discussion of screening were associated with a 60% increase in CRC surveillance. Educational interventions targeted at survivors and their primary care physicians are needed to heighten knowledge of CRC risk after radiotherapy and the importance of appropriate surveillance.

Expanding Cervical Cancer Screening and Treatment in Tanzania: Stakeholders' Perceptions of Structural Influences on Scale-Up.

UNLABELLED: Tanzania has the highest burden of cervical cancer in East Africa. This study aims to identify perceived barriers and facilitators that influence scale-up of regional and population-level cervical cancer screening and treatment programs in Tanzania. Convenience sampling was used to select participants for this qualitative study among 35 key informants. Twenty-eight stakeholders from public-sector health facilities, academia, government, and nongovernmental organizations completed in-depth interviews, and a seven-member municipal health management team participated in a focus group discussion. The investigation identified themes related to the infrastructure of health services for cervical cancer prevention, service delivery, political will, and sociocultural influences on screening and treatment. Decentralizing service delivery, improving access to screening and treatment, increasing the number of trained health workers, and garnering political will were perceived as key facilitators for enhancing and initiating screening and treatment services. In conclusion, participants perceived that system-level structural factors should be addressed to expand regional and population-level service delivery of screening and treatment. IMPLICATIONS FOR PRACTICE: Tanzanian women have a high burden of cervical cancer. Understanding the perceived structural factors that may influence screening coverage for cervical cancer and availability of treatment may be beneficial for program scale-up. This study showed that multiple factors contribute to the challenge of cervical cancer screening and treatment in Tanzania. In addition, it highlighted systematic developments aimed at expanding services. This study is important because the themes that emerged from the results may help inform programs that plan to improve screening and treatment in Tanzania and potentially in other areas with high burdens of cervical cancer.

Older Adult Health in Alabama's Black Belt Region.

Health issues are a concern in Alabama's Black Belt region, which runs across the southwestern part of the state and includes some of the poorest counties in the USA. As part of a Center for Disease Control (CDC)-sponsored study, we collected data covering several cancer (e.g., prostate, breast, skin) and other health-related indicators (e.g., stress, insurance, stroke, heart disease) from 647 predominantly African-American adults over the age of 50 in 20 communities in 7 Black Belt counties in 2005 and 2006. Here, we provide an account of the state of the health of older African-Americans and compare their outcomes to those of their White counterparts in the region. African-Americans report having generally lower levels of health and were less apt to have a cancer history (ps<0.05) than the Whites in the region. Gender differences with respect to BMIs and smoking are also evident, with women having higher BMIs but lower levels of smoking. Physicians and researchers covering or interested in generally impoverished rural areas may find our results useful for comparative purposes.

Differences in Electronic Cigarette Awareness, Use History, and Advertisement Exposure Between Black and White Hospitalized Cigarette Smokers.

E-cigarette use has increased rapidly over the past decade. There is growing concern about e-cigarette use and advertising given limited regulation of these products. This cross-sectional study reports on data collected at baseline from hospitalized cigarette smokers (N=944) recruited in monthly cohorts between December 2012 and September 2013. Participants were queried regarding e-cigarette awareness and use, and number and sources of e-cigarette advertisement exposures in the previous 6 months. Most Whites (99%) reported ever hearing of an e-cigarette compared to 96% of Blacks (p<0.001). Over two thirds (64%) of Whites reported ever using an e-cigarette compared to 30% of Blacks (p<0.001). There were significant trends in increasing e-cigarette use for both racial groups with an average increase of 13% each month (p<0.005) and in increasing e-cigarette advertisement exposure reported for the previous 6 months, with a 14% increase each month (p<0.0001). Whites reported 56% greater advertisement exposure than Blacks (mean=25 vs. 8 in month 1 to 79 vs. 45 in month 9, respectively; p<0.0001). For Blacks, advertisement exposure was significantly associated with e-cigarette use (p<0.001). Whites reported more advertisement exposure from stores and the Internet, and Blacks reported more advertisement exposure from radio or television. Results suggest that e-cigarette marketing is beginning to breach the Black population who are, as a consequence, "catching up" with Whites with regard to e-cigarette use. Given the significant disparities for smoking-related morbidity and mortality between Blacks and Whites, these findings identify new areas for future research and policy.

Electronic cigarette awareness, use history, and expected future use among hospitalized cigarette smokers.

INTRODUCTION: E-cigarette use has surged during the past few years while the debate about the product's safety and efficacy for smoking cessation continues. Little is known about the characteristics that distinguish users from nonusers; in this study, we aimed to elucidate these characteristics among hospitalized smokers, a heretofore unstudied population. METHODS: Cross-sectional data were collected from cigarette smokers via hospital bedside interviews. Participants reported e-cigarette use status, reasons for use (if used), e-cigarette advertising exposure, expected likelihood of future e-cigarette use, desire to quit smoking, and demographic characteristics. RESULTS: Of the 657 English-speaking hospitalized smokers who provided data, 97% reported awareness of e-cigarettes and 46.4% reported e-cigarette use, with 20% reporting use in the previous 30 days. Previous e-cigarette use was significantly more likely among those who were White (odds ratio [OR] = 4.7; confidence interval [CI] = 3.2-6.7), were married/had a domestic partner (OR = 1.5; CI = 1.0-2.2), had more than a high school education (OR = 1.7; CI = 1.1-2.7), had e-cigarette advertising exposure (OR = 1.6; CI = 1.1-2.4), and were younger (OR = 1.3; CI = 1.1-1.5). Expected likelihood of future e-cigarette use was high and positively correlated with desire to quit smoking (Spearman's ρ = .18, p < .0001). CONCLUSIONS: Rates of awareness and use of e-cigarettes may be elevated among hospitalized smokers, with more use reported among those who were White, younger, more educated, in a relationship, and exposed to e-cigarette advertising. The association between desire to quit smoking and expected likelihood of future e-cigarette use suggests that cigarette smokers may perceive e-cigarettes as a useful cessation aid.

African American organ donor registration: a mixed methods design using the theory of planned behavior.

CONTEXT: A large racial disparity exists in organ donation. OBJECTIVE: To identify factors associated with becoming a registered organ donor among African Americans in Alabama. METHODS: Concurrent mixed methods design guided by the Theory of Planned Behavior to analyze African Americans' decisions to become a registered organ donor by using both qualitative (focus groups) and quantitative (survey) methods. RESULTS: The sample consisted of 22 registered organ donors and 65 non registered participants from 6 focus groups completed in urban (n = 3) and rural (n = 3) areas. Participants emphasized the importance of the autonomy to make one's own organ donation decision and have this decision honored posthumously. One novel barrier to becoming a registered organ donor was the perception that organs from African Americans were often unusable because of the high prevalence of chronic medical conditions such as diabetes and hypertension. Another novel theme discussed as an advantage to becoming a donor was the subsequent motivation to take responsibility for one's health. Family and friends were the most common groups of persons identified as approving and disapproving of the decision to become a donor. The most common facilitator to becoming a donor was information, whereas fear and the lack of information were the most common barriers. In contrast, religious beliefs, mistrust, and social justice themes were infrequently referenced as barriers to becoming a donor. CONCLUSION: Findings from this study may be useful for prioritizing organ donation community-based educational interventions in campaigns to increase donor registration.

Do trained specialists solicit familial authorization at equal frequency, regardless of deceased donor characteristics?

CONTEXT: The Organ Donor Breakthrough Collaborative recommended high-leverage changes including "master effective requesting. OBJECTIVE: To measure who approaches decedent families to request organ donation and to determine whether trained specialists will solicit authorization at equal frequency regardless of donor characteristics. METHODS: Retrospective analysis of data from 2006 to 2009 in an organ center's donor database. Decedents were stratified into 2 groups: those that met the Organ Procurement and Transplantation Network's eligible death criteria (ED donors) and those that did not (not eligible death [NED] donors). RESULTS: Of decedents whose families were approached for authorization, 46% were ED donors and 54% were NED donors. Trained specialists solicited authorization from 76% of the total population but were more likely to solicit authorization from ED donors than NED donors (86% vs 68%, P<.001). Trained specialists were more likely to solicit authorization from donors whose cause of death was overrepresented in ED donors and donors less than 50 years old. Trained specialists were more likely than others to obtain authorization from families of all donors. Multivariable modeling demonstrated that having a trained specialist approach the decedent's family was associated with the highest odds of obtaining authorization. CONCLUSIONS: Trained specialists approached most families of decedents for authorization, but disproportionately approached fewer families of NED donors. Having a trained specialist approach the decedent family has the strongest impact on obtaining donor authorization. These data suggest that fewer resources are allocated to NED donors, which may adversely affect the supply of deceased donor organs.

Exploring pre-school vision screening in primary care offices in Alabama.

PURPOSE: To investigate practices, barriers, and facilitators of universal pre-school vision screening (PVS) at pediatric primary care offices. METHODS: Focus group sessions (FGS) were moderated on-site at nine pediatric practices. A semi-structured topic guide was used to standardize and facilitate FGS. Discussions were audiotaped, and transcriptions were used to develop themes. All authors reviewed and agreed on the resultant themes. RESULTS: FGS included 13 physicians and 32 nurses/certified medical assistants (CMAs), of whom 82% personally conducted some facet of PVS. In all practices, nurses/CMAs tested visual acuity (most using a non-recommended test), and physicians completed vision screening with external observation, fix/follow, red reflex, and cover test. Facilitators included (1) accepting that PVS is a routine part of the well-child visit, and (2) using an electronic medical record with prompts to record acuity (eight of nine practices). Barriers were related to difficulty testing pre-schoolers, distractions in the office setting, time constraints, and limited reimbursement. CONCLUSIONS: Responsibility for PVS is shared by physicians and nurses/CMAs; thus, interventions to improve PVS should target both. Few practices are aware of new evidence-based PVS tests; thus, active translational efforts are needed to change current primary care practices.

Engaging a community in developing an entertainment-education Spanish-language radio novella aimed at reducing chronic disease risk factors, Alabama, 2010-2011.

BACKGROUND: US Hispanics have disproportionate rates of diabetes and other chronic diseases. We used the entertainment-education approach to develop a Spanish-language radio novella aimed at reducing risk factors for diabetes, obesity, and tobacco use. The approach is based on social cognitive theory and proposes modeling as a source of vicarious learning of outcome and efficacy expectations. COMMUNITY CONTEXT: The Hispanic population in Alabama increased by 145% between 2000 and 2010. Nearly one-quarter of Hispanics aged 18 to 64 live below the federal poverty level, and 49% are uninsured. Several lifestyle factors lead to poor health behaviors in this community. Radio is a popular medium among Hispanic immigrants. The single local Spanish-language radio station reaches a large proportion of the local community and several communities beyond. METHODS: Through various methods, including workshops, review sessions, and other feedback mechanisms, we engaged stakeholders and community members in developing and evaluating a 48-episode radio novella to be broadcast as part of a variety show. We tracked participation of community members in all phases. OUTCOME: Community members participated significantly in developing, broadcasting, and evaluating the intervention. The desired outcome - development of a culturally relevant storyline that addresses salient health issues and resonates with the community - was realized. INTERPRETATION: Our approach to community engagement can serve as a model for other organizations wishing to use community-based participatory methods in addressing Hispanic health issues. The radio novella was a unique approach for addressing health disparities among our community's Hispanic population.

Explaining and improving breast cancer information acquisition among African American women in the Deep South.

OBJECTIVES: A major challenge facing contemporary cancer educators is how to optimize the dissemination of breast cancer prevention and control information to African American women in the Deep South who are believed to be cancer free. The purpose of this research was to provide insight into the breast cancer information-acquisition experiences of African American women in Alabama and Mississippi and to make recommendations on ways to better reach members of this high-risk, underserved population. METHODS: Focus group methodology was used in a repeated, cross-sectional research design with 64 African American women, 35 years old or older who lived in one of four urban or rural counties in Alabama and Mississippi. RESULTS: Axial-coded themes emerged around sources of cancer information, patterns of information acquisition, characteristics of preferred sources, and characteristics of least-preferred sources. CONCLUSIONS: It is important to invest in lay health educators to optimize the dissemination of breast cancer information to African American women who are believed to be cancer free in the Deep South.

Impact of content-specific email reminders on provider participation in an online intervention: a dental PBRN study.

Engaging busy healthcare providers in online continuing education interventions is challenging. In an Internet-delivered intervention for dental providers, we tested a series of email-delivered reminders - cues to action. The intervention included case-based education and downloadable practice tools designed to encourage providers to increase delivery of smoking cessation advice to patients. We compared the impact of email reminders focused on 1) general project announcements, 2) intervention related content (smoking cessation), and 3) unrelated content (oral cancer prevention focused content). We found that email reminders dramatically increased participation. The content of the message had little impact on the participation, but day of the week was important - messages sent at the end of the week had less impact, likely due to absence from clinic on the weekend. Email contact, such as day of week an email is sent and notice of new content post-ing, is critical to longitudinal engagement. Further research is needed to understand which messages and how frequently, will maximize participation.

Community-Engaged Use of Cultural Narratives to Create HIV Prevention Stories for African American Women.

BACKGROUND: Culture-specific interventions based on storytelling can address the social and cultural context of HIV that is unique to Southern African American women. METHODS: We describe a community-engaged process to construct scripted stories to promote HIV prevention based on cultural narratives from African American women living with HIV. Our process involved (1) the collection of cultural narratives, (2) establishment of a community advisory board (CAB), (3) identification of important intervention themes, (4) narrative analysis to identify stories, and (5) script writing/peer review to produce composite narrative HIV prevention messages. LESSONS LEARNED: Engaging community members is a strength; however, outreach should be strategic to individuals interested in a script writing creative process. This process is an adaptation of widely accepted methods to produce stories that incorporate culture organically in ways that allow for greater identification and engagement by the target audience. CONCLUSIONS: Authentic stories harvested and produced from and for a culture-specific population is a critical consideration for narrative health promotion.

Fourth graders' reports of fruit and vegetable intake at school lunch: does treatment assignment affect accuracy?

OBJECTIVE: Dietary interventions with children often use self-reported data to assess efficacy despite that objective methods rarely support self-report findings in validation studies. This study compared fourth graders' self-reported to observed lunch fruit and vegetable intake to determine if the accuracy of self-reported intake varied by treatment condition. DESIGN: Matched randomized follow-up design examined three treatment groups (high and low intensity interventions and control) post-intervention. SUBJECTS/SETTING: Three hundred seventy-nine middle-school children participating in a randomized controlled trial of a school-based fruit and vegetable intervention were observed during school lunch one day and asked to recall intake the following day. MAIN OUTCOME MEASURES: Food items were coded as: "match," "omission," or "intrusion." Students were classified as accurate if all food items matched, otherwise inaccurate. Matched foods' portions were compared for accuracy. Servings were computed for total fruit and vegetable intake. ANALYSES: Accuracy for fruits and vegetables were compared in separate analyses and tested for multiple potential associates: treatment condition, sex, race, body mass index, subsidized meal eligibility, school district, fruit/vegetable availability, age, and test scores. Fitted multivariable regression models included variables found to be significant in univariate or chi(2) analyses. RESULTS: Variables found to be significant for fruit item accuracy were availability at lunch, body mass index, and subsidized lunch eligibility. For vegetable item accuracy, availability at lunch was significant. No differences were found for food portions or for efficacy of the intervention between the two methods of dietary data collection: observation and self-report. CONCLUSIONS: Condition assignment did not bias recalled fruit and vegetable intakes among fourth graders.

Development and Validation of Instruments to Assess Potential Religion-Health Mechanisms in an African American Population.

The health disparities that negatively affect African Americans are well-documented; however, there are also many sociocultural factors that may play a protective role in health outcomes. Religious involvement is noted to be important in the African American community and to have a positive association with health outcomes. However, few studies have explained why this relationship exists. This article reports on the development and validation of instruments to assess two proposed mediators of the relationship between religiosity and health for an African American population; perceived religious influence on health behaviors and illness as punishment from a higher power. We used a systematic iterative process, including interviews and questionnaire data from African Americans who provided feedback on item wording. We also solicited input from African American pastors. In a sample of 55 African Americans, the instruments appeared to have strong internal reliability (alpha = .74 and .91, respectively) as well as test-retest reliability (r = .65, .84, respectively, p < .001). Evidence far construct validity is also discussed, as are recommendations for health disparities research using these instruments.

Internet delivered support for tobacco control in dental practice: randomized controlled trial.

BACKGROUND: The dental visit is a unique opportunity for tobacco control. Despite evidence of effectiveness in dental settings, brief provider-delivered cessation advice is underutilized. OBJECTIVE: To evaluate an Internet-delivered intervention designed to increase implementation of brief provider advice for tobacco cessation in dental practice settings. METHODS: Dental practices (N = 190) were randomized to the intervention website or wait-list control. Pre-intervention and after 8 months of follow-up, each practice distributed exit cards (brief patient surveys assessing provider performance, completed immediately after the dental visit) to 100 patients. Based on these exit cards, we assessed: whether patients were asked about tobacco use (ASK) and, among tobacco users, whether they were advised to quit tobacco (ADVISE). All intervention practices with follow-up exit card data were analyzed as randomized regardless of whether they participated in the Internet-delivered intervention. RESULTS: Of the 190 practices randomized, 143 (75%) dental practices provided follow-up data. Intervention practices' mean performance improved post-intervention by 4% on ASK (29% baseline, adjusted odds ratio = 1.29 [95% CI 1.17-1.42]), and by 11% on ADVISE (44% baseline, OR = 1.55 [95% CI 1.28-1.87]). Control practices improved by 3% on ASK (Adj. OR 1.18 [95% CI 1.07-1.29]) and did not significantly improve in ADVISE. A significant group-by-time interaction effect indicated that intervention practices improved more over the study period than control practices for ADVISE (P = 0.042) but not for ASK. CONCLUSION: This low-intensity, easily disseminated intervention was successful in improving provider performance on advice to quit. TRIAL REGISTRATION: clinicaltrials.gov NCT00627185, http://www.webcitation.org/5c5Kugvzj.