RESUMEN
BACKGROUND: From 2000 to 2006, moist snuff sales have increased and now account for 71% of the smokeless tobacco market. Previous research has shown that major manufacturers of smokeless tobacco products manipulated free nicotine, the form most readily absorbed, to promote tolerance and addiction. AIM: This study examines the possibility that company-specific and brand-specific strategies of the major moist snuff manufacturers involve controlling free nicotine content and ease of dosing with products that are designed and targeted to specific groups. This study looks at the current total US moist snuff market with product design data from the Massachusetts Department of Public Health; moist snuff use from the National Survey on Drug Use and Health; market data from ACNielsen; and magazine advertising expenditures from TNS Media Intelligence. RESULTS: (1) The levels of free nicotine of moist snuff products have increased over time for several major manufacturers; (2) the number and variety of sub-brands have increased over time; (3) changes in design, as reflected by variation in free nicotine associated with pH or tobacco leaf, or both, have enhanced the ease and uniformity of dosing; (4) marketing through price and advertising has increased; and (5) youth use has increased. CONCLUSION: A combination of factors including brand proliferation, control of free nicotine and product design has most likely resulted in the expanded consumption of moist snuff, particularly among young people.
Asunto(s)
Mercadotecnía , Nicotina/análisis , Tabaco sin Humo/química , Adolescente , Adulto , Publicidad/economía , Distribución por Edad , Niño , Femenino , Humanos , Concentración de Iones de Hidrógeno , Masculino , Distribución por Sexo , Tabaquismo/epidemiología , Tabaco sin Humo/economía , Estados Unidos/epidemiología , Adulto JovenRESUMEN
OBJECTIVES: This study examines empirical evidence from the New York experience testing tobacco industry arguments made in opposition to fire safety standards for cigarettes. DESIGN: Percentages of cigarettes exhibiting full length burns (FLBs), cigarette sales before and following the implementation of the New York standards, a sample of retail cigarette prices, brand availability, and selected smoke constituent yields were compared between cigarettes sold in New York and two other states. Cigarette paper analysis was conducted on cigarettes sold in New York. RESULTS: New York cigarette brands averaged 10.0% FLBs as compared to 99.8% for California and Massachusetts brands. Reduced ignition propensity (RIP) appears to have been achieved by cigarette paper banding. Cigarette sales, prices, and brand availability do not appear to have been affected by the New York standards. Yields of the majority of smoke constituents tested did not differ substantially between RIP cigarettes sold in New York as compared to the same brands sold in Massachusetts. Average yields of tar, carbon monoxide, and two compounds were slightly higher, the yields of seven compounds were higher for one brand only, and nicotine was lower, among New York brands tested. CONCLUSIONS: RIP cigarette brands have been designed to meet the New York fire safety standards. Their introduction has not affected cigarette sales or prices in New York. There is no evidence that the small increases in smoke constituent yields affect the already highly toxic nature of cigarette smoke. Data on smoking caused fires, deaths, and injuries dating from after the change in law are not yet available. Such data will be able to address the question of whether the demonstrated reduced ignition standards are associated with reduced fires and injuries. Based on the New York experience, prior industry objections to producing RIP cigarettes are unfounded. Other states and nations should adopt similar standards.
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Seguridad de Productos para el Consumidor/legislación & jurisprudencia , Incendios/prevención & control , Humo/análisis , Fumar/legislación & jurisprudencia , Comercio/estadística & datos numéricos , Comportamiento del Consumidor/estadística & datos numéricos , Costos y Análisis de Costo , Incendios/legislación & jurisprudencia , Humanos , Ensayo de Materiales/métodos , New York , Administración de la Seguridad/legislación & jurisprudencia , Fumar/economía , Industria del Tabaco/legislación & jurisprudenciaRESUMEN
BACKGROUND: Some have suggested that advance directives elicit goals of care from patients, instead of or in addition to specific intervention preferences, but little is known about whether goals of care can be used in a meaningful way on documents or whether they can predict preferences for specific interventions. METHODS: Attending physicians (n = 716) at the Massachusetts General Hospital in Boston were surveyed to elicit general goals of care (eg, treat everything or comfort measures only) along with specific preferences for 11 medical, interventions in 6 scenarios. In each scenario, each goal was classified as an adequate predictor of acceptance or rejection of an intervention if its predictive value of the preference for that intervention was at least 80%. RESULTS: Goals varied with scenarios (P < .001) in a predictable manner. The goal treat everything was an adequate predictor of acceptance of each intervention, and comfort was an adequate predictor of rejection for nearly every intervention. Attempt cure adequately predicted acceptance of almost every nonaggressive intervention, but did not predict acceptance of aggressive interventions. Quality of life predicted rejection of aggressive interventions in 3 scenarios, but was not useful in other cases. When goals were predictors of preferences, the mean range of 95% confidence intervals for their predictive values was generally 20% or less. CONCLUSIONS: Goals have a valid role in advance directives, since the goal choices had a logical relationship to scenarios and intervention choices. However, the 2 goals attempt cure and choose quality of life were not predictive in many instances. If these findings hold true for more general populations of patients, then advance directive documents will need to rely on more than these general goal statements if they are to adequately represent patient preferences.
Asunto(s)
Directivas Anticipadas , Atención Dirigida al Paciente , Médicos , Registros , Enfermedad Aguda , Adulto , Enfermedad Crónica , Coma , Demencia , Femenino , Humanos , Masculino , Enfermos Mentales , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Calidad de Vida , Encuestas y Cuestionarios , Privación de TratamientoRESUMEN
BACKGROUND: Asthma continues to be a substantial cause of morbidity in pediatric populations. New strategies are needed to provide cost-effective educational interventions for children with asthma, particularly those in the inner city. OBJECTIVE: To assess the effectiveness of a multimedia educational software program about asthma. SETTING: A hospital-based primary care clinic and an affiliated neighborhood health center. DESIGN: Randomized, controlled trial. POPULATION: Children 3 to 12 years old with physician-diagnosed asthma. INTERVENTION: An interactive educational computer program, Asthma Control, designed to teach children about asthma and its management. Using a graphic display of a child going through simulated daily events, the game emphasizes: 1) monitoring; 2) allergen identification; 3) use of medications; 4) use of health services; and 5) maintenance of normal activity. Control group participants reviewed printed educational materials with a research assistant. OUTCOMES: Acute health care use (emergency department and outpatient) was the primary outcome. Secondary outcome measures included maternal report of asthma symptom severity, child functional status and school absences, satisfaction with care, and parental and child knowledge of asthma. RESULTS: A total of 137 families were enrolled in the study (76 intervention, 61 control). Both intervention and control groups showed substantial improvement in all outcomes during the 12-month follow-up period. Aside from improvement in knowledge after use of the computer program, no differences were demonstrated between the 2 groups in primary or secondary outcome measures. Children reported enjoyment of program use. CONCLUSIONS: This trial of an educational software program found that it did not produce greater improvement than occurred with review of traditional written materials. Because both groups showed substantial improvement over baseline, computer-based education may be more cost-effective. Alternatively, improvements in illness severity over time may overshadow the effects of such interventions. Rigorous comprehensive evaluations such as this are necessary to assess new interventions intended to improve management and outcomes of asthma.
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Asma/terapia , Educación del Paciente como Asunto , Programas Informáticos , Niño , Preescolar , Instrucción por Computador , Femenino , Humanos , Masculino , Salud UrbanaRESUMEN
BACKGROUND: While many previous studies describe workplace-associated injuries in adolescents, few focus on toxic exposures. Such incidents are unlikely to be reported to either federal or state agencies. However, poison control centers often get called about these poisonings and might serve as a resource for monitoring their occurrence. OBJECTIVE: To describe the frequency and severity of job-related toxic exposures involving adolescents, the specific toxic agents involved, and trends over time. METHODS: Occupational toxic exposures occurring in the United States between 1993 and 1997 were analyzed using the Toxic Exposure Surveillance System database compiled by the American Association of Poison Control Centers. Contingency tables with the chi(2) statistic were used to test bivariate associations. Logistic regression was performed to investigate trends over time. RESULTS: Of 301 228 workplace toxic exposures reported over 5 years, 8779 (3%) involved adolescents younger than 18 years. The most common agents involved were alkaline corrosives (13.2%), gases and fumes (12.0%), cleaning agents (9.7%), bleaches (8.3%), drugs (7.4%), acids (7.2%), and hydrocarbons (6.9%). The injuries were rated as severe in 14.2% of exposures, life-threatening in 0.3%, and there were 2 deaths. The proportionate frequency of occupational exposures occurring among adolescents vs adults increased over time (odds ratio, 1.003; P<.001). CONCLUSIONS: Adolescent occupational toxic exposures are an underrecognized hazard in the United States. Poison control center experience can be used to fill a gap in the surveillance of such injuries.
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Exposición Profesional , Intoxicación/epidemiología , Adolescente , Distribución de Chi-Cuadrado , Femenino , Humanos , Modelos Logísticos , Masculino , Centros de Control de Intoxicaciones , Vigilancia de la Población , Índice de Severidad de la Enfermedad , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: To determine whether women who frequently bring their neonates for problem-oriented primary care visits or emergency department visits are at elevated risk of having depressive symptoms. DESIGN: Analysis of 2 prospective cohort studies of mothers and their infants: (1) a telephone interview study of mothers and infants after birth at an urban teaching hospital (the hospital cohort) and (2) the 1988 National Maternal and Infant Health Survey, a nationally representative sample of women who had live births in 1988. PARTICIPANTS: A total of 1015 women in the hospital cohort surveyed at 3 and 8 weeks post partum and 6779 women with data from the national survey. MAIN OUTCOME MEASURE: Depressive symptoms above the Center for Epidemiologic Studies Depression Scale cutoff score of 15. RESULTS: After controlling for sociodemographic variables and parity, women exhibited high levels of depressive symptoms if their infants had more than 1 problem-oriented primary care visit (hospital cohort: odds ratio, 2.0 [95% confidence interval, 1.1-4.3]; national survey cohort: odds ratio, 2.0 [95% confidence interval, 1.5-3.0]). Women were more likely to have high levels of depressive symptoms if their infants had even 1 emergency department visit (hospital cohort: odds ratio, 3.2 [95% confidence interval, 1.5-6.9]). Frequent well-child visits were not associated with maternal depressive symptoms. CONCLUSIONS: Neonatal health care use patterns predict women at risk for postpartum depression. Recognition of these signature patterns of service use by pediatric health care providers may facilitate early diagnosis and treatment of postpartum depression and improve outcomes for women and their families.
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Servicios de Salud del Niño/estadística & datos numéricos , Depresión Posparto/epidemiología , Madres/psicología , Adolescente , Adulto , Boston/epidemiología , Depresión Posparto/prevención & control , Depresión Posparto/psicología , Femenino , Humanos , Lactante , Recién Nacido , Modelos Logísticos , Oportunidad Relativa , Valor Predictivo de las Pruebas , Estudios ProspectivosRESUMEN
OBJECTIVES: To develop a measure of parental perceptions of pediatric inpatient quality of care, to identify processes of care that influence these perceptions, and to describe these perceptions of care. DESIGN: An interdisciplinary team modified an existing measure of inpatient care for adults using focus groups and expert review. The resulting survey was administered by telephone. SETTING: Tertiary care pediatric hospital. PATIENTS: Trained telephone interviewers obtained reports from parents of children discharged from the hospital during specified months. This report is based on the answers to 122 questions provided by 3622 (77%) of 4724 parents who responded when surveyed from 1991 through 1995. MAIN OUTCOME MEASURES: Parents provided reports about specific clinical experiences, overall ratings of care, and patient demographic and illness characteristics 2 weeks after patient discharge from the hospital. The analysis classified reports about pediatric care as either problems or not problems. Problems in different areas of care were averaged to create scores for the dimensions. RESULTS: Parents most often noted problems related to hospital discharge planning (18%) and pain management (18%) and less often reported problems concerning communication about surgery (10%) or transmission of information to children (6%). Problems in communication between clinicians and parents correlated most strongly with overall quality ratings by parents (r=0.59). Parents' specific reports of problems with care accounted for 42% of the variation in their overall assessments of the inpatient care experience. CONCLUSIONS: Parental assessment of inpatient pediatric care rests heavily on the quality of communication between the clinician and parent. Specific processes of care strongly influence overall assessments. Such reports could be used to focus the quality-improvement activities of hospitals and increase the accountability of providers of care to children and families.
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Actitud Frente a la Salud , Hospitales Pediátricos/normas , Padres/psicología , Calidad de la Atención de Salud/estadística & datos numéricos , Adolescente , Adulto , Niño , Enfermedad Crónica , Comunicación , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Cuidados Paliativos , Alta del Paciente , Estados UnidosRESUMEN
End-of-life care has benefited from the recognition that multiple dimensions exist to patient care needs. However, well-designed clinical tools to evaluate these multiple dimensions are few. Such tools are available for evaluations of pain and other specific areas, but clinicians need a sensitive and reliable set of bedside questions to assess and screen individual patients' overall care. We set out to develop a practical tool that we called the Needs at the End-of-Life Screening Tool (NEST). As part of a larger study, we conducted a series of focus groups and interviews with patients, family caregivers, and professionals followed by a survey of a nationally representative sample of 988 patients with a terminal diagnosis. From the former we derived a frame-work with a full range of identified dimensions that are important in end-of-life care. Dimensions were empirically tested using factor analysis of the patients' survey responses. We developed criteria for selecting questions within the dimensions. Modifications were made to the questions to suit the clinical context. Finally, to assist in their ready use at the bedside, we assigned questions to four core themes of palliative care. Thirteen questions resulted and were assigned themes corresponding, for mnemonic purposes, to each letter of NEST: for Needs (social), for Existential matters, for Symptoms and for Therapeutic matters. NEST is the first data-driven, comprehensive tool designed from an empirically validated framework and tested survey questions for clinical use in end-of-life care. Evaluation of its performance in another population is needed to complete NEST's fuller evaluation.
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Actitud Frente a la Muerte , Evaluación de Necesidades , Planificación de Atención al Paciente , Encuestas y Cuestionarios , Cuidado Terminal/normas , Cuidadores , Grupos Focales , Encuestas de Atención de la Salud , Humanos , Entrevistas como Asunto , Cuidados Paliativos , Pacientes , Estados UnidosRESUMEN
BACKGROUND: Citizens have conveyed to professionals that care at the end of life is less than optimal. Efforts to improve matters have tended to work in piecemeal fashion, on tangible more than personal aspects of care, and without the benefit of documented perspectives of those who face dying. Policy initiatives and clinical interventions need guidance from a broad framework that is validated by patients' perspectives. PURPOSE: Our goals were to: (1) assess the construct validity and stability over time of the portions of a conceptual framework that concern patients' subjective experiences; (2) develop a foundation for measurement of these personally meaningful factors; and (3) examine these factors' associations for potential clinical or policy significance. POPULATION: Patients were from six diverse geographical areas whose physicians judged their survival prognosis to be 6 months or less. Physicians who referred the patients were randomly selected from state and specialty association lists. METHODS: We used in-person survey methodology and multivariate analysis of patient responses. The analysis fell into two parts. Using exploratory factor analysis, we looked for evidence of discrete dimensions of experiences. Using regression analysis, we examined associations among them. RESULTS: Of 1,131 eligible patients, 988 were interviewed (87.4% response rate). Of 682 patients who survived to follow-up interview 4-6 months later, 650 were interviewed (95.3% response rate). Exploratory factor analysis identified 12 discrete factors (accounting for 55% of variance; maximum Spearman's p = 0.24), 8 of which met criteria for representing measurable dimensions (accounting for 46% of variance). These 8 were: patient-clinician relationship; social connectedness; caregiving needs; psychological distress; spirituality/religiousness; personal acceptance; sense of purpose; and clinician communication. Eigenvalues ranged from 1.45 to 6.30 and Cronbach's alpha from 0.63 to 0.85. The concordance between these dimensions and those in the proposed framework indicated that two dimensions required minor modifications and six were confirmed, providing evidence of good construct validity for this portion of the framework. The same dimensions were also evident at follow-up except that the first two above-listed loaded on one combined factor, clinician interaction (eigenvalues 1.83-7.92; Cronbach's alpha from 0.64 to 0.86). This provides evidence of the construct's stability over time. Clinical communication and patient-clinician relationship were associated (odds ratio [OR] 2.79, 2.31-3.36). Better clinician communication correlated with somewhat better personal acceptance (OR 1.10,1.02-1.19), and a better patient-clinician relationship correlated with less psychological distress (OR 0.84, 0.75-0.95). CONCLUSIONS: We conclude that: (1) Personally meaningful aspects of patients' experience of terminal illness can be represented in valid, multidimensional constructs that are stable over time; (2) They are measurable; and (3) Aspects of the therapeutic relationship appear to correlate with patients' experience of the dying process.
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Dieta , Judaísmo , Cese del Hábito de Fumar , Seguridad de Productos para el Consumidor , Humanos , Israel , Salud PúblicaRESUMEN
OBJECTIVE: The movement for advance planning of end-of-life care was motivated in part by the assumption that medical intervention for terminally ill patients varies from what these patients would prefer. We examined the validity of this assumption by comparing actual life-sustaining treatment practices for patients in critical illness scenarios and surveyed patients' advance care preferences. MEASUREMENTS AND MAIN RESULTS: We selected at random and reviewed 7,400 inpatient medical records from a single urban teaching hospital during the period just prior to the Patient Self-Determination Act. Records of 198 patients with conditions that matched advance directive scenarios were examined, and practices to withhold or withdraw seven life-sustaining treatments were documented. Practices were compared with surveyed preferences of 102 members of the general public and 495 outpatients who were followed by the same physicians as the 198 patients. Concordance of practices and preferences for the 19 surveyed outpatients who eventually fell into one of the scenarios was also evaluated. One hundred sixty-seven inpatient cases met review criteria for the scenario coma with a small chance of recovery. Hospital patients received medical interventions that were not consistently greater or less than the preferences of the surveyed outpatients or members of the general public. Resuscitation, the most frequently withheld treatment (94% of cases), was withheld more often than surveyed preferences to decline it (56% of outpatients, p < .001). Four treatments--mechanical breathing, artificial nutrition, major surgery, and hemodialysis--were utilized comparably to surveyed outpatients' preferences (range p = .704-.055). Antibiotics and artificial hydration were withheld (9% and 6%, respectively) less often than surveyed outpatient's prior preferences to decline them (48% and 52%, respectively, p < .001 for each). Conversely, treatments given to the 19 surveyed patients who subsequently developed one of the illness scenarios were often incongruent with the patients' prior preferences. Again, in some cases more interventions were provided (26 of 63 declined treatments were given), and in some cases less (10 of 21 desired treatments were withheld). CONCLUSIONS: This study does not support the assumption that, collectively, patients' advance care preferences are less interventionist than actual practices for patients in corresponding scenarios. Nevertheless, these results do support the assumption that life-sustaining treatment decisions do not conform well to individual patients' specific preferences. Progress in end-of-life care should focus on shared decision making at the patient-proxy-physician level rather than on overall life-sustaining treatments utilization.
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Directivas Anticipadas , Cuidados para Prolongación de la Vida/estadística & datos numéricos , Opinión Pública , Anciano , Coma/terapia , Femenino , Humanos , Modelos Logísticos , Masculino , Registros Médicos , Satisfacción del Paciente , Estudios Prospectivos , Distribución AleatoriaRESUMEN
OBJECTIVES: Reliability and validity are as necessary for predrafted advance directive forms as they are for all clinical assessment instruments. Performance of predrafted advance directive forms with both lay persons and clinicians is relevant. Evidence relating to test- retest reliability, content validity, and criterion-related validity of one form, the Medical Directive, has been documented for outpatients. The authors investigated construct validity and external validity among outpatients, physicians, and the general public. METHODS: Four hundred ninety-five outpatients, 513 physicians, and 102 members of the general public were surveyed with the Medical Directive. Preference for 11 specific treatments in four to six illness scenarios were recorded. Mokken modeling of responses was used to produce a psychometric scale of receptiveness-to-treatment and desirability of treatments. The Kuder Richardson-20 statistic, Friedman's procedure for analysis of variance, and the Kruskall-Wallis test were used, respectively, to measure inter-item reliability, the relation with scenarios, and the relation between physicians' general goals for care and their scaled preferences. RESULTS: All model diagnostic tests indicated a close-fitting scale for all three respondent groups. Kuder Richardson-20 for outpatients (.98), physicians (.97), and the public (.93) demonstrated high inter-item reliability. Treatment desirabilities were related to invasiveness. Receptiveness-to-treatment was related to prognoses and disabilities of described illness scenarios among each group and to physicians' goals for care. CONCLUSIONS: The Medical Directive has construct validity in relations among specific treatment preferences and between treatment preferences, illness scenarios, and goals for care. External validity is supported by study of separate outpatient, physician, and general public populations. The treatment items constitute a highly reliable scale that can be used in further empirical research regarding life-sustaining treatment.