Accuracy of self-reported tobacco use status among hematopoietic SCT patients.

Tobacco use is a risk factor for adverse outcomes among hematopoietic SCT (HSCT) patients. Accurate identification of tobacco use offers a vital opportunity to treat this risk factor. The current study compared self-reported tobacco use status with serum cotinine levels among HSCT patients at the time of pre-transplant evaluation. A total of 444 participants completed both assessments; 44 participants (9.9%) were classified as tobacco users with serum cotinine concentrations >2 ng/mL vs 29 with self-reporting. Sensitivity and specificity of self-reporting were 65.9% and 100%, respectively. Positive and negative predictive values were 100% and 96.4%, respectively. Comparing tobacco use documented in the medical record with cotinine, sensitivity and specificity were 51.2% and 99.2%, respectively. Factors associated with tobacco use were male gender, single relationship status, less education and younger age. In summary, utilization of serum cotinine assays increased detection of tobacco use cases >50% over self-reporting. Results are discussed in the context of translation to care, including clinical and ethical implications, and current tobacco use treatment guidelines. When cotinine assays are not available, self-reporting of any tobacco use in the year before HSCT should trigger brief advice and cessation or relapse prevention counseling.

Lessons learned on the road to a smoke-free Italy.

In the face of strong and protracted opposition by the Tobacco Industry (TI) and its allies, Italy's national smoke-free legislation came into force in 2005 prohibiting smoking in all indoor public places and workplaces including offices, bars, and restaurants. Using internal TI documents made public through US litigation, we reveal the industry's nearly 40-year effort to influence health policy related to secondhand smoke, including attempts to block Italy's national smoke-free legislation. Strategies included manipulating hospitality groups and establishing front organizations, manipulating journalists and media, and manipulating the science and direct lobbying against smoking restrictions. The TI's extensive plan to thwart smoke-free efforts in Italy can be used to inform other countries about the industry's tactics and Italy's experience in overcoming them by ultimately implementing a comprehensive workplace smoke-free law.

The impact of smoking on outcomes among patients undergoing hematopoietic SCT for the treatment of acute leukemia.

A paucity of research exists examining the potential impact of tobacco use on cancer treatment outcomes, especially among patients treated with hematopoietic SCT (HSCT). A retrospective cohort study design was used to examine the impact of smoking on duration of hospitalization and overall survival among 148 consecutive patients undergoing HSCT for treatment of acute leukemia from 1999 to 2005. Of the 148 patients, 15% reported current smoking, 30% former smoking, and 55% never used tobacco. Patients were followed for a median 3.5 years (interquartile range=2.1-5.5). Compared to no history of smoking, current smoking was associated with worse pre-HSCT pulmonary function tests (P<0.02 in each case), more days hospitalization (46.2 days versus 25.7 days, P=0.025), and poorer overall survival (hazard ratio (HR)=1.88; 95% CI 1.09-3.25). Results were similar after multivariate adjustment, although the association with overall survival attenuated slightly (HR=1.75; 95% CI 1.00-3.06). Current smoking appears to adversely affect the number of days hospitalized post HSCT and overall survival. Translational research focused on interventions to promote tobacco cessation may lead to improved HSCT outcomes.

Interventions for smokeless tobacco use cessation.

BACKGROUND: Use of smokeless tobacco (ST) can lead to nicotine addiction and long-term use can lead to health problems including periodontal disease and cancer. OBJECTIVES: To assess the effects of behavioural and pharmacologic interventions for the treatment of ST use. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO, Dissertation Abstracts Online, and Scopus. Date of last search: March, 2007. SELECTION CRITERIA: Randomized trials of behavioural or pharmacological interventions to help users of ST to quit with follow up of at least six months. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data. MAIN RESULTS: Two trials of bupropion SR did not detect a benefit of treatment at six months or longer (Odds Ratio (OR) 0.86, 95% Confidence Interval (CI): 0.47 to 1.57). Four trials of nicotine patch did not detect a benefit (OR 1.16, 95% CI: 0.88 to 1.54), nor did two trials of nicotine gum (OR 0.98, 95% CI: 0.59 to 1.63). There was statistical heterogeneity among the results of 12 behavioural interventions included in the meta-analyses. Six trials showed significant benefits of intervention. In post-hoc subgroup analyses, behavioural interventions which include telephone counselling or an oral examination may increase abstinence rates more than interventions without these components. AUTHORS' CONCLUSIONS: Behavioural interventions should be used to help ST users to quit and telephone counselling or an oral examination may increase abstinence rates. Pharmacotherapies have not been shown to affect long-term abstinence.

Interventions for tobacco cessation in the dental setting. A systematic review.

UNLABELLED: Oral health professionals have a unique opportunity to increase tobacco abstinence rates among patients who use tobacco. OBJECTIVE: To assess the effectiveness of interventions for tobacco cessation offered to cigarette smokers and smokeless tobacco users in the dental office or community setting. RESEARCH DESIGN: We searched standard electronic retrieval systems and databases including the specialized registers of the Cochrane Tobacco Addiction Group and the Cochrane Oral Health Group through 2006. Selection criteria included randomised and pseudo-randomised clinical trials assessing tobacco cessation interventions for tobacco users conducted by oral health professionals in the dental office or community setting. The most rigorous abstinence outcome reported with at least six months of follow-up was recorded. Data collection and analysis involved two authors who independently reviewed abstracts for inclusion and abstracted data from included trials. RESULTS: Six clinical trials assessing the efficacy of interventions in dental office or school community settings were included. All studies assessed the efficacy of interventions for smokeless tobacco users, one also included cigarettes smokers, all employed oral exam and behavioral components, and one offered pharmacotherapy. The results showed that interventions conducted by oral health professionals increase tobacco abstinence rates (OR 1.44; 95% CI: 1.16-1.78) at 12 months or longer. Heterogeneity was evident and could not be adequately explained through subgroup or sensitivity analyses. CONCLUSIONS: Available evidence suggests that behavioral interventions for tobacco use conducted by oral health professionals incorporating an oral exam component in the dental office and community setting increase tobacco abstinence rates.

Smokeless tobacco brand switching: a means to reduce toxicant exposure?

The purpose of this study was to examine the effects of smokeless tobacco (ST) brand switching on biomarkers of ST exposure and on ST use. Subjects seeking treatment to reduce their use were randomized to ST brand switching with controlled ST topography, brand switching with ad libitum ST use, or a waitlist control with subsequent randomization to one of these two conditions. The waitlist control group was included to assess whether changes were a consequence of time effect. During the intervention, Copenhagen or Kodiak ST users were asked to switch to products that were sequentially lower in nicotine content: Skoal Long Cut Straight or Wintergreen for 4 weeks and then Skoal Bandits for the subsequent 4 weeks. Measures were obtained during the course of treatment and at 12-week follow-up. Significant reductions in total urinary cotinine and 4-(methylnitrosamino)-L-(3-pyridyl)-L-butanol (NNAL) plus its glucuronides (total NNAL) were observed with no significant differences between the controlled topography and ad libitum conditions. Significant reductions were also observed in the amount and duration of dips with a significant intervention effect for durational measures. At 12 weeks, the 7-day biochemically-verified tobacco abstinent rate was 26% in the ad libitum group. ST brand switching may be a feasible alternative intervention for ST users interested in quitting but unwilling to stop ST use completely.

Interventions for tobacco cessation in the dental setting.

BACKGROUND: Tobacco use has significant adverse effects on oral health. Oral health professionals in the dental office or community setting have a unique opportunity to increase tobacco abstinence rates among tobacco users. OBJECTIVES: This review assesses the effectiveness of interventions for tobacco cessation offered to cigarette smokers and smokeless tobacco users in the dental office or community setting. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction group Specialized Register (CENTRAL), MEDLINE (1966-2004), EMBASE (1988-2004), CINAHL (1982-2004), Healthstar (1975-2004), ERIC (1967-2004), PsycINFO (1984-2004), National Technical Information Service database (NTIS, 1964-2004), Dissertation Abstracts Online (1861-2004), Database of Abstract of Reviews of Effectiveness (DARE, 1995-2004), and Web of Science (1993-2004). SELECTION CRITERIA: We included randomized and pseudo-randomized clinical trials assessing tobacco cessation interventions conducted by oral health professionals in the dental office or community setting with at least six months of follow up. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed abstracts for potential inclusion and abstracted data from included trials. Disagreements were resolved by consensus. MAIN RESULTS: Six clinical trials met the criteria for inclusion in this review. Included studies assessed the efficacy of interventions in the dental office or a school community setting. All studies assessed the efficacy of interventions for smokeless tobacco users, one of which included cigarettes smokers. All studies employed behavioural interventions and only one offered pharmacotherapy as an interventional component. All studies included an oral examination component. Pooling of the studies suggested that interventions conducted by oral health professionals increase tobacco abstinence rates (odds ratio [OR] 1.44; 95% confidence interval [CI]: 1.16 to 1.78) at 12 months or longer. Heterogeneity was evident (I(2) = 75%) and could not be adequately explained through subgroup or sensitivity analyses. AUTHORS' CONCLUSIONS: Available evidence suggests that behavioural interventions for tobacco use conducted by oral health professionals incorporating an oral examination component in the dental office and community setting may increase tobacco abstinence rates among smokeless tobacco users. Differences between the studies limit the ability to make conclusive recommendations regarding the intervention components that should be incorporated into clinical practice.

Duration of smoking abstinence as a predictor for non-small-cell lung cancer survival in women.

BACKGROUND: Previous studies have attempted to investigate the impact of smoking cessation on lung cancer survival but have been limited by small numbers of former smokers and incomplete data. METHODS: Over a six-year period, 5229 patients with non-small-cell lung cancer (NSCLC) and small-cell lung cancer (SCLC) were enrolled in a prospective cohort of whom 2052 were former smokers. Patient's characteristics were obtained from medical records and a baseline interview. Vital status was determined through multiple sources. Cox proportional hazards models were used to estimate the effect of smoking abstinence on post-diagnosis mortality. RESULTS: For all patients with NSCLC, the median survival among never, former, and current smokers was 1.4 years, 1.3 years, and 1.1 years, respectively (P < 0.01). Female NSCLC patients had a significantly lower risk of mortality with a longer duration of smoking abstinence (RR per 10 years of smoking abstinence = 0.85; 95% CI: 0.75, 0.97). No effect of smoking abstinence on mortality was observed for women with SCLC or for men with either histologic group. CONCLUSIONS: The identification of smoking history as a prognostic factor in lung cancer survival supports previous research suggesting a direct biologic effect of smoking on survival. However, this effect may vary by sex and type of lung cancer.

Interventions for smokeless tobacco use cessation.

BACKGROUND: Use of smokeless tobacco (ST) can lead to nicotine addiction and health problems including periodontal disease and oral cancer OBJECTIVES: To assess the effects of behavioural and pharmacotherapeutic interventions to treat ST use. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group trials register (February 2004), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2004), MEDLINE (January 1966-February 2004), EMBASE (1988-January 2004), CINAHL (1982-February 2004), PsycINFO (1984-February 2004), Database of Abstract of Reviews of Effectiveness (DARE, The Cochrane Library, Issue 1, 2004). SELECTION CRITERIA: Randomized trials of behavioural or pharmacological interventions to help users of ST to quit, with follow-up of at least six months. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data. MAIN RESULTS: One trial of bupropion did not detect a benefit of treatment after six months (Odds Ratio (OR) 1.00, 95% Confidence Interval (CI): 0.23 to 4.37). Three trials of nicotine patch did not detect a benefit (OR 1.16, 95% CI: 0.88 to 1.54), nor did two trials of nicotine gum (OR 0.98, 95% CI: 0.59 to 1.63). There was statistical heterogeneity among the results of eight trials of behavioural interventions included in the meta-analysis. Three trials showed significant benefits of intervention. In a post-hoc analysis the trials of interventions which included an oral examination and feedback about ST-induced mucosal changes had homogeneous results and when pooled showed a significant benefit (OR 2.41 95% CI: 1.79 to 3.24). REVIEWERS' CONCLUSIONS: Behavioural interventions should be used to help ST users to quit. Pharmacotherapies have not been shown to affect long-term abstinence but larger trials are needed.

Glutathione pathway genes and lung cancer risk in young and old populations.

Multiple enzymes with overlapping functions and shared substrates in the glutathione (GSH) metabolic pathway have been associated with host susceptibility to tobacco smoke carcinogens and in lung cancer etiology. However, few studies have investigated the differing and interacting roles of GSH pathway enzymes with tobacco smoke exposure on lung cancer risk in young (<50 years of age) and old (>80 years of age) populations. Between 1997 and 2001, 237 primary lung cancer patients (170 young, 67 old) and 234 controls (165 young, 69 old) were enrolled at the Mayo Clinic. Using PCR amplification of genomic DNA, polymorphic markers for gammaGCS, GPX1, GSTP1 (I105V and A114V), GSTM1 and GSTT1 were genotyped. Recursive partitioning and logistic regression models were used to build binary classification trees and to estimate odds ratios (OR) and 95% confidence intervals for each splitting factor. For the young age group, cigarette smoking had the greatest association with lung cancer (OR = 3.3). For never smokers, the dividing factors of recursive partitioning were GSTT1 (OR = 1.7), GPX1 (OR = 0.6) and GSTM1 (OR = 4.3). For the old age group, smoking had the greatest association with lung cancer (OR = 3.6). For smokers, the dividing factors were GPX1 (OR = 3.3) and GSTP1 (I105V) (OR = 4.1). Results from logistic regression analyses supported the results from RPART models. GSH pathway genes are associated with lung cancer development in young and old populations through differing interactions with cigarette smoking and family history. Carefully evaluating multiple levels of gene-environment and gene-gene interactions is critical in assessing lung cancer risk.

Environmental tobacco smoke exposure in women with lung cancer.

BACKGROUND: Investigations on environmental tobacco smoke (ETS) exposure that include source intensity, childhood exposure, and association with histologic subtypes among never smoking lung cancer cases are limited. We report the patterns of ETS exposure history in a clinical cohort of women with newly diagnosed lung cancer. METHODS: From 1997 to 2001, 810 women with lung cancer were interviewed to obtain data including the source, intensity, and duration of ETS exposure. In this descriptive study, relationships between smoking history, ETS exposure, and lung cancer histologic subtypes were analyzed. RESULTS: Among the 810 patients, 773 (95.4%) reported personal smoking or ETS exposure including 170 of 207 (82%) never smokers. Among the never smokers with a history of ETS exposure, the mean years of exposure were 27 from a smoking spouse, 19 from parents, and 15 from co-workers. For each major subtype of lung cancer (adenocarcinoma, squamous cell, unclassified non-small cell lung cancer, small cell, or carcinoids) among never smokers, 75-100% of patients had ETS exposure. Trends for adenocarcinoma, squamous, and small cell carcinoma are statistically significant using the Cochran-Armitage Test for Trend (P<0.001) among never smokers without ETS exposure, never smokers with ETS exposure, former smokers, and current smokers. CONCLUSIONS: Over 95% of women with lung cancer in our study were exposed to tobacco smoke through a personal smoking history or ETS. The cumulative amount of tobacco smoke exposure may be significantly underestimated if only personal smoking history is considered. Our results add to the public health implications of exposure to tobacco smoke and highlight the importance of eliminating tobacco smoking in public and private settings.

Lung cancer risk reduction after smoking cessation: observations from a prospective cohort of women.

PURPOSE: We conducted this study because the duration of excess lung cancer risk among former smokers has been inconsistently reported, doubt has been raised regarding the population impact of smoking cessation, and differential risk reduction by histologic cell type after smoking cessation needs to be confirmed. METHODS: The Iowa Women's Health Study is a prospective cohort study of 41,836 Iowa women aged 55 to 69 years. In 1986, mailed questionnaires were used to collect detailed smoking history. Age-adjusted lung cancer incidence through 1999 was analyzed according to years of smoking abstinence. Relative risks were estimated using Cox regression analysis. RESULTS: There were 37,078 women in the analytic cohort. Compared with the never smokers, former smokers had an elevated lung cancer risk (relative risk, 6.6; 95% confidence interval, 5.0 to 8.7) up to 30 years after smoking cessation for all former smokers. However, a beneficial effect of smoking cessation was observed among recent and distant former smokers. The risk of adenocarcinoma remained elevated up to 30 years for both former heavier and former lighter smokers. CONCLUSION: The risk for lung cancer is increased for both current and former smokers compared with never smokers and declines for former smokers with increasing duration of abstinence. The decline in excess lung cancer risk among former smokers is prolonged compared with other studies, especially for adenocarcinoma and for heavy smokers, suggesting that more emphasis should be placed on smoking prevention and lung cancer chemoprevention.

Tobacco use outcomes of adolescents treated clinically for nicotine dependence.

OBJECTIVE: To evaluate the tobacco use outcomes and baseline characteristics of adolescents treated for nicotine dependence. DESIGN: Retrospective cohort study. SETTING: Mayo Clinic Nicotine Dependence Center, Rochester, Minn. PATIENTS: Ninety-six adolescents (60 boys, 36 girls) receiving clinical services for treatment of nicotine dependence between January 1, 1988, and November 30, 1997. Their mean age was 15.6 years (range, 11-17 years), and 91.7% were white. INTERVENTION: The Nicotine Dependence Center intervention involves a 45-minute consultation with a nicotine dependence counselor. A treatment plan individualized to the patient's needs is then developed. Telephone follow-up is conducted at 6 and 12 months. As part of this study, a long-term follow-up was conducted by telephone at a mean of 5.3 years (range, 1.6-10.6 years) following the intervention. MAIN OUTCOME MEASURES: Self-reported 7-day point-prevalence abstinence from tobacco at 6 and 12 months, and 30-day point-prevalence tobacco abstinence at the long-term follow-up. RESULTS: The tobacco abstinence rates were 17.7% (17/96 patients) at 6 months, 7.3% (7/96 patients) at 12 months, and 11.5% (11/96 patients) at the long-term follow-up. A high proportion of the sample had smoking-related medical morbidity and psychiatric diagnoses documented in the medical record prior to or at the time of the intervention. CONCLUSIONS: Adolescents utilize the medical community to seek treatment for nicotine dependence. The 6-month tobacco abstinence rate is higher than the estimates of the natural history of smoking cessation in adolescents. Medical and psychiatric diagnoses are common in this population.

The journal club in postgraduate medical education: a systematic review.

An investigation was made as to whether studies have found journal clubs for physicians in training to be effective for improving patient. care, teaching critical appraisal skills, improving reading habits, increasing knowledge of clinical epidemiology and biostatistics, and increasing the use of medical literature in clinical practice. A literature search was undertaken using 10 databases and retrieval systems and hand searches of journals, conference proceedings and personal files. The rigor of studies meeting the inclusion criteria was analyzed using a protocol based on methods established by the Cochrane Collaboration. One randomized controlled trial found an improvement in knowledge of clinical epidemiology and biostaristics, reading habits, and the use of medical literature in practice, but no improvement in critical appraisal skills. Six less methodologically rigorous studies found possible improvement in critical appraisal skills. It is concluded that journal clubs may improve knowledge of clinical epidemiology and biostatistics, reading habits, and the use of medical literature in practice. A multi-center, randomized controlled trial of journal clubs is needed to assess whether journal clubs improve critical appraisal skills.

Treatment of nicotine dependence.

Nicotine dependence is characterized by periods of relapse and remission. Health care workers can have a pivotal role in the treatment of nicotine dependence. Smokers should be identified and categorized based on their readiness to change. Smokers who are preparing to stop smoking should be given multicomponent therapy in a step-care approach using behavioral treatment, addiction treatment, pharmacotherapy, and techniques of relapse prevention. Pharmacotherapies approved by the Food and Drug Administration for smoking interventions include sustained-release bupropion, nicotine gum, the nicotine inhaler, nicotine nasal spray, and nicotine patches.

Report of a rotavirus outbreak in an adult nursing home population.

UNLABELLED: Rotavirus is a double-stranded RNA enteric virus that is the most important cause of severe, dehydrating diarrhea in infants and young children worldwide. Symptoms range from mild diarrhea to a life-threatening illness. Rotavirus occasionally afflicts adult members of the infected infant's family, geriatric patients, and immunocompromised hosts. We report the outbreak of rotavirus infection in a large nursing home facility. REPORT: In September 1996, 19 residents and 15 staff members of a 64-bed nursing home facility began to develop an acute, febrile illness associated with vomiting and diarrhea. The Public Health Service conducted an outbreak investigation. The infection displayed fecal-to-oral transmission with an incubation period of 1 to 2 days. The median duration of illness was 3 days for residents and 1 day for staff members. One resident died as a result of illness complications. Stool antigen tests from five residents and two employees were positive for rotavirus. Infection control policies were reevaluated, and interventions to arrest the outbreak were undertaken. The employee sick leave policy was strictly enforced. Education seminars were held, with employees reinforcing the concepts of enteric isolation and proper handwashing techniques. Surfaces and objects in the dining area were disinfected with a weak chloride solution. Once these measures were implemented, the rotavirus outbreak was contained. CONCLUSION: Rotavirus is a common cause of infectious diarrhea that can afflict the geriatric population. When infection occurs in a nursing home facility, rapid transmission can develop and morbidity can result. Nursing home infection control policies need to be evaluated constantly and new measures need to be implemented should an outbreak of rotavirus occur.