Dose-response association between salivary cotinine levels and Mycobacterium tuberculosis infection.

SETTING: Tijuana, Mexico. OBJECTIVE: To describe the association between salivary cotinine levels and interferon-gamma (IFN-γ) release assay results. DESIGN: We conducted a cross-sectional study among injection drug users. Salivary cotinine levels were measured using NicAlert, a semi-quantitative dipstick assay. QuantiFERON©-TB Gold In-Tube (QFT-GIT) was used to determine Mycobacterium tuberculosis infection. RESULTS: Among 234 participants, the prevalence of QFT-GIT positivity for NicAlert cotinine categories 0 (non-smoking), 1 (second-hand smoke exposure or low-level smoking) and 26 (regular smoking) were respectively 42.1%, 46.4% and 65.2% (Ptrend 0.012). We found increasing trends in QFT-GIT positivity (Ptrend 0.003) and IFN-γ concentrations (Spearman's r 0.200, P 0.002) across cotinine levels 0 to 6. In multivariable log-binomial regression models adjusted for education, cotinine levels were not associated with QFT-GIT positivity when included as smoking categories (1 and 26 vs. 0), but were independently associated with QFT-GIT positivity when included as an ordinal variable (prevalence ratio 1.09 per 1 cotinine level, 95%CI 1.021.16). CONCLUSION: Our findings suggest that a dose-response relationship exists between tobacco smoke exposure and M. tuberculosis infection. Longitudinal studies that use biochemical measures for smoking status are needed to confirm our findings.

Patient and doctor perspectives on incorporating smoking cessation into tuberculosis care in Beijing, China.

SETTING: Tuberculosis (TB) hospital in Beijing, China. OBJECTIVE: To describe perspectives of patients and physicians regarding the incorporation of smoking cessation interventions as part of TB treatment. DESIGN: Seven focus groups were conducted with 39 patients and 17 physicians. RESULTS: Patients were more receptive to physicians' advice to quit smoking due to increased concerns about their health after becoming ill with TB. However, patients indicated that they might start smoking again after they recovered from TB. Patients' attempts to quit smoking may have been inhibited by exposure to smoking at the TB facility. Physicians had low levels of knowledge regarding the effect of smoking on TB. Many doctors, particularly those who smoked, did not view smoking cessation as an integral part of TB treatment. CONCLUSION: Despite the presence of a 'teachable moment', TB patients experience significant barriers to quitting smoking. Patient education in TB treatment programs should address the specific effects of smoking on TB and the general health benefits of cessation. Smoke-free policies should be strictly enforced in TB facilities. Successful integration of smoking cessation interventions within TB treatment regimens may require that providers adopt smoking cessation as an essential part of TB treatment.

Ethical and legal aspects of global tobacco control.

On 28 February 2005, the Framework Convention on Tobacco Control came into force as a result of at least 40 countries becoming State Parties through ratification of this first ever health treaty sponsored by the World Health Organization. This article discusses the bioethical, trade, and legal aspects of global tobacco control. Special emphasis is given to globalisation of tobacco use and the challenges it poses to sovereign nations. It also advocates a bioethical basis in the pursuit of global solutions to expanding tobacco use.

Trends in adult cigarette smoking in California compared with the rest of the United States, 1978-1994.

OBJECTIVES: This study compared trends in adult cigarette smoking prevalence in California and the remainder of the United States between 1978 and 1994. METHODS: We used data from National Health Interview Surveys and Behavioral Risk Factor Surveillance System surveys to compare trends in smoking prevalence among persons 18 years and older. RESULTS: In both California and the remainder of the United States, the estimated annual rate of decline in adult smoking prevalence accelerated significantly from 1985 to 1990: to -1.22 percentage points per year (95% confidence interval [CI] = -1.51, -0.93) in California and to -0.93 percentage points per year (95% CI = -1.13, -0.73) in the remainder of the nation. The rate of decline slowed significantly from 1990 to 1994: to -0.39 percentage points per year (95% CI = -0.76, -0.03) in California and to -0.05 percentage points per year (95% CI = -0.34, 0.24) in the remainder of the United States. CONCLUSIONS: The presence of an aggressive tobacco control intervention has supported a significant decline in adult smoking prevalence in California from 1985 to 1990 and a slower but still significant decline from 1990 to 1994, a period in which there was no significant decline in the remainder of the nation. To restore nationwide progress in reducing smoking prevalence, other states should consider similar interventions.

Extended degree and continuing education preferences of California public health professionals.

The authors conducted a randomized mail survey of members of six public health organizations in California. The purpose of the survey was to assess public health practitioner interest and resources available to participate in public health extended degree programs and public health continuing education (CE). The response rate was 52 percent (N = 262). Three CE topics of greatest interest to public health professionals were health policy, computer applications, and community-based interventions. Respondents were interested in both distance-based and on-site learning formats.

Consumption and production waste: another externality of tobacco use.

OBJECTIVE: To describe the waste produced by and environmental implications of individual cigarette consumption (filter tips, packages, and cartons) and tobacco manufacturing. STUDY SELECTION: All available articles and reports published since 1970 related to cigarette consumption and production waste were reviewed. DATA SOURCES: Global cigarette consumption data were used to estimate cigarette butt and packaging waste quantities. Data from the Center for Marine Conservation's International Coastal Cleanup Project were used to describe some environmental impacts of tobacco-related trash. Data from the United States Environmental Protection Agency's (EPA's) Toxics Release Inventory and reported global cigarette consumption totals were used to estimate waste production from cigarette manufacturing. DATA EXTRACTION AND SYNTHESIS: In 1995, an estimated 5.535 trillion cigarettes (27,675 million cartons and 276,753 million packages) were sold by the tobacco industry globally. Some of the wastes from these products were properly deposited, but a large amount of tobacco consumption waste ends up in the environment. Some is recovered during environmental clean-up days. For the past eight years (1990-1997), cigarette butts have been the leading item found during the International Coastal Cleanup Project; they accounted for 19.1% of all items collected in 1997. The tobacco manufacturing process produces liquid, solid, and airborne waste. Among those wastes, some materials, including nicotine, are designated by the EPA as Toxics Release Inventory (TRI) chemicals. These are possible environmental health hazards. In 1995, the global tobacco industry produced an estimated 2262 million kilograms of manufacturing waste and 209 million kilograms of chemical waste. In addition, total nicotine waste produced in the manufacture of reduced nicotine cigarettes was estimated at 300 million kilograms. CONCLUSIONS: Laws against littering relative to cigarette butts could be better enforced. Additional taxes might be levied on cigarette products that would then be directed to environmental clean-up efforts. The tobacco industry should improve the biodegradability of filters, reduce packaging waste, and educate its customers. Worksites and public buildings should be encouraged or required to supply appropriate disposal mechanisms at all building entrances. Public awareness campaigns about the magnitude and prevention of cigarette consumption waste could be developed through partnerships among environmental groups, health organisations, and environmental protection agencies. Tobacco production waste should be a source of concern and regulation by governments throughout the world; it contains numerous chemicals which may be considered health hazards, not the least of which is nicotine produced in the manufacture of low-nicotine cigarettes.

Black-white differences in cigarette smoking uptake: progression from adolescent experimentation to regular use.

BACKGROUND: More U.S. adolescents and young adults have initiated cigarette smoking in recent years. Blacks have been less likely than whites to start smoking, and the gap has widened recently. Reasons accounting for this large black-white difference remain unclear. METHODS: A multiple logistic regression analysis was performed using a cohort of 2,467 adolescent smoking experimenters ages 11-18, within the 1989-1993 Teenage Attitudes and Practices Survey, a nationally representative survey. RESULTS: Among experimenters (1989), 25.7% of whites and 10.3% of blacks had progressed to current smoking (1993). The unadjusted odds ratio (OR) of progression for blacks (vs whites) was 0.33 [95% confidence interval (CI) 0.23, 0.48]. Adjustment for factors significantly predictive of progression (most parsimonious model) modified the black-white OR to 0.36 (CI 0.24, 0.55), while the full model yielded a black-white OR of 0.39 (CI 0.24, 0.66). CONCLUSIONS: The observed black-white difference in smoking progression was only partly explained by the factors evaluated, and some additional factor(s) must be important. Understanding the black-white difference in the progression from experimentation to current smoking may help prevent uptake among all adolescents.

Rates and independent correlates of Pap smear testing among Korean-American women.

OBJECTIVES: This study reports population estimates of Pap smear testing among Korean-American women and evaluates correlates of testing. METHODS: Korean Americans in 2 California counties were surveyed by telephone. Frequencies were age-adjusted to the 1990 census to produce population estimates of testing. Logistic regression models were used to evaluate independent correlates of testing RESULTS: Only 50% of the Korean-American women surveyed had a Pap test in the previous 2 years. The strongest independent correlate was having had a regular check-up in the previous 2 years (odds ratio 7.2, 95% confidence interval 4.2, 12.1). CONCLUSIONS: Rates of Pap testing among Korean-American women are well below national objectives. Collaboration and community-sensitive research are essential to collect data and design programs to improve the health of ethnic minority communities.

Mammography and clinical breast examination among Korean American women in two California counties.

BACKGROUND: Mammography and clinical breast examination (CBE) are underutilized, especially by women from some racial/ethnic minorities. Few published studies of screening practices or correlates for these subgroups exist. METHODS: A population-based telephone survey of 1,090 Korean Americans living in two California counties was conducted. To produce population estimates of mammography and CBE testing, we adjusted frequencies to account for different selection probabilities. Multivariable logistic regression was performed to determine independent correlates of testing. RESULTS: Only 34% [95% confidence intervals (CI) 30%, 39%] of Korean American women age 50 and older were estimated to have had a mammogram in the past 2 years. Only 32% (95% CI 28%, 37%) had had a CBE in the past 2 years. The strongest independent correlate of testing was having a regular medical checkup [odds ratio (OR) for mammogram = 9.21, 95% CI 3.98, 21.35; OR for CBE = 11.58, 95% CI 4.71, 28.46]. CONCLUSIONS: These estimates are lower than the Healthy People 2000 objectives as well as published estimates for other populations in the United States. Planning and implementing tailored programs to improve screening are best done using a community-sensitive approach, which, because racial/ethnic subgroups are growing, will assume increasing public health importance.

Trends in black/white differences in current smoking among 18- to 24-year-olds in the United States, 1983-1993.

OBJECTIVES: A study was undertaken to analyze the independent relationship between race (black/white) and cigarette smoking among 18- to 24-year-olds in the United States, 1983-1993. METHODS: An 11-year analysis of cross-sectional national surveys was used in the study. Odds ratio for current smoking among black-surveyed subjects (vs. whites) was determined. RESULTS: The multiple logistic regression-derived odds ratio (OR) for current smoking for blacks aged 18 to 24 years, vs. whites, decreased from 0.69 (95% CI 0.53, 0.89) in 1983 to 0.26 (95% CI 0.17, 0.42) in 1993. The combined-years model predicted a decrease in OR for blacks from 0.82 in 1983 to 0.30 in 1993, adjusted for sex, age, education, poverty status, and geographic region. CONCLUSION: From 1983 to 1993, blacks aged 18 to 24 years became decreasingly at risk to be smokers, compared to whites, even after adjustment for confounding factors. Young blacks have been more resistant than young whites to begin smoking in recent years. Understanding reasons behind this widening black/white difference could lead to better prevention strategies.

Poverty status and cigarette smoking prevalence and cessation in the United States, 1983-1993: the independent risk of being poor.

OBJECTIVE: To analyse the independent relations between poverty status and cigarette smoking prevalence and cessation in the United States, 1983-1993. DESIGN: An analysis of eight cross-sectional national surveys. SETTING: The United States, 1983-1993. PARTICIPANTS: 236,311 civilian, non-institutionalised adult residents of the United States, aged 18 years and older. MAIN OUTCOME MEASURES: Probability of current cigarette smoking and proportion of former smokers among ever-smokers (quit ratio) in surveyed subjects below the poverty threshold, compared with those at or above the poverty threshold. RESULTS: The odds ratio for current smoking among persons below the poverty threshold ranged from a low of 1.10 in 1985 to a high of 1.45 in 1990, and remained between 1.26 and 1.30 during 1991-1993. The odds ratio for smoking cessation (quit ratio) among persons below the poverty threshold ranged from 0.81 in 1985 to 0.64 in 1991, and remained between 0.73 and 0.66 during 1991-1993. These measures of the relations between poverty status and smoking were derived using multiple logistic regression models, which adjusted for the effects of sex, age, education, race, employment status, marital status, and geographic region. CONCLUSIONS: Persons below the poverty threshold continue to be more likely than those at or above the threshold both to be current smokers and not to have quit. Poverty may be an indicator of underparticipation in the changing social norms regarding smoking behaviour in recent years. Individuals below the poverty threshold may need focused efforts to help achieve the Healthy People 2000 objectives for reducing adult smoking prevalence. Further understanding of the relation between poverty and smoking is essential to develop effective programmes for this vulnerable population subgroup.

Hospital smoking bans and employee smoking behavior: Results of a national survey.

OBJECTIVE: To examine the impact of workplace smoking bans on smoking behavior of employees. PARTICIPANTS: A total of 1469 current or former smokers (intervention group) employed in smoke-free hospitals and 920 current or former smokers (comparison group) employed in non-smoke-free workplaces were surveyed to determine smoking behavior. DESIGN: This cross-sectional study is part of a larger, ongoing prospective study. The study design was quasi-experimental. We randomly selected sites consisting of a hospital and a corresponding community. Furthermore, we randomly selected subjects from hospitals and their corresponding communities. MAIN OUTCOME MEASURES: Postban quit ratio and progression along the stages-of-change continuum. METHODS: The Cox proportional hazards model was used to compare the postban quit ratio between the intervention and comparison groups. The Cochran-Mantel-Haenszel analysis of variance statistic was used to compare groups on the stages-of-change variables. RESULTS: Beginning with the smoking ban and continuing for 5 years after implementation, statistically significant differences in the postban quit ratio were observed between employees of smoke-free hospitals who were smokers and counterparts in the community (P<.001). Despite preban differences in smoking intensity, the overall difference in postban quit ratios remained significant even after multivariate adjustment for socioeconomic, demographic, and smoking intensity variables. For those sites that were 5 years postban, the quit ratio was 0.506 in smoke-free workplaces compared with 0.377 in workplaces where smoking was permitted. In all but 1 category, the intervention group was further along the stages-of-change continuum toward quitting smoking than the comparison group (P<.001). CONCLUSION: American hospitals' experiences with smoking bans, which directly affect more than 5 million workers, should be examined by other industries as a method of improving employee health. Workplace smoking bans could also be effective in saving lives, reducing health care costs, addressing safety concerns, and decreasing operating and maintenance expenses of employers.

Use of a 24-hour recall diary to assess exposure to environmental tobacco smoke.

Methods to assess exposure to environmental tobacco smoke need to be valid and relatively easy to use. We therefore explored the use of a 24-h environmental tobacco smoke exposure-recall diary by comparing data from the 24-h diary with questionnaire responses and levels of salivary cotinine--a biochemical marker of environmental tobacco smoke exposure. A total of 875 nonsmokers at five Rhode Island worksites participated in the study. Twenty-five percent of the participants lived with smokers, and 96% had regular exposure to environmental tobacco smoke at work. Individuals who lived with smokers reported more exposures in the 24-h diary, both outside of work and during work hours, compared with those who had no smokers in their household. The correlation between saliva cotinine concentrations and the exposures recorded in the diary was weak (r = .10). Brief instruments for assessment of environmental tobacco smoke should be viewed cautiously, and use of this 24-h recall diary is not recommended.

California's tobacco control saga.

The California tobacco control program known as Proposition 99 was established in 1989 using a portion of a twenty-five-cent increase in the cigarette tax. With an initial availability of more than $150 million, tobacco control was the state's single most important public health activity. Health and medical care programs also were supported by the tax. Despite sustained public support, the tobacco control component was weakened by political actions of the tobacco industry and also by the competing efforts of organized medicine and the lack of support from the executive and legislative branches of government. Nevertheless, Proposition 99 succeeded in reducing exposure to environmental tobacco smoke, cigarette consumption, and smoking prevalence among adults in California.

Environmental and policy interventions to control tobacco use and prevent cardiovascular disease.

Despite its declining prevalence during the past few decades, tobacco use remains one of the most significant public health issues of the 1990s. Environmental and policy interventions are among the most cost-effective approaches to control tobacco use and prevent cardiovascular diseases. In this article, the authors review and offer to state and local health departments and other public health partners a summary of recommended policy and environmental interventions that have either reduced or show potential to reduce tobacco use. Priority recommendations include clean indoor air policies, restrictions on tobacco advertising and promotion, policies limiting youth access to tobacco, comprehensive school health programs, and excise taxes and other economic incentives. Many of these recommendations should be integrated with other health promotion interventions to also improve nutrition and physical activity. The authors also highlight several successful interventions and strategies used to establish policies at the state and local levels.

The efficacy of two comprehensive perinatal programs on reducing adverse perinatal outcomes.

Through the collaboration among University of California at Berkeley School of Public Health, Samuel Merritt College, and a private nonprofit, community-based medical center, the adequacy of two perinatal programs was assessed based on the pregnancy outcomes of teenaged Medi-Cal clients. Historical data from June 1991 to June 1992 were compiled on the pregnancy outcomes of 312 Medi-Cal clients, 12-18 years of age, delivering at the study medical center in Oakland, California. The effect of enrollment in two special perinatal programs, Comprehensive Perinatal Services Program (CPSP) and a school-based program, the Comprehensive Teenage Pregnancy and Parenting Program (CTAPPP), on the occurrence of adverse perinatal outcomes was examined. Adverse perinatal outcomes were defined as the occurrence of one of the following: low birthweight (< 2,500 grams), gestational age less than 37 weeks, or admission to the neonatal intensive care unit (NICU), not related to congenital syphilis. The percentage of teens experiencing adverse perinatal outcomes was 10.9% at the study hospital. No significant association was observed between CTAPPP enrollment and reduced adverse perinatal outcomes, but CPSP enrollment was associated with reduced adverse perinatal outcomes. This association persisted after controlling for potential confounders, including substandard prenatal care, which were also found to be risk factors for adverse perinatal outcomes. Enrollment in both programs simultaneously was not associated with a reduction in adverse outcomes. The significant association between CPSP enrollment and reduced adverse perinatal outcomes indicates that a more comprehensive prenatal program may be beneficial in improving birth outcomes, specifically among high-risk teenage populations.(ABSTRACT TRUNCATED AT 250 WORDS)