Enrollee Characteristics in an Intensive Tobacco Dependence Treatment Program: The Relationship of Race and Sex to Demographic Factors and Tobacco Use Patterns.

Intensive tobacco treatment programs offer many advantages relative to other treatment options, particularly for more complex patients, e.g., highly nicotine dependent, or those with medical and psychiatric symptoms and disorders. Efforts to better understand those who choose to enroll in these programs, particularly regarding the characteristics they possess known to mediate outcomes, are important considerations in tailoring available services. In this study, we examined how participants differed on key descriptive and tobacco use variables within race (i.e., African-American, Caucasian) and sex subgroups. Baseline characteristics from a large group of consecutive program enrollees were examined across targeted subgroups. Strong racial effects and some sex effects were noted for marital status, education, employment and health insurance status, alcohol consumption, presence of medical and psychiatric disorders, as well as participant tobacco use patterns and tobacco use rates of family, friends and coworkers. The differences in participant tobacco use measures across race and sex factors remained significant after adjusting for the confounding effects of all other covariates. These findings have implications for characterizing key patient subgroups who present at tobacco treatment clinics. Such information may contribute to options for tailoring treatment regimens.

In vivo measurement of trabecular meshwork stiffness in a corticosteroid-induced ocular hypertensive mouse model.

Ocular corticosteroids are commonly used clinically. Unfortunately, their administration frequently leads to ocular hypertension, i.e., elevated intraocular pressure (IOP), which, in turn, can progress to a form of glaucoma known as steroid-induced glaucoma. The pathophysiology of this condition is poorly understood yet shares similarities with the most common form of glaucoma. Using nanotechnology, we created a mouse model of corticosteroid-induced ocular hypertension. This model functionally and morphologically resembles human ocular hypertension, having titratable, robust, and sustained IOPs caused by increased resistance to aqueous humor outflow. Using this model, we then interrogated the biomechanical properties of the trabecular meshwork (TM), including the inner wall of Schlemm's canal (SC), tissues known to strongly influence IOP and to be altered in other forms of glaucoma. Specifically, using spectral domain optical coherence tomography, we observed that SC in corticosteroid-treated mice was more resistant to collapse at elevated IOPs, reflecting increased TM stiffness determined by inverse finite element modeling. Our noninvasive approach to monitoring TM stiffness in vivo is applicable to other forms of glaucoma and has significant potential to monitor TM function and thus positively affect the clinical care of glaucoma, the leading cause of irreversible blindness worldwide.

Tobacco dependence treatment: influence of training experiences on clinical activities among otolaryngologists.

OBJECTIVES/HYPOTHESIS: Although one in five U.S. adults continue to smoke, healthcare providers often fail to provide basic, effective interventions. This is particularly true for physician specialists. This study sought to investigate perceived role, self-efficacy, practice behaviors, and attitudes among otolaryngologists as they relate to the delivery of tobacco treatment services. STUDY DESIGN: This study involved a single administration of a survey questionnaire to current members of the American Academy of Otolaryngology Head and Neck Surgery (AAO-HNS). METHODS: A questionnaire was mailed up to three times to active members. RESULTS: Survey response rate was 39% (N = 2127). Based on an evaluation of treatment factors categorized according to the National Cancer Institute's 5A's approach, trained providers generally rated themselves consistently higher than untrained providers across areas of clinical activity. Minimal differences were noted for Ask and Advise, moderate for Assess, and the greatest for Assist and Arrange. Trained providers also indicated more positive attitudes towards treatment. CONCLUSIONS: While the level of performance was reasonable for otolaryngologists relative to other specialists in the published literature, overall tobacco treatment activity remains unacceptably low. This study suggests the positive impact of training and the potential value of making such experiences widely available.

Depressive symptoms among heavy cigarette smokers: the influence of daily rate, gender, and race.

INTRODUCTION: Cigarette smokers experience higher levels of depressive symptoms and are more likely to be diagnosed with depressive disorders than nonsmokers. To date, the nature of the smoking-depression relationship has not been adequately studied among heavy smokers, a group at elevated risk for poor health outcomes. In this study, we examined depressive symptom expression among heavy smokers while considering the moderating roles of smoking status, gender, and race. We also explored whether amount of tobacco usually consumed had an impact. METHODS: We extracted data from a large, highly nicotine-dependent, nontreatment cigarette smoking study sample (N = 6,158). Participants who consented were screened for major exclusions, and they completed questionnaires. RESULTS: Smokers reported a higher, clinically meaningful level of depressive symptoms relative to nonsmokers (27.3% of smokers vs. 12.5% of nonsmokers) scored above the clinical cutoff on the Center for Epidemiological Studies Depression (CES-D) scale (p < .001), which differed among race × gender subgroups. Further, amount of daily intake was inversely associated with self-report of depressive symptoms. For every 10-cigarette increment, the likelihood of scoring above the CES-D clinical cutoff decreased by 62% (p < .0001). CONCLUSIONS: These findings improve our understanding of tobacco's influence on depressive symptom expression among heavy smokers, with implications for tailoring evidence-based tobacco treatments.

Do faxed quitline referrals add value to dental office-based tobacco-use cessation interventions?

BACKGROUND: The Ask, Advise, Refer (AAR) model of intervening with patients who use tobacco promotes a brief office-based intervention plus referral to a tobacco quitline. However, there is little evidence that this model is effective. The primary aim of this study was to evaluate the effects on patients' tobacco use of two levels of a dental office-based intervention compared with usual care. METHODS: The authors randomly assigned 68 private dental clinics to one of three conditions: 5 As (Ask, Advise, Assess, Assist, Arrange); 3 As (AAR model); or usual care, and they enrolled 2,160 participants. RESULTS: At the 12-month assessment, compared with those in usual care, participants in the two intervention conditions combined were more likely to report cessation of tobacco use, as measured by nine-month prolonged abstinence (3 percent versus 2 percent; F(1,66) = 3.97, P < .10) and 12-month point prevalence (12 percent versus 8 percent; F(1,66) = 7.32, P < .01). There were no significant differences between participants in the clinics using the 5 As and 3 As strategies. CONCLUSIONS: The results of this study are inconclusive as to whether referrals to a quitline add value to brief dental office-based interventions. Patients receiving telephone counseling quit tobacco use at higher rates, but only a small percentage of those proactively referred actually received counseling. CLINICAL IMPLICATIONS: The results confirm those of previous research: that training dental practitioners to provide brief tobacco-use cessation advice and assistance results in a change in their behavior, and that these practitioners are effective in helping their patients to quit using tobacco.

Tobacco cessation via public dental clinics: results of a randomized trial.

OBJECTIVES: We sought to compare the effectiveness of a dental practitioner advice and brief counseling intervention to quit tobacco use versus usual care for patients in community health centers on tobacco cessation, reduction in tobacco use, number of quit attempts, and change in readiness to quit. METHODS: We randomized 14 federally funded community health center dental clinics that serve diverse racial/ethnic groups in 3 states (Mississippi, New York, and Oregon) to the intervention (brief advice and assistance, including nicotine replacement therapy) or usual care group. RESULTS: We enrolled 2549 smokers. Participants in the intervention group reported significantly higher abstinence rates at the 7.5-month follow-up, for both point prevalence (F(1,12) = 6.84; P < .05) and prolonged abstinence (F(1,12) = 14.62; P < .01) than did those in the usual care group. CONCLUSIONS: The results of our study suggest the viability and effectiveness of tobacco cessation services delivered to low-income smokers via their dental health care practitioner in community health centers. Tobacco cessation services delivered in public dental clinics have the potential to improve the health and well-being of millions of Americans.

Consensus Report: 2nd European Workshop on Tobacco Use Prevention and Cessation for Oral Health Professionals.

Tobacco use has been identified as a major risk factor for oral disorders such as cancer and periodontal disease. Tobacco use cessation (TUC) is associated with the potential for reversal of precancer, enhanced outcomes following periodontal treatment, and better periodontal status compared to patients who continue to smoke. Consequently, helping tobacco users to quit has become a part of both the responsibility of oral health professionals and the general practice of dentistry. TUC should consist of behavioural support, and if accompanied by pharmacotherapy, is more likely to be successful. It is widely accepted that appropriate compensation of TUC counselling would give oral health professionals greater incentives to provide these measures. Therefore, TUC-related compensation should be made accessible to all dental professionals and be in appropriate relation to other therapeutic interventions. International and national associations for oral health professionals are urged to act as advocates to promote population, community and individual initiatives in support of tobacco use prevention and cessation (TUPAC) counselling, including integration in undergraduate and graduate dental curricula. In order to facilitate the adoption of TUPAC strategies by oral health professionals, we propose a level of care model which includes 1) basic care: brief interventions for all patients in the dental practice to identify tobacco users, assess readiness to quit, and request permission to re-address at a subsequent visit, 2) intermediate care: interventions consisting of (brief) motivational interviewing sessions to build on readiness to quit, enlist resources to support change, and to include cessation medications, and 3) advanced care: intensive interventions to develop a detailed quit plan including the use of suitable pharmacotherapy. To ensure that the delivery of effective TUC becomes part of standard care, continuing education courses and updates should be implemented and offered to all oral health professionals on a regular basis.

Tobacco cessation education for dentists: an evaluation of the lecture format.

Dentists with tobacco cessation training perform more interventions, report increased self-efficacy, preparedness and fewer barriers than those without training. The aim of this study was to assess changes in knowledge, attitudes and behavior of dentists (CE group) at six months following presentation of a standardized tobacco cessation lecture module. These data were compared to those from age and gender-matched controls who did not receive training. The CE group was more likely to feel cessation was very important, score higher on knowledge questions, update tobacco use of continuing patients, ask former smokers about relapse and ask about daily consumption. The CE group was also more likely to discuss the personal relevance of quitting, roadblocks and setting quit dates, identify triggers, discuss pharmacotherapy and provide follow-up. These results suggest that group education appears to be a cost-efficient and effective method of teaching dentists about the latest methods of tobacco cessation.

Tobacco education in dentistry and dental hygiene.

INTRODUCTION AND AIMS: Dentists and dental hygienists are in a unique position to motivate and assist their patients to quit smoking and using smokeless tobacco, and there is ample evidence that they can be effective. Tobacco plays a major role in the development and treatment of many oral diseases, and the repeated nature of dental treatment provides multiple opportunities for information, advice and brief counselling. However, dentists and dental hygienists in practice report lack of training in effective tobacco cessation skills as a significant barrier to incorporating these behaviours into routine care. DESIGN AND METHODS: In this paper, we summarise the rationale for addressing tobacco use within dentistry and dental hygiene, review the extant policies regarding provision of tobacco-related education, and make recommendations for the content and format of tobacco dependence treatment training in undergraduate curricula and continuing education courses. RESULTS: Although worldwide dental education organisations have policies encouraging their members to provide tobacco cessation services to their patients, there are no national standards for tobacco cessation curriculum in US dental schools. In addition, tobacco cessation is not considered a clinical competency. DISCUSSION AND CONCLUSIONS: For dental professionals to systematically assist their patients to quit tobacco, changes must be made to the ways treatment of tobacco dependence is viewed within dentistry and taught at the undergraduate and post-graduate levels. Until that time, the dental profession will continue to fall short of the Clinical Practice Guidelines and the policies set out by its professional organisations.

A survey of oral and maxillofacial surgeons' tobacco-use-related knowledge, attitudes and intervention behaviors.

BACKGROUND: Oral and maxillofacial surgeons (OMS) treat oral disease attributable to and/or complicated by tobacco use and have unique opportunities to treat patients with tobacco dependence. This study assessed the tobacco-use-related knowledge, attitudes and intervention behaviors of OMS in the United States. METHODS: The authors mailed a 38-item survey to members of the American Association of Oral and Maxillofacial Surgeons (N = 5,234). RESULTS: More than one-half (52.4 percent) of recipients responded; 21.9 percent reported that they assisted tobacco-using patients most of the time; 14.5 percent reported having an awareness of the U.S. Public Health Service Clinical Practice Guideline; and 8.7 percent had received training in treating tobacco dependence. Most respondents (90.1 percent) identified tobacco users and 63.3 percent advised tobacco users to quit; less than 15 percent assisted most patients with various interventions. Most respondents did not view providing tobacco treatment as their professional responsibility. Self-efficacy ratings were low, as was perceived treatment effectiveness. Providers with training performed more interventions, perceived interventions to be more effective, reported greater self-efficacy and perceived fewer barriers than did those without training. Most respondents (71.4 percent) were interested in improving their skills in this area. Being female and having received training in treating patients with tobacco dependence predicted a higher frequency of providing interventions. Current tobacco use by providers predicted a lower frequency of providing interventions. CONCLUSIONS: OMS provide interventions for tobacco use at an unacceptably low rate but report that they desire to improve their skills in this area. Training is associated with a higher frequency of intervention behaviors. PRACTICE IMPLICATIONS: Training is likely to be well-received and to increase the frequency with which dentists provide treatment for tobacco dependence.

A survey of tobacco-related knowledge, attitudes and behaviours of primary care providers in Mississippi.

RATIONALE: Relative to other regions in the USA, Mississippi has a high prevalence of tobacco use and tobacco-related disease. This study assessed the tobacco-related knowledge, attitudes and intervention behaviours of family doctors, dentists and nurse practitioners in the state of Mississippi. METHODS: The Provider Attitude Survey, an 85-item measure of tobacco-related knowledge, attitudes and intervention behaviours was mailed to all members of Mississippi's Family Medicine, Dentistry and Nurse Practitioner professional organizations (N=2043). RESULTS: Over one-third (n=802, 39.2%) of eligible providers responded. Just 24.3% had received training in tobacco cessation and 33.7% were aware of the Public Health Service clinical practice guideline. Over 90% indicated that it was their role to prevent tobacco use; felt rewarded when they helped patients quit; and were bothered and upset by the health effects of tobacco. Doctors assisted more patients than nurses or dentists. Doctors and nurses reported more self-efficacy, motivation and preparedness for treating tobacco use than dentists. Providers with training performed more interventions and reported more self-efficacy, preparedness and fewer barriers than those without training. Training was associated with greater increases in self-efficacy, preparedness and intervention behaviours for dentists than for the other groups. CONCLUSIONS: Despite a high prevalence of tobacco use and tobacco-related disease in Mississippi, primary care providers in Mississippi provide tobacco cessation interventions at an unacceptably low frequency relative to other regions. Training is likely to increase the frequency of intervention behaviours.

Serving the public good: challenges of dental education in the twenty-first century.

The purpose of this study was to explore perceptions of the roles and responsibilities of dental education in serving the public good, and the extent to which they are being met, from the vantage point of leaders at the university and state level. Five questions were developed to gather views on dental education's success in meeting the expectations and needs of the public. Fifty-one interviews were conducted with leaders at seven institutions and with public officials in six states. Overall, dental education was perceived as fulfilling its public purpose in promoting oral health, providing access to care, and conducting relevant research. However, significant areas for improvement were noted including better communication of accomplishments to key stakeholders, graduating a more socially aware, culturally sensitive, and community-oriented dental practitioner, and being a committed partner with other community leaders in improving access to care for all citizens. Current programs aimed at addressing these gaps (e.g., Pipeline, Profession, and Practice program) are discussed. Dental education can address these perceptions only by producing graduates who desire to fulfill their obligations to society and serve the public good.

The 5A's vs 3A's plus proactive quitline referral in private practice dental offices: preliminary results.

AIMS: The primary aim of our randomised control trial (RCT) was to evaluate the relative efficacy of two dental office based interventions compared to usual care. One intervention consisted of a combination of dental practitioner advice to quit and proactive telephone counselling (3A's), and the other arm consisted of a dental practitioner delivered intervention based on the 5A's of the Clinical Practice Guideline (5A's). METHOD: 2177 tobacco using patients were enrolled from 68 dental practices in Mississippi. We collected 3-month outcome data from 76% (n = 1652) of participants. RESULTS: Smokers in the two intervention conditions quit at a higher rate than those in usual care; chi2 (1, n = 1381) = 3.10, p<0.05. Although not significant, more patients in the 5A's condition quit than those in the 3A's. Of patients in the 3A's Condition, 50% reported being asked by their dentist or hygienists about fax referral to the quitline, and 35% were referred. Quitline counsellors contacted 143 (70%) referred participants. CONCLUSION: These results suggest that there are both advantages and disadvantages to the use of quitlines as an adjunct to brief counselling provided by dental practitioners. Patients receiving quitline counselling quit at higher rates than those who did not; however, only a small percentage of patients received counselling from the quitline. Therefore, it appears that dental professionals may be most effective in helping their patients to quit by regularly providing the 5A's plus proactively referring only those patients who are highly motivated to a quitline for more intensive counselling.

Association of specific haplotypes of neurotrophic tyrosine kinase receptor 2 gene (NTRK2) with vulnerability to nicotine dependence in African-Americans and European-Americans.

BACKGROUND: The gene encoding neurotrophic tyrosine kinase receptor 2 (NTRK2) has been localized to a region on chromosome 9q22-q23 that showed a "suggestive" linkage to nicotine dependence (ND) in our previous linkage analyses. However, no association of NTRK2 with ND has been identified. METHODS: Family-based association analyses of 2037 participants (1366 African Americans [AA], 671 European Americans [EA]) representing 602 nuclear families were performed to evaluate association of nine single nucleotide polymorphisms (SNPs) within NTRK2 with ND. RESULTS: Individual SNP-based association analysis indicated that in the EA sample, SNPs rs1659400 and rs1187272 were significantly associated with at least one adjusted ND measure. Haplotype analysis revealed that even after Bonferroni correction, the haplotype T-T-A of rs1659400-rs1187272-rs1122530 had a highly significant positive association, with adjusted ND measures in the EA sample (max Z = 3.78; p = .0001, frequency 59.9%). We further identified a major haplotype, T-G-C-A-A (26%), formed by rs993315-rs736744-rs920776-rs4075274-rs729560, which showed a significant positive association (max Z = 2.97, p = .003) with adjusted ND measures in the AA sample. CONCLUSIONS: These results strongly suggest that NTRK2 is a susceptibility gene for ND. These findings imply that NTRK2 plays a role in the etiology of ND and represents an important biological candidate for further investigation.

A genomewide search finds major susceptibility loci for nicotine dependence on chromosome 10 in African Americans.

Epidemiological studies have demonstrated that genetic factors account for at least 50% of the liability for nicotine dependence (ND). Although several linkage studies have been conducted, all samples to date were primarily of European origin. In this study, we conducted a genomewide scan of 1,261 individuals, representing 402 nuclear families, of African American (AA) origin. We examined 385 autosomal microsatellite markers for ND, which was assessed by smoking quantity (SQ), the Heaviness of Smoking Index (HSI), and the Fagerstrom Test for ND (FTND). After performing linkage analyses using various methods implemented in the GENEHUNTER and S.A.G.E. programs, we found a region near marker D10S1432 on chromosome 10q22 that showed a significant linkage to indexed SQ, with a maximum LOD score of 4.17 at 92 cM and suggestive linkage to HSI, SQ, and log-transformed SQ. Additionally, we identified three regions that met the criteria for suggestive linkage to at least one ND measure: on chromosomes 9q31 at marker D9S1825, 11p11 between markers D11S1993 and D11S1344, and 13q13 between markers D13S325 and D13S788. Other locations on chromosomes 15p11, 17q25, and 18q12 exhibited some evidence of linkage for ND (LOD >1.44). The four regions with significant or suggestive linkage were positive for multiple ND measures by multiple statistical methods. Some of these regions have been linked to smoking behavior at nominally significant levels in other studies, which provides independent replication of the regions for ND in different cohorts. In summary, we found significant linkage on chromosome 10q22 and suggestive linkage on chromosomes 9, 11, and 13 for major genetic determinants of ND in an AA sample. Further analysis of these positive regions by fine mapping and/or association analysis is thus warranted. To our knowledge, this study represents the first genomewide linkage scan of ND in an AA sample.

Significant association of BDNF haplotypes in European-American male smokers but not in European-American female or African-American smokers.

Brain-derived neurotrophic factor (BDNF) influences dopamine and serotonin neurotransmission in the brain, both of which are involved in the reward system of addiction. The BDNF gene is located in a genomic region on chromosome 11p where we and others have found 'significant' linkage to nicotine dependence (ND). We tested the potential role of variants within BDNF in vulnerability to ND, which was assessed by Smoking Quantity (SQ), the Heaviness of Smoking Index (HSI), and the Fagerström Test for ND (FTND). Six single nucleotide polymorphisms (SNPs) in BDNF were analyzed in an extensively phenotyped cohort of 602 nuclear families with smokers and non-smokers of African-American (AA) or European-American (EA) ancestry. Individual SNP analysis revealed that two SNPs in the pooled male and three SNPs in the EA male samples were significantly associated with at least one adjusted ND measure. However, none of these associations remained significant after correction for multiple testing. Haplotype analysis of rs6484320-rs988748-rs2030324-rs7934165 revealed that a major T-C-T-G haplotype was significantly associated, even after Bonferroni correction, with the three ND measures in the pooled and EA male samples (maximum Z = 3.00, P = 0.002 and maximum Z = 3.13, P = 0.0009 for SQ, respectively). No significant association of a major haplotype with ND was found in the AA or EA female smokers. The significant association of BDNF variants with ND implies that this gene plays a role in the etiology of ND in EAs and that its involvement is gender specific. BDNF may warrant further investigation in ND.

Ethnic- and gender-specific association of the nicotinic acetylcholine receptor alpha4 subunit gene (CHRNA4) with nicotine dependence.

We tested six single nucleotide polymorphisms (SNPs) in the alpha4 subunit gene (CHRNA4) and four SNPs in the beta2 subunit gene (CHRNB2) of nicotinic acetylcholine receptors (nAChRs) for association with nicotine dependence (ND), which was assessed by smoking quantity (SQ), the heaviness of smoking index (HSI) and the Fagerstrom test for ND (FTND) in 2037 subjects from 602 nuclear families of either European-American (EA) or African-American (AA) ancestry. Analysis of the six SNPs within CHRNA4 demonstrated that in the EA sample SNPs rs2273504 and rs1044396 are significantly associated with the adjusted SQ and FTND score, respectively. In the AA samples, SNPs rs3787137 and rs2236196 are each significantly associated with at least two adjusted ND measures. Association of rs2236196 with the adjusted HSI and FTND scores in the AA samples remained significant after correction for multiple testing. Furthermore, analysis revealed gender- and ethnic-specific associations for several SNPs with ND measures in both ethnic samples; however, only the association of SNP rs2236196 with the three adjusted ND measures remained significant after correcting for multiple testing in the AA female samples. Haplotype analysis of rs2273505-rs2273504-rs2236196 showed significant association after Bonferroni correction of a C-G-G haplotype (53.4%) with three adjusted ND measures in samples from the AA females. A similar analysis for the four SNPs within CHRNB2 did not reveal significant association with the three ND measures. In summary, our findings provide convincing evidence for the involvement of the nAChR alpha4 subunit, but not of the nAChR beta2 subunit, in nicotine addiction.

Single- and multilocus allelic variants within the GABA(B) receptor subunit 2 (GABAB2) gene are significantly associated with nicotine dependence.

Twelve single-nucleotide polymorphisms (SNPs) in the human gamma-aminobutyric acid type B (GABA(B)) receptor subunit 2 gene (GABAB2) were tested for association with nicotine dependence (ND) in an extensively phenotyped cohort of 1,276 smokers and nonsmokers, representing approximately 404 nuclear families of African American (AA) or European American (EA) origin. The GABAB2 gene encodes a subunit of the GABA(B) receptor for GABA, an inhibitory neurotransmitter involved in the regulation of many physiological and psychological processes in the brain. The gene is located within a region of chromosome 9q22 that showed a "suggestive" linkage to ND. Individual SNP analysis performed using the PBAT-GEE program indicated that two SNPs in the AAs and four SNPs in the EAs were significantly associated with ND. Haplotype analysis using the Family-Based Association Test revealed that, even after Bonferroni correction, the haplotype C-C-G of rs2491397-rs2184026-rs3750344 had a significant positive association with ND in both the pooled and the AA samples. In the EAs, we identified two haplotypes, C-A-C-A and T-A-T-A, formed by SNPs rs1435252-rs378042-rs2779562-rs3750344, that showed a highly significant negative and positive association with ND, respectively. In summary, our findings provide evidence of a significant association of GABAB2 variants with ND, implying that this gene plays an important role in the etiology of this drug addiction.