Impact of vitamin D supplementation on adiposity in African-Americans.

BACKGROUND: African-Americans have higher rates of obesity-associated chronic diseases. Serum 25-hydroxyvitamin D (25(OH)D) shows an inverse association with obesity status. We investigated whether vitamin D supplementation changes body mass index (BMI). SUBJECTS: In total, 328 overweight African-Americans were enrolled over three consecutive winter periods (2007-2010) into a randomized, double-blind, placebo-controlled trial to receive cholecalciferol supplementation (0, 1000 international units (IU), 2000 IU or 4000 IU per day) for 3 months. Plasma concentrations of 25(OH)D and anthropometric measurements were done at baseline, 3 and 6 months. RESULTS: At 3 months, vitamin D supplementation in three dose groups (1000 IU, 2000 IU or 4000 IU per day) did not cause any significant changes in BMI as compared with placebo group 3-month change in BMI per 1000 IU per day estimate (SE): 0.01 (0.039); P=0.78. CONCLUSIONS: In overweight African-Americans, short-term high-dose vitamin D supplementation did not alter BMI.

Home matters: work and household predictors of smoking and cessation among blue-collar workers.

OBJECTIVE: This study examined the joint influence of work- and household-related variables on smoking behavior among a population representative sample of blue-collar workers with live-in partners. METHODS: The study used data on 1389 blue-collar workers from the Tobacco Use Supplement to the United States Current Population Survey 2002 to 2003 longitudinal overlap sample. Unadjusted and adjusted logistical regression analyses, which employed sampling and replicate weights to account for sampling design, were run to estimate independent and joint effects of the predictors. RESULTS: In adjusted analyses, partner smoking (OR=4.97, 95%CI=3.02-8.18) and complete and partial home smoking policy (OR=0.16, 95%CI=0.09-0.29 and OR=0.39, 95%CI=0.23-0.68, respectively) were significant predictors of smoking status, but worksite smoking policies and presence of a young child under 5 in the household were not (p>0.05). Baseline complete home smoking ban was a significant predictor of subsequent cessation (OR=3.49, 95%CI=1.19-10.23), while partner smoking status, workplace smoking policy, and the presence of a young child in the home did not predict cessation (p>0.05). CONCLUSION: Household-related variables were significant predictors of smoking status and cessation among blue-collar workers. Current efforts to decrease smoking in this group, which are mostly focused on work-related risk factors, should consider how to incorporate household risk factors.

Views of female breast cancer patients who donated biologic samples regarding storage and use of samples for genetic research.

Although social and ethical issues related to the storage and use of biologic specimens for genetic research have been discussed extensively in the medical literature, few empiric data exist describing patients' views. This qualitative study explored the views of 26 female breast cancer patients who had consented to donate blood or tissue samples for breast cancer research. Participants generally did not expect personal benefits from research and had few unprompted concerns. Few participants had concerns about use of samples for studies not planned at the time of consent. Some participants did express concerns about insurance or employment discrimination, while others believed that current privacy protections might actually slow breast cancer research. Participants were generally more interested in receiving individual genetic test results from research studies than aggregate results. Most participants did not want individual results of uncertain clinical significance, although others believed that they should be able to receive such information. These data examined the range of participants' views regarding the storage and use of biologic samples. Further research with different and diverse patient populations is critical to establishing an appropriate balance between protecting the rights of human subjects in genetic research and allowing research to progress.

Understanding the potential of teachable moments: the case of smoking cessation.

The label 'teachable moment' (TM) has been used to describe naturally occurring health events thought to motivate individuals to spontaneously adopt risk-reducing health behaviors. This manuscript summarizes the evidence of TMs for smoking cessation, and makes recommendations for conceptual and methodological refinements to improve the next generation of related research. TM studies were identified for the following event categories: office visits, notification of abnormal test results, pregnancy, hospitalization and disease diagnosis. Cessation rates associated with pregnancy, hospitalization and disease diagnosis were high (10-60 and 15-78%, respectively), whereas rates for clinic visits and abnormal test results were consistently lower (2-10 and 7-21%, respectively). Drawing from accepted conceptual models, a TM heuristic is outlined that suggests three domains underlie whether a cueing event is significant enough to be a TM for smoking cessation: the extent to which the event (1) increases perceptions of personal risk and outcome expectancies, (2) prompts strong affective or emotional responses, and (3) redefines self-concept or social role. Research in TMs could be improved by giving greater attention to assessment of conceptually grounded cognitive and emotional variables, appropriately timed assessment and intervention, and inclusion of appropriate target and comparison samples.

Smoking-cessation counseling in the home. Attitudes, beliefs, and behaviors of home healthcare nurses.

BACKGROUND: Despite advances in smoking treatment, cessation rates remain stagnant, possibly a function of the lack of new channels to reach heavily addicted smokers. This cross-sectional study examined home care nurses' attitudes, beliefs, and counseling behaviors regarding counseling their home care patients who smoke. METHODS: Home healthcare nurses (N=98) from the Visiting Nurse Association of Rhode Island were randomly selected to participate in a study helping home-bound medically ill smokers to quit. At baseline, nurses completed a questionnaire that assessed a constellation of cognitive factors (self-efficacy, outcome expectations, perceived effectiveness, risk perception, motivation, and perceived patient adherence) as correlates of self-reported nurse counseling behaviors. RESULTS: Nurses with higher outcome expectations spent more time counseling their patients about quitting (p<0.04). Nurses' self-efficacy was the only variable associated with consistent counseling (p<0.05). While the majority of nurses "asked and advised" their patients, a minority of nurses "assisted or arranged" follow-up. Perceived importance of counseling was associated with a greater likelihood of asking, advising and assisting (p<0.05). None of the nurses who currently smoked (n=13) provided follow-up to their patients. Nurses who reported higher levels of both risk perception (regarding the harmful effects of smoking) and perceived effectiveness were more likely to recommend the nicotine patch. CONCLUSIONS: Attitudes and beliefs about smoking are significantly associated with nurse counseling behaviors. Helping nurses to overcome their barriers to smoking counseling may open up new channels for smoking intervention.

Relationship among alcohol use, depression, smoking behavior, and motivation to quit smoking with hospitalized smokers.

Relationships among depression, alcohol use, and motivation to quit smoking were examined in a sample of 350 hospitalized smokers. Multivariate multiple regression and logistic regression analyses indicated that participants with depressed mood were more likely to have a history of problematic drinking. Participants with depressed mood and a history of problematic drinking were more likely to be nicotine dependent and anticipated greater difficulty refraining from smoking while hospitalized. Alcohol use in heavier amounts was associated with a decreased concern with negative aspects of smoking, whereas history of depression was associated with increased concern in that area. Finally, current drinking was associated with increased confidence in quitting in 1 month whereas depressed mood was associated with decreased confidence in quitting. Overall, depression and alcohol use had stronger associations with smoking-related variables than with smoking cessation motivation variables.

Using theory to understand the multiple determinants of low participation in worksite health promotion programs.

Low participation at the employee or worksite level limits the potential public health impact of worksite-based interventions. Ecological models suggest that multiple levels of influence operate to determine participation patterns in worksite health promotion programs. Most investigations into the determinants of low participation study the intrapersonal, interpersonal, and institutional influences on employee participation. Community- and policy-level influences have not received attention, nor has consideration been given to worksite-level participation issues. The purpose of this article is to discuss one macrosocial theoretical perspective--political economy of health--that may guide practitioners and researchers interested in addressing the community- and policy-level determinants of participation in worksite health promotion programs. The authors argue that using theory to investigate the full spectrum of determinants offers a more complete range of intervention and research options for maximizing employee and worksite levels of participation.

Oral contraceptive use is associated with increased cardiovascular reactivity in nonsmokers.

Women who smoke and take oral contraceptives (OCs) have significantly increased risk of cardiovascular disease, but the exact mechanismsfor the increased risk are not known. Cardiovascular reactivity to psychological stress may be one mechanism for the enhanced risk, but the small number of studies examining whether OC users who smoke have greater reactivity have produced mixed results. The purpose of this study was to examine the effect of chronic cigarette smoking, acute nicotine administration, and OC use on cardiovascular and lipid reactivity. Sixty healthy women, half of whom had been using OCs for at least the previous 6 months, participated in the study. Approximately two thirds were smokers and were randomized to be tested after either a 12-hr nicotine deprivation or administration of nicotine gum. One third were nonsmokers. Heart rate, blood pressure, and lipid measures were taken at rest, during a videotaped speech task, and during recovery from the task. Results indicated that, among OC nonusers, there was no effect of smoking status or nicotine administration on cardiovascular reactivity. However, among OC users, nonsmokers had significantly greater heart rate and diastolic blood pressure reactivity to stress. These data show that acute nicotine administration, in the form of nicotine gum, has no effect on cardiovascular or lipid stress reactivity in women. However OC use among nonsmoking women is associated with greater cardiovascular reactivity to stress.

A randomized trial to reduce passive smoke exposure in low-income households with young children.

OBJECTIVE: Passive smoke exposure among children is widespread in the United States; estimates suggest that almost 40% of children who are younger than 5 years live with a smoker. Few randomized studies of passive smoke exposure reduction among children have been conducted, and the impact of interventions that have been evaluated has been limited. The objective of this study was to determine whether a motivational intervention for smoking parents of young children will lead to reduced household passive smoke exposure. METHODS: Project KISS (Keeping Infants Safe From Smoke), a theory-driven exposure reduction intervention targeting low-income families with young children, was a randomized controlled study in which participants-smoking parents/caregivers (N = 291) who had children who were younger than 3 years and who were recruited through primary care settings-were randomly assigned to either the motivational intervention (MI) or a self-help (SH) comparison condition was used. Follow-up assessments were conducted at 3 and 6 months. The MI condition consisted of a 30- to 45-minute motivational interviewing session at the participant's home with a trained health educator and 4 follow-up telephone counseling calls. Feedback from baseline household air nicotine assessments and assessment of the participant's carbon monoxide level was provided as part of the intervention. Participants in the SH group received a copy of the smoking cessation manual, the passive smoke reduction tip sheet, and the resource guide in the mail. Household nicotine levels were measured by a passive diffusion monitor. RESULTS: The 6-month nicotine levels were significantly lower in MI households. Repeated measures analysis of variance across baseline, 3-month, and 6-month time points showed a significant time-by-treatment interaction, whereby nicotine levels for the MI group decreased significantly and nicotine levels for the SH group increased but were not significantly different from baseline. CONCLUSIONS: This study targeted a large sample of racially and ethnically diverse low-income families, in whom both exposure and disease burden is likely to be significant. This is the first study to our knowledge that has been effective in reducing objective measures of passive smoke exposure in households with healthy children. These findings have important implications for pediatric health care providers, who play an important role in working with parents to protect children's health. Providers can help parents work toward reducing household passive smoke exposure using motivational strategies and providing a menu of approaches regardless of whether the parents are ready to quit.

Intervention and policy issues related to children's exposure to environmental tobacco smoke.

BACKGROUND: Children's exposure to environmental tobacco smoke (ETS) is unacceptably high; almost 40% of children in the United States are regularly exposed to ETS. METHODS: This paper presents a review of the literature that evaluates interventions designed to reduce ETS exposure among young children. In addition, it presents the study design for Project KISS (Keeping Infants Safe from Smoke), an intervention designed to utilize exposure-related feedback to increase parents' motivation for ETS reduction and to reduce household ETS levels. Baseline data are presented to illustrate factors that should be addressed in ETS interventions. RESULTS: The literature review demonstrates the dearth of studies in the literature targeting ETS reduction among children. Participants in Project KISS believed that smoking had affected their children's health and were in later stages of motivational readiness to quit smoking than is typically observed. However, they face a number of challenges to smoking, such as high prevalence of nicotine dependence, high prevalence of living with other smokers, and socioeconomic and stress-related barriers. CONCLUSIONS: The policy implications of this research are discussed, and recommendations are made for future research.

Motivational interviewing in health care settings. Opportunities and limitations.

Motivational interviewing (MI) has been well studied in specialist settings. There has been considerable interest in applying MI to community health care settings. Such settings represent a significant departure from the more traditional, specialist settings in which MI has been developed and tested. The purpose of this paper is to provide a brief overview of MI and to identify and discuss the key issues that are likely to arise when adapting this approach to health care and public health settings. This paper provides an overview of important issues to consider in adapting an effective counseling strategy to new settings, and is intended to begin a dialogue about the use of MI in community health care settings.

Stages of change versus addiction: a replication and extension.

Data from the Working Well trial (n = 2379) were used to test the capacity of 19 variables to predict smoking cessation at 1- and 2-year follow-ups. Among the core constructs of transtheoretical model (TTM), stage of change was the best predictor. The processes of change and the pros and cons of smoking were relatively ineffective predictors. Among other variables, self-efficacy, cigarettes per day, duration of longest quit attempt during the previous year, and the contemplation ladder were the most effective stand-alone predictors. A composite of cigarettes per day and quit duration was particularly effective for predicting cessation. Consistent with Farkas et al. (Farkas AJ, Pierce JP, Zhu SH, Rosbrook B, Gilpin EA, Berry C, Kaplan RM, Addiction 91:1271-1280, 1996), multivariate analyses including the composite variable (cigarettes per day and quit duration) and the stages of change revealed the composite variable to be the better predictor of cessation.

Reported measures of environmental tobacco smoke exposure: trials and tribulations.

OBJECTIVE: This report extends previous summaries of reported environmental tobacco smoke (ETS) exposure measures, reviews the empirical evidence of their validity for children's exposure, and discusses future research. DATA SOURCES: Studies were identified by computer search and from the authors' research. STUDY SELECTION: Studies were selected for inclusion of nicotine and/or cotinine and quantitative reported measures of ETS exposure. DATA SYNTHESIS: Five studies found significant associations between reported quantitative exposure of children to ETS and either environmental nicotine or urine cotinine assays. Correlation coefficients between parent reports and nicotine ranged from 0.22 to 0.75. Coefficients for cotinine ranged from 0.28 to 0.71. Correlations increased over time and were stronger for parents' reports of their own smoking as a source of children's exposure than for reports of exposure from others. CONCLUSIONS: Empirical studies show general concordance of reported and either environmental or biological measures of ETS exposure. Relationships were moderate, and suggest sufficient validity to be employed in research and service programs. Future studies need to identify the differences in types of reported or objective measures, population characteristics, etc, contributing to observed variability in order to understand better the conditions under which more valid reported ETS exposure and other measures can be obtained. Reported and either environmental or biological measures should be used in combination, and existing measures should be directed to interventions that may reduce ETS exposure among children.

Application of motivational interviewing to prenatal smoking cessation: training and implementation issues.

OBJECTIVE: Three of the Smoke-Free Families projects incorporated motivational interviewing (MI) into prenatal smoking cessation interventions. This paper describes the process involved in training healthcare providers to use MI and the issues encountered in implementing the protocols. DESIGN: Health care providers at all three sites attended local training workshops in which they learned to apply the basics of MI to their study protocol. All sites followed a similar outline and schedule for training and monitoring. SETTINGS: The MI interventions were delivered through home visits in Boston, Massachusetts; phone based counselling calls to patients' homes in Southern California; and in urban and rural prenatal clinics throughout East Texas. PARTICIPANTS: Public health nurse and social work case managers, who were already employed by health care agencies, delivered the MI interventions. MEASURES: Pre- and postintervention assessments and feedback from trainers and investigators at all three sites. RESULTS: Providers were enthusiastic about the training workshops, which they rated as effective in preparing them to deliver the intervention. Barriers to implementation included difficulty in contacting patients and competing demands on providers' time. CONCLUSIONS: Conducting initial training for providers is the first step in developing skills to deliver motivational interventions. Additional time and resources are needed for ongoing skill building and monitoring of intervention delivery.

The relationship between organizational characteristics and the adoption of workplace smoking policies.

Organizational-level variables that are hypothesized to influence the level of smoking policy restrictions and the prevalence of smoking control activities were tested in a sample of 1 14 worksites that participated in the Working Well Trial, a national trial of worksite health promotion. Predictors related to more restrictive policies included smaller size, larger percentage of white-collar workers, larger number of complaints about environmental tobacco smoke, less complexity, more formalization, and having a CEO who valued health and employees' well-being. The number of smoking control activities offered in a worksite was predicted by having a larger blue-collar workforce, a higher percentage of female employees, higher levels of workforce stability, and a CEO who valued health and employees' well-being. Efforts to identify predictors of companies' adoption and implementation of workplace-based policies and interventions are an important part of tobacco control efforts and will enhance future intervention and research efforts.

Relapse and maintenance issues for smoking cessation.

This article reviews short-term (6 months) and longer term (12-24 months) maintenance of cessation and relapse in adult smokers and the factors and treatments that affect these outcomes. MedLine and PsycLIT searches were done for research published in English between 1988 and 1998 meeting a defined set of criteria. Intensive intervention, telephone counseling, and use of pharmacotherapy were found to improve outcomes; however, compared with public health approaches, they reach relatively few smokers. Brief interventions during medical visits are cost-effective and could potentially reach most smokers but are not consistently delivered. Predictors of relapse include slips, younger age, nicotine dependence, low self-efficacy, weight concerns, and previous quit attempts. Potential areas for research, recommendations for longer follow-up assessments, and standard definitions for slip, relapse, and long-term maintenance are discussed.