Minors' tobacco possession law violations and intentions to smoke: implications for tobacco control.

OBJECTIVES: To test: (1) whether citation under the Minors in Possession (MIP) law, vicarious citation (knowing someone who was cited), and threat of driving licence suspension are associated with decreased intentions to smoke next year; and (2) whether the policy is differentially enforced. SUBJECTS: 28,249 white, Hispanic, and African American students in grades 6-12 (11-18 years old) participated in the study. METHOD: The 86 item anonymous Texas Youth Tobacco Survey was completed by students attending 37 schools in 14 east and central Texas communities. RESULTS: Hierarchical linear modelling showed that MIP citation was unrelated to the future smoking intentions of most youth. However, there was a negative association between citation and smoking intentions for ever daily smoking youth at four schools. Threat of licence suspension was associated with a lower likelihood of future smoking intentions among ever daily smoking youth and vicarious citation did not deter youth from future smoking. African American and Hispanic youth had a higher probability of being cited than their peers. CONCLUSIONS: Threat of driving licence suspension has the intended effect upon youth who are/were committed smokers and MIP citation has the intended effect upon committed smokers at only four schools. However, differential enforcement of the law based on ethnicity may be occurring. Before drawing firm conclusions, current findings must be replicated with longitudinal data to determine the consequences of citation on subsequent tobacco use.

Texas Tobacco Prevention Pilot Initiative: processes and effects.

The study was designed to examine how intensity of anti-smoking media campaigns and differing types of anti-smoking community-based programs influence young adolescents' tobacco use and related psychosocial variables. Sixth grade students attending 11 middle schools in eight study communities assigned to varying intervention conditions were assessed by a pre-intervention survey conducted in spring 2000. The assessment was followed by summer and fall 2000 media and community interventions that were evaluated by post-intervention data collection taking place with a new cohort of sixth graders in the same 11 schools in late fall 2000. In analyses conducted at the school level, the enhanced school and comprehensive community program conditions outperformed the no intervention program condition to reduce tobacco use and intentions to use tobacco. Combining the intensive or low media campaign with the comprehensive community program was most effective in suppressing positive attitudes toward smoking, while the enhanced school program alone was less effective in influencing attitudes. The most consistent changes, at least short-term, to reduce teen tobacco use, susceptibility to smoking and pro-smoking attitudes were achieved by combining the intensive media campaign with the comprehensive community program condition.

Individual and contextual factors related to family practice residents' assessment and counseling for tobacco cessation.

BACKGROUND: Tobacco use is the chief avoidable cause of death in the United States. Physicians, however, are not routinely assessing this risk and providing counseling for risk reduction. This study examines tobacco cessation counseling practices among family practice residents and explores the determinants of residents' smoking-counseling behaviors and counseling duration. METHODS: One hundred ten family practice residents (response rate = 93.2%) from four Texas residency training programs completed a survey designed to assess tobacco cessation counseling practices. RESULTS: A high proportion of residents reported that they usually or always assessed tobacco use (59.3%) and advised their patients to quit smoking (80.9%), with a lower proportion reporting specific counseling behaviors (7.3% - 21.9%), referrals (1.8%), or follow-up visits (1.8%). Year of residency, perceived effectiveness, and the interaction between perceived effectiveness and residency year were significantly associated with number of counseling behaviors, and year of residency and perceived effectiveness were significantly associated with counseling duration. CONCLUSIONS: Faculty physicians should assist residents to implement the Public Health Service-sponsored clinical practice guideline for tobacco control. There is a need to increase behavioral skills and perceived effectiveness for assessing and counseling smokers among first-year residents.

The impact of Put Prevention into Practice on selected clinical preventive services in five Texas sites.

OBJECTIVE: To determine whether the implementation of the Put Prevention Into Practice (PPIP) office-based system would increase the delivery rates of specific clinical preventive services among demonstration clinics. METHODS: Chart review was conducted before (n=372) and 33 to 39 months after (n=376) the implementation of the PPIP office-based system in two community health centers and three family practice residency programs in Texas. The population included all adult patients aged > or = 19 years who had presented to the clinic during the study periods. RESULTS: Documentation of timely cholesterol screening increased from 70% to 84%; smoking assessment, from 56% to 80%; for women, up-to-date Papanicolaou smear, from 70% to 81%; annual mammograms (women aged > or =51), from 30% to 48%; and up-to-date tetanus-diphtheria immunizations, from 19% to 59%. For adults aged > or =66 years, documentation of pneumococcal immunization increased from 22% to 48%, while influenza immunizations improved, although not significantly (45% to 49%). Blood pressure screening was almost universal (99%) at baseline and at 33- to 39-month follow-up. CONCLUSION: PPIP system changes were associated with an observed increase in delivery of selected clinical preventive services.

Comparison of participation in federal worksite and community health promotion programs.

The extent to which employees rely on the worksite exclusively for health promotion programs was examined in a cross-sectional study of 10 federal worksites. Responses were received from 3,403 of the 5,757 employees surveyed (59%). Fewer than 10% of employees exclusively used agency programs for physical fitness, nutrition, substance abuse, smoking cessation, and support group meetings. A higher percentage participated in health risk assessment (27%), health and disease risk education activities (17%), medical care services (23%), personal safety and first aid training 26%, and stress management programs (17%) only at the worksite. Men were more likely than women to participate exclusively in workplace programs.

Maintaining prevention in practice: survival of PPIP in primary care settings. Put Prevention Into Practice.

INTRODUCTION: Put Prevention Into Practice (PPIP) consists of a kit of office-based tools intended to support the provision of preventive services by primary care providers. The purpose of this study was to examine the institutionalization of PPIP within five primary care clinics funded by the Texas Department of Health to implement PPIP, and to examine the organizational determinants of program institutionalization. METHODS: We utilized an adaptation of the Level of Institutionalizaton (LoIn) scales for qualitative data collection and for development of an institutionalization score for each site. The determinants of institutionalization were derived from the organizational behavior and health promotion literatures and used as categories for analysis. In addition, for purposes of triangulation, chart audit data for three documentation behaviors were also collected. RESULTS: PPIP has been maintained--at varying degrees of integration--in four of the five sites studied, for 6 years after adoption. Organizational factors that facilitated the institutionalization process were the site's institutional strength, the integration of PIPP within extant programs and services, visibility of the program within and outside the site, planning for the termination of grant funding, and presence of a program champion with mid- to upper-level managerial authority. Successful initiation of the program was not a predictor of institutionalization outcomes. CONCLUSIONS: We have highlighted the need to consider organizational determinants of institutionalization in relation to their specific sociopolitical contexts, and in relation to each other, not in isolation.

Efficacy and safety of troglitazone in the treatment of lipodystrophy syndromes.

BACKGROUND: Troglitazone promotes adipocyte differentiation in vitro and increases insulin sensitivity in vivo. Therefore, troglitazone may have therapeutic benefit in lipoatrophic diabetes. OBJECTIVE: To determine whether troglitazone ameliorates hyperglycemia and hypertriglyceridemia or increases fat mass in lipoatrophic patients. DESIGN: Open-labeled prospective study. SETTING: United States and Canada. PATIENTS: 20 patients with various syndromes associated with lipoatrophy or lipodystrophy. INTERVENTION: 6 months of therapy with troglitazone, 200 to 600 mg/d. MEASUREMENTS: Levels of hemoglobin A1c triglycerides, free fatty acids, and insulin; respiratory quotient; percentage of body fat; liver volume; and regional fat mass. RESULTS: In the 13 patients with diabetes who completed 6 months of troglitazone therapy, hemoglobin A1c levels decreased by a mean of 2.8% (95% CI, 1.9% to 3.7%; P < 0.001). In all 19 study patients, fasting triglyceride levels decreased by 2.6 mmol/L (230 mg/dL) (CI, 0.7 to 4.5 mmol/L [62 to 398 mg/dL]; P = 0.019) and free fatty acid levels decreased by 325 micromol/L (CI, 135 to 515 micromol/L; P = 0.035). The respiratory quotient decreased by a mean of 0.12 (CI, 0.08 to 0.16; P < 0.001), suggesting that troglitazone promoted oxidation of fat. Body fat increased by a mean of 2.4 percentage points (CI, 1.3 to 4.5 percentage points; P = 0.044). Magnetic resonance imaging showed an increase in subcutaneous adipose tissue but not in visceral fat. In one patient, the serum alanine aminotransferase level increased eightfold during the 10th months of troglitazone treatment but normalized 3 months after discontinuation of treatment Liver biopsy revealed an eosinophilic infiltrate, suggesting hypersensitivity reaction as a cause of hepatotoxicity. CONCLUSION: Troglitazone therapy improved metabolic control and increased body fat in patients with lipoatrophic diabetes. The substantial benefits of troglitazone must be balanced against the risk for hepatotoxicity, which can occur relatively late in the treatment course.

Partnerships for comprehensive school health: collaboration among colleges/universities, state-level organizations, and local school districts.

A qualitative survey on the collaborative experiences of colleges and universities, state-level organizations, and school districts related to comprehensive school health programs in 12 states found four primary collaborative outcomes: training, consultation, research, and networking. Five common dimensions of collaboration also were identified: interpersonal and organizational interactions, level of awareness and understanding of comprehensive school health programs, organizational priorities and reward systems, political forces, and availability and sharing of resources. The potential for such linkages to advance comprehensive school health programs remains largely untapped. Recommendations for developing such collaborations are presented.