Effects of reducing television viewing on children's requests for toys: a randomized controlled trial.

Previous attempts to reduce the effects of television advertising on children's purchase requests have had little success. Therefore, we tested the effects of a classroom intervention to reduce television, videotape, and video game use on children's toy purchase requests, in a school-based randomized controlled trial. Third- and fourth-grade children (mean age, 8.9 years) in two sociodemographically and scholastically matched public elementary schools were eligible to participate. Children in one randomly selected elementary school received an 18-lesson, 6-month classroom curriculum to reduce television, videotape, and video game use. In both schools, in September (before intervention) and April (after intervention) of a single school year, children and parents reported children's prior week's purchase requests for toys seen on television. After intervention, children in the intervention school were significantly less likely to report toy purchase requests than children in the control school, with adjusting for baseline purchase requests, gender, and age (odds ratio, 0.29; 95% confidence interval, 0.12-0.69). Among intervention school children, reductions in self-reported purchase requests were also associated with reductions in television viewing. There was no significant difference between schools in parent reports of children's requests for toy purchases. These findings suggest that reducing television viewing is a promising approach to reducing the influences of advertising on children's behavior.

Effects of reducing children's television and video game use on aggressive behavior: a randomized controlled trial.

CONTEXT: The relationship between exposure to aggression in the media and children's aggressive behavior is well documented. However, few potential solutions have been evaluated. OBJECTIVE: To assess the effects of reducing television, videotape, and video game use on aggressive behavior and perceptions of a mean and scary world. DESIGN: Randomized, controlled, school-based trial. SETTING: Two sociodemographically and scholastically matched public elementary schools in San Jose, Calif. PARTICIPANTS: Third- and fourth-grade students (mean age, 8.9 years) and their parents or guardians. INTERVENTION: Children in one elementary school received an 18-lesson, 6-month classroom curriculum to reduce television, videotape, and video game use. MAIN OUTCOME MEASURES: In September (preintervention) and April (postintervention) of a single school year, children rated their peers' aggressive behavior and reported their perceptions of the world as a mean and scary place. A 60% random sample of children were observed for physical and verbal aggression on the playground. Parents were interviewed by telephone and reported aggressive and delinquent behaviors on the child behavior checklist. The primary outcome measure was peer ratings of aggressive behavior. RESULTS: Compared with controls, children in the intervention group had statistically significant decreases in peer ratings of aggression (adjusted mean difference, -2.4%; 95% confidence interval [CI], -4.6 to -0.2; P =.03) and observed verbal aggression (adjusted mean difference, -0.10 act per minute per child; 95% CI, -0.18 to -0.03; P =.01). Differences in observed physical aggression, parent reports of aggressive behavior, and perceptions of a mean and scary world were not statistically significant but favored the intervention group. CONCLUSIONS: An intervention to reduce television, videotape, and video game use decreases aggressive behavior in elementary schoolchildren. These findings support the causal influences of these media on aggression and the potential benefits of reducing children's media use.

Nicotine patch and paroxetine for smoking cessation.

Smokers (N = 224) were randomized to 1 of 3 groups: (a) transdermal system (TNS) + placebo; (b) TNS + paroxetine (20 mg); (c) TNS + paroxetine (40 mg). Assignment to treatment was double-blind. Nicotine patch (TNS) treatment was provided for 8 weeks; paroxetine or placebo was provided for 9 weeks. Abstinence rates at Weeks 4, 10, and 26 were as follows: (a) TNS + placebo: 45%, 36%, and 25%; (b) TNS + paroxetine (20 mg): 48%, 33%, and 21%; (c) TNS + paroxetine (40 mg): 57%, 39%, and 27%. The differences were not statistically significant. The combined treatment was more effective in reducing both craving and depression symptoms associated with smoking cessation. A subgroup analysis comparing compliant participants was also conducted. Abstinence rates at Weeks 4, 10, and 26 were as follows: (a) TNS + placebo: 46%, 35%, and 24%; (b) TNS + paroxetine (20 mg): 64%, 43%, and 33%; (c) TNS + paroxetine (40 mg): 74%, 51%, and 38%. The differences between paroxetine groups and placebo at Week 4 were statistically significant. Although paroxetine may add value to the current standard of care in excess of potential risk, more conclusive evidence is needed.

Effects of a community-wide health education program on cardiovascular disease morbidity and mortality: the Stanford Five-City Project.

The authors examined changes in morbidity and mortality from 1979 through 1992 during the Stanford Five-City Project, a comprehensive community health education study conducted in northern California. The intervention (1980-1986), a multiple risk factor strategy delivered through multiple educational methods, targeted all residents in two treatment communities. Potentially fatal and nonfatal myocardial infarction and stroke events were identified from death certificates and hospital records. Clinical information was abstracted from hospital charts and coroner records; for fatal events, it was collected from attending physicians and next of kin. Standard diagnostic criteria were used to classify all events, without knowledge of the city of origin. All first definite events were analyzed; denominators were estimated from 1980 and 1990 US Census figures. Mixed model regression analyses were used in statistical comparisons. Over the full 14 years of the study, the combined-event rate declined about 3% per year in all five cities. However, during the first 7-year period (1979-1985), no significant trends were found in any of the cities; during the late period (1986-1992), significant downward trends were found in all except one city. The change in trends between periods was slightly but not significantly greater in the treatment cities. It is most likely that some influence affecting all cities, not the intervention, accounted for the observed change.

Do heavy smokers benefit from higher dose nicotine patch therapy?

Heavy smokers (N = 408, smoking more than 25 cigarettes/day) were randomized to receive high-dose (25 mg) or standard-dose (15 mg) nicotine patch therapy delivered during the daytime only (16 hr) for a period of 6 weeks. Treatment effects of each dose were similar. The percentages of participants not smoking at 2-, 6-, and 12-month follow-ups were 26 versus 20, 14 versus 16, and 14 versus 14 for the 15-mg and 25-mg doses, respectively. The higher dose was well tolerated, and adverse event profiles for both treatment doses were very similar. Stepwise Cox proportional hazards analyses indicated that initial postrandomization craving and baseline scores on the Center for Epidemiological Studies Depression Instrument predicted time-to-relapse during treatment; only initial craving predicted relapse over the entire study interval (12 months). The results of this trial do not support the routine use of higher dose nicotine patch therapy in the treatment of nicotine dependence.

Ethnic and socioeconomic differences in cardiovascular disease risk factors: findings for women from the Third National Health and Nutrition Examination Survey, 1988-1994.

CONTEXT: Cardiovascular disease (CVD) risk factors are higher among ethnic minority women than among white women in the United States. However, because ethnic minority women are disproportionately poor, socioeconomic status (SES) may substantially explain these risk factor differences. OBJECTIVE: To determine whether differences in CVD risk factors by ethnicity could be attributed to differences in SES. DESIGN: Third National Health and Nutrition Examination Survey conducted between 1988 and 1994. SETTING: Eighty-nine mobile examination centers. PARTICIPANTS: A total of 1762 black, 1481 Mexican American, and 2023 white women, aged 25 to 64 years, who completed both the home questionnaire and medical examination. MAIN OUTCOME MEASURES: Ethnicity and years of education (SES) in relation to systolic blood pressure, cigarette smoking, body mass index (BMI, a measure of weight in kilograms divided by the square of height in meters), physical inactivity, non-high-density lipoprotein cholesterol (non-HDL-C [the difference between total cholesterol and HDL-C]), and non-insulin-dependent diabetes mellitus. RESULTS: As expected, most CVD risk factors were higher among ethnic minority women than among white women. After adjusting for years of education, highly significant differences in blood pressure, BMI, physical inactivity, and diabetes remained for both black and Mexican American women compared with white women (P<.001). In addition, women of lower SES from each of the 3 ethnic groups had significantly higher prevalences of smoking and physical inactivity and higher levels of BMI and non-HDL-C than women of higher SES (P<.001). CONCLUSIONS: These findings provide the greatest evidence to date of higher CVD risk factors among black and Mexican American women than among white women of comparable SES. The striking differences by both ethnicity and SES underscore the critical need to improve screening, early detection, and treatment of CVD-related conditions for black and Mexican American women, as well as for women of lower SES in all ethnic groups.

Nicotine patch and self-help video for cigarette smoking cessation.

A total of 424 smokers were randomized in a 2 x 2 factorial experiment. A pharmacologic factor contained 2 levels: transdermal nicotine path (TNP; 21 mg) and placebo. A self-help behavioral treatment factor contained 2 levels: video-enhanced self-help treatment manual and self-help treatment manual only. At 2 months, TNP produced a higher level of abstinence (36%) than placebo (20%), p < .001. No other comparison was significant. In secondary analyses, (at 2 months) and compliance with patch treatment regimen (at 2, 6, and 12 months) were associated with less relapse. Although nicotine replacement therapy has improved our ability to produce smoking cessation, the production of sustained, longer term abstinence remains an elusive goal.

Psychiatric risk associated with early puberty in adolescent girls.

OBJECTIVE: This study prospectively evaluated the relationship between early puberty and the onset of internalizing symptoms and disorders in adolescent girls. METHOD: The sample was drawn from 1,463 sixth-, seventh-, and eighth-grade girls who participated in a longitudinal school-based study of growth and development. Pubertal stage was determined by self-assessment of Tanner stage. Psychiatric assessments included self-report instruments and structured diagnostic interviews. Survival methods were utilized for data analysis. RESULTS: Girls with onset of internalizing symptoms were on average 5 months earlier in pubertal development than those who were asymptomatic (p < .001). In addition, girls with earlier maturation (earliest quartile) were more likely to develop internalizing symptoms than were nonearly matures (hazard ratio = 1.8, confidence interval = 1.2, 2.7). In a subsample of girls followed into high school, early-maturing girls were at marginally higher risk (p < .10) for developing internalizing disorders by the study's end. The highest risk for internalizing disorders was for those girls with both early puberty and prior internalizing symptoms (odds ratio = 3.3). CONCLUSION: Early puberty increases the risk of internalizing symptoms and perhaps internalizing disorders in adolescent girls.

Differences in treatment of acute myocardial infarction by sex, age, and other factors (the Stanford Five-City Project).

This study examines the temporal trends in the use of angiography followed by revascularization procedures for acute myocardial infarction (AMI) in 2,021 hospitalized men and 995 women aged 30 to 74 years who participated in the Stanford Five-City Project during the years 1986 to 1992. Our sample included hospitalized patients who received a discharge diagnosis code of 410 through 414 and met study criteria for either a definite or possible AMI. Incident and recurrent infarctions occurring in the years 1986 through 1992 were included, but only the first event in this period for each patient. We performed stepwise multiple logistic regression analysis to determine the probability of: (1) receiving coronary angiography, (2) revascularization by either coronary bypass surgery or angioplasty among those with angiogram, and (3) thrombolytic therapy. Age, year of procedure, disease severity, and time between symptom onset and medical treatment were included as covariates. After adjustment of these factors, women were less likely than men to undergo angiography but were equally likely to undergo revascularization and thrombolysis. Hispanics and whites were equally likely to receive angiography and thrombolysis, but Hispanics were less likely than whites to undergo revascularization. Age and disease severity were inverse predictors of coronary angiography but not of revascularization. Age, severity, and delay time between onset of symptoms and medical therapy were inverse predictors of thrombolysis; delay time was significantly greater in women than in men and averaged > 6 hours in both sexes. The likelihood of receiving angiography, revascularization, and thrombolysis increased sharply over the study period.

Interactive effects of depression symptoms, nicotine dependence, and weight change on late smoking relapse.

Signal detection methods were used to develop an algorithm useful in distinguishing those at risk for late relapse from those likely to maintain abstinence. Four subgroups with 24-month survival (nonrelapse) rates ranging from 79% to 33% were identified. Among participants whose depression symptoms decreased from baseline to the end of treatment, lower levels of nicotine dependence were associated with less relapse at the 24-month follow-up (odds ratio = 2.77; 95% confidence interval: 1.36-5.62). Among participants whose depression symptoms increased from baseline to the end of treatment, greater weight gain was associated with less relapse at follow-up (odds ratio = 2.90; 95% confidence interval: 1.41-5.96). This study suggested that it may become possible to use both baseline and treatment information to "titrate" interventions.

Predicting onset of drinking in a community sample of adolescents: the role of expectancy and temperament.

We report results of a prospective examination of the influence of outcome expectancy variables and inherited temperaments on the onset of drinking over a 12-month period in a sample of 1,164 high school students. While univariate prospective analysis indicated that drinkers and nondrinkers were different both on measures of outcome expectancy and temperament, multivariate analysis supported, most strongly, a social learning account of the processes influencing the onset and maintenance of drinking behavior in this sample. The multivariate analysis revealed that only expectancies for enhanced social behavior were consistently associated with the onset of drinking from baseline to 12-month follow-up (p < .001). Among all nondrinkers at baseline, those entertaining higher expectancies about the positive effects of alcohol on social interaction were more likely to begin drinking between baseline and follow-up. At present, few, if any, alcohol abuse prevention studies with adolescents have explicitly attempted to alter alcohol expectancies or to establish a link between expectancy and behavior change. Our results suggest that it may be useful to do so.

Mortality from coronary heart disease and stroke for six ethnic groups in California, 1985 to 1990.

Coronary heart disease and stroke death rates were compared for six ethnic groups (non-Hispanic white, Hispanic, African-American, Chinese, Japanese, and Asian Indian) by sex and age (25 to 44, 45 to 64, 65 to 84, and 25 to 84 years old) using California census and 1985 to 1990 death data. African-American men and women in all age groups had the highest rates of death from coronary heart disease, stroke, and all causes (except for coronary heart disease in the oldest men). Hispanics, Chinese, and Japanese in all age-sex groups had comparatively low death rates for coronary heart disease and stroke, although stroke was proportionally an important cause of death for Chinese and Japanese groups. Coronary heart disease was an important cause of death for Asian Indians although death rates were generally not higher than those for other ethnic groups. Ethnic differences were most marked for women and younger age groups.

Pursuit of thinness and onset of eating disorder symptoms in a community sample of adolescent girls: a three-year prospective analysis.

Community-based prospective studies are needed to shed light on mechanisms that may influence development of eating disorders and identify variables that could serve as potential targets for prevention efforts. In this paper we examine level of weight preoccupation and other variables prospectively associated with age of onset of eating disorder symptoms over a 3-year interval in a community sample (N = 939) of young adolescent girls. 3.6% (32/887) experienced onset of symptoms over the interval. Only one factor, a measure of Weight Concerns, was significantly associated with onset (p < .001). Girls scoring in the highest quartile on the measure of Weight Concerns had the shortest survival time (12% incidence by age 14.5) and those scoring in the lowest quartile had the highest survival time (2% incidence by age 14.5; p < .001). This finding is consistent with both theoretical and clinical perspectives and represents one of the first prospective demonstrations of a linkage between weight and body shape concerns and later onset of eating disorder symptoms. An understanding of the independent variables that predispose girls to development of symptoms is a useful step towards the establishment of a rational basis for the choice of a prevention intervention target.

Timing and rate of sexual maturation and the onset of cigarette and alcohol use among teenage girls.

OBJECTIVE: To test the hypothesis that the patterns of pubertal progression, early vs late puberty and fast vs slow, are associated with the age at which girls start to drink alcohol and smoke cigarettes. DESIGN: The study included 1463 female students, 10.7 to 18.2 years of age, who were assessed five times during the 2.7-year study. Data regarding pubertal stage, alcohol use, and cigarette use were obtained at each assessment. These data were used to calculate two indexes of pubertal development, the age at which the midpoint of puberty was achieved and the rate of progression through puberty, and the ages when each subject first drank, first drank moderate amounts of alcohol, and first smoked. RESULTS: Girls with earlier puberty (midpoint < 12.2 years) first reported drinking any alcohol at a median age of 12.5 years, 0.7 years younger than girls whose puberty was later. Similarly, girls with earlier puberty reported drinking moderate amounts of alcohol at a median age of 13.7 years, 0.9 years younger than girls with later puberty. Girls with earlier puberty further reported first smoking cigarettes at a median age of 12.8 years, 0.6 years younger than girls with later puberty. The rate of pubertal progression was significantly associated only with the age when girls first drank moderate amounts of alcohol. CONCLUSION: Earlier puberty is associated with a younger age of onset for both drinking and smoking among adolescent girls.

The favorite cigarette of the day.

The choice of a favorite cigarette smoked during a given day varies considerably. Preferences are related to nicotine dependence and the lifestyles of smokers. In a sample of 5124 smokers, the "after-dinner cigarette" was chosen as the cigarette which they would miss most, while the next largest proportion of smokers (33%) said that they would miss the "first cigarette of the morning" most. The latter group scored highest on tests of nicotine dependence. In contrast, infrequent smokers ("chippers") chose the after-dinner cigarette.

An attempt to modify unhealthful eating attitudes and weight regulation practices of young adolescent girls.

This is the first long-term, controlled study evaluating the effectiveness of a prevention curriculum designed to modify the eating attitudes and unhealthful weight regulation practices of young adolescent girls. Nine hundred sixty-seven sixth and seventh-grade girls were randomized to experimental healthy weight regulation curriculum or no-treatment control classes. A prevention intervention was developed around three principal components: (1) Instruction on the harmful effects of unhealthful weight regulation; (2) promotion of healthful weight regulation through the practice of sound nutrition and dietary principles and regular aerobic physical activity; (3) development of coping skills for resisting the diverse sociocultural influences that appear linked to the current popular obsessions with thinness and dieting. The intervention failed to achieve the hoped-for impact. We did observe a significant increase in knowledge among girls receiving the intervention and among high-risk students only, there was a small albeit statistically significant effect on body mass index. These findings question the wisdom of providing a curriculum directed at all young adolescents, most of whom are not at risk to develop an eating disorder. Rather than targeting the entire population, a healthy weight curriculum designed to modify the eating attitudes and unhealthful weight regulation practices of young adolescent girls might better focus on "at risk" students.

Who will relapse? Symptoms of nicotine dependence predict long-term relapse after smoking cessation.

Results of a prospective examination (N = 618) of factors associated with smoking relapse are reported. At 1-year follow-up, a modified version of the Fagerstrom Tolerance Questionnaire (Dependence Index; DI) and a measure of craving entered the logistic model (odds ratio of 2.7 [p less than .001]). At Year 2, only the DI entered the model (odds ratio of 2.2 [p less than .001]). The ability of signal detection analysis (SDA) to produce clinically useful decision rules was also examined. At Year 1, SDA produced 1 subgroup with a 25% nonrelapse rate and another with a 9% nonrelapse rate (odds ratio of 3.4 [p less than .001]). At Year 2, SDA produced 1 subgroup with a nonrelapse rate of 19% and another with a nonrelapse rate of 7% (odds ratio of 3.0 [p less than .001]). The use of signal detection methods may help clinicians to identify those at greater or lesser risk of relapse.

Is puberty a risk factor for eating disorders?

OBJECTIVE: To examine the association between stage of sexual maturation and eating disorder symptoms in a community-based sample of adolescent girls. PARTICIPANTS: All sixth- and seventh-grade girls (N = 971) enrolled in four northern California middle schools. MAIN VARIABLES EXAMINED: Pubertal development measured using self-reported Tanner stage and body mass index (kg/m2). The section of the Structured Clinical Interview for DSM-III-R Disorders (SCID) discussing bulimia nervosa was used to evaluate symptoms of bulimia nervosa. RESULTS: Girls manifesting eating disorder symptoms, while not significantly older than their peers without such symptoms, were more developmentally advanced as determined with Tanner self-staging. The odds ratio for the association between sexual maturity and symptoms was 1.8 (95% confidence interval, 1.2 to 2.8); ie, at each age, an increase in sexual maturity of a single point was associated with a 1.8-fold increase in the odds of presenting symptoms. The odds ratio for the association between body mass index (adjusted for sexual maturity) and symptoms was 1.02 (95% confidence interval, 1.0 to 1.05). There was no independent effect of age or of the interaction between age and the sexual maturity index. CONCLUSIONS: These results suggest that (1) puberty may be a risk factor for the development of eating disorders, and (2) prevention efforts might best be directed at prepubertal and peripubertal adolescents.

Prospective study of factors influencing the development of craving associated with smoking cessation.

There have been few prospective studies of craving following smoking cessation. This paper presents findings from a prospective examination of factors associated with craving over an 8-week treatment period. Two findings merit attention: (1) dependence, as measured by the Dependence Index (DI), was associated with craving at 48 h, 4 and 8 weeks post-cessation. The magnitude of the association between the DI and short-term craving was, at the least, comparable to that previously reported among several biochemical measures of smoke intake; (2) a measure of craving obtained 48 h after smoking cessation was associated with treatment outcome. Forty-three per cent of participants with low initial craving scores were abstinent at a 2-month follow-up compared to only 26% of those with high craving scores. The DI was also associated with participants' status at follow-up. This result is interesting because evidence that craving or other abstinence effects are prospectively associated with outcome has been lacking.

Evaluation of a treatment approach combining nicotine gum with self-guided behavioral treatments for smoking relapse prevention.

1,218 smokers able to quit smoking for 48 hr were randomly assigned to one of 12 cells in a 4 x 3 fully crossed factorial experiment. A pharmacologic factor contained four levels: nicotine polacrilex (gum) delivered ad lib or on a fixed regimen, placebo gum, and no gum. A self-guided behavioral treatment factor contained three levels: self-selected relapse prevention modules, randomly administered modules, and no modules. Those receiving nicotine gum were more likely to be abstinent at the 2- and 6-month follow-ups. The fixed regimen accounted for most of the effect for gum. There was no effect for the relapse prevention module factor. Men and women showed a differential treatment response. Men who received nicotine gum were more likely to be abstinent at each follow-up (2, 6, and 12 months). No treatment was significantly better among women. We conclude that research on different gum chewing regimens is warranted and that further examination of possible gender differences in response to replacement therapy is needed.