Predictors of quitting smoking: the NHANES I followup experience.

There are no published prospective studies on the predictors of spontaneously quitting cigarette smoking in a nationally-representative U.S. population. This paper describes such a study, using a cohort taken from the First National Health and Nutrition Examination Survey (NHANES I, 1971-1975) and traced by the NHANES I Epidemiologic Followup Survey (1982-1984). "Successful" quitting (for at least 1 year at time of followup) was ascertained among 4779 adults (age 25-74 years) who were smokers at the time of NHANES I and not disabled at followup. Independent predictors of quitting (by proportional hazards multiple regression) were: (1) older age; (2) White race; (3) fewer cigarettes smoked/day; (4) higher household income; and (5) hospitalization in the followup period. Predictors of relapse (ex-smokers at NHANES I who were smoking again at time of followup) were: (1) younger age; (2) urban residence; and (3) female gender. These findings have implications for intervention strategies, public health projections and further research.

Personality-based subtypes of chemically dependent patients.

Jackson's Personality Research Form E (PRF) was administered to a large, heterogeneous group of adult inpatients with diagnoses of alcohol and/or drug dependence. Cluster analysis of PRF factor scores yielded five distinct patient subtypes: hostile-dependent, cooperative-nonreflective, socially uninvolved, impulsive-unsociable, and hostile-overcontrolled. The subtypes differed on two MMPI canonical variables and on self-reported high risk factors for substance usage. Implications of the findings for more appropriate matching of patients to chemical dependency interventions are offered.

Clinical applications: the transition from research to practice.

As validated and improved alcoholism treatment methods emerge from Project MATCH and other studies, a dedicated and systematic effort will be needed to incorporate them into ongoing programs, to monitor their success in real world settings and to make adjustments and refinements as needed. Accomplishing this involves responsibilities for both researchers and practitioners. A complex continuum of activities designed to move interventions from research to practice is common to all therapeutic areas, with a fundamental component being researcher-provider interactions. Challenges include "debunking" myths; realistic evaluations of the feasibility of making changes in the treatment system; effective communication between providers and researchers; and proactive guidance from leaders who set standards of practice. Findings from relevant studies in alcoholism research can be assimilated into the treatment system with as little delay as possible as linkages between researchers and providers are strengthened. These linkages will be further strengthened by research in organizational, management and delivery mechanisms conducted by emerging applied research areas such as health services.

Alcoholism treatment matching research: methodological and clinical issues.

Client-treatment matching is an area receiving increased attention both in clinical practice and research with alcoholism. While the notion of potentially improving treatment outcomes by matching has been suggested for some time, there are a number of methodological and practical barriers that have impeded progress in the development of theoretically and clinically relevant matching models. This article provides an overview of the potential benefits of matching, the methodological factors that increase the complexity of research in this area, and some of the clinical barriers that make implementation more difficult. This overview also serves to introduce this special issue of the Journal of Studies on Alcohol, which examines in more detail each of the methodological issues involved in clinical research on treatment matching. While these methodological issues present unique challenges to the clinical researcher, the potential benefits of matching appear promising and should serve to motivate clinicians and researchers to pursue continued work in this area.

Quality of life as an outcome variable in alcoholism treatment research.

Although a number of approaches to measuring alcohol consumption are available, these alone do not reflect the full range of changes that may be associated with response to treatment for alcohol abuse and dependence. What constitutes a sufficient index of response to alcohol treatment? At the very least, research should measure negative consequences of alcohol consumption, although they may be difficult to specify beyond the client's own perception. Associations between alcohol consumption and dimensions of life quality may be negative or positive in value and may be broadly or narrowly conceptualized, depending upon the aims of the study. Although models exist for the conceptualization and measurement of many aspects of quality of life in alcoholism and other fields, much remains to be specified. Still to be accomplished is a careful examination of the interrelationships between alcohol consumption and specific dimensions of life quality, particularly as these interrelationships are affected by time since treatment and client characteristics among other potential mediators and moderators. Project MATCH has attempted a broad assessment of dimensions of life quality beyond alcohol consumption. These variables are viewed as secondary, rather than primary, measures of treatment outcome. The extent to which Project MATCH's strategy was effective is a question that will be answered when we examine the interrelationships among the various dimensions of outcome and the differential effects of treatments on these outcome dimensions.

A chronological review of empirical studies matching alcoholic clients to treatment.

During the past 20 years researchers have become increasingly interested in exploring the benefits of differential assignment of alcoholics to treatments based on client-specific characteristics, rather than searching for a single "most effective" intervention for all clients. Thirty-one empirical studies on "client-treatment matching" are reviewed, particularly from the perspective of how research methodology in this area has evolved. In addition, general observations are provided on how research methodology on this topic can be further enhanced. Finally, several promising interactions between client characteristics and particular interventions are noted, based on empirical studies to date.

Multisite clinical trials in alcoholism treatment research: organizational, methodological and management issues.

Multisite clinical trials have two major advantages over single-site studies: the large sample size of multisite studies allows for adequate statistical power and better representativeness of the population being studied. However, they are more complex to implement than single-site studies. This article reviews previous multisite clinical trials of alcohol abuse and alcoholism, reasons for selecting a multisite design, management of such studies, and some statistical issues.

Psychometric instruments to assist in alcoholism treatment planning.

The clinical practice of alcoholism treatment can be enhanced by the judicious use of standardized psychometric instruments to characterize clients during the course of treatment. Knowledge of key behavioral, personality, and alcohol-specific factors will increase the clinician's ability to select the most appropriate treatment option, or, even if treatment options are limited, at least to develop a treatment plant with the patient's unique needs in mind. Monitoring of progress towards treatment goals can also be facilitated by the use of selected assessment tools. Seven examples of well-validated instruments are discussed, with suggestions on how data derived from them may be applied in the treatment planning process.

Developments in alcoholism treatment research: patient-treatment matching.

This article describes patient-treatment matching, a recent advance in alcoholism treatment research. A general description of the concept is presented and the challenges patient-treatment matching poses for investigators and for treatment providers are described. Project MATCH, a multisite clinical trial designed to test the matching hypothesis is used to illustrate approaches to addressing the research challenge. Two additional avenues of promising patient-treatment matching research, one relating to patient characteristics and the other to pharmacological treatments, are also summarized. The article concludes with a brief prescription for individual providers to implement and test treatment matching strategies in their own clinical practice.

Self-reports of physical, sexual and emotional abuse in an alcoholism treatment sample.

OBJECTIVE: There is a growing appreciation that emotional, physical and sexual abuse events are frequently part of the life histories of individuals in treatment for alcohol disorders. The present study examines reports of lifetime abuse in a clinical trial for treatment of alcohol dependency. METHOD: Data were obtained from baseline assessments conducted with participants (N = 1,726; 1,307 men) entering Project MATCH, a multisite clinical trial conducted at nine geographically dispersed research sites. Differences on a broad range of participant characteristics were examined by gender and by reported abuse type. RESULTS: More than half (59%) of the participants reported lifetime abuse. Women were more likely (77%) to report abuse than were men (54%). A lower proportion of men than women (6% vs 31%) reported experiencing both physical and sexual abuse. Gender differences were found on the majority of psychosocial measures. Comparisons of the psychosocial measures by abuse type generally indicated that participants without abuse histories had better functioning than did participants reporting abuse. CONCLUSIONS: The high frequency of lifetime abuse in this geographically dispersed sample underscores the necessity for including assessment of emotional, physical and sexual abuse with alcoholism treatment seeking populations. Participants reporting such events may require other treatment in addition to that for alcohol dependency.

Telescoping of landmark events associated with drinking: a gender comparison.

OBJECTIVE: The literature suggests that women exhibit "telescoped" development of (i.e., faster progression to) alcoholism, with fewer years drinking than men. The purpose of this study was to use data gathered in the course of a large clinical trial to further examine this issue. METHOD: Subjects in this retrospective study were from a pool of 1,307 men and 419 women enrolled in Project MATCH, a multisite alcohol treatment matching study. MATCH subjects were recruited from both outpatient and aftercare settings over a 2-year period. Age-of-onset for landmark events in the development of alcoholism were determined from self-report and clinical interviews given at baseline entry into the study. Gender differences in age-of-onset variables were assessed within both outpatient and aftercare settings. Gender differences in progression times between successive landmarks were also examined. Differences were tested with both multivariate and univariate ANOVA techniques. RESULTS: Women generally began getting drunk regularly at a later average age than men (26.6 versus 22.7 years, p< or =.001), began experiencing their first drinking problems at a later average age than men (27.5 versus 25.0 years, p< or =.001) and exhibited loss of control over their drinking at a later average age than men (29.8 versus 27.2 years, p< or =.001). However, these gender differences were most pronounced for older individuals and attenuated for younger subjects. Women also progressed faster than men, on average, between first getting drunk regularly and first encountering drinking problems (0.9 versus 2.3 years, p< or =.001) and between first loss of drinking control and onset of worst drinking problems (5.5 versus 7.8 years, p< or =.001). Women also exhibited shorter average progression times between first getting drunk regularly and first seeking treatment (11.6 versus 15.8 years, p< or =.001), although this effect was negligible for younger subjects. CONCLUSIONS: Telescoping is a relatively robust phenomenon in treatment-seeking alcoholics and indicates that women are more likely to progress faster through the landmark events in the development of alcoholism than are men.

Research on matching alcoholic patients to treatments: findings, issues, and implications.

No single treatment has emerged as effective for all persons diagnosed as alcoholics. "Patient-treatment matching" is a method of choosing between alternative treatment options based on particular patient characteristics that interact differentially with interventions to produce more beneficial results than if "matching" had not been done. This review distinguishes three models for interactions between patient characteristics and interventions in terms of their clinical implications. Supporting empirical evidence for matching is also summarized. Requirements for the future research agenda are discussed and the pros and cons of implementing patient treatment matching in the clinical setting are addressed.

Issues in medication adherence assessment in clinical trials of the National Heart, Lung, and Blood Institute.

The mission of the National Heart, Lung, and Blood Institute is to sponsor research in the prevention, diagnosis, and treatment of heart, lung, and blood diseases. As a part of its activities toward this end, the Institute plans and conducts clinical trials that test the safety and efficacy of a broad range of preventive and treatment regimens. Many of these trials involve thousands of patients and require the cooperation of many research clinics under a common protocol, often for many years. An essential component in these efforts is a standardized methodology to allow accurate tracking of adherence patterns so that problem adherence situations can be identified and rectified. This article reviews the methods that have been used to assess adherence patterns in selected clinical trials supported by the NHLBI. The most frequently used methods have been pill count and direct measurement of the drug, its metabolites, or physiological effects in some bodily fluid. Supplementary information is frequently obtained by self-report. Experience with markers has been very limited and no systematic data are available. The Aspirin Myocardial Infarction Study is used as a case study to illustrate specific strengths and weaknesses of three types of adherence assessment methods, namely, assay of salicylates in the urine, platelet aggregation, and pill count. Generalizations to other clinical trials are discussed. Based on experience to date with traditional methods of compliance assessment, several conclusions are drawn. Combinations of measures, in general, provide the most useful profiles of adherence patterns in clinical trials.(ABSTRACT TRUNCATED AT 250 WORDS)

Smokeless tobacco: association with increased cancer risk.

Smokeless tobacco (chewing tobacco and snuff) contains known carcinogens shown to increase the risk for oral cancer. The effect of snuff has been more fully documented than other forms of smokeless tobacco, although the carcinogenic potential of all such products is acknowledged. Risk increases with increasing length of exposure, with risks greatest for anatomic sites where the product has been held in contact the longest time. In some studies, other organs, such as the esophagus, larynx, and stomach, have been shown to be at increased risk for cancer from the use of smokeless tobacco, although at present the data are insufficient to substantiate fully a causal association. Numerous reports have shown an association between snuff use and leukoplakia, with less evidence at present linking chewing tobacco use with leukoplakia. The documented early onset of the smokeless tobacco habit and reports of increases in certain oral cancers among young men raise serious concerns of an impending oral cancer epidemic in this population. In addition, synergistic interactions with other oral cancer risk factors, e.g., smoking and alcohol, and a high rate for second primaries observed for these cancers add to the concern. Unless the tide of its use is stemmed, long-term use can be expected to produce an increase in oral cancers, and perhaps cancers of other sites, as youthful users mature and accumulate exposure to this carcinogenic agent.

Health risks associated with residence near a primary copper smelter: a preliminary report.

Mortality for three groups of ICD codes covering acute, chronic, and malignant respiratory diseases were studied for adult white women in communities near or adjacent to primary copper smelting facilities in the United States between 1968 and 1975, a period when women had not as yet entered the industrial work force. A previous comprehensive survey, sponsored by the EPA, of all U.S. counties used multiple regression analysis as a method of statistical surveillance to assess the association of mortality with industrial activity. This preliminary study suggested an excess mortality from nonmalignant respiratory diseases in copper mining and smelting counties. We directly examined town mortality rates for white female residents, aged 35 to 74, in eight U.S. copper smelting communities and compared them to demographically and geographically matched communities without industries likely to produce significant air pollution, using death certificates obtained from state sources. Site-specific air quality data were also obtained for these communities. Our direct examination of community death rates for copper smelting towns confirmed the preliminary observation at the county level of an excess risk from acute respiratory diseases but did not detect evidence of an elevated mortality from chronic respiratory diseases or cancer of the respiratory tract.

Assessment of double-blindness at the conclusion of the beta-Blocker Heart Attack Trial.

At the conclusion of a double-blinded, randomized clinical trial of propranolol hydrochloride, but before unblinding, the patients and clinic personnel were asked to guess the treatment group assignment of each patient. While 79.9% of the patients receiving propranolol correctly identified their treatment group assignment, 57.2% of the patients receiving placebo incorrectly guessed that they were also in the propranolol group. No specific mechanism was identified to explain why more patients receiving propranolol were better able to guess their group assignment. Clinic physicians correctly identified the group assignment of 69.9% of the patients receiving propranolol and 68.8% of the patients receiving placebo. Clinic coordinators correctly identified the group assignment of 67.1% of the patients receiving propranolol and 70.6% of the patients receiving placebo. For clinic personnel, heart rate level and heart rate change seem to be the mechanisms employed to identify their patients' treatment assignment.

KIE: At the conclusion of the Beta-Blocker Heart Attack Trial (BHAT), a major research project sponsored by the National Heart, Lung, and Blood Institute, investigators conducted a survey to assess the effectiveness of the trial's double-blind design. Patients, physicians, and coordinators were asked to guess the treatment group assignment of each subject. Patients receiving the drug, propanolol, were better able to identify their assignment than those receiving a placebo. Clinic personnel were better able than the patients to differentiate between the two groups, probably due to their monitoring of patients' heart rates. The BHAT researchers concluded that, although double-blindness was not completely achieved, this fact did not influence the conduct of the trial, as no group differences in drug and visit compliance or in the use of concomitant therapy were found.

What are the odds that smoking will kill you?

We calculated the long-term risks of death from smoking for individuals of various ages and smoking status in terms of the excess mortality contributed by smoking, over and above the baseline mortality from the same diseases caused by factors other than smoking using standard life table procedures. Since mortality data for specific smoking categories were available only from prospective studies in the late 1950s, we scaled these to the 1982 mortality levels. We assumed, for lung cancer, that the death rates for nonsmokers have not changed and, for other smoking-related diseases, that the risks of death for smokers relative to those for nonsmokers have not changed since the 1950s. Probabilities that result from alternative assumptions were also investigated and are presented. As many as one-third of heavy smokers age 35 will die before age 85 of diseases caused by their smoking. The probabilities of death from smoking when compared with other causes may be persuasive as public education tools. Their effective use for this purpose is affected not only by the deficiencies in the public's factual knowledge of the magnitude of the risks from smoking, but also by numerous apparent misconceptions relating to the interpretation of risk information. Risk data should be presented to the public in a manner that clarifies these misconceptions and facilitates their understanding of the overwhelming risk imposed by smoking.

Participation in a clinical trial: the patients' point of view.

Little systematic information is available concerning the advantages and disadvantages of participation in a clinical trial from the patients' point of view. Surveys were undertaken among participants in the Beta-Blocker Heart Attack Trial (BHAT) and the Aspirin Myocardial Infarction Study (AMIS) to obtain data on these perceptions. In AMIS, an open-ended personal interview format was employed. For BHAT, a questionnaire partially based on hypotheses generated in AMIS, was mailed out. Results from the two studies suggested that patients in both trials felt that the additional medical monitoring, the opportunity for a "second opinion," and the reassurance received were more important benefits than actual physical improvement. Altruistic motivations were high in both studies. Frequency of perceived disadvantages was low, centering mainly around transportation problems and clinic waiting time. The large majority of patients indicated that they would volunteer for similar research in the future. The results are discussed in the context of the available literature and of the possibilities for extensions of this line of research.

Food and nutrient intake differences between smokers and non-smokers in the US.

Data from the Second National Health and Nutrition Examination Survey were analyzed to determine food and nutrient intake differences between current smokers (also categorized as light, moderate, and heavy smokers) and non-smokers. Smokers in several age-race-sex categories have lower intakes of vitamin C, folate, fiber, and vitamin A than non-smokers, and intake tended to decrease as cigarette consumption increased, particularly for vitamin C, fiber, and folate. Smokers were less likely to have consumed vegetables, fruits (particularly fruits and vegetables high in vitamins C and A), high fiber grains, low fat milk, and vitamin and mineral supplements than non-smokers. A negative linear trend was found between smoking intensity and intake of several categories of fruits and vegetables. These data suggest that the high cancer risk associated with smoking is compounded by somewhat lower intake of nutrients and foods which are thought to be cancer protective.