An Antiestrogenic Activity Score for tamoxifen and its metabolites is associated with breast cancer outcome.

PURPOSE: Endoxifen concentrations have been associated with breast cancer recurrence in tamoxifen-treated patients. However, tamoxifen itself and other metabolites also show antiestrogenic anti-tumor activity. Therefore, the aim of this study was to develop a comprehensive Antiestrogenic Activity Score (AAS), which accounts for concentration and antiestrogenic activity of tamoxifen and three metabolites. An association between the AAS and recurrence-free survival was investigated and compared to a previously published threshold for endoxifen concentrations of 5.97 ng/mL. PATIENTS AND METHODS: The antiestrogenic activities of tamoxifen, (Z)-endoxifen, (Z)-4-hydroxytamoxifen, and N-desmethyltamoxifen were determined in a cell proliferation assay. The AAS was determined by calculating the sum of each metabolite concentration multiplied by an IC50 ratio, relative to tamoxifen. The AAS was calculated for 1370 patients with estrogen receptor alpha (ERα)-positive breast cancer. An association between AAS and recurrence was investigated using Cox regression and compared with the 5.97 ng/mL endoxifen threshold using concordance indices. RESULTS: An AAS threshold of 1798 was associated with recurrence-free survival, hazard ratio (HR) 0.67 (95% confidence interval (CI) 0.47-0.96), bias corrected after bootstrap HR 0.69 (95% CI 0.48-0.99). The concordance indices for AAS and endoxifen did not significantly differ; however, using the AAS threshold instead of endoxifen led to different dose recommendations for 5.2% of the patients. CONCLUSIONS: Endoxifen concentrations can serve as a proxy for the antiestrogenic effect of tamoxifen and metabolites. However, for the aggregate effect of tamoxifen and three metabolites, defined by an integrative algorithm, a trend towards improving treatment is seen and moreover, is significantly associated with breast cancer recurrence.

Evidence for a satellite secretory pathway in neuronal dendritic spines.

Long-term information storage within the brain requires the synthesis of new proteins and their use in synapse-specific modifications [1]. Recently, we demonstrated that translation sites for the local synthesis of integral membrane and secretory proteins occur within distal dendritic spines [2]. It remains unresolved, however, whether a complete secretory pathway, including Golgi and trans Golgi network-like membranes, exists near synapses for the local transport and processing of newly synthesized proteins. Here, we report evidence of a satellite secretory pathway in distal dendritic spines and distal dendrites of the mammalian brain. Membranes analogous to early (RER and ERGIC), middle (Golgi cisternae), and late (TGN) secretory pathway compartments are present within dendritic spines and in distal dendrites. Local synthesis, processing, and transport of newly translated integral membrane and secretory proteins may thus provide the molecular basis for synapse-specific modifications during long-term information storage in the brain.

Nicotine patch use in the general population: results from the 1993 California Tobacco Survey.

BACKGROUND: Evidence from controlled clinical trials indicates that use of a transdermal nicotine patch improves abstinence rates up to a year after initial smoking cessation. Whether these results can be generalized to the general population has not been extensively investigated. PURPOSE: We sought to determine what characteristics of smokers trying to quit are associated with nicotine patch use in the general population and whether there is evidence that patch use promotes successful smoking cessation. METHODS: As part of the 1993 California Tobacco Survey, 3281 respondents who had attempted to quit smoking cigarettes within the last year were asked whether they had used a prescribed medication to help them quit smoking and, if so, what type of medication it was. They were also asked whether they used other assistance. RESULTS: Compared with nonusers, patch users (nearly 11% of quitters) were more likely to be female, white or Asian, middle-aged, and to smoke more heavily. Many people relapsed to smoking while they were still using a patch. However, no evidence suggested that the patch was addictive. Use of a nicotine patch did not result in a statistically significant difference in abstinence rates among those who did not also use some other form of assistance (logrank test, P = .466). It did make a statistically significant difference when used in combination with another aid (logrank test, P = .017). At 6 months, abstinence rates were 15% for those without other forms of assistance whether or not they used a patch, 10.9% (95% confidence interval [CI] = 5.1-16.8) for those with other assistance who did not use a patch, and 18.8% (95% CI = 5.7-31.8) for those with other assistance who did use a patch. CONCLUSIONS: The nicotine patch appears to be an important aid to smokers who want to quit, primarily when used as an adjuvant to other forms of assistance. IMPLICATIONS: Further studies are needed to determine what factors are associated with quitting success among patch users.

Duration of smoking abstinence and success in quitting.

BACKGROUND: For most smokers, quitting is a difficult process. Many smokers try to quit repeatedly before they succeed, with some relapsing even after a lengthy period of abstinence. Few population-based cohort studies have examined relapse among former smokers. Quantification of the relationship between the duration of abstinence and the likelihood of continued abstinence is important for the evaluation of ongoing public health interventions and the design of smoking-cessation programs. PURPOSE: We analyzed longitudinal data from a large, representative population cohort of former smokers and estimated the probability of future relapse for different durations of abstinence at baseline (e.g., 1 to <3 months and 3 to <6 months). METHODS: From the 1990 California Tobacco Survey that used a random-digit-dialed computer-assisted telephone survey to interview 24296 California adults (baseline interview) from June 1990 through February 1991, a stratified random sample of 4642 adults was reinterviewed from March 1992 through July 1992. Both surveys assessed smoking status using standard questions about the lifetime use of 100 cigarettes and the self-classification of current smoking: 1) "Have you smoked at least 100 cigarettes in your lifetime?" and 2) "Do you smoke cigarettes now?" We included all 1449 former smokers at baseline interview who answered "yes" to the first question and "no" to the second and who also provided a valid date at both of the surveys when asked, "When did you last smoke regularly?" All data were weighted to account for the study design and to ensure that the estimates were representative of the California population by age, sex, race/ethnicity, education, and geographic region. RESULTS: Only about 12% of the former smokers who had quit for less than 1 month at baseline remained continuously abstinent at the follow-up interview. This percentage increased to 25% for those who had quit from 1 to less than 3 months; it increased again to 52% if the duration of quitting was from 3 to less than 6 months, but it increased only slightly to 59.2% for those who had quit from 6 to less than 12 months. Overall, the likelihood of remaining continuously abstinent until the follow-up interview was about 90% for former smokers who had quit for 3 months or longer and 95% for those who had quit for 1 year or longer. CONCLUSIONS AND IMPLICATIONS: We suggest that self-reported cessation for more than 3 months be considered as an intermediate criterion for success both in longitudinal studies and the cross-sectional evaluation of community interventions. If a more stringent criterion is needed, we recommend self-reported cessation for at least 1 year.

Influence of tobacco marketing and exposure to smokers on adolescent susceptibility to smoking.

BACKGROUND: Today the uptake of smoking is primarily an adolescent pursuit. Awareness of tobacco advertising and promotion is high, and evidence suggests that it plays a role in adolescent smoking uptake. PURPOSE: We evaluated the influence of tobacco advertising and promotion and exposure to smokers on never-smoking adolescents' susceptibility to smoking. METHODS: We used data on 3536 adolescent never smokers (those who had never even puffed on a cigarette) from the 1993 California Tobacco Survey. That survey questioned adolescents about smoking history and inclinations. For this analysis, we defined as susceptible to smoking those never smokers who said on the survey that they could not rule out independently deciding to try a cigarette soon or smoking one offered by a friend. Also for this analysis, we devised two indices: 1) a 5-point index of an individual's receptivity to tobacco advertising as determined by the number of positive responses to five survey items (recognition of advertising messages, having a favorite advertisement, naming a brand he/she might buy, owning a tobacco-related promotional item, and willingness to use a tobacco-related promotional item) and 2) an index classifying an individual's reported exposure to family and peer smoking into one of four levels. Using logistic regression, we assessed the independent importance of our indices in predicting susceptibility to smoking after adjustment for sociodemographic variables, including age, sex, and race/ethnicity, and for perceived school performance. Tests of statistical significance were two-sided. RESULTS: Receptivity to tobacco advertising and exposure to smokers were independently associated with susceptibility to smoking, but the relationship appeared stronger for receptivity to advertising. Adolescents exposed to family members and peers (n = 489) who smoked were 1.89 (95% confidence interval [CI] = 1.30-2.74) times as likely to be susceptible, whereas adolescents who scored 4 or more on the Index of Receptivity to Tobacco Marketing (n = 361) were 3.91 (95% CI = 2.38-6.42) times as likely to be susceptible as those who scored 0. Even adolescents who scored 2 (n = 1090) were 2.03 (95% CI = 1.31-3.15) times as likely to be susceptible. There was no interaction effect between score on the Index of Receptivity to Tobacco Marketing and exposure to smokers. CONCLUSION: Our results support the hypothesis that tobacco marketing may be a stronger current influence in encouraging adolescents to initiate the smoking uptake process than exposure to peer or family smokers or sociodemographic variables including perceived school performance.

Smoking initiation in the United States: a role for worksite and college smoking bans.

Data from four National Health Interview Surveys were combined, and a birth-cohort analysis was undertaken to determine the age when regular smoking is initiated. By the age of 25 years, most smokers have already become regular smokers. Among men, the proportion of each birth cohort who become regular smokers has declined at a rate of about 1.0% for each year of birth since 1945. There has been no identifiable decline in successive birth cohorts of women. For those born in the most recent birth cohorts, there was no sex difference in the proportion who became regular smokers. The proportion of smokers beginning to smoke during the secondary-school years (less than or equal to 18 years of age) has increased steadily, especially among people with a high-school education or less. However, in the latest birth cohort (1960-1962), over 18% of ever smokers with at least a high-school education did not start to smoke regularly until their young-adult years (19-24 years of age). If the effect of tobacco-education programs in the schools is to postpone the uptake of regular smoking, it is important to have tobacco policies in place in other areas of society that will maintain non-smoking behavior through the young-adult years. Accordingly, the banning of smoking in colleges, universities, and worksites, as well as in secondary schools, may significantly decrease the proportion of young people who eventually become regular smokers.

Promoting smoking cessation in the United States: effect of public service announcements on the Cancer Information Service telephone line.

BACKGROUND: Although many smokers report making attempts to quit, few seek help or are successful in their attempts. Some of the barriers to seeking help can be overcome by a telephone counseling and information service like that offered by the Cancer Information Service of the National Cancer Institute. This service has been promoted by antismoking public service announcements produced by the Office on Smoking and Health, Centers for Disease Control, Public Health Service, U.S. Department of Health and Human Services. PURPOSE: We determined whether such nationally televised public service announcements were associated with increased use of the Cancer Information Service. We assessed the importance of specifically promoting the telephone line and identified the characteristics of the individuals who responded to such promotion. METHODS: We combined the frequency-of-call data from the Cancer Information Service with the data on the frequency and reach of the television spots. RESULTS: During this 5-year study (1983-1987), the Cancer Information Service received a notably disproportionate number of calls in 3 specific months (August 1983, January 1985, and January 1987). In each case, more than 20% of all calls in that year were received in that month (expected percentage = 8% if the calls had been evenly distributed). These peak periods were associated with the showing of the three public service announcements that mentioned the telephone number of the Cancer Information Service. These promotions were particularly effective in increasing the percentage of callers who were male, who were under the age of 40 years, or who had received a high school education or less. CONCLUSIONS: Television is an effective medium for supporting antismoking goals by motivating more smokers to seek help to quit. IMPLICATIONS: It is important to identify whether the aid offered by the Cancer Information Service hotline is effective in helping the caller to quit. Future work must concentrate on the most effective strategies for using this initial contact to provide aid to prevent relapse, thus maximizing the potential impact of the public service announcement campaigns.

Quitting smoking in the United States in 1986.

In an analysis of recent behavior with regard to quitting smoking, detailed histories were obtained on a representative sample of 5,623 Americans who had smoked in the year preceding the 1986 Adult Use of Tobacco Survey. An estimated 55.8 million Americans smoked regularly for some period during the year prior to the survey. Approximately one third (34.8%) quit for at least a day during the year prior to the survey, 28.3% quit for at least 7 days during the year prior to the survey, and 16.2% were still not smoking at the time of the survey. Of those who quit for a day, 54% had relapsed by the time of the survey. Demographic characteristics, such as age, sex, race, marital status, and education, were evaluated as predictors of making a major attempt to quit for 7 days or more. Among those who had made a major attempt, a similar analysis was done predicting success in maintaining cessation for 3 months or more. Ordinal logistic regression analyses showed that younger age and higher education predicted a major attempt to quit. There was only one group who differed markedly from all others: those who were younger and were more highly educated. Older age and being white predicted those who abstained for 3 months or longer.

How effective are tobacco industry bar and club marketing efforts in reaching young adults?

OBJECTIVE: Recently, the tobacco industry has focused marketing efforts on young adults through bar and club promotions, such as advertising and distribution of free cigarettes in these settings. This study estimates the fraction of the California young adult population that might be exposed and potentially influenced by these efforts. DESIGN AND PARTICIPANTS: Data were from 9364 young adult (18-29 years) respondents to the cross sectional population based 2002 California Tobacco Survey. As background, we analysed social smoking (only smoke with other smokers), and enjoyment of smoking while drinking. Our main focus was on bar and club attendance, what was observed in bars and clubs, and how this might differ according to respondents' risk for future smoking. RESULTS: Social smokers comprised 30.0 (2.2)% of all current smokers, including experimenters. Nearly three quarters (74.5 (2.3)%) of current smokers/experimenters said they enjoyed smoking while drinking. About one third (33.8 (1.2)%) of all young adults said they attended bars and clubs at least sometimes; attendance was significantly higher among smokers and those at risk for future smoking. Close to 60% (57.9 (2.2)%) of bar and club attenders reported seeing cigarette advertising and promotions in these settings. Again, smokers and those at risk were more likely to report seeing such advertising and promotions in these settings. CONCLUSIONS: About 20% of all young adults and about 30% of those at risk for future smoking (including current smokers) were exposed to tobacco advertising and promotions in bars and clubs. These California results may be conservative, but nonetheless indicate that the group potentially influenced is sizable.

Adolescent smoking decline during California's tobacco control programme.

OBJECTIVE: California's comprehensive tobacco control programme was 13 years old in 2002; by then, children entering adolescence at the start of the programme were young adults. This study examines whether adolescent smoking declined over this period, whether any decline carried through to young adulthood, and whether it was specific to California. SETTING AND PARTICIPANTS: Most data were from the 1990-2002 California Tobacco Surveys (CTS) (adolescents 12-17 years, > 5000/survey, young adults 18-24 years, > 1000/survey). Additional data were from the national 1992/93-2001/02 Current Population Survey (CPS) (young adults 18-24 years, > 15,000/survey). RESULTS: Over the 13 year period in California, ever puffing declined by 70% in 12-13 year olds, by 53% in 14-15 year olds from 1992-2002, and by 34% in 16-17 year olds from 1996-2002 (CTS). As noted, the decline commenced progressively later in each older group. Smoking experimentation (1+ cigarettes) and established smoking (> 100 cigarettes in lifetime) showed similar patterns. Compared to 1990, the percentage of California young adults (CTS data) who ever experimented declined by 14%, with half of the decline from 1999-2002. CPS young adult smoking prevalence (established and now smoke everyday or some days) was constant in the rest of the USA over the entire period, but California showed a recent 18% decline from 1998/99 to 2001/02. CONCLUSIONS: California's comprehensive programme may have kept new adolescent cohorts from experimenting with cigarettes. Low young adolescent experimentation rates at programme start appeared to carry through to young adulthood, resulting in a recent drop in young adult smoking prevalence in California not observed in the rest of the USA.

Thioridazine and the neuroleptic radioreceptor assay.

When the neuroleptic radioreceptor assay (NRRA) has been used to monitor total neuroleptic-like activity (NLA) in the blood of patients taking thioridazine, the NLA values obtained from the NRRA are much lower than values calculated in the same sample by measuring the actual concentrations of parent drug and active metabolites and multiplying these values by the relative potency of each compound. The present report demonstrates that in the NRRA for thioridazine or its active metabolites, the normal displacement of [3H]-spiperone from striatal membranes by thioridazine is altered in the presence of sera. The inclusion of serum (50 microliter/ml) distorts the sigmoidal displacement curves, such the resulting log-logit (or Hill) slope is markedly decreased. Similar serum-induced changes in the log-logit slope are seen for two active metabolites of thioridazine, but not for chlorpromazine or haloperidol. As a consequence, when one of these latter drugs is used as a standard, the NRRA substantially underestimates the actual NLA (chlorpromazine equivalents) values for patients treated with thioridazine. Moreover, because of differences in the magnitude of the effect with serum from different individuals, it is not possible to control completely for this effect. Thus, these data reconcile discrepancies that have been reported for data from the NRRA versus that from direct analytical measurements, and demonstrate that the use of the NRRA as a quantitative tool in the clinical pharmacology of thioridazine may lead to erroneous estimations of active drug and metabolites in the blood.

Projecting international lung cancer mortality rates: first approximations with tobacco-consumption data.

Cigarette smoking is strongly associated with later lung cancer; British data show a 0.83 correlation between tobacco consumption and lung cancer mortality 21 years later. We apply a simple tobacco-consumption model to data from countries in the Organization for Economic Cooperation and Development (OECD) to test the model in some nations and to roughly estimate future rates in others. This analysis provides some indication of the usefulness of the model, which could be applied to predictions for countries in which data are limited. This model predicts a US decline in male lung cancer mortality of approximately 25% by 2005 (a plausible prediction given recent declines in birth-cohort-specific lung cancer mortality rates); it also predicts reasonably well the start of documented declines in lung cancer mortality. According to this admittedly simple model, lung cancer mortality rates will increase in most European countries and Japan until 2000, but the twenty-first-century lung cancer epidemic will mostly occur in Asia.

Single fiber studies of ascending input to the cuneate nucleus of cats: I. Morphometry of primary afferent fibers.

The morphology of afferent fibers ascending to the cuneate nucleus has been examined in this and the subsequent paper in order to quantify the pattern of arborization and bouton arrangement of selected classes of primary afferents and to compare these data with data from postsynaptic fibers ascending to the cuneate nucleus. Electrophysiologically identified G hair and Ia muscle afferent fibers in the cuneate fasciculus were intraaxonally injected with horseradish peroxidase. Cutaneous afferents terminated dorsal to proprioceptive afferents, especially at middle levels of the cuneate nucleus. The spacing of collaterals along G hair fibers was variable, but averaged 1.46 collaterals per mm; collateral density was higher at middle cuneate levels than in the rest of the nucleus. Collateral density of Ia fibers was lower than for G hair fibers and was lowest at caudal levels of the nucleus. Branches of G hair collaterals, though often initially diverging, usually converged to terminate in a single focus in the dorsal part of the nucleus. The probability of bifurcation of Ia collaterals decreased steadily at successive branch points. These collaterals branched less symmetrically than G hair collaterals, and terminated in the ventral cuneate with less dense arbors, stretched mediolaterally, but of comparable cross-sectional area. Individual G hair collaterals gave rise to more boutons than Ia collaterals; in both cases they were mostly of the en passant type. Boutons were restricted to distal branches of G hair collaterals, whereas boutons of Ia collaterals were also located on proximal branches. Bouton size was similar for the two classes of collaterals. The data reported here, in combination with the published literature, suggest that the collaterals of roughly 300 G hair fibers overlap at any given point at middle levels of the cuneate nucleus. This high degree of anatomical convergence is not predicted by the functional segregation described with electrophysiological mapping, implying the presence of intrinsic nuclear mechanisms enhancing response specificity.

Single fiber studies of ascending input to the cuneate nucleus of cats: II. Postsynaptic afferents.

The morphology of single postsynaptic afferent fibers terminating in the feline cuneate nucleus was investigated by using transport of Phasolus vulgaris leucoagglutinin from the cervical spinal cord and intraaxonal injections of horseradish peroxidase into identified postsynaptic fibers in the cuneate fasciculus. Injections of Phaseolus in C5 and C6 of both rhizotomized and non-rhizotomized cats gave similar results and confirmed previous observations with other techniques. In one animal with the smallest injection and the fewest labeled fibers in the cuneate nucleus, ten individual collaterals were reconstructed from serial sections. Most of these collaterals were at middle levels of the cuneate (from obex to about 4 mm caudal to it); they were largely confined to the rim and ventral regions of the nucleus, and their terminal fields were restricted rostrocaudally. Electrophysiologically identified fibers stained with horseradish peroxidase had large receptive fields on the ipsilateral forepaw, and latencies suggesting an oligosynaptic link to the periphery. Most of the collaterals from these fibers were also at middle cuneate levels and terminated mainly at the periphery of the nucleus but gave rise to larger terminal arbors, including sparse terminal branches to the core of the nucleus. Individual postsynaptic fibers differed in several respects from primary afferent fibers. While the spacing of collaterals of postsynaptic fibers was intermediate between that of G hair and Ia fibers, their arbors were larger than either, and could extend through the dorsoventral extent of the cuneate nucleus. The pattern of bifurcation of postsynaptic fibers resulted in stringier arbors which encompassed larger and less dense terminal fields than those of primary afferents. The number of boutons per collateral was intermediate between G hair and Ia fibers, but boutons of postsynaptic fibers were substantially smaller. These morphological differences are consistent with distinct functional roles for the two main ascending afferent systems, as suggested by electrophysiological data.

Selective changes in hippocampal neuropeptide Y neurons following removal of the cholinergic septal inputs.

The number and distribution of subpopulations of hilar interneurons containing neuropeptide Y (NPY), somatostatin (SOM), or gamma-aminobutyric acid (GABA) immunoreactivities were examined in the hilus of the dentate gyrus following removal of the cholinergic septal inputs. One, 2, 4, 8, 12, and 24 weeks after intracerebroventricular injections of immunotoxin, consisting of antibody to the low-affinity nerve growth factor receptor conjugated to saporin (192 IgG-saporin), lesioned rats were processed simultaneously with controls for NPY, SOM, or GABA immunolabeling. Across all time points, the number of NPY-labeled neurons was reduced to a statistically significant level (paired t-test, P = 0.001) in the injected rats (73% of control values, on average). The decrease in the number of NPY-labeled neurons was not limited to any particular subregion rostrally but appeared greater in the central region caudally. The size of NPY-labeled neurons did not differ statistically between control and immunolesioned rats examined at 1, 2, and 24 week time points. In contrast, the number of both SOM- and GABA-immunoreactive neurons in injected rats did not appear to be affected in any consistent manner. Examination of the hilus in adjacent Nissl-stained sections with the optical dissector revealed that although the total number of small nonprincipal cells (5-15 microm in diameter) did not appear affected at the 4-week time point, there was a statistically significant (P = 0.03) reduction across the 8-24-week time points (to 80% of control values, on average). Dual-labeling studies on separate rats showed that a small subpopulation of the NPY- and SOM-labeled neurons, primarily in the infragranular hilus, were colocalized with neurons containing GABA immunoreactivity (18% and 5%, respectively). These studies demonstrate that removal of the cholinergic septal inputs (1) can cause relatively rapid, selective decreases in the number of NPY-immunoreactive hippocampal interneurons and (2) appears to lead to the death of hippocampal interneurons over a longer time course. The changes in NPY immunoreactivity seem to occur in the portion of interneurons that probably does not contain either SOM or GABA immunoreactivity.

Measuring smoking cessation: problems with recall in the 1990 California Tobacco Survey.

Measures of quitting activity are important both to evaluate public health interventions and to predict the likelihood of future quitting in the individual smoker. In population surveys, such measures are generally based on recall and thus may lack validity. In this article, we present the results of a 1-year quitting history of 8924 persons from a random-digit dialed population survey conducted in California in 1990. Respondents often forgot dates of quit attempts other than the most recent. Also, our results suggest that respondents may not recall short quit attempts at all, especially if they took place more than a few months before the interview. Thus, accurate population measures of relapse rates or quitting activity should rely on recall only for the last few months before the interview. Using data from quit attempts that took place within 4 months of the interview, actuarial analysis showed that 71.1% of attempts lasted at least 2 days, 58.5% at least 3 days, but only 39.2% lasted a week or more; this rate dropped to 19.6% at 1 month and to 14.1% at 3 months. As a predictive measure, a quit attempt that lasted a week or longer in the last year appears less biased by recall than any attempt of a day or longer in the last year.

Changes in the patterns of initiation of cigarette smoking in the United States: 1950, 1965, and 1980.

We examined changes in the patterns of the rates of smoking initiation in the United States by gender for 1950, 1965, and 1980. Data from National Health Interview Surveys on the ages people started smoking (survey years 1970, 1978, 1979, 1980, 1987, and 1988) were used to construct age-specific rates of smoking initiation for males and females 10 to 24 years of age for 1950, 1965, and 1980. We used information from 87,483 white respondents who were between 20 and 50 years of age when surveyed. In 1950, initiation was higher for males of all ages than for females, and smoking initiation rates were higher among those age 18 years and older compared to those younger. Although still somewhat higher, the rates for males in 1965 had declined much more than those for females, and the tendency for higher rates in older youth was still evident. In 1980, no gender difference was seen and most initiation clearly took place in those younger than 18 years of age. We concluded that the public health campaign has been successful in convincing older youth not to smoke. However, smoking initiation rates in younger adolescents have changed little, indicating that new approaches to tobacco control are necessary if smoking prevalence in the United States is to be further reduced.

Can strategies used by statewide tobacco control programs help smokers make progress in quitting?

Many states have recently adopted programs to encourage smokers to quit. Here, we seek evidence that strategies generally used by these programs have the potential to influence smoking cessation. In California, 1,736 smokers from a population-based telephone survey were interviewed in 1990 and 1992. We examined the association of demographic and program-related variables (reporting of work area smoking bans; belief in the harmfulness of environmental tobacco smoke, including in-home smoking restrictions; and quitting assistance) with quitting progress. Smokers were categorized into levels in a previously developed Quitting Continuum, which considers their addiction level and quitting history. Smokers in each higher continuum category had an increased likelihood of future successful cessation. Smokers progressed if they were at a higher continuum level in 1992 than in 1990. College graduates showed 2.3 times more progress than did high school dropouts. Smokers reporting work area smoking bans showed 1.6 times more progress than did workers not reporting such restrictions. Smokers with the strongest beliefs (home smoking restrictions) regarding the harmfulness of environmental tobacco smoke showed 3.4 times more progress than smokers with no belief. Smokers who reported having some form of cessation assistance showed 3.0 times more progress. The more program-related factors were reported, the higher the rate of progress was: 13.1% for those reporting no factors, 23.4% for one factor, and 40.6% for two or more. These results suggest but do not prove that strategies promoted by statewide tobacco control programs can potentially be effective and that these efforts should be continued and expanded.

Low-energy reporting in women at risk for breast cancer recurrence. Women's Healthy Eating and Living Group.

This study examined the extent of low-energy reporting and its relationship with demographic and lifestyle factors in women previously treated for breast cancer. This study used data from a large multisite clinical trial testing the efficacy of a dietary intervention to reduce risk for breast cancer recurrence (Women's Healthy Eating and Living Study). Using the Schofield equation to estimate energy needs and four 24-h dietary recalls to estimate energy intakes, we identified women who reported lower than expected energy intakes using criteria developed by G. R. Goldberg et al. (Eur. J. Clin. Nutr., 45: 569-581, 1991). We examined data from 1137 women diagnosed with stage I, stage II, or stage IIIA primary, operable breast cancer. Women were 18-70 years of age at diagnosis and were enrolled in the Women's Healthy Eating and Living Study between August 19, 1995, and April 1, 1998, within 4 years after diagnosis. The Goldberg criteria classified about one-quarter (25.6%) as low-energy reporters (LERs) and 10.8% as very LERs. Women who had a body mass index >30 were almost twice (odds ratio, 1.95) as likely to be LERs. Women with a history of weight gain or weight fluctuations were one and a half times as likely (odds ratio, 1.55) to be LERs as those who were weight stable or weight losers. Age, ethnicity, alcohol intake, supplement use, and exercise level were also related to LER. Characteristics (such as body mass index, age, ethnicity, and weight history) that are associated with low-energy reporting in this group of cancer survivors are similar to those observed in other populations and might affect observed diet and breast cancer associations in epidemiological studies.

Regional differences in the incidence and treatment of carcinoma in situ of the breast.

Greater use of mammography in the United States in recent years has increased the detection of early neoplasms of the breast, including carcinoma in situ. However, the occurrence and treatment of diagnosed carcinoma in situ of the breast has not been fully described. Our goal was to examine temporal, geographic, and demographic patterns in the incidence and treatment of in situ breast cancer. The study included data from all women with in situ breast cancer that had been detected in the nine Surveillance, Epidemiology, and End Results areas of the United States from 1975 through 1990 (Surveillance Program, Cancer Statistics Branch, Bethesda, MD: National Cancer Institute, November, 1993). We calculated age-adjusted incidence rates (1970 United States standard) using data on histology and treatment from the Surveillance, Epidemiology, and End Results data tape. We assessed predictors of treatment by mastectomy using multiple logistic regression. From 1975-1979 to 1986-1990, the age-adjusted incidence rate of in situ breast cancer increased from 4.7 to 16.9/100,000 women. The increase occurred in all age groups and among both white and black women. However, there was nearly a 2-fold difference in incidence rates across geographic areas in 1986-1990, ranging from < 12/100,000 in Iowa and New Mexico to > 20/100,000 in San Francisco and Seattle. Geographic variability in treatment was also evident, with mastectomy, rather than breast-conserving therapy, performed on 46% of the women with in situ breast cancer in San Francisco and on 66% of those in Iowa. The incidence of diagnosed in situ breast cancer increased markedly during the 1980s, and there was substantial geographic variability in the rates of detection of these tumors and in the type of therapy received. Although mastectomy became a less common treatment over time, it was still performed on a high proportion of women with in situ breast cancer during the latter part of the decade.