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Introduction: Cervical cancer is the second leading cause of cancer death among women in the Dominican Republic, and high rates persist despite existing Pap smear screening programs. The purpose of this study was to explore Dominican women’s knowledge and attitudes regarding human papillomavirus (HPV) and cervical cancer, cervical cancer screening practices, and perceived barriers and facilitators to early detection of cervical cancer. Method: Six focus groups ( N = 64) were conducted in Spanish in urban, suburban, and rural locations, in private and public school settings, community and workplace settings, in or near Santo Domingo, as part of a larger study on barriers and facilitators to HPV vaccine implementation. Audio recordings were transcribed verbatim and translated from Spanish to English. Qualitative data analysis used inductive and deductive approaches. Results: Knowledge regarding HPV and cervical cancer varied across groups, but all agreed there was significant stigma and fear regarding HPV. Most women reported having Pap screening at least yearly. Follow-up of abnormal Pap testing was less consistent, with cost and uncertainty about provider recommendations identified as barriers. Discussion: Broader examination of provider-level and health system barriers and facilitators to cervical cancer prevention in the Dominican Republic is essential, in order to inform interventions to improve the effectiveness of cervical cancer screening and treatment programs and reduce preventable deaths.

The Tobacco Master Settlement Agreement Numerous public health problems could be targets for litigation or settlements similar to the Master Settlement Agreement, including the opioid epidemic, firearm violence, excessive consumption of fast food and sugar-sweetened beverages, alcohol use, and climate change.

The author comments on the progress of tobacco control. According to the author, smoking rates are decreasing but population growth is increasing the number of smokers. Additional topics of discussion include the Framework Convention for Tobacco Control, the reduction in tobacco advertising, and the use of electronic cigarettes.

Public health education is experiencing record growth and transformation. The current emphasis on learning outcomes necessitates attention to creating and evaluating the best curricula and learning methods for helping public health students develop public health competencies. Schools and programs of public health would benefit from active engagement in pedagogical research and additional platforms to support dissemination and implementation of educational research findings. We reviewed current avenues for sharing public health educational research, curricula, and best teaching practices; we identified useful models from other health professions; and we offered suggestions for how the field of public health education can develop communities of learning devoted to supporting pedagogy. Our goal was to help advance an agenda of innovative evidence-based public health education, enabling schools and programs of public health to evaluate and measure success in meeting the current and future needs of the public health profession.

Correspondence avoid surgery in rapidly progressive or chemo-insensitive disease. 4 Genotyping of pancreatic tumours via fine needle aspiration could influence the clinical management of pancreatic cancer. Fine-needle aspiration sequencing was used to identify subgroups of patients with specific actionable mutations related to resectable or locally advanced tumours. 5 In patients with radiologically resectable or borderline resectable tumours, preoperative fine-needle aspiration sequencing could distinguish between patients with a genetic pattern associated with micrometastatic tumours, who should undergo neoadjuvant therapy, and those with a truly localised disease that would be amenable to a surgery-first strategy. Michele Reni has served as a consultant for or on the advisory boards of Celgene, Boehringer-Ingelheim, Lilly, Genentech, Baxalta, Novocure, Astra-Zeneca, Pfizer, and Merck-Serono, and has received honoraria from Celgene. Massimo Falconi has received honoraria from Celgene, Ipsen and Novartis. The other authors declare no competing interests. *Stefano Crippa, Michele Reni, Gianpaolo Balzano, Claudio Doglioni, Massimo Falconi crippa1.stefano@hsr.it Division of Pancreatic Surgery, IRCCS San Raffaele Hospital, Milan, Italy (SC, GB, MF); Medical Oncology Department, IRCCS San Raffaele Hospital , Milan, Italy (MR); Department of Pathology, IRCCS San Raffaele Hospital , Milan, Italy (CD); Clinical and Translational Research Program on Pancreatic Cancer, IRCCS San Raffaele Hospital, Milan, Italy (SC, MR, GB, CD, MF) e178 Barreto SG, Windsor JA. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24 Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefit of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; 103: 179–91. Bapat AA, Hostetter G, Von Hoff DD, Han H. Perineural invasion and associated pain in pancreatic cancer. Nat Rev Cancer 2011; Sohal DP, Walsh RM, Ramanathan RK, Khorana AA. Pancreatic adenocarcinoma: treating a systemic disease with systemic therapy. J Natl Cancer Inst 2014; 106: dju011 Valero V, Saunders TJ, He J, et al. Reliable detection of somatic mutations in fine needle aspirates of pancreatic cancer with next-generation sequencing: implications for surgical management. Ann Surg 2016; Author’s reply Stefano Crippa and colleagues, in responding to our manuscript, 1 agree that increasing the radicality of surgery for pancreatic ductal adenocarcinoma, including synchronous vein resection, is suspect. Indeed, a recent meta-analysis 2 indicates that synchronous vein resection, as reported, increases mortality and decreases survival. Crippa and colleagues put forward two interesting ideas that warrant further discussion. The first is that the surgery-first approach for pancreatic ductal adenocarcinoma might ultimately be retired, given that pancreatic ductal adenocarcinoma is usually systemic at presentation, local treatments have little effect, and neoadjuvant therapy has possible benefits. For now, the absence of high-level evidence for neoadjuvant therapy leaves largely theoretical benefits; namely that neoadjuvant therapy will reveal the biology (ie, those patients that can progress on neoadjuvant therapy will avoid futile surgery), or alter the biology (ie, those patients that are downstaged will become resectable). The preliminary results of the ALLIANCE trial 3 damages the lustre of these purported benefits with no improvement in the number of resections (10 [50%] of 20 patients who completed all preoperative therapy), and no rescue of aggressive tumour biology. This leads to the second idea, in which Crippa and colleagues suggest a biological (rather than radiological) basis for selecting patients for neoadjuvant therapy with a view to reduce the number of synchronous vein resections. Endoscopic ultrasonography- guided genotyping is a possible way to select subgroups of patients with heterogenous pancreatic ductal adenocarcinoma 4 who will benefit from neoadjuvant therapy. In support of this method, Hruban and colleagues 5 suggested that an intact SMAD4/DPC4 gene might be used to select surgery because there is lesser risk of distant metastases for this genotype. 6 In the future, we hope to more accurately select a subgroup of patients in whom a surgery-first approach, and even synchronous vein resection, is justified, but it is much more likely that precision neoadjuvant therapy will ultimately result in less radical surgery and the introduction of non-surgical techniques to support the response to neoadjuvant therapy. We declare no competing interests. Savio G Barreto, *John A Windsor j.windsor@auckland.ac.nz Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India (SGB); Hepatobiliary Pancreatic and Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand (JAW) Barreto S, Windsor J. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24. Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; Varadhachary G, Fleming J, Crane C, et al. Phase II study of preoperation mFOLFIRINOX and chemoradiation for high-risk resectable and borderline resectable pancreatic adenocarcinoma. Proc Am Soc Clin Oncol 2015; 33 (suppl 3): abstr 362. Killock D. Pancreatic cancer: a problem quartered—new subtypes, new solutions? Nat Rev Clin Oncol 2016; 13: 201. Hruban RH, Adsay NV. Molecular classification of neoplasms of the pancreas. Hum Pathol Iacobuzio-Donahue CA, Fu B, Yachida S, et al. DPC4 gene status of the primary carcinoma correlates with patterns of failure in patients with pancreatic cancer. J Clin Oncol 2009; The US Cancer Moonshot initiative We recently sent the following letter to Vice President of the USA, Joe Biden, to state that we, as Deans and Directors of Public Health schools and programmes around the USA, strongly support the goals of the Cancer Moonshot initiative to www.thelancet.com/oncology Vol 17 May 2016

Objectives. We examined the effectiveness of a program to increase exposure to national “truth” tobacco countermarketing messages among youths in rural and low-population-density communities. Methods. A longitudinal survey of 2618 youths aged 12 to 17 years was conducted over 5 months in 8 media markets receiving supplemental advertising and 8 comparison markets receiving less than the national average of “truth” messages. Results. Confirmed awareness of “truth” increased from 40% to 71% among youths in treatment markets while remaining stable in comparison markets. Over 35% of all youths who were unaware of the campaign at baseline became aware of it as a direct result of the increased advertising. Youths living in rural and low-population-density communities were receptive to the campaign's messages. Conclusions. Through purchase of airtime in local broadcast media, the reach of a national tobacco countermarketing campaign was expanded among youths living in rural and low-population-density areas. This strategy of augmenting delivery of nationally broadcast antitobacco ads can serve as a model for leveraging limited tobacco control resources to increase the impact of evidence-based tobacco prevention campaigns.

OBJECTIVES To develop, implement, and assess the efficacy of a comprehensive, evidence-based smoking cessation program for entertainment industry workers and their families. METHODS Study participants were recruited from 5 outpatient medical clinics and a worksite setting. Tobacco use data were collected during the initial counseling visit and at 6-month follow-up. Univariate and multivariate regressions were used in analysis. RESULTS More than 50% of participants (n=470) self-reported 7-day abstinence at follow-up. The majority of participants used combination cessation medications, with more than 50% still using at least 1 medication at 6 months. CONCLUSIONS This evidence-based smoking cessation program using behavioral counseling and combination pharmacotherapy was successful with entertainment industry workers.

This paper describes adult women's knowledge of the leading causes of cancer mortality among women. Exposure to antismoking advertisements or media messages also is examined as a potentially effective mechanism for changing inaccurate beliefs. We used data from the 2002 and 2003 American Smoking and Health Survey (ASHES), a national telephone survey of adults, to measure women's knowledge about cancer mortality. Logistic regression models were used to estimate the likelihoods of women indicating either breast or lung cancer as the leading cause of cancer mortality among women. The independent influence of individual characteristics such as race, smoking status, education, and awareness of antismoking messages or advertising on women's knowledge of cancer mortality was assessed. Overall, 66.7% of women inaccurately indicated breast cancer as the leading cause of cancer death among women, whereas 29.7% of women correctly indicated lung cancer. Black women were 43% less likely than White women to indicate lung cancer as the leading cause of cancer mortality among women. Current smokers were 35% less likely than noncurrent smokers to state that lung cancer is the leading cause of cancer mortality among women. Awareness of antismoking messages or advertisements was associated with a higher probability of correctly indicating lung cancer as the leading cause of cancer mortality among women. Our evidence suggests that antismoking media messages may help to correct inaccurate beliefs about the leading causes of cancer death among women.

Tobacco companies have recently introduced products that they claim have reduced toxins and carcinogens, and that they say may be less harmful to smokers. These are potential reduced exposure products, or PREPs. This study measured smokers' awareness of PREPs, use of PREPs, interest in trying PREPs, and beliefs about the regulation of PREPs. This study was based on nationally representative data collected in 2002 and 2003 through the American Smoking and Health Survey. The final sample included 1,174 adult smokers. Descriptive and multivariate analyses were conducted to produce estimates and explore potential correlates of the outcomes. A total of 41.9% of adult smokers reported having heard of at least one of the PREPs measured, and 11.0% reported having tried one of these products. Half of adult smokers (49.9%) said they would like to try PREPs. Interest in trying PREPs was associated with having made a quit attempt, being concerned about the effect of smoking on one's health, and having a household income of less than US dollars 20,000. About half of adult smokers (49.1%) incorrectly believed that PREPs are evaluated for safety by the government before being placed on the market, and 84.2% believed that the government should evaluate the safety of PREPs before they are sold to consumers. This study provides new and timely information on the use of, interest in trying, and beliefs about the regulation of PREPs among a nationally representative sample of adult smokers. With half of adult smokers interested in trying PREPs, the need for concrete scientific evidence on the potential impact of these products is critical.

This research is designed to share valuable experiences and transferable principles from program staff of the Legacy/Community Voices initiative who have been involved in planning, implementing, evaluating, and sustaining tobacco control activities in underserved communities. Interviews were conducted with 13 front line staff from 9 sites: Alameda County, California; Detroit, Michigan; El Paso, Texas; Ingham County, Michigan; Miami, Florida; New Mexico; North Carolina; Northern Manhattan; and West Virginia. A model emerged from these interviews that places the life cycle of a program in a central position, with many of the identified themes (working with local champions, obtaining support from multiple partners, increasing organizational capacity) repeated throughout, albeit in different forms at different stages. Reflecting upon wisdom gained and identifying best processes for such work may help ensure that tobacco control programs are developed that are culturally safe and effective in meeting the needs of diverse communities throughout the United States.

This study examined youth reactions to four tobacco countermarketing messages from the national truth® and “Think. Don't Smoke” tobacco countermarketing campaigns through Web TV using a forced exposure approach. More than 900 respondents completed a baseline survey that established their smoking intentions and behaviors; viewed a series of randomly ordered tobacco countermarketing advertisements; and, after each ad, answered six items gauging individual ad reactions. Respondents across smoking risk groups had more favorable reactions to two ads produced for Legacy's truth® campaign (“Body Bags” and “Daily Dose”) compared with all other messages tested. Philip Morris' “My Reasons” received favorable evaluations among teens at lowest risk for future smoking, but consistent with our predictions derived from the theory of psychological reactance (Brehm, 1966), older teens at elevated risk of future smoking responded much less favorably. Teens without prior exposure to another truth® ad using the counter-industry message (“Shredder”) rated this ad less favorably. Results underscore the importance of both prior exposure and message features and suggest the presence of other factors associated with ad effectiveness, including message clarity and stylistic presentation.

In August 2002, the Subcommittee on Cessation of the Interagency Committee on Smoking and Health (ICSH) was charged with developing recommendations to substantially increase rates of tobacco cessation in the United States. The subcommittee’s report, A National Action Plan for Tobacco Cessation, outlines 10 recommendations for reducing premature morbidity and mortality by helping millions of Americans stop using tobacco. The plan includes both evidence-based, population-wide strategies designed to promote cessation (e.g., a national quitline network) and a Smokers’ Health Fund to finance the programs (through a $2 per pack excise tax increase). The subcommittee report was presented to the ICSH (February 11, 2003), which unanimously endorsed sending it to Secretary Thompson for his consideration. In this article, we summarize the national action plan.

Objectives. This study examines how the American Legacy Foundation's “truth” campaign and Philip Morris's “Think. Don't Smoke” campaign have influenced youths' attitudes, beliefs, and intentions toward tobacco. Methods. We analyzed 2 telephone surveys of 12- to 17-year-olds with multivariate logistic regressions: a baseline survey conducted before the launch of “truth” and a second survey 10 months into the “truth” campaign. Results. Exposure to “truth” countermarketing advertisements was consistently associated with an increase in anti-tobacco attitudes and beliefs, whereas exposure to Philip Morris advertisements generally was not. In addition, those exposed to Philip Morris advertisements were more likely to be open to the idea of smoking. Conclusions. Whereas exposure to the “truth” campaign positively changed youths' attitudes toward tobacco, the Philip Morris campaign had a counterproductive influence. (Am J Public Health. 2002;92:901–907)

The November 1998 Master Settlement Agreement between tobacco manufacturers and state attorneys general significantly restricted the marketing of tobacco products, made possible markedly expanded tobacco control programs in the states, and provided for the creation of a new foundation whose primary purpose is to combat tobacco use in the United States. This commentary describes the American Legacy Foundation, with particular emphasis on one of its efforts--the "truth" Campaign, a countermarketing effort to reduce smoking among youths. The "truth" Campaign has been well received by the public and is expected to be [corrected] effective in reducing smoking among youths. The only negative reaction to the campaign has been, predictably, from the tobacco industry.

This study examined the immediate effects of exposure to a patient education brochure concerning the risks and benefits of zidovudine (ZDV) therapy during pregnancy to reduce perinatal HIV transmission (protocol ACTG 076) on related knowledge, behavioural intentions and attitudes of women with and at-risk for HIV-infection. Self-reports were collected from 653 women of childbearing age from community family planning clinics and hospital-based HIV centres in 19 sites from nine US cities between May and November 1995. The intervention was a nine-page patient education brochure in Spanish, Creole and English versions, evently presenting the pros and cons of ZDV therapy to reduce perinatal HIV-transmission. Brochure exposure increased knowledge (p0.001) for all but one scale concerning ZDV resistance and increased the likelihood of women reporting intentions to take ZDV during pregnancy (p0.001) and to believe ZDV reduced transmission (p0.001). Brochure exposure had differential effects for some subpopulations. Intentions to have or terminate current or future pregnancies, knowledge about ZDV and attitudes toward ZDV varied mostly by ethnicity/race, language preference and HIV status. Pregnancy status, age, education and having an HIV-positive child had less impact on the brochure's effect, while income had no impact.

In response to several reports issued by the federal government and private foundations on the under-training of public health practitioners, Joseph L. Mailman School of Public Health of Columbia University (SPH) and the New York City Department of Health (NYC DOH) initiated the Public Health Scholars program (SPH-PHS) to make degree-level public health training available to NYC DOH employees. Public Health Scholars receive a 50% tuition scholarship and enroll part-time while working full-time at NYC DOH. Sixteen scholars have enrolled during the past three years. The SPH-PHS program is considered a success by both SPH and NYC DOH. This article details the history of the collaboration between the two agencies and the structure of the program and provides a critical analysis of the SPH-PHS program based on interviews with 16 scholars. It also examines the cost and benefit to other schools of public health of implementing such a program.

Background This study evaluates the stresses and satisfactions experienced by health care and social service providers working in HIV/AIDS service agencies in New York City. This study was part of the Ryan White Title I Evaluation in New York City. Methods This study is based on semi-structured interviews with 86 randomly sampled providers from a representative sample of 29 HIV/AIDS service agencies. Personal interviews were completed with a cross section of AIDS care providers. All staff interviewed were audiotaped to facilitate data analysis. Staff discussed their frustrations and their personal satisfaction at working in AIDS care. In addition, all staff completed the Maslach Burnout Inventory (MBI) to facilitate a structured comparison of their levels of burnout. Results Using the three subscales of the MBI, we found that interviewed AIDS care providers experienced lower than expected levels of burnout. Compared to national norms, health care and social service providers showed above-average levels of personal accomplishment, below-average levels of depersonalization, and average levels of emotional exhaustion. Interview transcripts were analyzed focusing on three broad themes: unique stressors of HIV/AIDS services, positive aspects of HIV/AIDS services, and effective provider supports. The study confirms that HIV/AIDS care providers feel a high level of personal commitment to working with HIV-positive clients. Personal commitment to HIV-positive clients may blunt some of the stresses associated with HIV/AIDS care.

This study sought (1) to identify factors that influence women's willingness to accept voluntary HIV counseling and testing at New York State Family Planning Programs (FPPs) and Prenatal Care Assistance Programs (PCAPs) and (2) to evaluate the effectiveness of such a voluntary counseling and testing program. Telephone interviews elicited organizational-level data from 136 agencies; a combination of telephone and face-to-face interviews was used to gather provider data from 98 HIV counselors; and client data were gathered from 354 women in face-to-face interviews at counseling sites. Slightly fewer than 60% of women agreed to be counseled, and, of those, under half consented to an HIV test at the counseling site. Approximately two thirds of the women who were tested returned for their results and posttest counseling. Clients' recall of pretest counseling content was relatively poor. Bivariate and regression analyses suggest that client, provider, and organizational factors are all associated with rates of pretest counseling and testing. The current voluntary counseling and testing program is achieving only moderate success. Although a substantial number of clients accept HIV counseling, many women remain reluctant to consent to HIV testing, and many who accept testing do not return for their results. Moreover, among those who receive pretest counseling, many do not recall important informational content, which suggests variation may exist in the quality of counseling or that one-time HIV counseling interventions are insufficient to communicate complex information. Medical Subject Headings (MeSH): AIDS, HIV serodiagnosis, women's health, patient education.

The Doctor of Public Health (DrPH) Core Competency Model aspires to rigorously train future leaders of public health practice to direct and advance societal efforts that address socially rooted causes of health and illness. Although there is no proven formula for success, 3 principles derived from practice may guide the way forward: (1) institutionalize mutual learning and reciprocity between schools of public health and public health agencies and organizations, (2) capitalize on the full resources of the larger university to enrich the educational experiences of DrPH candidates and public health leaders, and (3) globalize the search for model DrPH programs that may be adapted for US schools. Schools of public health must ensure that DrPH programs gain the status and resources needed to fulfill their societal mandate.

Menthol is a cigarette flavoring that makes smoking more appealing to smokers. The US Food and Drug Administration (FDA) has regulatory authority to ban mentholated cigarettes to reduce youth uptake and encourage adult cessation. Survey findings indicate that more than half of all Americans (56.1%) and of Blacks alone (68.0% in one sample and 75.8% in another) support banning menthol. Endorsement of a ban—especially by Blacks, who have the highest rates of menthol cigarette use—would support FDA action to ban menthol to protect the public's health.

Smoking and other forms of tobacco use affect virtually every organ system.1–3 To see the range of effects one only needs to consider the chapter titles for the 2010 Report of the Surgeon General, How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease 3: The Changing Cigarette, Chemistry and Toxicology of Cigarette Smoke and Biomarkers of Exposure and Harm, Nicotine Addiction, Cancer, Cardiovascular Diseases, Pulmonary Diseases, Reproductive and Developmental Effects. The National Institutes of Health (NIH), particularly the National Cancer Institute (NCI), the National Heart Lung and Blood Institute (NHLBI) and the National Institute on Drug Abuse (NIDA) have supported extramural, and conducted intramural, research that has built the knowledge base that led to the conclusions in this report. They have also developed population-based and clinical interventions which have fuelled the extraordinary reductions in tobacco-induced disease which we have experienced in the USA over the past half-century. Recognising that smoking kills more people through heart, lung and vascular disease than cancer,4 the NHLBI has recently increased its efforts to contribute to the ongoing development of the knowledge base to reduce smoking.5 Since 2002, the NIH Fogarty International Center, in collaboration with other NIH institutes, has built international tobacco and health research capacity by supporting transdisciplinary research in low- and middle-income countries.6 Tobacco control at NCI is fully integrated into the infrastructure within NCI in complex ways, as it should be, because tobacco use causes nearly one-third of all cancer deaths. The Tobacco Control Branch has contributed to reducing the cancer burden of our nation. The Branch is a complex integrated transdisciplinary programme, that has been developed over a quarter century, and embedded within the NCI structure in a manner difficult to replicate elsewhere (eg, in a new institute) …

To determine the quantity of tobacco use in network television programming popular among US youth and to examine variation in tobacco depictions by TV Parental Guidelines system rating and television network.A content analysis was conducted of broadcast network television programming popular among youth. Nielsen viewership rating data were used to identify a sample of top-rated television series for youth aged 12 to 17 years during the fall 2007 television season. Depictions of tobacco use per television episode were examined by TV Parental Guidelines rating and television network. χ(2) testing was used to examine differences in proportions of tobacco depictions across television episode ratings and networks.Data collection and analysis were conducted at the American Legacy Foundation (now known as Legacy).Broadcast television viewers in 2007.Tobacco use depictions on broadcast television were examined.Forty percent of television episodes examined had at least 1 depiction of tobacco use. Of these depictions, 89% were of cigarettes. Among episodes rated TV-PG (ie, parental guidance suggested) (N = 73), 50% showed 1 or more incidents of cigarette use, in contrast to 26% of TV-14 (ie, parents strongly cautioned) episodes. The percentage of episodes with any tobacco use depictions was highest on the FOX network (44%; n = 32), followed closely by The CW (CBS-Warner Brothers) (41%; n = 30).Substantial tobacco use was observed in television shows popular among youth. It is projected that almost 1 million youth were exposed to tobacco depictions through the programming examined. Tobacco use on television should be a cause for concern, particularly because of the high volume of television viewing among younger audiences.

CONTEXT: The 1998 Master Settlement Agreement (MSA) restricted tobacco industry advertising practices that targeted teens. OBJECTIVE: To assess whether cigarette-advertising campaigns conducted after the MSA continue to influence smoking among adolescents. DESIGN, SETTING, AND PARTICIPANTS: Participants were a national longitudinal cohort of 1036 adolescents (baseline age: 10–13 years) enrolled in a parenting study. Between 2003 and 2008, 5 sequential telephone interviews were conducted, including the participant's report of brand of “favorite” cigarette advertisement. The fifth interview was conducted after the start of RJ Reynolds' innovative “Camel No. 9” advertising campaign in 2007. Smoking outcome reported from the fifth survey. RESULTS: The response rate through the fifth survey was 71.8%. Teenagers who reported any favorite cigarette ad at baseline (mean age: 11.7 years) were 50% more likely to have smoked by the fifth interview (adjusted odds ratio: 1.5 [95% confidence interval: 1.0–2.3]). For boys, the proportion with a favorite ad was stable across all 5 surveys, as it was for girls across the first 4 surveys. However, after the start of the Camel No. 9 advertising campaign, the proportion of girls who reported a favorite ad increased by 10 percentage points, to 44%. The Camel brand accounted almost entirely for this increase, and the proportion of each gender that nominated the Marlboro brand remained relatively stable. CONCLUSIONS: After the MSA, adolescents continued to be responsive to cigarette advertising, and those who were responsive were more likely to start smoking. Recent RJ Reynolds advertising may be effectively targeting adolescent girls.

A program to provide health care workers instruction in acquired immunodeficiency syndrome (AIDS) infection control was developed to run on IBM microcomputers. This program can be used by individuals with no computer experience. It was assessed by medical resident physicians who were randomized into a control and an experimental group. A 48‐item true‐false test on AIDS knowledge was administered to both groups. The experimental group completed a questionnaire on their views of CAI. The mean knowledge score for the control group (n = 33) was 35.9 (SD = 3.9), whereas the mean knowledge score for the experimental group (n = 24) was 42.4 (SD = 4.6), a statistically significant difference (p < .001). Questionnaire responses indicated that the physicians viewed the computer program as easy to use and as an effective educational tool that they would recommend to colleagues. Most preferred CAI to printed presentation of the material. The results of this study suggest that CAI may be a useful instructional method ...

Objectives. We sought to fill gaps in knowledge of smoking behaviors among college-educated and non–college-educated young adults. Methods. We used data from the 2003 Tobacco Use Supplement of the Current Population Survey to analyze smoking behaviors among young adults aged 18–24 years and older young adults aged 25–34 years by college status (enrolled, or with a degree, but not enrolled) and other measures of socioeconomic position. Results. Current smoking prevalence among US young adults aged 18–24 years who are not enrolled in college or who do not have a college degree was 30%. This was more than twice the current smoking prevalence among college-educated young adults (14%). Non–college-educated young adults were more likely than were college-educated young adults to start smoking at a younger age and were less likely to have made a quit attempt, although no differences were found in their intentions to quit. Higher rates of smoking in the non–college-educated population were also evident in the slightly older age group. Conclusions. Non–college-educated young adults smoke at more than twice the rate of their college-educated counterparts. Targeted prevention and cessation efforts are needed for non–college-educated young adults to prevent excess morbidity and mortality in later years.

Our society bears a tremendous public health burden from tobacco-related disability and death, particularly in the realm of cancer. Yet research in lung cancer and other tobacco-related diseases research is dramatically underfunded when compared to the number of people affected. Persuading policy makers to increase funding for tobacco-related research, treatment, and policy initiatives will require considerable cooperation among the researchers, clinicians, and advocates who focus on tobacco control and those who concentrate on tobacco-related disease. Traditionally, these groups have battled over resources, expending precious energy competing for scarce funding. We propose a new way forward: these forces should come together in support of a common agenda that includes both increased tobacco control efforts and additional funding for disease-related research and treatment. Speaking with a unified voice in support of a full continuum of tobacco-related policy initiatives would significantly increase the size and influence of the coalition working to address this public health epidemic. Working together offers our nation the best chance of significantly reducing the scourge of disease and death caused by tobacco use. (Cancer Epidemiol Biomarkers Prev 2007;16(5):859–63)

OBJECTIVE: To determine the proportion of televised movie trailers that included images of tobacco use during 1 year and the extent of youth exposure to those trailers. DESIGN: Content analysis combined with Nielsen data measuring media exposure. All movie trailers (N = 216) shown on television from August 1, 2001, through July 31, 2002. MAIN OUTCOME MEASURES: Exposure among youth aged 12 to 17 years to televised movie trailers that included smoking imagery. RESULTS: Of the movie trailers televised during the study period, 14.4% (31 trailers) included images of tobacco use. Tobacco use was shown in 24.0% of the 23 trailers for R-rated (restricted) movies and 7.5% of the 8 trailers for PG-13- and PG-rated (parental guidance) movies. Ninety-five percent of all youth aged 12 to 17 years in the United States saw at least 1 movie trailer depicting tobacco use on television during this 1 year, and 88.8% saw at least 1 of these trailers 3 or more times. CONCLUSIONS: Nearly all US youth aged 12 to 17 years were exposed to images of tobacco use on television in the context of a movie trailer during the study period. Given the relationship between youth exposure to tobacco use in movies and smoking initiation, the public health community should work to enact policy to reduce or eliminate the influence of tobacco use in televised movie trailers.

Objectives To describe the prevalence of obesity, smoking, and both health risk factors together among adults in the United States. Design Cross sectional analysis of a national health interview survey. Setting United States. Participants 29 305 adults (aged ≥ 18) in 2002. Main outcome measures Prevalence of adults who are obese (body mass index ≥ 30), who smoke, and who are obese and smoke. Prevalence was stratified by age, sex, ethnic group, education, and income. Results 23.5% of adults were obese, 22.7% smoked, and 4.7% smoked and were obese. Conclusions Although the proportion of adults who smoke and are obese is relatively low, this subgroup is concentrated among lower socioeconomic groups.

Objectives: Epidemiological surveys make it clear that youth smoking contributes to both current and future tobacco industry revenue: over 80% of adult smokers reportedly began smoking before age 18. This paper estimates annual and lifetime revenue from youth smoking, and highlights the association between declines in youth smoking and declines in tobacco industry revenue. Main outcome measures: This paper reports the amount of tobacco industry revenue generated by youth smoking at two points in time (1997 and 2002), and describes the distribution of youth generated tobacco income among the major tobacco companies. The authors project the amount of tobacco industry revenue that will be generated by members of two cohorts (the high school senior classes of 1997 and 2002) over the course of their lifetimes. Results: In 1997, youth consumed 890 million cigarette packs, generating $737 million in annual industry revenue. By 2002, consumption dropped to 541 million packs and revenue increased to nearly $1.2 billion. Fifty eight per cent of youth generated revenue goes to Philip Morris USA, 18% to Lorillard, and 12% to RJ Reynolds. The authors project that, over the course of their lives, the 1997 high school senior class will smoke 12.4 billion packs of cigarettes, generating $27.3 billion in revenue. The 2002 high school senior class is projected to smoke 10.4 billion packs, generating $22.9 billion in revenue over the course of their lives. Conclusions: Cigarette price increases from 1997 to 2002 have resulted in greater revenue for the tobacco industry, despite declines in youth smoking prevalence. However, in the absence of further cigarette price increases, declines in youth smoking are projected to lead ultimately to a loss of approximately $4 billion in future tobacco industry revenue from a single high school cohort.

Objective. The present study describes patterns of tobacco use counseling among physicians and dentists as reported by adolescents and determines the association between provider advice to quit and cessation activities among current smokers. Methods. Data were analyzed from the 2000 National Youth Tobacco Survey, an anonymous, self-administered, school-based survey. The National Youth Tobacco Survey was administered to a nationally representative sample of 35828 students in grades 6 to 12 in 324 schools. Results. Thirty-three percent of adolescents who visited a physician or a dentist in the past year reported that a physician counseled them about the dangers of tobacco use, and 20% reported that a dentist provided a similar message. Among students who smoked in the past year, 16.4% received advice to quit from a physician and 11.6% received advice to quit from a dentist. Physician or dentist advice to quit was correlated with 1 or more quit attempts in the past 12 months. Conclusion. On the basis of adolescent reports, physician and dentist practice patterns remain well below recommended guidelines. Results suggest that provider advice to quit is associated with cessation activity. Additional studies are needed to confirm whether the low prevalence of brief provider tobacco use counseling is a missed opportunity to affect adolescent smoking behavior.

Objectives. In early 2000, the American Legacy Foundation launched the national “truth” campaign, the first national antismoking campaign to discourage tobacco use among youths. We studied the impact of the campaign on national smoking rates among US youths (students in grades 8, 10, and 12). Methods. We used data from the Monitoring the Future survey in a pre/post quasi-experimental design to relate trends in youth smoking prevalence to varied doses of the “truth” campaign in a national sample of approximately 50000 students in grades 8, 10, and 12, surveyed each spring from 1997 through 2002. Results. Findings indicate that the campaign accounted for a significant portion of the recent decline in youth smoking prevalence. We found that smoking prevalence among all students declined from 25.3% to 18.0% between 1999 and 2002 and that the campaign accounted for approximately 22% of this decline. Conclusions. This study showed that the campaign was associated with substantial declines in youth smoking and has accelerated recent declines in youth smoking prevalence.

Data suggest that 12%-22% of women smoke during pregnancy. The link between smoking during pregnancy and adverse health and reproductive outcomes has been well documented. Great Start is a public education and smoking cessation program developed especially for pregnant women. Launched in December 2001, Great Start was the first national program focused on providing free and confidential smoking cessation counseling to pregnant women through a toll-free quitline. Great Start consisted of a media campaign to raise awareness and direct women to telephone counseling tailored for the pregnant smoker, and educational materials designed to support pregnant women through cessation counseling. The program was evaluated to assess the ability of the television ads to reach pregnant smokers and the effectiveness of a quitline for increasing cessation rates among pregnant women. Great Start demonstrates that it is possible to reach pregnant smokers through television ads that provide information about the consequences of smoking while pregnant, are affirming in tone, and provide direction for women to take action. Initial response to the program indicates that pregnant women want to quit and confirms the need for programs designed specifically to address the needs of this population.

Knowledge of current public opinion is important as the Food and Drug Administration (FDA) applies the best scientific evidence available to tobacco product regulation. Based on a nationally representative survey of the US adult population, we report 43% support for banning of cigarettes, 65% for reducing nicotine, and 77% for reducing nicotine if such an action could cause fewer children to become addicted to cigarettes. The FDA should consider protecting children by removing all but nonaddictive cigarettes from the marketplace.

In their article, Jamrozik et al ( see page 258 ) have explored the mortality hazard associated with smoking by gender and provide evidence that Australian men and women with similar smoking histories (namely, cigarettes smoked per day and time since quit) experience similar rates of death from smoking.1 Given the limitations of the data in this study, caution should be used in interpreting these results. In fact, results from studies conducted across the globe provide conflicting evidence as to whether gender influences tobacco-related mortality patterns. More specifically, Freedman et al found, using a prospective cohort, that men in the USA have slightly higher incidence rates of lung cancer than women with similar smoking histories.2 A case–control study concluded that women have increased risk for developing lung cancer than men across all levels of cigarette use.3 On the other hand, in two other prospective US cohorts, findings indicate that overall risk did not differ by gender.4 5 The effect of gender on chronic obstructive pulmonary disease is also controversial, with studies showing conflicting results.6 These studies may reflect the complex history of smoking-related gender differences in the USA. Women who smoke have …

Much has been written about the potential benefits in health promotion that are possible through partnerships between academic institutions and community-based organizations, but little practical advice has been provided on how to sustain these relationships when the original grant funds have been exhausted. Here we document our experiences in Harlem, New York City, a community with grave social, structural, and physical environmental inequities, and describe the successes and failings of a partnership now in its "adolescence" between researchers at the Joseph L. Mailman School of Public Health of Columbia University and community activists at West Harlem Environmental Action (WE ACT).

Women clients of a methadone maintenance treatment clinic were targeted for an intervention aimed to reduce unsafe sex. The hierarchical model was the basis of the single intervention session, tested among 63 volunteers. This model requires the educator to discuss and demonstrate a full range of barriers that women might use for protection, ranking these in the order of their known efficacy. The model stresses that no one should go without protection. Two objections, both untested, have been voiced against the model. One is that, because of its complexity, women will have difficulty comprehending the message. The second is that, by demonstrating alternative strategies to the male condom, the educator is offering women a way out from persisting with the male condom, so that instead they will use an easier, but less effective, method of protection. The present research aimed at testing both objections in a high-risk and disadvantaged group of women. By comparing before and after performance on a knowledge test, it was established that, at least among these women, the complex message was well understood. By comparing baseline and follow-up reports of barriers used by sexually active women before and after intervention, a reduction in reports of unsafe sexual encounters was demonstrated. The reduction could be attributed directly to adoption of the female condom. Although some women who had used male condoms previously adopted the female condom, most of those who did so had not used the male condom previously. Since neither theoretical objection to the hierarchical model is sustained in this population, fresh weight is given to emphasizing choice of barriers, especially to women who are at high risk and relatively disempowered. As experience with the female condom grows and its unfamiliarity decreases, it would seem appropriate to encourage women who do not succeed with the male condom to try to use the female condom, over which they have more control.

The benefit of antiretroviral therapy in reducing maternal-fetal transmission of HIV during pregnancy has caused a public policy debate about the relative benefits of mandatory HIV screening and voluntary HIV screening in pregnant women.To evaluate the benefits and risks of mandatory compared with voluntary HIV testing of pregnant women to help guide research and policy.A decision analysis that incorporated the following variables: acceptance and benefit of prenatal care, acceptance and benefit of zidovudine therapy in HIV-infected women, prevalence of HIV infection, and mandatory compared with voluntary HIV testing.The threshold deterrence rate (defined as the percentage of women who, if deterred from seeking prenatal care because of a mandatory HIV testing policy, would offset the benefit of zidovudine in reducing vertical HIV transmission) and the difference between a policy of mandatory testing and a policy of voluntary testing in the absolute number of HIV-infected infants or dead infants.Voluntary HIV testing was preferred over a broad range of values in the model. At baseline, the threshold deterrence rate was 0.4%. At a deterrence rate of 0.5%, the number of infants (n = 167) spared HIV infection annually in the United States under a mandatory HIV testing policy would be lower than the number of perinatal deaths (n = 189) caused by lack of prenatal care.The most important variables in the model were voluntary HIV testing, the deterrence rate associated with mandatory testing compared with voluntary testing, and the prevalence of HIV infection in women of child-bearing age. At high levels of acceptance of voluntary HIV testing, the benefits of a policy of mandatory testing are minimal and may create the potential harms of avoiding prenatal care to avoid mandatory testing.

OBJECTIVES: This study examined the relationship between directly observed therapy and treatment completion rates in the years before and after infusion of federal funding for tuberculosis (TB) control in 1993. METHODS: An ecological study of estimated directly observed therapy rates and 12-month treatment completion rates from 1990 through 1994 was undertaken for TB control programs in all 25 cities and counties across the nation with 100 or more incident TB cases in any year from 1990 to 1993. Three cohorts were formed: high treatment completion, intermediate completion, and low completion. RESULTS: In 1990, the median 12-month treatment completion rate was 80% for the entire study population, with a median estimated directly observed therapy rate of 16.8%. By 1994, those rates had increased to 87% and 49.4%, respectively, and increases were shown in all 3 cohorts. CONCLUSIONS: Directly observed therapy has had a marked impact on treatment completion rates in jurisdictions with historically low rates. But TB treatment completion rates of more than 90% can be attained with directly observed therapy rates far lower than those proposed by advocates of universal supervised therapy.

The termination of the perinatal HIV transmission trial, ACTG 076, by the Data Safety and Monitoring Board in February 1994 because of the efficacy of zidovudine (ZDV) in substantially reducing maternal-infant HIV transmission has created a considerable need for efficacious patient education approaches and materials for women with and at risk of HIV infection. Complexities surrounding patients' decisions to use ZDV in accordance with the treatment arm protocol of this study must be communicated to women, especially the consequences for both themselves and their potential children. In March 1994, a public-private partnership was formed to develop and test the impact of patient education information on 076 and to explore cultural differences in decision-making surrounding ZDV use during pregnancy. Objectives were (1) to develop an efficacious patient informational booklet on the results of ACTG 076 and (2) to determine the differential attitudes and behavioral intentions of women toward taking AZT during pregnancy. A multi-disciplinary group of providers and researchers developed the patient education booklet and field-tested it in five New York City area sites. Subjects were a multiethnic group of women of childbearing age who were predominantly HIV-positive or at risk of HIV infection (n = 120). This 076 education resulted in a substantial increase in intention to use ZDV to reduce perinatal transmission despite full disclosure of the unknowns (P.001). There were differences in knowledge acquired between racial/ethnic groups, which must be viewed cautiously since the study did not assess socioeconomic status adequately. Attitudes toward ZDV (P.05), trust in health care providers (P.03), and opinions on whether testing should be voluntary (P.02) also varied by race/ethnicity. Medical Subject Headings (MeSH): perinatal transmission, AIDS education, pregnancy, HIV, ACTG 076.

8 intervention studies investigating patient education and treatment adherence in the sexually transmitted disease (STD) clinic setting are reviewed. Across the 8 studies selected for analysis meta-analytic procedures were applied to compare the impact of educational and prevention approaches. The effect of video was compared with that of other modes of health education on: 1) knowledge and attitudes about STDs and condoms and 2) treatment compliance as measured by return for test of cure drug compliance premature resumption of sexual activity and condom coupon redemption rates. The largest effects were those for video on knowledge and attitudes about STDs and condoms followed by the effects of other non-video interventions on STD knowledge. Lower effects were found among video and non-video interventions targeting treatment compliance outcomes. These results are consistent with prior prevention studies that have demonstrated difficulty in achieving behavior change. (authors)

In Response: Dr. Mirvish raises several timely and controversial issues that continue to be the focus of many vigorous discussions in the tobacco control community, often under the rubric of “harm reduction.” In 2006, WHO adopted the theme for World No Tobacco Day: “Tobacco: deadly in any form

PIP: Cuba has initiated a program to control Acquired Immune Deficiency Syndrome (AIDS) that is designed to limit the spread of infection with the human immunodeficiency virus (HIV) by implementing compulsory elements of the public health tradition. Widespread screening for HIV infection began 3 years ago, and persons identified as infected have been sent to a sanatorium located in a Havana suburb. The program also reflects concern over the marked increase in prevalence of sexually transmitted diseases. Educational effects in Cuba stress that AIDS is not a disease exclusively of homosexuals and can affect any individual. Condoms are recommended for protection. In contrast to virtually every other nation, Cuba has not made education the key focus of its anti-AIDS strategy. Education is relegated to a marginal role. Key to the policy is identifying infected individuals and bringing them under medical control. Cuba's HIV surveillance program has been carried out with use of an enzyme-linked immunosorbent assay (ELISA), Western blot assay, and antigen tests that have been developed domestically. The director of the Cuban AIDS Investigations Laboratory reports that nearly 3 million Cubans have been tested. It is estimated that among the 7 low-infection groups tested in Cuba, between 21 and 53 persons may have been inaccurately considered positive as a result of testing. Cuban authorities have expressed much interest in obtaining commercially available HIV screening kits -- both ELISA and Western blot assays -- as a standard against which to measure their own test. Despite the inevitability of continued viral transmission, Cuba's policy of a modified quarantine certainly will limit the toll of HIV infection markedly yet comes at a great price. For other nations, the imperatives of prevention, however important, are not the only values to be considered in the battle against AIDS.