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In 1999, Group Health Cooperative (GHC), a health system with 575,000 enrollees, launched a quality improvement initiative to systematically record patient tobacco-use status and provider intervention using an automated billing system. Performance feedback and senior-level incentives were added to foster compliance with the automated recording. Prior to this period, tobacco-use status was recorded primarily via a paper-based chart system, with billing-system recording averaging only 7.5% of primary care visits. In 2000, tobacco-use status was recorded using the billing system in an average of 82% of visits (p

BackgroundMobile health (mHealth) smoking cessation programs are typically designed for smokers who are ready to quit smoking. In contrast, most smokers want to quit someday but are not yet ready to quit. If mHealth apps were designed for these smokers, they could potentially encourage and assist more people to quit smoking. No prior studies have specifically examined the design considerations of mHealth apps targeting smokers who are not yet ready to quit. ObjectiveTo inform the user-centered design of mHealth apps for smokers who were not yet ready to quit by assessing (1) whether these smokers were interested in using mHealth tools to change their smoking behavior; (2) their preferred features, functionality, and content of mHealth programs addressing smoking; and (3) considerations for marketing or distributing these programs to promote their uptake. MethodsWe conducted a sequential exploratory, mixed-methods study. Qualitative interviews (phase 1, n=15) were completed with a demographically diverse group of smokers who were smartphone owners and wanted to quit smoking someday, but not yet. Findings informed a Web-based survey of smokers from across the United States (phase 2, n=116). Data were collected from April to September, 2016. ResultsFindings confirmed that although smokers not yet ready to quit are not actively seeking treatment or using cessation apps, most would be interested in using these programs to help them reduce or change their smoking behavior. Among phase 2 survey respondents, the app features, functions, and content rated most highly were (1) security of personal information; (2) the ability to track smoking, spending, and savings; (3) content that adaptively changes with one’s needs; (4) the ability to request support as needed; (5) the ability to earn and redeem awards for program use; (6) guidance on how to quit smoking; and (7) content specifically addressing management of nicotine withdrawal, stress, depression, and anxiety. Results generally did not vary by stage of change for quitting smoking (precontemplation vs contemplation). The least popular feature was the ability to share progress via social media. Relevant to future marketing or distribution considerations, smokers were price-sensitive and valued empirically validated programs. Program source, expert recommendations, and user ratings were also important considerations. ConclusionsSmokers who are not yet ready to quit represent an important target group for intervention. Study findings suggest that many of these individuals are receptive to using mHealth tools to reduce or quit smoking, despite not having made a commitment to quit yet. The preferences for specific mHealth intervention features, functionality, and content outlined in this paper can aid addiction treatment experts, design specialists, and software developers interested in creating engaging interventions for smokers who want to quit in the future but are not yet committed to this important health goal.

124 Background: The symptom burden faced by long-term head and neck cancer survivors could inform clinical decision making but it is not well understood. Methods: In 2016 we surveyed current enrollees of Group Health (an integrated health care delivery system in Washington State) who were aged ≥18 years when diagnosed with head and neck cancer in 2011 (n = 54). Symptoms experienced in the past 24 hours were assessed using the validated MD Anderson Symptom Inventory head and neck cancer module (MDASI-HN). Survivors were asked to report on a 10-point scale the severity of the problem at its worst (“not present” to “as bad as you can imagine”). Self-reported risk factor and demographic information were also collected. Results: Eighty percent of persons responded to the survey (n = 43) via web questionnaire (n = 12), mailed questionnaire (n = 26) or telephone interview (n = 5). One person who reported to have not been diagnosed with head and neck cancer was excluded, leaving 42 participants. Overall, 29% had no more than mild symptoms (all MDASI-HN symptoms rated

Author(s): Bergen, Andrew W; Javitz, Harold S; Krasnow, Ruth; Michel, Martha; Nishita, Denise; Conti, David V; Edlund, Christopher K; Kwok, Pui-Yan; McClure, Jennifer B; Kim, Richard B; Hall, Sharon M; Tyndale, Rachel F; Baker, Timothy B; Benowitz, Neal L; Swan, Gary E | Abstract: IntroductionWe evaluated chr6q25.3 organic cation transporter gene (SLC22A1, SLC22A2, SLC22A3) variation and response to smoking cessation therapies. The corresponding proteins are low-affinity transporters of choline, acetylcholine and monoamines, and smoking cessation pharmacotherapies expressed in multiple tissues.MethodsWe selected 7 common polymorphisms for mega-regression analysis. We assessed additive model association of polymorphisms with 7-day point prevalence abstinence overall and by assigned pharmacotherapy at end of treatment and at 6 months among European-ancestry participants of 7 randomized controlled trials adjusted for demographic, population genetic, and trial covariates.ResultsInitial results were obtained in 6 trials with 1,839 participants. Nominally statistically significant associations of 2 SLC22A2 polymorphisms were observed: (1) with rs316019 at 6 months, overall ([c.808TgG; p.Ser270Ala], OR = 1.306, 95% CI = 1.034-1.649, p = .025), and among those randomized to nicotine replacement therapy (NRT) (OR = 1.784, 95% CI = 1.072-2.970, p = .026); and (2) with rs316006 (c.1502-529AgT) among those randomized to varenicline (OR = 1.420, 95% CI = 1.038-1.944, p = .028, OR = 1.362, 95% CI = 1.001-1.853, p = .04) at end of treatment and 6 months. Individuals randomized to NRT from a seventh trial were genotyped for rs316019; rs316019 was associated with a nominally statistically significant effect on abstinence overall at 6 months among 2,233 participants (OR = 1.249, 95% CI = 1.007-1.550, p = .043).ConclusionsThe functional OCT2 Ser270Ala polymorphism is nominally statistically significantly associated with abstinence among European-ancestry treatment-seeking smokers after adjustments for pharmacotherapy, demographics, population genetics, and without adjustment for multiple testing of 7 SNPs. Replication of these preliminary findings in additional randomized controlled trials of smoking cessation therapies and from multiple continental populations would describe another pharmacogenetic role for SLC22A2/OCT2.

Background Alcohol use, and particularly unhealthy alcohol use, is associated with poor human immunodeficiency virus (HIV)-related outcomes among persons living with HIV (PLWH). Despite a rapidly growing proportion of PLWH ≥50 years, alcohol use and its associated characteristics are underdescribed in this population. The authors describe alcohol use, severity, and associated characteristics using data from a sample of PLWH ≥50 years who participated in a trial of a telephone-based intervention to improve adherence to antiretroviral therapy (ART). Methods Participants were recruited from acquired immunodeficiency syndrome (AIDS) service organizations in 9 states and included PLWH ≥50 years who were prescribed ART, reported suboptimal adherence at screening (missing >1.5 days of medication or taking medications 2 hours early or late on >3 days in the 30 days prior to screening), and consented to participate. The AUDIT-C (Alcohol Use Disorders Identification Test—Consumption) alcohol screen, sociodemographic characteristics, substance use, and mental health comorbidity were assessed at baseline. AUDIT-C scores were categorized into nondrinking, low-level drinking, and mild-moderate unhealthy, and severe unhealthy drinking (0, 1–3, 4–6, and 7–12, respectively). Analyses described and compared characteristics across drinking status (any/none) and across AUDIT-C categories among drinkers. Results Among 447 participants, 57% reported drinking in the past year (35%, 15%, and 7% reported low-level drinking, mild-moderate unhealthy drinking, and severe unhealthy drinking, respectively). Any drinking was most common among men and those who were lesbian, gay, bisexual, or transgender (LGBT), married/partnered, had received past-year alcohol treatment, and never used injection drugs ( P values all Conclusions In this sample of older PLWH with suboptimal ART adherence, a majority reported past-year alcohol use and 22% screened positive for unhealthy alcohol use. Any and unhealthy alcohol use were associated with demographics, depression, and substance use history. Further research is needed regarding alcohol use among older PLWH.

Introduction Research needs to systematically identify which components increase online intervention effectiveness (i.e., active ingredients). This study explores the effects of 4 potentially important design features in an Internet-based, population-level smoking intervention. Methods Smokers (n = 1,865) were recruited from a large health care organization, regardless of readiness to quit. Using a full factorial design, participants were randomized to 1 of the 2 levels of each experimental factor (message tone [prescriptive vs. motivational], navigation autonomy [dictated vs. not], e-mail reminders [yes vs. no], and receipt of personally tailored testimonials [yes vs. no]) and provided access to the online intervention. Primary outcomes were self-reported 7-day point-prevalent smoking abstinence and confirmed utilization of adjunct treatment (pharmacotherapy or phone counseling) available through the health plan at 1 year. Outcomes were also assessed at 2 and 6 months and were examined among all enrolled participants (intent-to-treat [ITT]) and all who viewed the intervention (modified ITT). Results At 1 year, 13.7% were abstinent and 26.0% utilized adjunct treatment. None of the contrasting factor levels differentially influenced abstinence or treatment utilization at 12 months. In the modified ITT sample, smokers receiving testimonials were less likely to use adjunct treatment at 6 months (odds ratio = 0.54, 95% confidence interval = 0.30-0.98, p = .04). Conclusions None of the design features enhanced treatment outcome. The negative effect observed for testimonials is provocative, but it should be viewed with caution. This study offers a model for future research testing the "active ingredients" of online interventions.

Ehrlichia chaffeensis, the etiologic agent of human monocytic ehrlichiosis, is a tick-borne rickettsial pathogen that is infectious to a wide range of mammals, including dogs and people. Amblyomma americanum, the lone star tick, is considered the primary vector of E. chaffeensis, but this pathogen has been detected in other tick species, including the brown dog tick, Rhipicephalus sanguineus. We hypothesized that the Arkansas strain of E. chaffeensis is infective to R. sanguineus, and used a novel PCR assay to test for acquisition of this pathogen by R. sanguineus and A. americanum ticks that were simultaneously fed on experimentally infected dogs. Although E. chaffeensis was not frequently detected in peripheral blood of these dogs, the pathogen was detected in both tick species and in canine lung, kidney, lymph node, bone marrow and frontal lobe samples. One dog (AFL) was maintained for several years, and ticks again acquired E. chaffeensis from this dog 566 days after intradermal inoculation with E. chaffeensis, but the pathogen was not detected in ticks fed on the same dog at 764 or 1,086 days after the intradermal inoculation.

BackgroundAccurately estimating the period of time that individuals are exposed to online intervention content is important for understanding program engagement. This can be calculated from time-stamped data reflecting navigation to and from individual webpages. Prolonged periods of inactivity are commonly handled with a time-out feature and assigned a prespecified exposure duration. Unfortunately, this practice can lead to biased results describing program exposure. ObjectiveThe aim of the study was to describe how multiple imputations can be used to better account for the time spent viewing webpages that result in a prolonged period of inactivity or a time-out. MethodsTo illustrate this method, we present data on time-outs collected from the Q2 randomized smoking cessation trial. For this analysis, we evaluate the effects on intervention exposure of receiving content written in a prescriptive versus motivational tone. Using multiple imputations, we created five complete datasets in which the time spent viewing webpages that resulted in a time-out were replaced with values estimated with imputation models. We calculated standard errors using Rubin’s formulas to account for the variability due to the imputations. We also illustrate how current methods of accounting for time-outs (excluding timed-out page views or assigning an arbitrary viewing time) can influence conclusions about participant engagement. ResultsA total of 63.00% (1175/1865) of participants accessed the online intervention in the Q2 trial. Of the 6592 unique page views, 683 (10.36%, 683/6592) resulted in a time-out. The median time spent viewing webpages that did not result in a time-out was 1.07 minutes. Assuming participants did not spend any time viewing a webpage that resulted in a time-out, no difference between the two message tones was observed (ratio of mean time online: 0.87, 95% CI 0.75-1.02). Assigning 30 minutes of viewing time to all page views that resulted in a time-out concludes that participants who received content in a motivational tone spent less time viewing content (ratio of mean time online: 0.86, 95% CI 0.77-0.98) than those participants who received content in a prescriptive tone. Using multiple imputations to account for time-outs concludes that there is no difference in participant engagement between the two message tones (ratio of mean time online: 0.87; 95% CI 0.75-1.01). ConclusionsThe analytic technique chosen can significantly affect conclusions about online intervention engagement. We propose a standardized methodology in which time spent viewing webpages that result in a time-out is treated as missing information and corrected with multiple imputations. Trial RegistrationClinicaltrials.gov NCT00992264; http://clinicaltrials.gov/ct2/show/NCT00992264 (Archived by WebCite at http://www.webcitation.org/6Kw5m8EkP).

Medical care for HIV disease may be most effective when medical surveillance and services are initiated early and consistently maintained over time. To benefit from continually improving HIV care regimens, persons living with HIV/AIDS must first adhere to their outpatient medical appointments. The purpose of this study was to examine psychosocial, illness, and demographic factors associated with appointment adherence problems early in HIV treatment. Results indicated that nonadherence to outpatient medical appointments was a significant problem. One hundred forty-four patients were followed for 6 months after their initial appointment at a public HIV clinic. One in five dropped out of treatment before completing their intake assessment (separate nurse and physician appointments). Men and individuals with lower levels of social support were most likely to drop out before seeing a physician. Emotional distress was not associated with early dropout, but elevated levels of anxiety and depression were found across the sample. Those still attending the clinic (n = 114) were then followed for 12 months after clinic enrollment. Overall, 35% of scheduled medical appointments were missed during this period. Higher baseline CD4 counts and injection drug use history were predictive of poor appointment adherence, but other demographic and psychosocial indices were not. These findings suggest increased research and early intervention efforts are needed to improve appointment adherence among persons living with HIV/AIDS.

Although most smokers in our society report that they would like to quit, smoking prevalence rates have remained relatively unchanged during most of the 1990s. This is in contrast to a nearly 50% reduction in prevalence observed over the past 3 decades. Presently, an estimated 25.5% of adults (48 million people) continue to smoke, although most smokers would like to quit. Recent research on the treatment of nicotine dependence has focused primarily on events that occur after the initial cessation period (i.e., the prevention of relapse with behavioral counseling and/or the management of withdrawal symptoms with nicotine replacement therapy). Although these methods are effective, there is evidence that cessation rates may also be enhanced by manipulating smoking behavior prior to quitting. One promising approach is scheduled reduced smoking. Early work with this approach has yielded superior abstinence rates compared to gradual reduction and abrupt “cold turkey” quitting techniques. In this article, we present an overview of research on scheduled reduced smoking and discuss the effects of the treatment on smoking urges, negative affect, and selfefficacy.

Although tobacco smoking has long been recognized as having negative health consequences, more than one quarter of the US adult population smokes. This article presents (a) national trends in the prevalence of tobacco smoking, (b) health consequences associated with tobacco smoking and tobacco's mode of action (how tobacco/nicotine cause the problems), and (c) a brief overview of the smoking cessation treatment literature and several recommendations based on the review of research.

Pharmacist- or nurse-led team care decreases patient blood pressure (BP) and cardiovascular disease (CVD) risk.To evaluate whether a Web-based dietitian-led (WD) team care intervention was feasible and resulted in decreased BP, CVD risk, and weight compared to usual care (UC).Electronic health record (EHR) data identified patients aged 30-69 years with BMI26, elevated BP, and 10%-25% 10-year Framingham CVD risk who were registered patient website users. Patients with uncontrolled BP at screening were randomized to UC or WD, which included a home BP monitor, scale, and dietitian team care. WD participants had a single in-person dietitian visit to obtain baseline information and create a plan to reduce CVD risk. Planned follow-up occurred via secure messaging to report BP, weight, and fruit and vegetable intake and receive ongoing feedback. If needed, dietitians encouraged patients and their physicians to intensify antihypertensive and lipid-lowering medications. Primary outcomes were change in systolic BP and weight loss ≥4 kg at 6 months. Feasibility outcomes included intervention utilization and satisfaction.Between 2010 and 2011, a total of 90 of 101 participants completed 6-month follow-ups. The WD group had higher rates of secure messaging utilization and patient satisfaction. The WD group lost significantly more weight than the UC group (adjusted net difference=-3.2 kg, 95% CI=-5.0, -1.5, p0.001) and was more likely to lose ≥4 kg (adjusted relative risk [RRadj]=2.96, 95% CI=1.16, 7.53). BP control and CVD risk reduction were greater in WD than UC, but differences were not statistically significant.WD intervention was feasible and resulted in decreased weight, BP, and CVD risk. A larger trial is justified.Trial Registration Number: NCT01077388.

The present study examined factors contributing to depressive symptomatology in a low SES, heterogeneous HIV seropositive sample. The sample was comprised of 120 HIV-infected patients who completed psychosocial measures upon their initial visit to an outpatient HIV clinic. Length of time since HIV seropositive notification and HIV-related symptomatology were also assessed. Social support, major life stress, and HIV-related symptomatology were significantly associated with depression. Perceived availability of social support accounted for the greatest variance in depression scores. Length of time since seropositive notification was not significantly associated with depression. These findings extend previous research with middle-class, homosexual, white males to the rapidly growing minority, heterosexual, and low SES populations and point to the need for the inclusion of social support interventions in the provision of services of these individuals.

Data have indicated psychosocial co-factors are important in predicting HIV disease progression. The present study examined the impact of stress, social support, coping, and mood on HIV disease status. A heterogenous sample of 100 HIV-positive individuals participated in the study. Correlational data suggested all of the variables were associated with HIV symptomatology but not CD4 count. A model was created and supported that illustrated the links among these psychosocial co-factors and HIV illness. Findings and applications are discussed with implications for future HIV research.

Background: Participant engagement influences treatment effectiveness, but it is unknown which intervention design features increase treatment engagement for online smoking cessation programs. Objective: We explored the effects of 4 design features (ie, factors) on early engagement with an Internet-based, motivational smoking cessation program. Methods: Smokers (N=1865) were recruited from a large health care organization to participate in an online intervention study, regardless of their interest in quitting smoking. The program was intended to answer smokers’ questions about quitting in an effort to motivate and support cessation. Consistent with the screening phase in the multiphase optimization strategy (MOST), we used a 2-level, full-factorial design. Each person was randomized to 1 of 2 levels of each factor, including message tone (prescriptive vs motivational), navigation autonomy (dictated vs not), proactive email reminders (yes vs no), and inclusion of personally tailored testimonials (yes vs no). The effects of each factor level on program engagement during the first 2 months of enrollment were compared, including number of visits to the website resulting in intervention content views (as opposed to supplemental content views), number of intervention content areas viewed, number of intervention content pages viewed, and duration of time spent viewing this content, as applicable to each factor. Results: Adjusting for baseline readiness to quit, persons who received content written in a prescriptive tone made the same number of visits to the website as persons receiving content in a motivational tone, but viewed 1.17 times as many content areas (95% CI 1.08-1.28; P

Few studies have examined how specific emotions may affect decision-making processes. Anxiety may be especially relevant in health decisions such as those related to cancer in which thoughts of illness or death may be abundant. We examined associations between women's anxiety about developing breast cancer and variables related to their decision to take a medication that could reduce their chances of the disease. Six-hundred and thirty-two American women, who had an increased risk of breast cancer, reviewed a web-based decision aid about tamoxifen. We examined associations between their baseline, self-reported anxiety about developing the disease and post decision aid measures including knowledge about tamoxifen, attitude toward the medication, and behavioral intentions to look for more information and take the medication. Results showed that anxiety was not associated with knowledge about tamoxifen, but it was associated with attitude toward the medication such that women who were more anxious about developing breast cancer were more likely to think the benefits were worth the risks. Greater anxiety was also associated with greater behavioral intentions to look for additional information and take the medication in the next few months. Secondary analyses showed that behavioral intentions were related to knowledge of tamoxifen and attitude toward the medication only for women who were reporting low levels of anxiety. Overall, the findings suggest that anxiety about breast cancer may motivate interest in tamoxifen and not necessarily through affecting knowledge or attitudes.

Since the previous version of this chapter was published (Swan, Hudmon, & Khroyan, 2003), many advances in the science of nicotine dependence have occurred. Although progress has been significant, nicotine dependence remains a substantial global problem, the solution of which will require sustained effort at the basic, genetic, environmental (individual and macro levels), and treatment levels. In this chapter, we highlight some of the most significant developments in the field of nicotine dependence research over the past 10 years. These highlights include an increased understanding of the role of individual variation in relevant neurochemical and metabolic pathways; the emergence of neuroimaging technologies that further specify areas in the brain that are influenced by environmental cues to smoke; a remarkable series of genetic epidemiological studies that have identified and replicated an association between variation in the CHRN A5-A3-B4 nicotinic gene cluster on chromosome 15 and nicotine dependence; a more complete picture of individual-level variables that influence risk for nicotine dependence, including gender, cultural, and psychiatric comorbidities; the recent development of new assessment tools for nicotine dependence; and a summary of empirically based behavioral and pharmacological treatments for nicotine dependence. We close the chapter with a review of the recent and current macroenvironmental contextual factors in which the science has taken place in the past decade, including the master settlement agreement between the states and the tobacco industry, the impact of continued public health efforts, evidence of the cost-effectiveness of treatment for nicotine dependence, implications of health care reform for tobacco use counseling, the emergence of potential reduced exposure products into the marketplace, and global efforts at tobacco control. Keywords: smoking cessation; clinical trials; tobacco control; risk factors; neurobiology

To examine when and why women disbelieve tailored information about their risk of developing breast cancer.690 women participated in an online program to learn about medications that can reduce the risk of breast cancer. The program presented tailored information about each woman's personal breast cancer risk. Half of women were told how their risk numbers were calculated, whereas the rest were not. Later, they were asked whether they believed that the program was personalized, and whether they believed their risk numbers. If a woman did not believe her risk numbers, she was asked to explain why.Beliefs that the program was personalized were enhanced by explaining the risk calculation methods in more detail. Nonetheless, nearly 20% of women did not believe their personalized risk numbers. The most common reason for rejecting the risk estimate was a belief that it did not fully account for personal and family history.The benefits of tailored risk statistics may be attenuated by a tendency for people to be skeptical that these risk estimates apply to them personally.Decision aids may provide risk information that is not accepted by patients, but addressing the patients' personal circumstances may lead to greater acceptance.

Background/Aims Multivariate cardiovascular disease (CVD) risk calculators, such as the Framingham risk equations can be used to identify populations most likely to benefit from treatments to decrease risk. We wanted to determine what proportion of adults in a large integrated health plan had sufficient automated laboratory data to calculate risk and when insufficient laboratory data was available whether BMI could be used.

Aversive symptoms of abstinence from nicotine have been posited to lead to smoking relapse and research on temporal patterns of abstinence symptoms confirms this assumption. However, little is known about the association of symptom trajectories early after quitting with post-cessation smoking or about the differential effects of tonic (background) versus phasic (temptation-related) symptom trajectories on smoking status. The current study examined trajectories of urge and negative mood among 300 women using the nicotine patch during the first post-cessation week. Ecological momentary assessments collected randomly and during temptation episodes were analyzed using hierarchical linear modeling yielding four individual trajectory parameters: intercept (initial symptom level), linear slope (direction and rate of change), quadratic coefficient (curvature), and volatility (scatter). Early lapsers, who lapsed during the first post-cessation week, exhibited more severe tonic urge and phasic negative mood immediately after quitting, and more volatile tonic and phasic urge compared to abstainers. Late lapsers, who were abstinent during the first week but lapsed by 1 month, exhibited more severe tonic urge immediately after quitting compared to abstainers. These results demonstrate the importance of early post-cessation urge and negative affect and highlight the value of examining both tonic and phasic effects of abstinence from nicotine.

Comparative risk perceptions may rival other types of information in terms of effects on health behavior decisions.We examined associations between comparative risk perceptions, affect, and behavior while controlling for absolute risk perceptions and actual risk.Women at an increased risk of breast cancer participated in a program to learn about tamoxifen which can reduce the risk of breast cancer. They reported comparative risk perceptions of breast cancer and completed measures of anxiety, knowledge, and tamoxifen-related behavior intentions. Three months later, the women reported their behavior.Comparative risk perceptions were positively correlated with anxiety, knowledge, intentions, and behavior 3 months later. After controlling for participants' actual risk of breast cancer and absolute risk perceptions, comparative risk perceptions predicted anxiety and knowledge, but not intentions or behavior.Comparative risk perceptions can affect patient outcomes like anxiety and knowledge independently of absolute risk perceptions and actual risk information.

Background: The current study evaluated the efficacy of an individualized, hand-held computer-delivered treatment (CDT) versus standard treatment (ST) for the maintenance of smoking abstinence following a quit attempt. Methods: Participants were 303 adult daily smokers randomized to CDT or ST, plus pharmacotherapy. Abstinence though 1 year was examined using logistic random intercept models, a type of generalized linear mixed model regression. Results: Results did not support the efficacy of the CDT program through 1 year postquit in analyses adjusted for time and study site (OR = 0.84, 95% CI = 0.55–1.30), or after further adjusting for race/ethnicity, age, gender, education, marital status, and the number of cigarettes smoked per day before quitting (OR = 0.89, 95% CI = 0.57–1.39). Conclusions: CDT did not increase short- or long-term abstinence rates over ST in this study. Impact: Findings differ from some in the literature and suggest the need for continued research on the use of CDT for smoking cessation. Cancer Epidemiol Biomarkers Prev; 20(7); 1555–7. ©2011 AACR.

This study evaluated association between common and rare sequence variants in 10 nicotinic acetylcholine receptor subunit genes and the severity of nausea 21 days after initiating the standard, Food and Drug Administration-approved varenicline regimen for smoking cessation. A total of 397 participants from a randomized clinical effectiveness trial with complete clinical and DNA resequencing data were included in the analysis (mean age=49.2 years; 68.0% female). Evidence for significant association between common sequence variants in CHRNB2 and nausea severity was obtained after adjusting for age, gender and correlated tests (all P(ACT)0.05). Individuals with the minor allele of CHRNB2 variants experienced less nausea than did those without the minor allele, consistent with previously reported findings for CHRNB2 and the occurrence of nausea and dizziness as a consequence of first smoking attempt in adolescents, and with the known neurophysiology of nausea. As nausea is the most common reason for discontinuance of varenicline, further pharmacogenetic investigations are warranted.

Relapse is the rule rather than the exception among smokers attempting to quit, and compared to men, women may have higher relapse rates. The current study was a randomized clinical trial testing a palmtop computer-delivered treatment for smoking relapse prevention among women. The intervention was individualized based on key theoretical constructs that were measured using ecological momentary assessment (EMA). All participants (N=302) received standard smoking cessation treatment consisting of nicotine replacement therapy and group counseling, and completed EMA procedures for one week after quitting. At the completion of the group counseling sessions and EMA procedures, participants were randomized to either computer-delivered treatment (CDT) or no further computer-delivered treatment or assessment (EMA-Only). CDT participants received a palmtop computer-delivered relapse prevention treatment for one additional month. CDT did not improve abstinence rates relative to EMA-Only. Process analyses suggested that heavier smokers were more likely to use CDT and that greater use among CDT participants may be associated with more positive outcomes. The rapid pace of technological advances in mobile computer technology and the ubiquity of such devices provide a novel platform for developing new and potentially innovative treatments. However, the current study did not demonstrate the efficacy of such technology in improving treatment outcomes.

Although tamoxifen can prevent primary breast cancer, few women use it as a preventive measure. A second option, raloxifene, has recently been approved. The objective of the study was to determine women’s interest in tamoxifen and raloxifene after reading a decision aid describing the risks and benefits of each medication. Women with 5-year risk of breast cancer ≥1.66 from two large health maintenance organizations were randomized to receive a decision aid versus usual care. After reading an on-line decision aid that discussed the risks and benefits of tamoxifen and raloxifene, women completed measures of risk perception, decisional conflict, behavioral intentions and actual behavior related to tamoxifen and raloxifene. 3 months following the intervention, 8.1% of participants had looked for additional information about breast cancer prevention drugs and 1.8% had talked to their doctor about tamoxifen and/or raloxifene. The majority, 54.7%, had decided to not take either drug, 0.5% had started raloxifene, and none had started tamoxifen. Participants were not particularly worried about taking tamoxifen or raloxifene and did not perceive significant benefits from taking these drugs. Over 50% did not perceive a change in their risk of getting breast cancer if they took tamoxifen or raloxifene. After reading a DA about tamoxifen and raloxifene, few women were interested in taking either breast cancer prevention drug.

INTRODUCTION Phone counseling has become standard for behavioral smoking cessation treatment. Newer options include Web and integrated phone-Web treatment. No prior research, to our knowledge, has systematically compared the effectiveness of these three treatment modalities in a randomized trial. Understanding how utilization varies by mode, the impact of utilization on outcomes, and predictors of utilization across each mode could lead to improved treatments. METHODS One thousand two hundred and two participants were randomized to phone, Web, or combined phone-Web cessation treatment. Services varied by modality and were tracked using automated systems. All participants received 12 weeks of varenicline, printed guides, an orientation call, and access to a phone supportline. Self-report data were collected at baseline and 6-month follow-up. RESULTS Overall, participants utilized phone services more often than the Web-based services. Among treatment groups with Web access, a significant proportion logged in only once (37% phone-Web, 41% Web), and those in the phone-Web group logged in less often than those in the Web group (mean = 2.4 vs. 3.7, p = .0001). Use of the phone also was correlated with increased use of the Web. In multivariate analyses, greater use of the phone- or Web-based services was associated with higher cessation rates. Finally, older age and the belief that certain treatments could improve success were consistent predictors of greater utilization across groups. Other predictors varied by treatment group. CONCLUSIONS Opportunities for enhancing treatment utilization exist, particularly for Web-based programs. Increasing utilization more broadly could result in better overall treatment effectiveness for all intervention modalities.

Oral disease affects tens of millions of Americans. It results in unnecessary pain, physical disfigurement, emotional suffering, and puts individuals at greater risk for morbidity and mortality.1 Treating oral disease and preventing future disease are important public health goals. Tobacco users are an important target for oral health promotion efforts. Smokers are three-times as likely as non-smokers to have gum disease1 and have a higher prevalence of untreated tooth decay.2 They are also less likely to visit the dentist 3,4 and more likely to engage in other behaviors that increase their risk for oral disease, such as drinking alcohol 5,6 and eating a poor diet.7 Nearly 20% of US adults are current smokers.8 Tobacco cessation counselors could prove an important ally in promoting better oral health among smokers, especially in activating smokers to see a dentist and engaging them in better oral self-care including quitting smoking, improved daily hygiene, use of fluoride, dietary change, and decreased alcohol consumption. Partnering with tobacco quitlines could be a particularly effective strategy to achieve this goal. Quitline counselors are already trained in motivating and supporting behavior change. Additionally, tobacco quitlines have broad reach. Nearly 440,000 Americans received free services from publically-funded quitlines in 2010 alone.9 Two recent surveys of tobacco quitline callers confirmed smokers’ interest in improving their oral health, as well as opportunities to promote improved oral hygiene behavior (daily brushing and flossing) and utilization of regular professional dental care.10,11 To explore the feasibility of partnering with U.S. tobacco quitlines to counsel smokers about better oral health, we interviewed key stakeholders from Alere Wellbeing (the leading US tobacco quitline service provider) and 21 of the states with whom they contract their services. Both groups were generally supportive of offering an integrated tobacco cessation-oral health promotion program and noted that the dual focus could open new sources of state revenue to support the quitline infrastructure (e.g., public funding for oral health promotion). The latter has particular relevance in light of recent funding cuts to many state quitlines. However, several realistic concerns were raised. First, stakeholders agreed that the program should not improve oral health behaviors at the expense of decreasing tobacco abstinence rates. To be successful, both behaviors must be impacted positively. Next, all oral health promotion activities and materials should fit within the existing quitline infrastructure (e.g., brief phone counseling with supplemental intervention delivered by mail, Internet, and/or text messaging). Finally, since many quitline callers may not have dental insurance, the intervention should refer people to local low-cost dental professionals (e.g., local dental schools or other low-cost resources) and focus on what people can do on their own to improve their oral health outcomes, in the absence of professional dental care. In addition to stopping use of tobacco, the latter includes proper daily oral hygiene (brushing and flossing), use of fluoride, healthy nutrition, limited alcohol use (given the synergistic effects of tobacco and alcohol in promoting oral cancers),1 and oral self-screenings to identify issues in need of professional dental care before they advance. Future research needs to establish the effectiveness and cost-effectiveness of integrating oral health promotion counseling with standard quitline cessation counseling, but this feedback from relevant program stakeholders provides further confirmation that this strategy is feasible for many state quitline programs and worth exploration. The specific guidance offered can inform the optimal design of this program, as well as offer insight into the design of other dual-behavioral programs offered to quitline callers. With recent reductions in public health funding, leveraging our existing infrastructures to expand their impact with minimal additional costs may become increasing important. Public health officials, funders, and researchers are all encouraged to consider these opportunities for the future.

There is a lack of evidence of the relative cost-effectiveness of proactive telephone counseling (PTC) and Web-based delivery of smoking cessation services in conjunction with pharmacotherapy. We calculated the differential cost-effectiveness of three behavioral smoking cessation modalities with varenicline treatment in a randomized trial of current smokers from a large health system. Eligible participants were randomized to one of three smoking cessation interventions: Web-based counseling (n = 401), PTC (n = 402), or combined PTC-Web counseling (n = 399). All participants received a standard 12-week course of varenicline. The primary outcome was a 7-day point prevalent nonsmoking at the 6 month follow-up. The Web intervention was the least expensive followed by the PTC and PTC-Web groups. Costs per additional 6-month nonsmoker and per additional lifetime quitter were $1,278 and $2,601 for Web, $1,472 and $2,995 for PTC, and $1,617 and $3,291 for PTC-Web. Cost per life-year (LY) and quality-adjusted life-year (QALY) saved were $1,148 and $1,136 for Web, $1,320 and $1,308 for PTC, and $1,450 and $1,437 for PTC-Web. Based on the cost per LY and QALY saved, these interventions are among the most cost-effective life-saving medical treatments. Web, PTC, and combined PTC-Web treatments were all highly cost-effective, with the Web treatment being marginally more cost-effective than the PTC or combined PTC-Web treatments.

Doxycycline is the treatment of choice for canine monocytic ehrlichiosis (CME), a well-characterized disease and valuable model for tick-borne zoonoses. Conflicting reports of clearance of Ehrlichia canis after treatment with doxycycline suggested that the disease phase during which treatment is initiated influences outcomes of these treatments. The purpose of this study was to evaluate the efficacy of a 28-day doxycycline regimen for clearance of experimental E. canis infections from dogs treated during three phases of the disease. Ten dogs were inoculated with blood from E. canis carriers and treated with doxycycline during acute, subclinical, or chronic phases of CME. Daily rectal temperatures and semiweekly blood samples were monitored from each dog, and Rhipicephalus sanguineus ticks were acquisition fed on each dog for xenodiagnosis. Blood collected from dogs treated during acute or subclinical CME became PCR negative for E. canis as clinical parameters improved, but blood samples collected from dogs treated during chronic CME remained intermittently PCR positive. R. sanguineus ticks fed on dogs after doxycycline treatments became PCR positive for E. canis , regardless of when treatment was initiated. However, fewer ticks became PCR positive after feeding on two persistently infected dogs treated with doxycycline followed by rifampin, suggesting that antibiotic therapy can reduce tick acquisition of E. canis .

Smoking remains the primary preventable cause of death and illness in the U.S. Effective, convenient treatment programs are needed to reduce smoking prevalence.This study compared the effectiveness of three modalities of a behavioral smoking-cessation program in smokers using varenicline.Current treatment-seeking smokers (n=1202) were recruited from a large healthcare organization between October 2006 and October 2007. Eligible participants were randomized to one of three smoking-cessation interventions: web-based counseling (n=401); proactive telephone-based counseling (PTC; n=402); or combined PTC and web counseling (n=399). All participants received a standard 12-week FDA-approved course of varenicline. Self-report determined the primary outcomes (7-day point prevalent abstinence at 3- and 6-month follow-ups); the number of days varenicline was taken; and treatment-related symptoms. Behavioral measures determined utilization of both the web- and Phone-based counseling.Intent-to-treat analyses revealed relatively high percentages of abstinence at 3 months (38.9%, 48.5%, 43.4%) and at 6 months (30.7%, 34.3%, 33.8%) for the web, PTC, and PTC-web groups, respectively. The PTC group had a significantly higher percentage of abstinence than the web group at 3 months (OR=1.48, 95% CI=1.12, 1.96), but no between-group differences in abstinence outcomes were seen at 6 months.Phone counseling had greater treatment advantage for early cessation and appeared to increase medication adherence, but the absence of differences at 6 months suggests that any of the interventions hold promise when used in conjunction with varenicline.

Background: In order to develop effective dietary interventions, public health researchers need to better understand the reasons people do not to eat the recommended minimum servings of fruits and vegetables (F&V). Methods: Adults were recruited from five U.S. health plans in Washington, Colorado, Minnesota, Michigan and Georgia and enrolled in an online dietary intervention study designed to increase F&V consumption (MENU). Prior to the intervention, 2,513 eligible participants completed a baseline questionnaire assessing demographics and other information relevant for tailoring the intervention content, including perceived barriers to eating F&V. Participants also indicated if they were currently trying to eat more F&V or not. We compared groups who were (n= 849) and were not (n = 1651) trying to increase F&V intake at baseline, to examine if there were distinguishing characteristics which would help inform future intervention development targeted at individuals not trying to change their diet. Results: Compared to persons trying to change their diet, those not trying to change were more likely to be male (P=.05), younger (45.9 years vs. 47.1 years, P=.01), and a higher mean BMI (29.5 vs. 27.1, P

Background: A sufficient daily consumption of fruits and vegetables (F&V) could help prevent chronic diseases. Since implementing the 5 A Day program, research has shown that awareness has increased, but average F&V intake among American adults remains under the minimum recommendation. This analysis examines factors related to increasing F&V intake among participants in the MENU study, a randomized trial with two intervention arms and one control arm. Methods: In 2005, 2,513 confirmed HMO members, aged 21–65, from five geographically-diverse health plans completed an online enrollment survey, reporting F&V intake and personal and family health history. Mean change in combined F&V servings per day was assessed at 12 months post baseline, using a validated self-report F&V food frequency questionnaire. Analysis of covariance adjusting for the baseline F&V intake, regardless of study arm, was performed for each factor considered. Results: Of the 2,513, 80% were followed up at 12 months. Those with a family history of hypertension or diabetes increased their F&V consumption, P=.03 and P=.04 compared to those with no family history of these conditions, regardless of race. There were no observed differences in consumption increase by reported family history of cancer, heart disease or obesity. Participants with a high perceived risk of developing diabetes increased their intake by more than 0.6 servings than those with no perceived diabetes risk, P=.05, regardless of race. There were no statistical differences for consumption increase by risk of hypertension, heart disease or obesity. We tested for interactions between race and family history (FH) and perceived risk (PR) individually for each condition. Only FH of obesity was significant, P=.09 showing that whites with FH were more likely to increase F&V intake while blacks were not. The only significant interaction for PR was PR of cancer, P=.07. Interestingly, while the overall change was not significant for either race, whites with high PR increased F&V and blacks with a low PR increased F&V. Conclusion: FH of hypertension and diabetes, as well as perceived higher risk for developing diabetes, were characteristics that contributed to increasing F&V consumption, regardless of race. FH of obesity and PR of cancer contributed to differences in F&V intake change between blacks and whites. Interventions addressing perceived risk of disease or family history of disease may be valuable in encouraging dietary lifestyle.

Objectives. We assessed change in fruit and vegetable intake in a population-based sample, comparing an online untailored program (arm 1) with a tailored behavioral intervention (arm 2) and with a tailored behavioral intervention plus motivational interviewing–based counseling via e-mail (arm 3). Methods. We conducted a randomized controlled intervention trial, enrolling members aged 21 to 65 years from 5 health plans in Seattle, Washington; Denver, Colorado; Minneapolis, Minnesota; Detroit, Michigan; and Atlanta, Georgia. Participants reported fruit and vegetable intake at baseline and at 3, 6, and 12 months. We assessed mean change in fruit and vegetable servings per day at 12 months after baseline, using a validated self-report fruit and vegetable food frequency questionnaire. Results. Of 2540 trial participants, 80% were followed up at 12 months. Overall baseline mean fruit and vegetable intake was 4.4 servings per day. Average servings increased by more than 2 servings across all study arms (P < .001), with the greatest increase (+2.8 servings) among participants of arm 3 (P = .05, compared with control). Overall program satisfaction was high. Conclusions. This online nutritional intervention was well received, convenient, easy to disseminate, and associated with sustained dietary change. Such programs have promise as population-based dietary interventions.

In a 7-week prospective multicentre study, the efficacy, tolerability and safety of moclobemide were compared to those of amitriptyline and placebo in parallel groups of out-patients (n = 173) fulfilling the DSM III-R criteria for a major depressive episode. Participants were required to have a minimum baseline total score of 18 on the 17-item Hamilton Depression Rating Scale (HAMD). After a 1-week placebo washout, patients were randomly allocated to the three treatment groups. Assessment of efficacy, as judged by the number of responders achieving a 50% reduction in HAMD score by the end of treatment, showed that both moclobemide and amitriptyline were significantly superior to placebo, but that they were not significantly different from each other. Both treatments differed significantly from placebo with respect to the Physician's Global Assessment of Efficacy ('very good' or 'good' response: moclobemide 57%, amitriptyline 60% and placebo 35%). Assessment of tolerance as judged by the spontaneous reporting of adverse events showed a significant superiority of moclobemide over amitriptyline, but there was no significant difference between moclobemide and placebo. At termination of the study, amitriptyline patients showed a significant elevation of heart rate both supine (10.8 beats/min) and standing (15.5 beats/min), as well as significant weight gain (1.7 kg), but no changes were seen in the moclobemide or placebo groups. In conclusion, both moclobemide and amitriptyline were found to be more effective than placebo in the treatment of depression, while moclobemide had fewer side effects.

1This may be a particularly important time to focus on innovations in self help technology for pregnant smokers. Printed materials are the major media by which current self help interventions are delivered, and in the general population their overall eVectiveness has been shown to be similar to no treatment control conditions. 1 Moreover, currently available treatments for pregnant smokers have often emphasised provider delivered counselling but have typically failed to incorporate treatment components that address some of the major contributors to relapse in the general population, such as negative aVect, depression, smoking cues, positive mood/celebration, etc. 2

Treatment outcomes were compared across smokers enrolled in the COMPASS cessation trial with (positive psychiatric history [PH+], n = 271) and without (PH-, n = 271) a diagnosis of PH based on medical record evidence of anxiety, depression, psychotic disorder, or bipolar disorder. Everyone received behavioral counseling plus varenicline and was followed for 6 months post quit date. PH+ smokers took varenicline for fewer days on average (59.4 vs. 68.5, p < or = .01) but did not differ in their use of behavioral treatment. PH+ smokers were more likely to report anxiety and depression, but side-effect intensity ratings did not differ after adjusting for multiple comparisons. Overall, all side effects were rated as moderate intensity or less. Groups had similar 30-day abstinence rates at 6 months (31.5% PH+ vs. 35.4% PH-, p = .35). In sum, having a psychiatric diagnosis in this trial did not predict worse treatment outcome or worse treatment side effects.

For 2 1/2 months, the Oregon Tobacco Quit Line (ORQL) offered a free 2-week starter kit of nicotine patches to all callers. The promotional plan, utilizing Roger's Diffusion of Innovation theory, targeted health plans, local policy makers, media sources, and referral sources, such as healthcare providers. Word-of-mouth advertising was also encouraged using a free patch card, which could be handed out to tobacco users. Six weeks prior to the public launch, information about the initiative was disseminated by e-mailing and sending letters to public and private sector partners. Call volume to the ORQL was monitored 6 months prior to the Free Patch Initiative and immediately following the launch. Demographic characteristics of callers pre- and postinitiative were compared using ORQL data. A media firm tracked earned media generated by the initiative. The Initiative generated free "earned" media attention, increased calls to the ORQL by 12-fold, and reached 1.3% of the smoking population within a 3-month period. Offering a short course of free NRT is an effective way to promote the use of quitlines.

Background: Web-based behavioral programs efficiently disseminate health information to a broad population, and online tailoring may increase their effectiveness. While the number of Internet-based behavioral interventions has grown in the last several years, additional information is needed to understand the characteristics of subjects who enroll in these interventions, relative to those subjects who are invited to enroll. Objective: The aim of the study was to compare the characteristics of participants who enrolled in an online dietary intervention trial (MENU) with those who were invited but chose not to participate, in order to better understand how these groups differ. Methods: The MENU trial was conducted among five health plans participating in the HMO Cancer Research Network in collaboration with the University of Michigan Center for Health Communication Research. Approximately 6000 health plan members per site, between the ages of 21 and 65, and stratified by gender with oversampling of minority populations, were randomly selected for recruitment and were mailed an invitation letter containing website information and a US$2 bill with the promise of US$20 for completing follow-up surveys. Administrative and area-based data using geocoding along with baseline survey data were used to compare invitees (HMO members sent the introductory letter), responders (those who entered a study ID on the website), and enrollees (those who completed the enrollment process). Generalized estimating equation multivariate and logistic regression models were used to assess predictors of response and enrollment. Results: Of 28,460 members invited to participate, 4270 (15.0%) accessed the website. Of the eligible responders, 2540 (8.9%) completed the consent form and baseline survey and were enrolled and randomized. The odds of responding were 10% lower for every decade of increased age (P < .001), while the likelihood of enrolling was 10% higher for every decade increase in age (P < .001). Women were more likely to respond and to enroll (P < .001). Those living in a census tract associated with higher education levels were more likely to respond and enroll, as well as those residing in tracts with higher income (P < .001). With a 22% (n = 566) enrollment rate for African Americans and 8% (n = 192) for Hispanics, the enrolled sample was more racially and ethnically diverse than the background sampling frame. Conclusions: Relative to members invited to participate in the Internet-based intervention, those who enrolled were more likely to be older and live in census tracts associated with higher socioeconomic status. While oversampling of minority health plan members generated an enrolled sample that was more racially and ethnically diverse than the overall health plan population, additional research is needed to better understand methods that will expand the penetration of Internet interventions into more socioeconomically diverse populations. Trial Registration: Clinicaltrials.gov NCT00169312; http://clinicaltrials.gov/ct2/show/NCT00169312 (Archived by WebCite at http://www.webcitation.org/5jB50xSfU) [J Med Internet Res 2009;11(3):e38]

We compared long-term outcomes among smokers with and without impaired lung functioning who received brief counseling highlighting their spirometric test results.Participants in this analysis all received a brief motivational intervention for smoking cessation including spirometric testing and feedback ( approximately 20 min), were advised to quit smoking, offered free access to a phone-based smoking cessation program, and followed for one year. Outcomes were analyzed for smokers with (n=99) and without (n=168) impaired lung function.Participants with lung impairment reported greater use of self-help cessation materials at 6 months, greater use of non-study-provided counseling services at 6 and 12 months, higher 7-day PPA rates at 6 months, and were more likely to talk with their doctor about their spirometry results.Further research is warranted to determine if spirometry feedback has a differential treatment effect among smokers with and without lung impairment.It is premature to make practice recommendations based on these data.

To use focus groups to inform a web-based educational intervention for increased fruit and vegetable (FV) consumption.Twelve groups (participants=137, aged 21-65) were recruited from four geographically diverse health systems. Four groups were stratified by gender and eight by race (white and African American) and gender. Questions included perceptions of healthy eating, factors that encourage or serve as barriers to FV consumption and features preferred for a web-based educational intervention.Though knowledgeable about healthy eating, participants did not know how to achieve or always care about healthy nutritional choices. Motivators for FV consumption included being role models and health concerns. Barriers included: lack of time, expense and FV availability. Website preferences included: visuals, links, tailored materials, menu suggestions, goal setting assistance, printable summaries and built in motivation. The developers incorporated nearly all suggestions.Focus groups provided needs-based tactical strategies for an online, education intervention targeting factors to improve FV consumption.Focus groups can provide valuable input to inform interventions. Further, web-based programs' abilities to offer information without time or geographic constraints, with capacity for tailoring and tracking progress makes them a valuable addition in the arsenal of efforts to promote healthy behaviors.

BACKGROUND Varenicline may be associated with greater mood disturbance and side-effects among smokers with psychiatric history, but empirical evidence is limited. Differential treatment effectiveness by psychiatric history may also exist. OBJECTIVE To compare mood, prevalence and intensity of treatment side-effects, and abstinence among people with a probable history of major depression (DH+) or not (DH−) who took varenicline and received behavioral smoking cessation treatment. DESIGN Smokers participated in a randomized behavioral intervention effectiveness trial. Treatment side-effects and outcomes were compared between DH+ and DH− participants (n = 1,117) at 2 days and 3 months after the target quit date. PARTICIPANTS Smokers recruited from a large regional health plan. MEASUREMENTS Change in stress and depression scores, prevalence and intensity of treatment side-effects, and abstinence rates. RESULTS All side-effects averaged moderate intensity or less and were similar across DH groups, except DH+’s endorsed slightly worse confusion, nausea (adjusted P = 0.04) and trouble sleeping (adjusted P = 0.008) at 21 days. Depression and stress scores declined in both DH groups and an equal proportion of each evidenced new/worsening depressive symptoms. Despite few differences in symptom intensity, more DH+ participants reported recent tension/agitation, irritability/anger, confusion, and depression at 21 days (adjusted P

The authors examined the relation between smoking status and fruit and vegetable (FV) consumption among a population-based sample and examined differences in psychosocial factors that may influence diet and inform intervention efforts. The authors recruited adults (N = 2,540) from 5 US health plans to participate in a Web-based dietary intervention trial. At baseline, smokers ate fewer FV servings per day (p < .001) and were less likely to meet the 5 A Day goal (p < .001). Smokers reported lower self-efficacy, overall motivation, and intrinsic motivation for meeting daily FV recommendations. Fewer smokers expected that eating 5 FV servings a day would reduce their risk for diabetes (p = .02) or obesity (p = .008). Smokers are an important target group for dietary intervention. Intervention efforts should attempt to increase smokers' motivation and confidence in their abilities to change their eating patterns and educate them about the health benefits of eating FV.

All states offer telephone quit lines but they are under-used in part because of the costs associated with promotion. Offering nicotine replacement therapy (NRT) as well as behavioral counseling can increase treatment participation and abstinence rates, but is expensive. Offering less than a full NRT 8-week course can also generate calls to the quit line but less is known about its impact on program outcomes. In October 2004, Oregon--a state with over 3 million people, 500,000 smokers, and a state-funded quit line--introduced the Free Patch Initiative: a free 2-week introductory supply of NRT with phone counseling offered to all callers. We examined the impact of this intervention among insured callers. Most (97.2%) requested free patches, 86.2% used them, and 47.2% obtained additional patches on their own. Six-month outcome data were obtained from insured quit line participants before (n = 268) and after (n = 614) the Initiative launched. Compared with pre-Initiative controls, Free Patch participants were more satisfied with the quit line (84.8% vs. 89.8%; p = .04) and had higher 7-day quit rates using the assumption that eligible nonrespondents are smokers (9.3% vs. 17.0%, OR = 2.0; 95% CI 1.4-2.8) and using respondent only analysis (19% vs. 33.6%, OR = 2.15; 95% CI 1.52-3.04). Offering a free direct mail starter pack of NRT along with telephone counseling is an effective, cost-sharing method for promoting quit line use, enhancing participant satisfaction, and increasing the reach and effectiveness of quit lines among quit line callers with health insurance.

Objective To experimentally test whether using pictographs (image matrices), incremental risk formats, and varied risk denominators would influence perceptions and comprehension of side effect risks in an online decision aid about prophylactic use of tamoxifen to prevent primary breast cancers. Methods We recruited 631 women with elevated breast cancer risk from two healthcare organizations. Participants saw tailored estimates of the risks of 5 side effects: endometrial cancer, blood clotting, cataracts, hormonal symptoms, and sexual problems. Presentation format was randomly varied in a three factor design: (A) risk information was displayed either in pictographs or numeric text; (B) presentations either reported total risks with and without tamoxifen or highlighted the incremental risk most relevant for decision making; and (C) risk estimates used 100 or 1000 person denominators. Primary outcome measures included risk perceptions and gist knowledge. Results Incremental risk formats consistently lowered perceived risk of side effects but resulted in low knowledge when displayed by numeric text only. Adding pictographs, however, produced significantly higher comprehension levels. Conclusions Pictographs make risk statistics easier to interpret, reducing biases associated with incremental risk presentations. Practice implications Including graphs in risk communications is essential to support an informed treatment decision-making process.

State-level tobacco quitlines are integrating nicotine replacement therapy (NRT) into service. Because of funding limitations some provide short courses of NRT. No randomized trial has evaluated the relative benefit of short versus standard treatment.A two-cell randomized trial comparing 2 weeks of NRT to 8 weeks.Uninsured callers to the Oregon Quit Line during a free-patch initiative from October 18, 2004, to May 5, 2005, who were 18 years or older, smoked five or more cigarettes per day, did not have a medical contraindication to NRT use, and were interested in quitting in 30 days. Data were collected from April to November 2005, and analyzed in 2006--2007.Participants were eligible for two phone counseling sessions. 1154 participants were randomized to receive via the mail either 2 or 8 weeks of nicotine patches.Primary outcome was self-reported complete abstinence from tobacco for 30 or more days at the 6-month phone survey. Secondary outcomes were 7-day point prevalence and 90-day abstinence, satisfaction, and patch use. ORs and CIs were computed. Cost per quit and incremental cost per additional quit were computed based on program costs.Intent-to-treat 30-day abstinence was 14.3% in the 2-week group, and 19.6% in the 8-week group (OR 1.45 [CI=1.01, 2.12]). Average cost per quit was $1156 for 2 weeks and $1405 for 8 weeks, with an incremental cost effectiveness of $2068. Satisfaction increased from 90% to 97% with 8 weeks. Those receiving 8 weeks of NRT took more calls (2.0 vs 1.6) and used more patches (6.3 weeks vs 4.3 weeks), but were less likely to purchase patches (16.2% vs 39.3%).Eight weeks of patches improved quit rates compared with 2 weeks, and was cost effective.

Peptide Nucleic Acids (PNAs) are single-stranded synthetic nucleic acids with a pseudopeptide backbone in lieu of the phosphodiester linked sugar and phosphate found in traditional oligos. PNA designed complementary to the bacterial Shine-Dalgarno or start codon regions of mRNA disrupts translation resulting in the transient reduction in protein expression. This study examines the use of PNA technology to interrupt protein expression in obligate intracellular Rickettsia sp. Their historically intractable genetic system limits characterization of protein function. We designed PNA targeting mRNA for rOmpB from Rickettsia typhi and rickA from Rickettsia montanensis, ubiquitous factors important for infection. Using an in vitro translation system and competitive binding assays, we determined that our PNAs bind target regions. Electroporation of R. typhi and R. montanensis with PNA specific to rOmpB and rickA, respectively, reduced the bacteria's ability to infect host cells. These studies open the possibility of using PNA to suppress protein synthesis in obligate intracellular bacteria.