Commentary ... realignment of the nation's tobacco agenda.
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Health Policy↗
Biomedical subjects
K Emmons
Publications and source records attributed to K Emmons.
EatSmart: efficacy of a multifaceted preventive nutrition intervention in clinical practice.
BACKGROUND: We evaluated a multifaceted preventive nutrition intervention to improve dietary habits among adult primary care patients. METHODS: We randomized six group practices in a managed care organization. Participants completed baseline and 3-month follow-up surveys. The intervention comprised (1) mailed personalized dietary recommendations and educational booklets focusing on fruits and vegetables, red meat, and dairy foods, tailored to patients' baseline intake and stage of readiness to change eating behaviors; (2) verbal endorsement by the primary care provider of the benefits of these recommendations; and (3) two motivational counseling sessions with telephone counselors to set dietary goals. RESULTS: Among the 230 subjects in the intervention group and 274 in the control group, mean age was 54 years, 70% were female, and 91% were white and 7% African American. Eighty-nine percent of the participants completed the follow-up survey. We measured change in intake of foods using results from the baseline and follow-up food frequency questionnaires. Using an intention-to-treat analysis and adjusting for age, sex, race, and baseline intake, the change in fruit and vegetable intake in the intervention group was 0.6 (95% confidence interval 0.3, 0.8) servings/day higher than in the control group. There was no intervention effect on red meat and dairy products. CONCLUSIONS: Tailored clinical nutrition interventions that combine brief physician endorsement with practice supports may be effective in changing patients' eating behavior.
Diet↗
Process evaluation of a clinical preventive nutrition intervention.
BACKGROUND: We report process data on the feasibility of delivering a clinical preventive nutrition intervention that was effective in increasing participants' consumption of fruits and vegetables. We also examine relationships between process variables and study outcomes. METHODS: We randomly assigned six practice sites in a managed care organization to a dietary intervention or control condition. We invited adults 18 years of age or older scheduled for routine health visits within the subsequent 2 months to participate. Of the 566 patients we contacted from the intervention sites, 230 (41%) enrolled. From the control sites, we contacted 617, and 274 (44%) enrolled. Intervention participants received a tailored letter providing feedback on their consumption of target foods together with recommendations for improvement, stage-matched nutrition education booklets, a diet-health endorsement from their primary care providers (PCPs), and two motivational counseling telephone calls. Of enrollees, 195 (85%) in the intervention group and 252 (92%) in the control group returned the final survey 3 months later. RESULTS: Seventy-one percent of both participants and PCPs reported that the PCPs had discussed the relationship between diet and health at their visit. Fifty-seven percent of participants and 62% of PCPs reported that they discussed the complete diet-health endorsement, which included: (1) acknowledgment of the relationship between diet and health and (2) tailored study recommendations. The inclusion of both parts of the diet-health endorsement, but not the length of time spent, appeared to correlate with healthful outcomes. CONCLUSIONS: These process data suggest that the brief PCP diet-health endorsement contributed to the intervention effect on fruits and vegetables.
Counseling↗
Coverage of smoking cessation treatment by union health and welfare funds.
OBJECTIVES: This study determined the level of insurance coverage for smoking cessation treatment and factors associated with coverage among health and welfare funds affiliated with a large labor union. METHODS: A self-administered written survey was mailed to fund and union officials. Analyses were conducted by chi2 tests. RESULTS: Twenty-nine percent of funds provided coverage for some type of smoking cessation treatment, with the odds of coverage significantly increased among funds whose administrators reported having received members' requests for smoking cessation treatment in the past year (odds ratio = 4.9, P = .05). CONCLUSIONS: Coverage for smoking cessation services is low, comparable to coverage offered by other health insurers. Interventions with union members and fund officials are needed to provide union members with access to affordable and effective smoking cessation treatments.
Administrative Personnel↗
Harvard report on cancer prevention volume 4: Harvard Cancer Risk Index. Risk Index Working Group, Harvard Center for Cancer Prevention.
OBJECTIVE: Prediction of cancer risk is a minor component of current health risk appraisals. Perception of individual cancer risk is poor. A Cancer Risk Index was developed to predict individual cancer risk for cancers accounting for 80% of the cancer burden in the United States. METHODS: We used group consensus among researchers at the Harvard Medical School and Harvard School of Public Health to identify risk factors as definite, probable and possible causes of cancer. Risk points were allocated according to the strength of the causal association and summed. Population average risk of cancer and cumulative 10-year risk was obtained from SEER data. Individual ranking relative to the population average was determined. The risk index was evaluated for validity using colon cancer incidence in prospective cohort data. RESULTS: The Harvard Cancer Risk Index provides a broad classification of cancer risk. Validation against cohort data shows good agreement for colon cancer. CONCLUSION: The Harvard Cancer Risk Index offers a simple estimation of personal risk of cancer. It may help inform users of the major risk factors for cancer and identify changes in lifestyle that will reduce their risk. It offers the potential for tailored health-promotion messages.
Adult↗
Local labor unions' positions on worksite tobacco control.
OBJECTIVES: This report describes local unions' positions on tobacco control initiatives and factors related to these positions. METHODS: A national random sample of local union leaders was surveyed by telephone. RESULTS: Forty-eight percent of local unions supported worksite smoking bans or restrictions, and only 8% opposed both a ban and a restriction. CONCLUSIONS: Support for tobacco control initiatives among local unions was higher than might be expected on the basis of previous evidence. Engaging unions in smoking policy formation is likely to contribute to the larger public health goal of reducing smoking and exposure to second-hand smoke among workers.
Attitude↗
Measuring participatory strategies: instrument development for worksite populations.
A participatory strategies approach which involves employees in the planning and delivery of worksite health promotion programs was utilized in the 55 experimental worksites included in the national, NCI-funded Working Well Trial. According to study protocol, Employee Advisory Boards (EABs) were organized in each experimental worksite. This paper describes two substudies designed to develop and measure participatory strategies associated with the EABs in the Working Well Trial. Study 1 determined characteristics of the EABs, developed subscales and assessed the internal consistency of the scales. Study 2 used a confirmatory factor analysis to examine the structure of the developed questionnaire. The four subscales include: Autonomy/Independence, Management Involvement, Institutionalization/Commitment and Others Involvement. Results from Study 1 indicate that the four subscales of the 24-item instrument demonstrated strong internal consistency and three were sensitive enough to register differences by Study Center at the baseline. Study 2 results found that the EAB subscales again demonstrated good internal consistency, structural stability and acceptable sensitivity. An initial validity analysis was performed and yielded results which supported some but not all of the hypothesized associations. Implications for further refinement and application of this new instrument in worksite settings are explored.
Attitude↗
Air nicotine and saliva cotinine as indicators of workplace passive smoking exposure and risk.
We model nicotine from environmental tobacco smoke (ETS) in office air and salivary cotinine in nonsmoking U.S. workers. We estimate that: an average salivary cotinine level of 0.4 ng/ml corresponds to an increased lifetime mortality risk of 1/1000 for lung cancer, and 1/100 for heart disease; > 95% of ETS-exposed office workers exceed OSHA's significant risk level for heart disease mortality, and 60% exceed significant risk for lung cancer mortality; 4000 heart disease deaths and 400 lung cancer deaths occur annually among office workers from passive smoking in the workplace, at the current 28% prevalence of unrestricted smoking in the office workplace.
Air Pollutants, Occupational↗
Implications of the results of community intervention trials.
This paper examines the results of population-level interventions conducted in three settings: entire communities, worksites, and schools. Four major conclusions are discussed: (a) Directions for the next generation of community-based interventions include targeting multiple levels of influence; addressing social inequalities in disease risk; involving communities in program planning and implementation; incorporating approaches for "tailoring" interventions; and utilizing rigorous process evaluation. (b) In addition to randomized controlled trials, it is time to use the full range of research phases available, from hypothesis generation and methods development to dissemination research. (c) The public health research agenda may have contributed to observed secular trends by placing behavioral risk factors on the social and media agendas. (d) The magnitude of the results of community intervention trials must be judged according to their potential public health or population-level effects. Small changes at the individual level may result in large benefits at the population level.
Community Health Planning↗
Labor positions on worksite tobacco control policies: a review of arbitration cases.
Although worksite smoking restrictions have become increasingly common in recent years, organized labor has generally not been involved in the adoption of these policies; some evidence suggests that unions often oppose the adoption of worksite smoking policies. To contribute to an understanding of labor's role in tobacco control policies, this paper reports the results of a review of 85 arbitration cases and 5 cases of unfair labor practices charges published between 1986 and 1994. In most of the cases reviewed, management unilaterally imposed a new smoking policy, which the union then grieved. Union opposition to the policy generally focused on the process by which the policy was adopted, rather than the content of the policy; the concern was that management had breached its duty to bargain with the union regarding the adoption of the policy. These results underline the importance of joint labor-management actions on worksite tobacco control policies.
Employee Grievances↗
Work site-based cancer prevention: primary results from the Working Well Trial.
OBJECTIVES: This paper presents the behavioral results of the Working Well Trial, the largest US work site cancer prevention and control trial to date. METHODS: The Working Well Trial used a randomized, matched-pair evaluation design, with the work site as the unit of assignment and analysis. The study was conducted in 111 work sites (n = 28,000 workers). The effects of the intervention were evaluated by comparing changes in intervention and control work sites, as measured in cross-sectional surveys at baseline and follow-up. The 2-year intervention targeted both individuals and the work-site environment. RESULTS: There occurred a net reduction in the percentage of energy obtained from fat consumption of 0.37 percentage points (P = .033), a net increase in fiber densities of 0.13 g/1000 kcal (P = .056), and an average increase in fruit and vegetable intake of 0.18 servings per day (P = .0001). Changes in tobacco use were in the desired direction but were not significant. CONCLUSIONS: Significant but small differences were observed for nutrition. Positive trends, but no significant results, were observed in trial-wide smoking outcomes. The observed net differences were small owing to the substantial secular changes in target behaviors.
Cross-Sectional Studies↗
The Working Well Trial: baseline dietary and smoking behaviors of employees and related worksite characteristics. The Working Well Research Group.
BACKGROUND: The Working Well Trial, the largest randomized worksite health promotion trial to date, tests the effects of cancer prevention and control interventions on dietary and smoking behaviors of employees and the worksite environment. The trial is a 5-year cooperative agreement conducted in 57 matched pairs of worksites in 16 states by four study centers, a coordinating center, and the National Cancer Institute. The dual aims of this paper are to: (a) present a baseline description of the dietary and smoking habits of 20,801 employees, who are predominantly blue-collar workers; and (b) describe the social and physical environments of their worksites that may facilitate or hinder health behavior changes. METHODS: The self-administered baseline survey of individuals consisted of a core set of questions common across all study centers on diet and smoking. The organizational survey consisted of eight instruments administered via interviews with key informants in each worksite. Continuous variable were analyzed by a mixed linear model and binary data were analyzed by the Generalized Estimating Equation. RESULTS: The population represented is largely male (67.5%) and blue collar (53.5%). Mean levels of fat and fiber intakes were close to the national averages (36.6% of calories as fat and 13.1 g of fiber). Smoking prevalence (25.2%) was slightly lower than the national average. The worksites had a high level of health promotion activities (42% had nutrition programs, 53% had smoking control programs), but lacked environmental support for dietary behavior change and perceived support for smoking cessation. CONCLUSIONS: These findings replicate and extend previous research results to a large sample of diverse, largely blue-collar worksites. In addition the baseline results lay a foundation for the development of new insights into the relationship between individual and organizational level variables that may interact to influence behavioral and cultural norms.
Adult↗
ETS exposure in the workplace. Perceptions and reactions by employees in 114 work sites. Working Well Research Group [corrected].
Employees are often exposed to and bothered by environmental tobacco smoke (ETS) in the workplace; however, little is known about correlates of workers' perceptions of their exposure. In this study, 20,801 employees in 114 work sites in the United States were surveyed; variables related to perceptions of exposure and being bothered by ETS were entered into regression models. Many of the workplaces had total or partial restrictions on smoking in the workplace; however, over half of the respondents (52.4%) reported they were exposed to ETS at work. Smoking policy, smoking status, age, gender, living with a smoker, and occupation contributed to models for perceived exposure and being bothered by tobacco smoke. Work site smoking restrictions seem to have an impact on employee attitudes concerning exposure to ETS. About 35% of employees were bothered regularly by smokiness at their workplaces, which made their working conditions both uncomfortable and exposed them to an unsafe working environment.
Adult↗
Pharmacokinetics of intravenous metronidazole at different dosages in healthy subjects.
Metronidazole is effective in the treatment of trichomoniasis and serious anaerobic infections. Individual doses given clinically ranged from 250 mg to 2.0 gm. Most of the available pharmacokinetic data were obtained when the drug was administered at the low end of the dosage range. Several other studies were done using assays that were subject to interference by metabolites. We therefore conducted this investigation to evaluate the pharmacokinetics of metronidazole at different dosage levels in normal subjects in a crossover manner using a specific HPLC assay. Nine male normal volunteers were each administered 250 mg, 1.0 gm and 2.0 gm of intravenous metronidazole in a crossover manner. Serial blood samples were obtained immediately before and at 0, 15, 30, 60, 90 minutes, 2, 4, 6, 10, 24 and 32 hours after the dose. Serum concentrations of metronidazole and its metabolites were determined by HPLC. The half-lives, elimination rate constants, volumes of distribution and areas under the concentration-time curve were calculated. Analysis of variance revealed a statistically significant difference between the low dose (250 mg) and the high dose (1.0 gm and 2.0 gm) effect on the calculated pharmacokinetic parameters. In addition, the production and the elimination of the metronidazole hydroxy metabolite were also found to be reduced when higher doses of the drug were administered. These findings revealed that the pharmacokinetics of metronidazole and its hydroxy metabolite are altered when higher doses of the drug are given; the metabolic transformation of the parent drug is also expected to be reduced.
Adult↗
Evaluating worksite smoking policies. Methodologic issues.
This paper discusses the methodologic issues one confronts when studying the impact of worksite smoking policies, using one such study as an example. Topics covered include defining the research questions, deciding on timing of measurements in relation to policy implementation, advantages and disadvantages of cohort versus cross-sectional research designs, and alternative measurement techniques. The sample study examined changes over one year in the smoking-related behaviors and attitudes of employees of a hospital that initiated a restrictive smoking policy, in relation to employees of a comparable hospital without a restrictive policy. The short term impact on ambient carbon monoxide was also examined. A case is made for studying the impact of smoking policy in the context of other strategies for reducing smoking prevalence at the worksite, such as individual treatment and organizational initiatives to motivate smoking cessation.
Carbon Monoxide↗
Gender differences among smokers and quitters in the Working Well Trial.
BACKGROUND: Gender differences in smoking and smoking cessation among participants in the Working Well Trial are characterized. METHODS: A prospective randomized matched-pair evaluation was conducted among 90 predominantly blue-collar worksites. Cross-sectional surveys of employees' tobacco use behaviors were conducted at baseline and after a 2.5-year smoking cessation intervention. Respondents included 5,523 females and 12,313 males at baseline and 4,663 females and 10,919 males at follow-up. The main outcome measures included self-reported continuous smoking abstinence rates for 7 days and for 6 months. RESULTS: Smoking prevalence was significantly higher for women than for men at baseline, but not at follow-up. Variables believed to influence smoking cessation were compared at baseline. Significant gender differences were found for number of cigarettes smoked/day, number of previous quit attempts, job strain, stage of change, and behavioral processes of change. At follow-up, no gender differences in quit rates were observed; however, women in the intervention condition were more likely to quit than women in the control condition, whereas no differences were seen among men by treatment condition. CONCLUSIONS: Gender is not a strong predictor of smoking cessation in this population; however, women were more likely to quit with an intervention than without one.
Adult↗
Smoking cessation and acute airway response to ozone.
Pulmonary function and symptom responses of asymptomatic smokers were measured during chamber exposures to ozone or filtered air. Subjects were evaluated while habituated to smoking and after 6 mo of smoking abstinence. At the onset of treatment, subjects (n = 18) who had a history of smoking 33.4 +/- 15.6 packs/y and who had almost normal pulmonary function (forced vital capacity [FVC], forced expiratory volume in 1 s [FEV1.0], and mid-maximal flow [MMF] were greater than 82% of predicted) were unresponsive to ozone exposure (0.4 ppm for 2 h). A matched group of control smokers (n = 16) did not respond to filtered air exposure. After 6 mo of smoking cessation, baseline MMF rates improved significantly (p less than .02); exsmokers (n = 15) raised this index from 3.32 to 4.11 l/s. All 9 subjects who abstained from smoking cigarettes for 6 mo and who were re-exposed to 0.4 ppm ozone had significant (p less than .01) reductions in MMF (from a mean of 3.86 +/- 1.32 [standard deviation] to 2.99 +/- 0.94 l/s, i.e., 22.5% reduction) and marginally significant reductions in comfort, as evidenced by an increase in the incidence of dry cough (p less than .10). The FVC was not reduced during ozone exposure. Control exsmokers (n = 6) remained unresponsive to filtered air exposure. The exsmokers' responses to ozone and their improved MMF during the period of smoking abstinence were correlated (coefficient = .88), i.e., subjects with the largest baseline gains in MMF after withdrawal experienced the largest acute decrements in MMF during ozone exposure.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Reducing the risk of cancer through worksite intervention.
This chapter examines existing activities reported in the literature in the areas of smoking, nutrition, and screening; explores the prominent theories of behavior change that have guided some of these activities; and presents a model for worksite cancer prevention programs that is currently being tested in a large trial. A major theme of this chapter is the need for simultaneous changes in individual behaviors and the worksite environment. For each factor (smoking, nutrition, and screening) the discussion is divided into interventions for individuals and those for the environment or organization.
Health Promotion↗