Respiratory morbidity in smokers of low- and high-yield cigarettes

To study the association between smoking cigarettes with a low yield of tar and nicotine (tar less than 15.0 mg per cigarette and nicotine less than 1.0 mg) and respiratory disease, we reviewed the medical records of 4,610 current, regular cigarette smokers and 2,035 persons who had never used any form of tobacco and who were enrolled in a smoking study. In the year after recruitment to the study, the percentage of subjects with pneumonia or influenza was lower in female but not in male smokers of low-yield cigarettes. The percentage of subjects with any disease of the respiratory tract was lower in both male and female smokers of low-yield cigarettes. In multiple logistic regression analyses in which tar was included as a continuous variable and in which we also controlled for age, sex, race, and number of cigarettes smoked per day, smoking lower tar cigarettes was associated with lower risk for pneumonia or influenza, but not with the risk for other acute respiratory infections, other diseases of the upper respiratory tract, chronic obstructive pulmonary disease and allied conditions, or all respiratory diseases considered as a group. In other multiple logistic regression analyses, in which we controlled for age, race, and sex, smokers of low-yield cigarettes had a higher risk for pneumonia or influenza and chronic obstructive pulmonary disease when compared with subjects who had never used tobacco. We conclude that, with regard to pneumonia and influenza seen in an outpatient setting, smoking low-yield cigarettes is probably less hazardous than smoking high-yield cigarettes, but it still represents a considerable hazard compared with not smoking cigarettes at all.     

Alcohol consumption and blood pressure: analysis of data from the Canada Health Survey

Recent epidemiologic studies report a significant association between alcohol consumption and elevations in both systolic (SBP) and diastolic (DBP) blood pressures. To test this hypothesis, we conducted a multivariate analysis of physical examination and other data on 721 men and 697 women aged 20 or more collected during the Canada Health Survey in 1978-1979. SBP and DBP were considered as separate dependent variables in multiple regression models with the following independent variables: age, alcohol consumption (measured as a 7-day recall history and as an average frequency of consumption), serum cholesterol, plasma glucose, physical activity, Quetelet index, parental history of hypertension, cigarette consumption, income, education, and exogenous hormonal use in women. In both weighted and unweighted multiple regression analyses, we could not demonstrate for either sex, a significant association between alcohol consumption (as recorded and following quadratic and logarithmic transformations) and either SBP or DBP. For both sexes, only age and Quetelet index were highly significantly (P less than 0.0001) and consistently associated with both SBP and DBP. No other independent variables were consistently associated, for either sex, with SBP and DBP. Further, the dose-response patterns noted by other investigators suggesting either a positive and linear relationship or a curvilinear relationship were not found in either our univariate or multivariate analyses. Rather, the alcohol-blood pressure curves showed no consistent patterns of any kind in either sex. These findings do not support recent claims that alcohol consumption is a determinant of elevations in either SBP or DBP.     

Smoking cessation with young women in public family planning clinics: the impact of physician messages and waiting room media

This study evaluated the impact of a media program and a physician-delivered message in encouraging smoking cessation among young black women in public family planning clinics. Incorporated into the clinic visit, the 3- to 5-min physician message was intended to elicit a commitment from participants to take steps toward quitting, namely, to think about quitting, set a target date, enlist the help of family and friends, throw away matches and cigarettes, and to then quit "cold turkey." The media program consisted of specially designed posters in waiting rooms showing models of people in the process of quitting and a continuously run movie dealing with women and smoking. A total of 1,179 female smokers were recruited into the study when they came to three separate clinics in Baltimore, Maryland, to receive gynecological examinations and/or contraceptive services. Four separate interventions were tested: (I) a baseline questionnaire about smoking habits and related information; (II) baseline questionnaire plus media program; (III) baseline questionnaire plus physician message; and (IV) baseline questionnaire plus media program plus physician message. Conditions I and II were administered in Clinic A on alternating weeks, Condition III was administered in Clinic B, and Condition IV was administered in Clinic C. Follow-up was conducted at 3 and 12 months. Follow-up rates were 88.1% at 3 months, 79.9% at 12 months, and 84.1% for both 3 and 12 months. Among women receiving the physician message (Conditions III and IV), 9.9% reported not smoking at 12 months; the lowest selfreported cessation rate was 3.1% in Condition I. When verified through analyzing cotinine in saliva, quit rates were 0.09% in Condition I, 2.4% in Condition II, 3.7% in Condition III, and 2.1% in Condition IV. The fact that participants receiving the physician message quit smoking at a significantly greater rate than those who did not indicates the need for further study of the impact of physician-delivered smoking cessation messages and ways to increase their effectiveness.     

Multivariate evaluation of health attitudes and behaviors: development and validation of a method for health promotion research

Many self-reported measures of health status, attitudes, and knowledge used by clinicians and researchers suffer from a variety of shortcomings, including limited empirical justification, excessive complexity, assessments of nonmodifiable historic or hereditary factors, and limited utility for public health program planning. The Health Attitudes and Behavior Scale is an instrument designed to overcome many of these shortcomings and direct public health professionals toward more efficacious interventions. One hundred sixty-four subjects responded to true-false and Likert scale items related to health beliefs, attitudes, and behavioral practices. A principal component analysis of the Likert items yielded six components, tentatively labeled (a) Lack of Social Support, (b) Hurdles to Health, (c) Health Attitudes/Weight Concerns, (d) Positive Environment, (e) Disease Concerns, and (f) Time and Work Pressure. Analyses of these scales using coefficient alpha indicated adequate internal consistency for each of them. These scales were then related to demographic variables of age, educational level, sex, and marital status. Next, these scales were correlated with individual true-false items reflecting self-reported behavioral practices or health histories. A component analysis of the true-false items yielded four principal components labeled (a) Organizational Health Concerns, (b) Smoking and Exercise Concerns, (c) Coronary and Weight Concerns, and (d) Blood Pressure and Risk Factor Programs. Finally, a cluster analysis yielded six typical profiles reflecting different levels of the original six components. Of interest is the fact that the Lack of Social Support and Time and Work Pressure scales had a very limited integration into the overall patterns. The assumption that organizational and environmental factors can have an important impact on health was supported. The need for further research in this area is also discussed.     

Clustering of cardiovascular disease risk factors

In a population-based cardiovascular disease study we analyzed the associations among five risk factors—cholesterol, triglycerides, blood pressure, obesity, and cigarette smoking. Two methods were used: standard correlation analysis, and a percentile analysis method limited to associations at higher levels of these risk factors. The study population, 4,839 men and women aged 30–89, showed significantly positive standard and age-adjusted correlation coefficients for all comparisons between any two risk factors except for those comparisons involving smoking. In the percentile analysis, subjects with moderate or greater (?70th percentile) or high (?90th percentile) levels on one of these risk factors showed clustering of elevations in other risk factors in that observed/expected ratios were generally greater than unity, again excepting smoking comparisons. Clustering was strongest in subjects at the highest levels of these risk factors, a phenomenon which has not, to our knowledge, previously been reported. Because of the particularly high risk of subjects with several risk factors, this finding should caution clinicians who identify a patient with an elevation of one of these risk factors to evaluate the patient carefully for elevations of other risk factors.     

High- and low-density lipoprotein cholesterol: correlates in an older population

A predominantly upper-middle-class white population of 279 men and 345 women with an average age of 66 years was evaluated to determine correlates of high- and low-density lipoprotein cholesterol (HDL and LDL), since these may be the only cholesterol measurements predictive of cardiovascular disease after age 50. Associations of HDL and LDL with age, alcohol use, obesity, smoking, diet, exercise, and medication use were examined using multiple linear regression. Alcohol, average and above-average exercise, postmenopausal estrogen use (women), B vitamin intake, and corticosteroid use were all positively related to HDL levels, and obesity (men only), cigarette smoking, and thyroid hormone use were inversely related. The only statistically significant correlates of LDL were an increase with age (women only) and lower levels in women using thyroid hormone. However, the associations of several behavioral variables with LDL, although not statistically significant, were in the expected direction. These results may suggest the continuing potential for preventive intervention even in an elderly population.     

Techniques for characterizing a series of blood pressure measurements over time

To develop a technique for summarizing a blood pressure trajectory over a follow-up period, we evaluated four types of summary measures: blood pressure at the end of one year of follow-up, average of the last three recorded pressures, simple average of all readings over the interval, and a new measure which we present, the time-weighted average of all blood pressures over the interval. Though the four methods gave essentially similar mean values for diastolic pressures in this particular data set, the simple average and time-weighted averages were more precise. As a general principle the use of an average measure allows for smaller sample size. Comparison of the time-weighted and simple averages presents a check for the magnitude of the upward bias that could result from frequent return appointments during episodes of noncontrol.     

Improving the practice of pediatric patient education: A synthesis and selective review

Patient education within the pediatric-care setting can be defined as any combination of planned learning experiences designed to facilitate adaptations of behavior conducive to health. It is directed both toward patients and toward significant adult caretakers in the child's environment. Additionally, health promotion and health education outside of the patient-care setting are required to promote child health. These efforts include legislation directed toward environmental hazards as well as community- and school-based health education programs. Although educating children and their parents is a routine part of pediatric health care, patient education efforts often reflect poorly applied principles of learning. Social learning theory provides useful constructs that can serve as a basis for developing, implementing, and evaluating pediatric patient education. These constructs focus attention on environmental influences on the learner, the role of modeled behavior for health outcomes in children, and the key concepts of perceived self-efficacy and family and social support.     

The UCLA population studies of chronic obstructive respiratory disease. II. Determination of reliability and estimation of sensitivity and specificity

A probability sample of 218 adults tested at a mobile lung function (field) laboratory was retested at a UCLA reference laboratory. Results in the two laboratories were compared for (i) numerical correlation, (ii) variability, and (iii) agreement in disease classification.FEV₁ andFVC showed good agreement between laboratories. Plethysmography showed good agreement and moderate correlation. SBNT showed poor correlation, high variability, but good agreement. Test subjects were classified by two respiratory specialists as having or not having chronic obstructive respiratory disease. Individuals thus diagnosed were considered to be true positives and the results of each of the tests, groups of tests, and all tests in each laboratory were evaluated, using these criteria, for their estimated sensitivity and specificity: (i)FEV₁,FVC, and plethysmography were estimated to be specific but relatively insensitive; (ii)FEF 25–75% was less specific but more sensitive; (iii) the flow-volume curve had the highest sensitivity and reasonable specificity; (iv) closing volume showed reasonable sensitivity and specificity but was not reliable. Determination of specificity may have been confounded by the presence of disease too early to diagnose clinically. The disparity in classification between the two laboratories was no greater than that between the two physicians. Field screening using spirometry, SBNT, and body plethysmography is apparently comparable to comprehensive diagnostic procedures in a clinic setting.     

Adolescent smokers and nonsmokers: Profiles and their changing structure

The status of smoking among tenth-graders in Jerusalem high schools as part of a smoking prevention program was examined. Two consecutive cohorts of 792 and 771 subjects were given questionnaires on two occasions: at the onset of the study (fall 1980 for the first cohort and fall 1981 for the second), and either 2 years (first cohort) or 1 year (second cohort) later. Based on the theory that smoking relates to counterconformity entailing rebelliousness and conformity to a nonconformist peer culture, subjects were asked about their behaviors and cognitions concerning school, home, peers, drinking, and smoking. It was reasoned that no single variable can predict, let alone explain, the onset and continuation of smoking and that the various factors that relate to smoking and distinguish between smokers and nonsmokers (a) constitute a systematic and coherent syndrome of counterconformity variables, which (b) reinforce each other, and (c) that over time, smoking and counterconformity come to affect each other reciprocally. These hypotheses were supported by the data. Smokers were found to differ from nonsmokers in a number of ways that were all related to counterconformity. Truancy and an inability to resist peer pressure to smoke, manifestations of two aspects of this syndrome, were the best predictors of smoking for both sexes, both cohorts, and both measuring occasions. With time, personal rebelliousness tended to become a weaker predictor, while social interaction variables became relatively stronger. The intercorrelations among the nonsmokers who became smokers were the highest, as predicted. The nature of the syndrome, its changing structure, and implications for prevention are discussed.     

Response to O'Malley: cigarette smoking among high school seniors

P. M. O'Malley (Prev. Med. 13, 421-426, 1984) has stimulated discussion on the issues of self-reported smoking, the use of validation procedures to enhance self-report of smoking behavior, and the question of trends toward increases in underreporting of adolescent smoking. O'Malley's analysis was prompted by an earlier report of data from the Childhood Antecedents of Smoking Study. In response to O'Malley, further analysis comparing data from the Childhood Antecedents of Smoking Study with data from the Monitoring the Future study is presented, and recent evidence on the "bogus pipeline" methodology is reviewed.     

Comparison of patterns of smoking behavior change among smokers in the Multiple Risk Factor Intervention Trial (MRFIT)

The Multiple Risk Factor Intervention Trial (MRFIT) is a 6-year clinical trial for the study of the prevention of heart disease. Twelve thousand eight hundred and sixty-six men in the upper 10–15% of heart attack risk were randomly assigned to Special Intervention (SI) or Usual Care (UC). The SI participants received “risk factor” (hypertension, hypercholesterolemia, and cigarette smoking) intervention at the clinical centers; the UC participants were referred to their usual source of medical care for treatment. Forty percent of SI and 21% of UC smokers at entry reported not smoking at year 4, with lighter smokers in both treatment groups reporting significantly more cessation than heavier smokers. The greatest SI-UC difference in cessation rate was achieved during the first year of the program. The use of serum thiocyanate, an objective indicator of cigarette smoking, avoided problems inherent in self-reported data. Misreporting of smoking status was found in both groups with more occurring among the SI smokers. Cohort analysis revealed that of the smokers who stopped during the first year of the trial, 68% of SI and 57% of UC remained abstinent through the 4-year follow-up. Of the smokers who stopped later in the program the UC had better maintenance rates than the SI.     

Risk factors for chronic diseases in Norwegian school children: Preliminary findings of a baseline survey as part of an intervention study (The Oslo Youth Study)

Some preliminary results from a baseline screening as part of an intervention study in Norwegian school children are presented. The survey was part of the International “Know Your Body” program. The Oslo Youth Study (Kjenn Din Kropp), which is financed by the Norwegian Cancer Society, is one of the three national projects of the multicenter, WHO Collaborative Study on Health Promotion in Youth. The three studies also follow closely the protocol of the Study of the Precursors of Atherosclerosis, issued by WHO. Eight hundred fifty-six pupils (approximately 82% of the total eligible population aged 11–15 years) were examined with regard to their health knowledge, attitudes, and behavior (supervised questionnaire), height, weight, triceps skinfold thickness, blood pressure, aerobic work capacity (indirect method), total serum cholesterol, HDL cholesterol, fasting triglycerides, thiocyanate, and hematological parameters.     

Immunological aspects of exposure to emissions from burning coal of high beryllium content

An epidemiological study was conducted on groups of people exposed occupationally (45 persons) and nonoccupationally (36 persons) to the combustion products of coal containing a comparatively high concentration of beryllium. The concentration of beryllium in the working atmosphere ranged between 30 and 800 × 10^?5 mg × m^?3; in the town S, dwelling place of a nonoccupationally exposed cohort between 0.39 and 1.68 × 10^?5 mg × m^?3. A group of 100 subjects who had no occupational contact with beryllium and other industrial toxic agents, and lived outside of the polluted region served as control cohort. In all examined persons the main classes of immunoglobulins and autoantibodies (lung, heart, liver, spleen, thyroid gland, suprarenals, and native DNA) and antibodies against nuclear (ANA) and mitochondrial (AMA) antigens (obtained from the lungs of intact and of experimental berylliosis rats) were determined. In both exposed groups elevated levels of IgG and IgA and increased concentrations of autoantibodies were found in comparison with the control cohort of people. Specific AMA and ANA were also found in both the exposed groups, with higher values in women. The demonstrated immunological changes in humoral immunoreactivity might be considered as signs of beryllium exposure. In the discussion the authors emphasize the increasing importance of immunological aspects in the study of environmental pollution.     

A hypertension treatment program at the workplace to complement community care

A worksite hypertension control program was established for employees of the state of Maryland. Employees were screened for hypertension, and individuals identified as hypertensive were encouraged to seek care from community physicians. For those choosing not to seek such community care, a treatment program was initiated at the worksite. Of the 417 hypertensives identified, 54 (13%) elected to have their blood pressure treated at the worksite. Comparisons between the group choosing worksite care and the group choosing community care revealed that the worksite group was generally a higher risk group by virtue of having less awareness of their hypertension, being less likely to be on antihypertensive treatment, and being less likely to have their hypertension controlled by medication. This group made relatively little use of community physicians. Increases in hypertension treatment and control were greater in the worksite group after a 2-year follow-up examination. The project suggests an important role for worksite treatment programs for hypertension as a complement to existing community care.     

Alcohol consumption and 17-year mortality in the Chicago Western Electric Company study

The association between baseline alcohol intake and mortality from all causes and specific causes based on 17 years of follow-up experience was analyzed for 1,832 white males originally age 40–55 from the Chicago Western Electric Company study. Alcohol consumption was expressed as number of drinks per day for all intake combined, including hard liquor, beer, and wine, based on the maximum intake reported on three questionnaires. With mortality rates adjusted only for age, total intake was associated with increased risk of death from all causes, the cardiovascular diseases, coronary heart disease, cancer, and other causes at the level of six or more drinks per day. There was no increase in mortality with increasing alcohol consumption below this level. Only the associations between alcohol intake and death from the cardiovascular diseases and coronary heart disease failed to persist after adjustment for other risk factors, such as smoking and blood pressure. When the deaths were divided into those occurring within the first 10 years of follow-up and those occurring more than 10 years after entry, the association between baseline alcohol intake and mortality was generally stronger for those deaths occurring more than 10 years after entry.     

Evaluation of cigarette smoking among adolescents: The Muscatine study

In Muscatine, Iowa, the smoking behaviors and related factors were studied in 2,156 school children ages 12 through 18 years. Data were collected through a questionnaire, a “randomized question response,” and by saliva thiocyanate analyses. The proportion reporting smoking on the confidential questionnaire and the anonymous randomized question response were not significantly different. Those reporting the greatest frequency of smoking had the highest levels of saliva thiocyanate. No difference in self-reported smoking was observed in subjects who, prior to completing the questionnaire, were told their saliva would be analyzed for tobacco products and those who were not. These data suggest that children under certain circumstances may honestly and validly complete a questionnaire about their smoking behavior. Of respondents who report both parents as nonsmokers and whose best friends are nonsmokers, 80% have never smoked, and 3% are regular smokers. Of those with both parents and best friends who smoke, only 11% have never smoked and 74% are frequent smokers. Thus the smoking behaviors of parents and peers are important factors relating to children's smoking and nonsmoking decisions.     

Clustering and interrelationships of high-, low-, and very low-density lipoproteins in randomly recalled children and adults: The Cincinnati lipid research clinic's princeton school prevalence study

Within the frame of reference of no single, entirely satisfactory approach available for analysis of lipoprotein phenotypes, genotypes, and lipid—lipoprotein interactions with coronary heart disease, this analysis was designed to assess clustering of low-, high-, and very low-density lipoprotein cholesterols (LDL, HDL, and VLDL) in 943 randomly recalled children and 351 adults in the biracial Cincinnati Lipid Research Clinic's Princeton School Study using multivariate cluster analyses. The specific aims of this study were to better define and examine the interrelationships of LDL, HDL, and VLDL, and to focus upon the clinical and prognostic utility of multivariate cluster analysis of lipoproteins. The cluster analysis revealed a much more atherogenic constellation of lipoproteins for adults when compared with children, specifically, much higher adult LDL and VLDL with comparable HDL. Clusters of atherogenic and antiatherogenic lipoprotein cholesterols were substantively affected by race and sex. Whites were more likely to have predominantly elevated levels of LDL and/or VLDL with reciprocally low levels of HDL. Blacks, on the other hand, were more likely to have predominantly elevated HDL levels. White men primarily aggregated in clusters characterized by elevated LDL whereas white women aggregated in groups characterized by elevated HDL. Cluster analysis, a multidimensional scaling procedure, is a useful exploratory tool for assessment of the three-dimensional interactions of lipoprotein cholesterols and complements extant lipoprotein classification systems.     

Parent-child obesity and cardiovascular risk factors

Blood pressure, cholesterol, high density lipoprotein cholesterol, and triglycerides were studied in obese children and obese parents selected to participate in a weight treatment program. The relationships between parent and child risk levels, as well as the relationship between child and parent weight and risk factors, were established. Results showed that children's cholesterol and triglycerides were related to parental lipid levels, independent of weight. Children's blood pressure readings were strongly related to their weight, but not to parental blood pressure. High density lipoprotein cholesterol levels were negatively related to weight in both child and parent female populations, and weakly positively related to weight for male children. Implications of these risk factor patterns for intervention are discussed.