Cigarette Smoking among HIV+ Men and Women: Examining Health,Substance Use,and Psychosocial Correlates across the Smoking Spectrum

The prevalence of cigarette smoking among HIV+ individuals is greater than that found in the general population. However, factors related to smoking within this population are not well understood. This study examined the associations between smoking and demographic, medical, substance use, and psychosocial factors in a clinic-based sample of HIV+ men and women. Two hundred twelve participants completed self-report measures of tobacco use, HIV-related symptoms, viral load, CD4, alcohol and illicit drug use, depression, and social support. Multinomial logistic regression (MLR) analyses modeled the independent associations of the cross-sectional set of predictors with smoking status. Results indicated that 74% of the sample smoked at least one cigarette per day; using standard definitions, 23% of the sample were light smokers, 22% were moderate smokers, and 29% smoked heavily. Smoking was associated with more HIV-related symptoms, greater alcohol and marijuana use, and less social support. Light smoking was related to minority race/ethnicity and less income; moderate smoking was associated with less education; and heavy smoking was related to less education and younger age. Viral load, CD4 count, and depression were not associated with smoking status. Psychosocial interventions targeting this population should consider the relationships between biopsychosocial factors and smoking behavior.     

The association among depressive symptoms,smoking status and antidepressant use in cardiac outpatients

Both depression and smoking are highly prevalent and related to poorer outcomes in cardiac patients. In this study, the authors examined the association between depressive symptoms and smoking status, described the frequency and type of antidepressant use, and prospectively tested the effects of antidepressant use in smokers on smoking status and psychosocial outcomes. Participants comprised 1,498 coronary artery disease (CAD) outpatients who completed a baseline survey which assessed depressive symptoms, current medications, and smoking status. A second survey was mailed 9 months later that assessed depressive symptoms, anxiety, insomnia and smoking status. Results showed that current and former-smokers had significantly greater depressive symptoms than non-smokers. Ten percent of patients were taking antidepressants, most frequently SSRIs, with significantly more smokers on antidepressants than former and non-smokers. At follow-up, smokers on antidepressants were less likely to have quit, had greater anxiety, depressive symptoms and insomnia than smokers not using antidepressants. This study demonstrated that smokers and quitters with CAD had greater depressive symptoms and use of antidepressants than non-smokers, but that the antidepressants utilized may not be optimizing outcomes.     

Acculturation and cigarette smoking among Korean American men

This study examined the prevalence and correlated factors of cigarette smoking in a cross-sectional, epidemiological survey of Korean American men living in Maryland (n=333). In this sample, 26.1% were current smokers and 42.3% were former smokers. The older age group (> or = 40 years) was more likely to have quit smoking than the younger age group (< 40 years). In multiple logistic regression analysis, acculturation was associated with smoking status; those who stayed more than 20 years in the U.S. were less likely to be current smokers (OR=0.32, 95% CI 0.13-0.77) than those who stayed less than 10 years. Alcohol use was associated with smoking status; those who consumed alcohol were more likely to be current smokers (OR=5.24, 95% CI 2.33-11.79) or former smokers (OR=5.45, 95% CI=2.69-11.04) than those did not. Those with hypertension were more likely to have quit smoking (OR=3.11, 95% CI=1.33-7.24). The results suggest that the role of acculturation in smoking status among Korean American men deserves further attention by researchers as well as by health professionals who develop smoking prevention and cessation programs.     

Constraints and prospects in the management of pediatric HIV/AIDS

BACKGROUND: Pediatric HIV/AIDS is increasing in Nigeria through mother-to-child transmission. Lack of diagnostic facility and affordability of therapy are major constraints. These factors were examined in Lagos University Teaching Hospital (LUTH) between 1996 and 2002. MATERIALS AND METHODS: Case records of pediatric HIV/AIDS patients were examined for age, sex, mode of diagnosis, associated illnesses, treatment outcome and socioeconomic and HIV status of the parents. RESULTS: Out of 124 cases confirmed to have HIV/AIDS, 56.5% were aged <18 months and 89.5% had > or =4 clinical features at presentation. There was an increasing trend in the number of cases from 1996 to 2002. Diagnosis was by WHO clinical criteria as no polymerase chain reaction (PCR), was done and only 12.1% had CD4+ count done. The commonest associated illness was tuberculosis (25.8%). Only 20.2% were placed on antiretroviral drugs during the period. Mothers were significantly younger than fathers (P<0.05) and were more likely to be HIV positive. High rate of discharges against medical advice and default from follow-up occurred. CONCLUSION: Pediatric HIV/AIDS is on the increase at LUTH, and mothers were more HIV infected than fathers. The prohibitive cost of drugs prevented most patients from receiving therapy.     

Depression and smoking amongst older general practice patients

BACKGROUND: Cerebrovascular disease is associated with depression in later life. Smoking is a known risk factor for cerebrovascular disease and, as a consequence, may contribute to the development of depression in the elderly. This study was designed to investigate the association between smoking and depression in people aged 60 years or over. METHODS: Cross-sectional survey of older adults attending a representative sample of general practitioners in Western Australia. Subjects were divided into four groups according to their smoking status: never smoked, ex-light smoker, ex-heavy smoker (>20 cigarettes/day), and current smoker. Depressive symptoms were assessed with the Center for Epidemiologic Studies-Depression Scale (CES-D). CES-D score of 22 or more was used to define the presence of clinically significant depression. RESULTS: 1030 completed the assessment. Their age ranged from 60 to 101 years and 57.2% were female. The mean+/-S.D. CES-D score was 10.5+/-8.1, 10.6+/-8.3, 12.5+/-10.2 and 13.1+/-11.0 for never smokers, ex-light smokers, ex-heavy smokers and current smokers respectively (p=0.037), with 7.7%, 8.5%, 13.8% and 17.2% having CES-D > or =22 (p=0.016). Current or past heavy smoking was associated with increased risk of clinically significant depression when compared to never or past light smoking (OR=1.58, 95%CI=1.01-2.48-after adjustments were made for age, gender, place of birth, social isolation, self-perceived health and harmful or hazardous drinking). CONCLUSION: Past heavy smoking and current smoking are associated with increased frequency and severity of depression. Smoking cessation may play an important role in reducing the burden of depression in later life, but the success of smoking cessation interventions in decreasing the incidence and prevalence of depression might be predicated on the timing of the intervention; i.e., before the psychobiological changes associated with smoking become irreversible.     

Gender Differences in Factors Associated with Clinically Meaningful Weight Loss among Adults Who Were Overweight or Obese: A Population-Based Cohort Study

ObjectivesThe impact of heterogeneity on gender difference for achieving clinically meaningful weight loss (cmWL) remains unclear. Here, we explored the potential gender differences in factors associated with cmWL.MethodsA total of 60,668 participants with body mass index (BMI) ≥25 kg/m² at study entry and available BMI values at follow-up were included in this study. cmWL was defined as a weight loss of ≥5% from the study entry to follow-up. The associations of social-demographic factors, personal history of chronic diseases, lifestyle behaviors, and history of BMI with cmWL were evaluated using logistic regression models.ResultsDuring a median follow-up of 9.13 years, 26.6% of the participants had a cmWL (30.8% for females vs. 23.1% in males; p < 0.001). Participants with older age, obesity at study entry, being more physical activity compared to 10 years ago, being relapsed smokers or consistent current smokers, having a history of chronic diseases (i.e., diabetes, osteoporosis, and stroke), cancer diagnosis during the study period, and more than 10-year follow-up were more likely to achieve cmWL in both males and females (all p < 0.05). The new smoking quitters and participants with less active in physical activity compared to 10 years ago were less likely to achieve cmWL in both males and females (all p < 0.05). Specifically, males with a history of emphysema were more likely to reach cmWL, and for females, those being overweight at 20 years old and current drinkers were more likely to reach cmWL (p < 0.05). Sensitivity analyses demonstrated similar results.ConclusionAge, BMI status, physical activity, smoking status, family income, and health status were independent factors in males and females for weight management. However, further well-designed prospective studies are warranted to confirm our findings.     

Two-year prospective study of major depressive disorder in HIV-infected men

OBJECTIVE: The risks and factors contributing to major depressive episodes in HIV infection remain unclear. This 2-year prospective study compared cumulative rates and predictors of a major depressive episode in HIV-infected (HIV+) men (N=297) and uninfected (HIV-) risk-group controls (N=90). METHODS: By design participants at entry were without current major depression, substance dependence or major anxiety disorder. Standardized neuromedical, neuropsychological, neuroimaging, life events, and psychiatric assessments (Structured Clinical Interview for DSM III-R) were conducted semi-annually for those with AIDS, and annually for all others. RESULTS: Lifetime prevalence of major depression or other psychiatric disorder did not differ at baseline between HIV+ men and controls. On a two-year follow-up those with symptomatic HIV disease were significantly more likely to experience a major depressive episode than were asymptomatic HIV+ individuals and HIV-controls (p<0.05). Episodes were as likely to be first onset as recurrent depression. After baseline disease stage and medical variables associated with HIV infection were controlled, a lifetime history of major depression, or of lifetime psychiatric comorbidity (two or more psychiatric disorders), predicted subsequent major depressive episode (p<0.05). Neither HIV disease progression during follow-up, nor the baseline presence of neurocognitive impairment, clinical brain imaging abnormality, or marked life adversity predicted a later major depressive episode. LIMITATIONS: Research cohort of men examined before era of widespread use of advanced anti-HIV therapies. CONCLUSIONS: Symptomatic HIV disease, but not HIV infection itself, increases intermediate-term risk of major depression. Prior psychiatric history most strongly predicted future vulnerability.     

Men who have sex with men: estimated population sizes and mortality rates by race/ethnicity, Miami-Dade County, Florida

BACKGROUND: Estimated numbers of men who have sex with men (MSM) by race/ethnicity and mortality rates among such MSM with HIV/AIDS are unavailable. This hampers efficient targeting of HIV/AIDS prevention and care resources. METHODS: An existing estimation methodology was adapted to develop MSM population estimates by race/ethnicity for Miami-Dade County, Florida. We ascertained and characterized deaths that occurred during 2003 to 2005 among MSM HIV/AIDS cases, matching HIV/AIDS surveillance and vital statistics registries. We calculated estimated average annual racial/ethnic-specific mortality rates and rate ratios (RRs) among MSM HIV/AIDS cases. RESULTS: An estimated 63,020 men aged > or =18 years in the county are MSM (7.5% of all men aged > or =18 years; point estimate). Among 754 MSM HIV/AIDS deaths, point-estimate mortality rates per 100,000 MSM were higher for blacks (733.5) than for whites (229.2) (P < 0.01) and Hispanics (360.5) (P < 0.01). The best estimate of the black/white MSM mortality RR among HIV/AIDS cases was 3.20:1 (P < 0.01); for Hispanic/white MSM, it was 1.57:1 (P < 0.01). Sensitivity analyses suggested the estimates were reasonably robust to biases that we examined. CONCLUSIONS: Black and Hispanic MSM were more likely to die with HIV/AIDS than white MSM. Plausible racial/ethnic-specific MSM population and mortality rate estimates can inform effective HIV/AIDS prevention efforts and program planning.     

Gender differences among oral health care workers in caring for HIV/AIDS patients in Osun State, Nigeria

The study investigated the relationship between gender and knowledge, attitude and practice of infection control among oral health care workers in the management of patients with HIV/AIDS in Osun State of Nigeria. It was a cross-sectional survey using 85 oral Health care workers (OHCWs) enlisted in the public dental health clinics. A self-administered questionnaire was designed and used for data collection. A total of 85 questionnaires were distributed. The response rate was 93%; 42 (53%) were males and 37 (47%) females. The majority of the respondents were in the 25-40 year old age group and the mean age was 37.3 years. This study found significant differences in gender and ability to identify HIV/AIDS oral manifestations (p<0.001) and recognition of HIV/AIDS risk factors (p<0.001). There was statistically significant gender difference and infection control practices (p=0.02) among the OHCWs. Males were more compliant to the universal cross-infection control principle than the female respondents. A significant association (p< 0.001) was found between OHCW gender and their attitude to the management of HIV/AIDS patients with males showing a better attitude towards the care of HIV/AIDS patients. This study shows that there are significant gender difference in attitudes, behaviour and practices of OHCW with males faring better than the females. National AIDS Control Programme, Health Control bodies, Health educators and other organizations should make efforts to improve the attitude and practice of oral health care workers regarding the management of patients with HIV/AIDS.     

The prevalence of EGFR mutations in non‐small cell lung cancer in an unselected Caucasian population

EGFR mutation frequencies in unselected Caucasian populations are unknown. This study assesses the prevalence of EGFR mutations in an unselected population‐based cohort, and the correlation between mutation and gender, age, ethnicity, smoking habits, and pathological data. NSCLC patients diagnosed in a well‐defined Danish population were included. The type of the diagnostic material, and data on smoking were registered. The mutation analyses were investigated by Therascreen EGFR RGQ‐PCR Kit or Sanger sequencing. A total of 658 men and 598 women were included. 6.2% were never smokers, 38.9% were ex‐smokers, and 54.9% were current smokers. One thousand one hundred and sixty‐one (92.4%) patients had sufficient material for mutation analysis. Cytological material was used for 38% of the mutation analyses. 5.4% had mutation in the EGFR gene (4.3% men/6.7% women). 87% were activating mutations. 8.0% of adenocarcinomas, and 1.9% of squamous cell carcinomas were mutated. 29.4%, 4.4% and 2.9% of never, ex‐ and current smokers were mutated (p < 0.001). No difference in mutation rate was observed between patients with cytology only, histology only or both cytology and histology available. 5.4% of the patients had EGFR mutation. Adenocarcinomas were mutated more often (8.0%) than squamous cell carcinomas (1.9%). Mutations were found in never smokers as well as in former and current smokers. No difference in gender and age regarding mutation status was observed. EGFR mutations analysis was possible in almost all patients with no difference between cytology and histology specimens.     

Prevalence of psychiatric disorders in early stages of HIV infection.

As part of a military universal HIV screening program, 442 men were assessed for the presence of DSM-III-R defined psychiatric disorders and symptoms of anxiety and depression after notification of HIV seroconversion. Of them, 84.4% were in the earliest, asymptomatic stages of disease at the time of interview (96% did not have AIDS). The Structured Clinical Interview for DSM-III-R and Structured Interview Guide for the Hamilton Anxiety and Depression Scales were used. Relevant comparisons were made to Epidemiologic Catchment Area prevalence data. HIV seropositive men were more likely than age-matched men in the community to have current diagnoses of major depression (ages 18-44) and anxiety disorders (ages 25-44). Higher lifetime rates of major depression and alcohol use disorder, and high current prevalence of sexual dysfunction (21.7%) were noted. We conclude that men who become HIV seropositive have high rates of mood and substance use disorders prior to knowledge of seroconversion, and that early in the course of HIV infection men are at risk for developing major depression, anxiety disorders, and disorders of sexual desire.     

Prevalence and Predictors of Traditional Medicine Utilization Among Persons Living With Aids (PLWA) on Antiretroviral (ARV) and Prophylaxis Treatment in Both Rural and Urban Areas in South Africa

Previous studies have reported that majority of antiretroviral (ARV) treatment-naïve patients use traditional medicine (TM). Given that TM use is ubiquitous in South Africa especially for chronic conditions, there is a potential for ARV non-adherence and serious drug interactions among patients with HIV/AIDs who use TM. The motivating factors for TM use in HIV/AIDS patients on ARV and prophylaxis treatment have not been well defined in South Africa. This study aimed to investigate the prevalence, facilitators, predictors, and types of TM used among persons living with HIV/AIDS on antiretroviral treatment. The study was a cross-sectional survey which involved 100 participants enrolled at ARV clinics in two South African provinces. Univariate and bivariate analyses were performed to assess the relationships between variables and potential predictors of TM. Sixteen percent of participants on ARV reported TM use. Seventy-nine percent used TM prior to a diagnosis of HIV. Participants were more likely to use TM if they were from a rural province, female, older, unmarried, employed, had limited education, or were HIV-positive for less than five years. TM users reported utilizing herbal or medicinal mixtures that were claimed to heal all conditions. This study provides insights into the treatment modalities selected by patients with HIV/AIDS in South Africa who are receiving ARV. This study revealed that less than 20% of participants co-used TM and ARV. However, close to 80% of participants utilize TM before contracting HIV, which is in keeping with approximate estimates by the WHO.     

Fluoxetine, smoking, and history of major depression: A randomized controlled trial

The study was a randomized placebo-controlled trial testing whether fluoxetine selectively enhances cessation for smokers with a history of depression. Euthymic smokers with (H+, n = 109) or without (H-, n = 138) a history of major depression received 60 mg fluoxetine or placebo plus group behavioral quit-smoking treatment for 12 weeks. Fluoxetine initially enhanced cessation for H+ smokers (p = .02) but subsequently impaired cessation regardless of depressive history. Six months after quit date, fluoxetine-treated participants were 3.3 times more likely to be smoking (p = .02). Further research is warranted to determine why high-dose fluoxetine produces continuing effects that oppose tobacco abstinence.     

Cognitive-behavioral treatment for depression in smoking cessation

Cigarette smokers with past major depressive disorder (MDD) received 8 group sessions of standard, cognitive-behavioral smoking cessation treatment (ST; n = 93) or standard, cognitive-behavioral smokiig cessation treatment plus cognitive-behavioral treatment for depression (CBT-D; n = 86). Although abstinence rates were high in both conditions (ST, 24.7%; CBT-D, 32.5%, at 1 year) for these nonpharmacological treatments, no main effect of treatment was found. However, secondary analyses revealed significant interactions between treatment condition and both recurrent depression history and heavy smoking ( > or =25 cigarettes a day) at baseline. Smokers with recurrent MDD and heavy smokers who received CBT-D were significantly more likely to be abstinent than those receiving ST (odds ratios = 2.3 and 2.6, respectively). Results suggest that CBT-D provides specific benefits for some, but not all, smokers with a history of MDD.     

Smoking risk and the likelihood of quitting among African-American female light and heavy smokers

While African-American females are more likely to be light smokers compared to their counterparts of other racially classified social groups (RCSGs), they are more likely to carry a heavier burden of smoking-related morbidity and mortality. Thus, it is critical that African-American female light smokers are targeted to engage in smoking cessation. Research has revealed that African-American women are less likely to have a successful quit attempt following a cessation intervention than females from other RCSGs. It has been postulated that the low smoking cessation rates among African-American female light smokers may be due to the lack of appropriate psychosocioculturally tailored cessation interventions that address issues of stress and coping that explain why they smoke and continue to smoke that may differ from their heavy smoker counterparts. The purpose of this study was to ascertain whether African-American female light smokers differed from their heavy smoker counterparts on psychosociocultural stress and coping factors. Findings revealed no differences in the sociodemographic variables of age, income, education and BMI; in the psychosociocultural measures of acculturative stress, race-related stress and coping; or in the smoking characteristics of menthol smoking status, cotinine level and CYP2A6 metabolic functioning between light and heavy smokers. However, the study found that African-American female light smokers take longer to smoke their first cigarette of the day, have a lower smoking risk, are more likely to quit, and exhibit lower carbon monoxide levels than African-American female heavy smokers. The current study suggests that other than the obvious factors of greater likelihood of quitting, lower smoking risk, longer latency to smoke and lower carbon monoxide levels, specific smoking cessation programs may not need to be differentially psychosocio-culturally tailored for African-American female light smokers compared to their heavy-smoking counterparts.     

Declining Incidence of AIDS and Increasing Prevalence of AIDS Presenters Among AIDS Patients in Italy

Presented here are the results of a cohort study conducted on 3,483 consecutive HIV/AIDS patients between January 1993 and December 2000 to determine trends in AIDS incidence and presentation. The incidence of AIDS was calculated in the general population and examined further according to gender, age ( or >49 years), and heterosexual behaviour as a risk factor for HIV. Multivariate analysis was used to identify variables associated with AIDS presenters (defined as patients diagnosed with AIDS within 1 month of the first HIV-positive test). The numbers of patients with AIDS classified as (i) AIDS presenters, (ii) known HIV-positive patients on antiretroviral treatment, and (iii) known HIV-positive patients not receiving antiretroviral treatment were calculated. The overall incidence of AIDS decreased over time, mainly due to the lower number of patients on antiretroviral treatment developing AIDS. Factors associated with a higher risk of being an AIDS presenter were male gender and year of HIV diagnosis. Among patients with AIDS, the proportion of AIDS presenters increased from 13.8% prior to 1997 (when protease inhibitors were introduced in Italy) to 32.5% after 1997. Variables predictive of being an AIDS presenter were male gender, age at diagnosis, and AIDS diagnosis in the years 1997–2000. Heterosexuals had a higher risk of being AIDS presenters and a lower risk of being HIV-positive and not receiving antiretroviral treatment than intravenous drug users. In Italy, AIDS occurs mainly in subjects unaware of their HIV status (especially males, the elderly, and those infected heterosexually) or in patients refusing antiretroviral therapy (mainly intravenous drug users who do not refer to specialised centres).     

Smoking, fibrinogen and cancer mortality

Associations of race, smoking history and fibrinogen levels with cancer mortality were investigated prospectively using the ARIC study. Our cohort consisted of 14,320 participants aged 45-64 at baseline. In an adjusted Cox regression, black current heavy smokers (> or = 15 cigarettes per day) demonstrated higher risk of respiratory/intrathoracic organ cancer mortality than nonblack current heavy smokers. Black former heavy smokers were also found to be at an increased risk of respiratory/intrathoracic organ cancer mortality when compared to nonblack former heavy smokers. Elevated fibrinogen levels were associated with an increased risk of respiratory/intrathoracic organ cancer mortality. Compared to fibrinogen < 259 mg/dl, fibrinogen 294-335 mg/dl had an adjusted hazard ratio of 3.68 (95% CI: 1.80-7.55), and fibrinogen > or = 336 mg/dl had an adjusted hazard ratio of 3.78 (95% CI: 1.84-7.75). Fibrinogen was also a predictor of other types of cancer mortality among black participants, but not among nonblack participants. For 10 race/smoking history categories, fibrinogen levels ranged from a mean of 287 mg/dl for nonblack former light smokers to a mean of 338 mg/dl for black current heavy smokers. Smokers had higher fibrinogen levels than nonsmokers, and black smokers had higher fibrinogen levels than nonblack smokers. Smoking carries high risks of cancer mortality for African Americans. A factor that needs to be considered in the overall assessment of risk is fibrinogen level, which has been linked to angiogenesis and metastases of tumors.     

Relationship of smoking status, energy balance, and body weight: analysis of the Second National Health and Nutrition Examination Survey.

The relationship between smoking status and body mass index (weight/height) was evaluated, controlling for demographics, dietary intake, and physical activity. Subjects were 10,778 adult respondents from the Second National Health and Nutrition Examination Survey (NHANES II). Results indicate that never smokers and long-term quitters had similar relative body weights and that low-rate current smokers were not significantly different from never smokers. However, both medium- and high-rate current smokers weighed less than nonsmokers and low-rate smokers. When medium- versus high-rate smokers were contrasted, sex interacted with results. Specifically, weight-control properties of smoking were more pronounced in women than men. It is proposed that future research should more closely evaluate metabolic changes as a function of smoking status.     

Social support,distress, and well-being in older men living with HIV infection

Older men with HIV infection/AIDS, having often lived with the condition longer, are more likely to confront the stress of managing more advanced HIV disease than their younger counterparts. Meanwhile, they also are more likely to have less social support and experience more distress than younger persons with HIV infection. The moderating effect of social support on health functioning and distress is unknown for persons with HIV infection, particularly those who are older. Study objectives were to assess whether the association between perceived health functioning and psychological distress and well-being is moderated (or influenced) by social support and age and if the impact of social support on distress and well-being is more pronounced for older than for younger men living with HIV infection/AIDS. In this cross-sectional study of HIV-positive adult men (n = 199) who have sex with men, participants completed self-report assessments of perceived health functioning, social support, and psychological distress and well-being. Measures of health functioning and overall social support were significantly associated with outcome measures of distress and positive affect (all p < .05). However, the main effect for social support was qualified by a significant age-by-social support interaction for both outcomes (beta = -.190, p < .01 for distress; beta = .172, p < .05 for positive affect), indicating that the impact of social support on decreasing distress and increasing well-being was more pronounced in older men. The relationships between perceived health functioning and distress and well-being were not moderated by social support or age. The influence of social support on negative and positive moods in this population of HIV-infected men who have sex with men was significantly greater among older than among younger participants. With an increasing number of older people with HIV infection/AIDS, special efforts to create effective and sustainable social support interventions may be particularly beneficial to older persons living with HIV infection.     

Do cigarette smokers have unrealistic perceptions of their heart attack,cancer, and stroke risks?

This study examined whether perceived risks of heart attack, cancer, and stroke were higher among smokers than nonsmokers; whether smokers were more likely to underestimate these risks; and the demographic correlates of unrealistic risk estimation among smokers. Two thousand seven hundred eight-five patients from 12 North Carolina family practices completed a questionnaire including a health risk appraisal and questions concerning smoking behavior and perceived risks of heart attack, cancer, and stroke. While most smokers accurately perceived their health risks to be greater than nonsmokers', smokers were also more likely to underestimate their risks. This optimistic distortion of risk was associated with age, gender, and education levels. Smokers may not yet understand the magnitude of health risks posed by smoking. These data suggest the need for renewed attention to perceptions of the health risks of smoking. As long as smokers underestimate their risks, they underestimate the imperative to quit.This research was supported by Grant HL41886 from the National Heart, Lung and Blood Institute.