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1.  Expectations and changing attitudes of bar workers before and after the implementation of smoke-free legislation in Scotland 
BMC Public Health  2007;7:206.
Background
In Scotland on March 26, 2006 a comprehensive prohibition on smoking in all enclosed public places was introduced. This study examines bar workers' attitudes towards a smoke-free working environment.
Methods
An intervention study comparing bar workers' opinions before and after the implementation of the smoke-free legislation. Bars were randomly selected in three Scottish cities (Glasgow, Edinburgh & Aberdeen) and towns (Aberdeenshire & Borders). Bar workers were recruited from 72 bars that agreed to participate from159 approached. Pre- and post-implementation attitudes towards legislation, second-hand smoke and smoke-free working environments were compared.
Results
Initially the majority of bar workers agreed with the proposed legislation on smoking (69%) and the need for it to protect the health of workers (80%), although almost half (49%) thought the legislation would damage business. In 266 bar workers seen at both surveys, a significant positive attitudinal change towards the legislation was seen. Post-implementation, support for the legislation rose to 79%, bar workers continued to believe it was needed to protect health (81%) and concerns about the impact on business were expressed by fewer than 20%. Only the statement that the legislation would encourage smokers to quit showed reduced support, from 70% pre-implementation to fewer than 60% post-implementation. Initial acceptance was greater among younger bar workers; older workers, initially more sceptical, became less so with experience of the legislation's effects.
Conclusion
This study shows that bar workers had generally positive attitudes towards the legislation prior to implementation, which became stronger after implementation. The affirmative attitudes of these key stakeholders are likely to contribute towards the creation of 'smoke-free' as the new social norm.
doi:10.1186/1471-2458-7-206
PMCID: PMC1988823  PMID: 17697338
2.  A Comprehensive Functional Portrait of Two Heat Shock Factor-Type Transcriptional Regulators Involved in Candida albicans Morphogenesis and Virulence 
PLoS Pathogens  2013;9(8):e1003519.
Sfl1p and Sfl2p are two homologous heat shock factor-type transcriptional regulators that antagonistically control morphogenesis in Candida albicans, while being required for full pathogenesis and virulence. To understand how Sfl1p and Sfl2p exert their function, we combined genome-wide location and expression analyses to reveal their transcriptional targets in vivo together with the associated changes of the C. albicans transcriptome. We show that Sfl1p and Sfl2p bind to the promoter of at least 113 common targets through divergent binding motifs and modulate directly the expression of key transcriptional regulators of C. albicans morphogenesis and/or virulence. Surprisingly, we found that Sfl2p additionally binds to the promoter of 75 specific targets, including a high proportion of hyphal-specific genes (HSGs; HWP1, HYR1, ECE1, others), revealing a direct link between Sfl2p and hyphal development. Data mining pointed to a regulatory network in which Sfl1p and Sfl2p act as both transcriptional activators and repressors. Sfl1p directly represses the expression of positive regulators of hyphal growth (BRG1, UME6, TEC1, SFL2), while upregulating both yeast form-associated genes (RME1, RHD1, YWP1) and repressors of morphogenesis (SSN6, NRG1). On the other hand, Sfl2p directly upregulates HSGs and activators of hyphal growth (UME6, TEC1), while downregulating yeast form-associated genes and repressors of morphogenesis (NRG1, RFG1, SFL1). Using genetic interaction analyses, we provide further evidences that Sfl1p and Sfl2p antagonistically control C. albicans morphogenesis through direct modulation of the expression of important regulators of hyphal growth. Bioinformatic analyses suggest that binding of Sfl1p and Sfl2p to their targets occurs with the co-binding of Efg1p and/or Ndt80p. We show, indeed, that Sfl1p and Sfl2p targets are bound by Efg1p and that both Sfl1p and Sfl2p associate in vivo with Efg1p. Taken together, our data suggest that Sfl1p and Sfl2p act as central “switch on/off” proteins to coordinate the regulation of C. albicans morphogenesis.
Author Summary
Candida albicans can switch from a harmless colonizer of body organs to a life-threatening invasive pathogen. This switch is linked to the ability of C. albicans to undergo a yeast-to-filament shift induced by various cues, including temperature. Sfl1p and Sfl2p are two transcription factors required for C. albicans virulence, but antagonistically regulate morphogenesis: Sfl1p represses it, whereas Sfl2p activates it in response to temperature. We show here that Sfl1p and Sfl2p bind in vivo, via divergent motifs, to the regulatory region of a common set of targets encoding key determinants of morphogenesis and virulence and exert both activating and repressing effects on gene expression. Additionally, Sfl2p binds to specific targets, including genes essential for hyphal development. Bioinformatic analyses suggest that Sfl1p and Sfl2p control C. albicans morphogenesis by cooperating with two important regulators of filamentous growth, Efg1p and Ndt80p, a premise that was confirmed by the observation of concomitant binding of Sfl1p, Sfl2p and Efg1p to the promoter of target genes and the demonstration of direct or indirect physical association of Sfl1p and Sfl2p with Efg1p, in vivo. Our data suggest that Sfl1p and Sfl2p act as central “switch on/off” proteins to coordinate the regulation of C. albicans morphogenesis.
doi:10.1371/journal.ppat.1003519
PMCID: PMC3744398  PMID: 23966855
3.  The relationship between stress fiber-like structures and nascent myofibrils in cultured cardiac myocytes 
The Journal of Cell Biology  1984;99(6):2268-2278.
The topographical relationship between stress fiber-like structures (SFLS) and nascent myofibrils was examined in cultured chick cardiac myocytes by immunofluorescence microscopy. Antibodies against muscle- specific light meromyosin (anti-LMM) and desmin were used to distinguish cardiac myocytes from fibroblastic cells. By various combinations of staining with rhodamine-labeled phalloidin, anti-LMM, and antibodies against chick brain myosin and smooth muscle alpha- actinin, we observed the following relationships between transitory SFLS and nascent and mature myofibrils: (a) more SFLS were present in immature than mature myocytes; (b) in immature myocytes a single fluorescent fiber would stain as a SFLS distally and as a striated myofibril proximally, towards the center of the cell; (c) in regions of a myocyte not yet penetrated by the elongating myofibrils, SFLS were abundant; and (d) in regions of a myocyte with numerous mature myofibrils, SFLS had totally disappeared. Spontaneously contracting striated myofibrils with definitive Z-band regions were present long before anti-desmin localized in the I-Z-band region and long before morphologically recognizable structures periodically link Z-bands to the sarcolemma. These results suggest a transient one-on-one relationship between individual SFLS and newly emerging individual nascent myofibrils. Based on these and other relevant data, a complex, multistage molecular model is presented for myofibrillar assembly and maturation. Lastly, it is of considerable theoretical interest to note that mature cardiac myocytes, like mature skeletal myotubes, lack readily detectable stress fibers.
PMCID: PMC2113583  PMID: 6438115
4.  Legislation for smoke-free workplaces and health of bar workers in Ireland: before and after study 
BMJ : British Medical Journal  2005;331(7525):1117.
Objectives To compare exposure to secondhand smoke and respiratory health in bar staff in the Republic of Ireland and Northern Ireland before and after the introduction of legislation for smoke-free workplaces in the Republic.
Design Comparisons before and after the legislation in intervention and control regions.
Setting Public houses in three areas in the Republic (intervention) and one area in Northern Ireland (control).
Participants 329 bar staff enrolled in baseline survey; 249 (76%) followed up one year later. Of these, 158 were non-smokers both at baseline and follow-up.
Main outcome measures Salivary cotinine concentration, self reported exposure to secondhand smoke, and respiratory and sensory irritation symptoms.
Results In bar staff in the Republic who did not themselves smoke, salivary cotinine concentrations dropped by 80% after the smoke-free law (from median 29.0 nmol/l (95% confidence interval 18.2 to 43.2 nmol/l)) to 5.1 nmol/l (2.8 to 13.1 nmol/l) in contrast with a 20% decline in Northern Ireland over the same period (from median 25.3 nmol/l (10.4 to 59.2 nmol/l) to 20.4 nmol/l (13.2 to 33.8 nmol/l)). Changes in self reported exposure to secondhand smoke were consistent with the changes in cotinine concentrations. Reporting any respiratory symptom declined significantly in the Republic (down 16.7%, -26.1% to -7.3%) but not in Northern Ireland (0% difference, -32.7% to 32.7%). After adjustment for confounding, respiratory symptoms declined significantly more in the Republic than in Northern Ireland and the decline in cotinine concentration was twice as great.
Conclusion The smoke-free law in the Republic of Ireland protects non-smoking bar workers from exposure to secondhand smoke.
doi:10.1136/bmj.38636.499225.55
PMCID: PMC1283274  PMID: 16230313
5.  Roles of Candida albicans Sfl1 in Hyphal Development▿  
Eukaryotic Cell  2007;6(11):2112-2121.
The ability to switch between different morphological forms is an important feature of Candida albicans and is relevant to its pathogenesis. Many conserved positive and negative transcription factors are involved in morphogenetic regulation of the two dimorphic fungi Candida albicans and Saccharomyces cerevisiae. In S. cerevisiae, the transcriptional repressor Sfl1 and the activator Flo8 function antagonistically in invasive and filamentous growth. We have previously reported that Candida albicans Flo8 is a transcription factor essential for hyphal development and virulence in C. albicans. To determine whether a similar negative factor exists in C. albicans, we identified Candida albicans Sfl1 as a functional homolog of the S. cerevisiae sfl1 mutant. Sfl1 is a negative regulator of hyphal development in C. albicans. Deletion of C. albicans SFL1 enhanced filamentous growth and hypha-specific gene expression in several media and at several growth temperatures. Overexpression of the SFL1 led to a significant reduction of filament formation. Both deletion and overexpression of the SFL1 attenuated virulence of C. albicans in a mouse model. Deleting FLO8 in an sfl1/sfl1 mutant completely blocked hyphal development in various growth conditions examined, suggesting that C. albicans Sfl1 may act as a negative regulator of filamentous growth by antagonizing Flo8 functions. We suggest that, similar to the case for S. cerevisiae, a combination of dual control by activation and repression of Flo8 and Sfl1 may contribute to the fine regulatory network in C. albicans morphogenesis responding to different environmental cues.
doi:10.1128/EC.00199-07
PMCID: PMC2168412  PMID: 17715361
6.  Observations from behind the bar: changing patrons' behaviours in response to smoke-free legislation in Scotland 
BMC Public Health  2008;8:238.
Background
"Smoke-Free" legislation prohibiting smoking in all enclosed public places was introduced in March 2006. This qualitative study presents insights from bar workers about their observations of the changing social bar environment, changing patrons' behaviours and challenges bar workers have faced in managing smoke-free legislation.
Methods
Twelve in-depth interviews were conducted between November 2006 and January 2007 with a purposively-selected sample of bar workers, identified from a larger quantitative study evaluating the impact of the legislation in Scotland [the Bar Workers' Health and Environmental Tobacco Smoke Exposure project (BHETSE)].
Results
Bar workers all spoke of the improvements the legislation had brought to their working lives and the greater comfort it appeared to offer patrons. Bar workers reported that patrons were generally quick to accept and comply with the new law, and that families had become a greater feature of pub life since the legislation. However, they expressed concerns that older men seemed to have had most difficulty adjusting to the legislation and lack of knowledge about the best practices they should adopt in order to reduce the risks of unattended drinks being spiked and of anti-social behaviour associated with patrons moving outside to smoke.
Conclusion
Smoke-free legislation is changing the social context of smoking in Scotland. Further research to assess the impact the legislation is having on older male smokers and on the incidence of drink spiking would be useful. More specifically, bar workers would benefit from guidance on how to manage issues arising from patrons moving outside to smoke.
doi:10.1186/1471-2458-8-238
PMCID: PMC2475535  PMID: 18625044
7.  Knowledge and attitude of healthcare workers about middle east respiratory syndrome in multispecialty hospitals of Qassim, Saudi Arabia 
BMC Public Health  2014;14(1):1281.
Background
With the increase in prevalence of Middle East Respiratory Syndrome (MERS), healthcare workers (HCWs) are at risk of acquiring and subsequently transmitting this lethal virus. In view of this, HCWs were evaluated for their knowledge of and attitude towards MERS in Saudi Arabia.
Methods
A cross sectional study was performed in two hospitals of Qassim region in Saudi Arabia. A total of 280 healthcare workers were selected to participate in this study. Knowledge and attitude were assessed by using self-administered and pretested questionnaire. Descriptive statistics were carried out to express participants’ demographic information, mean knowledge score and mean attitude score of HCWs. Inferential statistics (Mann–Whitney U test and Kruskal Wallis tests, p < 0.05) were used to examine differences between study variables. Chi squares tests were used to assess the association between study variables and attitude questions. Spearman’s rho correlation was used to identify the association between the knowledge, attitude scores.
Result
Participants demonstrated good knowledge and positive attitude towards MERS. The mean scores of knowledge and attitude were 9.45 ± 1.69 (based on 13 knowledge questions) and 1.82 ± 0.72 (based on 7 attitude questions). The correlation between knowledge and attitude was significant (correlation coefficient: 0.12; P <0.001). HCWs were less educated about the management (42.4%), source (66%) and consequences of MERS (67.3%), while a majority of them were well aware of the hallmark symptoms (96%), precautionary measures (96%) and hygiene issues (94%). Although the majority of respondents showed positive attitude towards the use of protective measures (1.52 ± 0.84), their attitude was negative towards their active participation in infection control program (2.03 ± 0.97). Gender and experience were significantly associated with knowledge and attitude (P < 0.05).
Conclusions
The findings of this study showed that healthcare workers in Qassim region of Saudi Arabia have good knowledge and positive attitude towards MERS. Yet there are areas where low knowledge and negative attitude of HCWs was observed. However, studies are required to assess the knowledge and attitude of HCWs at national level so that effective interventions could be designed as surveillance and infection control measures are critical to global public health.
doi:10.1186/1471-2458-14-1281
PMCID: PMC4300996  PMID: 25510239
8.  The impact of a 100% smoke-free law on the health of hospitality workers from the city of Neuquén, Argentina 
Tobacco Control  2010;19(2):134-137.
Objectives
The objective of this study was to evaluate the impact of 100% smoke-free environment legislation on respiratory and sensory irritation symptoms and respiratory function among bar and restaurant workers from the city of Neuquén, Argentina.
Methods
Pre-ban and post-ban studies without a comparison group in an Argentinean city were conducted. A baseline survey and spirometric measurements were performed with a total of 80 bar and restaurant workers 1 month before (October 2007) and 3 months after (March 2008) the implementation of the new 100% smoke-free legislation.
Results
A significant reduction in secondhand smoke exposure was observed after the enactment and enforcement of the new legislation, and an important reduction in respiratory symptoms (from a pre-ban level of 57.5% to a post-ban level of only 28.8%). The reduction of sensory irritation symptoms was even higher. From 86.3% of workers who reported at least one sensory irritation symptom in October 2007, only 37.5% reported the same symptoms in March 2008. Also, data obtained by spirometry showed a significant forced vital capacity increase.
Conclusions
Consistent with other studies, 100% smoke-free legislation improved short-term health outcomes in the sample and should be implemented nationwide. Furthermore, undertaking this study has been highly important in promoting 100% smoke-free environment legislation at the workplace as a legitimate right of hospitality workers, and in reducing social acceptance of designated smoking areas in bars and restaurants.
doi:10.1136/tc.2009.032862
PMCID: PMC2989166  PMID: 20378587
Secondhand smoke; smoke-free legislation; hospitality workers; respiratory health; impact evaluation; environmental tobacco smoke; public policy
9.  Changes in hospitality workers' exposure to secondhand smoke following the implementation of New York's smoke-free law 
Tobacco Control  2005;14(4):236-241.
Objective: To assess the impact on hospitality workers' exposure to secondhand smoke of New York's smoke-free law that prohibits smoking in all places of employment, including restaurants, bars, and bowling facilities.
Design: Pre-post longitudinal follow up design.
Settings: Restaurants, bars, and bowling facilities in New York State.
Subjects: At baseline, 104 non-smoking workers in restaurants, bars, and bowling facilities were recruited with newspaper ads, flyers, and radio announcements. Of these, 68 completed a telephone survey and provided at least one saliva cotinine specimen at baseline. At three, six, and 12 month follow up studies, 47, 38, and 32 workers from the baseline sample of 68 completed a telephone survey and provided at least one saliva cotinine specimen.
Intervention: The smoke-free law went into effect 24 July 2003.
Main outcome measures: Self reported sensory and respiratory symptoms and exposure to secondhand smoke; self administered saliva cotinine specimens. Analyses were limited to subjects in all four study periods who completed a telephone survey and provided at least one saliva cotinine specimen.
Results: All analyses were limited to participants who completed both an interview and a saliva specimen for all waves of data collection (n = 30) and who had cotinine concentrations ⩽ 15 ng/ml (n = 24). Hours of exposure to secondhand smoke in hospitality jobs decreased from 12.1 hours (95% confidence interval (CI) 8.0 to 16.3 hours) to 0.2 hours (95% CI –0.1 to 0.5 hours) (p < 0.01) and saliva cotinine concentration decreased from 3.6 ng/ml (95% CI 2.6 to 4.7 ng/ml) to 0.8 ng/ml (95% CI 0.4 to 1.2 ng/ml) (p < 0.01) from baseline to the 12 month follow up. The prevalence of workers reporting sensory symptoms declined from 88% (95% CI 66% to 96%) to 38% (95% CI 20% to 59%) (p < 0.01); there was no change in the overall prevalence of upper respiratory symptoms (p < 0.16).
Conclusion: New York's smoke-free law had its intended effect of protecting hospitality workers from exposure to secondhand smoke within three months of implementation. One year after implementation, the results suggest continued compliance with the law.
doi:10.1136/tc.2004.008839
PMCID: PMC1748080  PMID: 16046685
10.  Health impacts of exposure to second hand smoke (SHS) amongst a highly exposed workforce: survey of London casino workers 
BMC Public Health  2007;7:257.
Background
Casino workers are exposed to high levels of secondhand smoke (SHS) at work, yet remain at risk of being excluded from smoke-free legislation around the world. If the prime motivation for smoke-free legislation is the protection of workers, then a workforce experiencing ill-health associated with SHS exposure should not be excluded from legislation. This study aimed to determine the prevalence of respiratory and sensory irritation symptoms among a sample of casino workers, to identify any association between the reporting of symptoms and exposure to SHS at work, and to compare the prevalence of symptoms with that in other workers exposed to SHS.
Methods
A postal questionnaire survey of 1568 casino workers in London. Using multivariate analysis we identified predictors of respiratory and sensory irritation symptoms.
Results
559 workers responded to the questionnaire (response of 36%). 91% of casino workers reported the presence of one or more sensory irritation symptoms in the previous four weeks, while the figure was 84% for respiratory symptoms. The presence of one or more sensory irritation symptoms was most strongly associated with reporting the highest exposure to SHS at work (OR 3.26; 1.72, 6.16). This was also true for reporting the presence of one or more respiratory irritation symptoms (OR 2.24; 1.34, 3.74). Prevalence of irritation symptoms in the casino workers was in general appreciably higher than that reported in studies of bar workers.
Conclusion
Our research supports the need for comprehensive smoke-free legislation around the world, covering all indoor workplaces including casinos.
doi:10.1186/1471-2458-7-257
PMCID: PMC2040157  PMID: 17888155
11.  Sonographic fatty liver and hepatitis B virus carrier status: Synergistic effect on liver damage in Taiwanese adults 
AIM: To examine the epidemiology of hepatitis B virus carrier status (HBVC) and sonographic fatty liver (SFL) in Taiwanese adults, and to evaluate their possible interaction in inducing liver damage (LD). From an epidemiological viewpoint, we analyzed previous studies which indicated that fatty liver sensitizes host immune response to HBV infection and enhances liver damage.
METHODS: A cross-sectional retrospective analysis of health records including medical history, physical examination, abdominal sonogram, blood biochemistry and hepatic virological tests. We utilized the Student’s t-test, chi-square, multivariate logistic regression and synergy index to assess risks for LD.
RESULTS: Among a total of 5406 Taiwanese adults (mean age 46.2 years, 51.5% males), the prevalence of LD, HBVC and SFL were 12.3%, 15.1% and 33.4%, respectively; 5.1% of participants had SFL plus HBVC. Multivariate logistic regression analysis demonstrated that male gender (odds ratio (OR) = 2.8, 95% confidence interval (CI): 2.3-3.5), overweight state (OR = 1.6, 95% CI: 1.3-2.0), HBVC (OR = 2.5, 95% CI: 2.0-3.1) and SFL (OR = 4.2, 95% CI: 2.2-5.3) were independently associated with LD. Synergism analysis showed that the adjusted OR for LD in adults with HBVC-alone was 3.3 (95% CI: 2.4-4.6), SFL-alone, 4.7 (95% CI: 3.7-6.1) and combined HBVC and SFL, 9.5 (95% CI: 6.8-13.3); the synergy index was 1.4 (95% CI: 1.001-2.0).
CONCLUSION: In Taiwanese adults, SFL plus HBVC have a significant synergistic association with LD.
doi:10.3748/wjg.v13.i12.1805
PMCID: PMC4149956  PMID: 17465470
Fatty liver; Hepatitis B virus; Sonography; Synergism
12.  The moderating role of parental smoking on their children's attitudes toward smoking among a predominantly minority sample: a cross-sectional analysis 
Background
In general having a parent who smokes or smoked is a strong and consistent predictor of smoking initiation among their children while authoritative parenting style, open communication that demonstrates mutual respect between child and parent, and parental expectations not to smoke are protective. It has been hypothesized that parental smoking affects their children's smoking initiation through both imitation of the behavior and effects on attitudes toward smoking. The goals of the current analysis were to examine these two potential mechanisms.
Methods
In 2003, 1,417 high school students in Houston, Texas, completed a cross-sectional survey as part of the evaluation of an interactive smoking prevention and cessation program delivered via CD-ROM. To assess the relationship between number of parents who currently smoke and children's smoking status, we completed an unconditional logistic regression. To determine whether the attitudes that children of smokers hold toward smoking are significantly more positive than the attitudes of children of non-smokers we examined whether the parents smoking status moderated the relationship between children's attitudes toward smoking and their ever smoking using unconditional logistic regressions.
Results
Compared to participants whose parents did not currently smoke, participants who reported one or both parents currently smoke, had increased odds of ever smoking (OR = 1.31; 95% CI: 1.03–1.68; Wald χ2 = 4.78 (df = 1) p = 0.03 and OR = 2.16; 95% CI: 1.51–3.10; Wald χ2 = 17.80 (df = 1) p < 0.001, respectively). In addition, the relationship between attitudes and ever smoking was stronger among participants when at least one parent currently smokes (OR = 2.50; 95% CI: 1.96–3.19; Wald χ2 = 54.71 (df = 1) p < 0.001) than among participants whose parents did not smoke (OR = 1.72; 95% CI: 1.40–2.12; Wald χ2 = 26.45 (df = 1) p < 0.001).
Conclusion
Children of smokers were more likely to smoke and reported more favorable attitudes toward smoking compared to children of non-smokers. One interpretation of our findings is that parental smoking not only directly influences behavior; it also moderates their children's attitudes towards smoking and thereby impacts their children's behavior. Our results demonstrate a continued need for primary prevention smoking interventions to be sensitive to the family context. They also underscore the importance of discussing parental smoking as a risk factor for smoking initiation, regardless of ethnicity, and of tailoring prevention messages to account for the influence that parental smoking status may have on the smoking attitudes and the associated normative beliefs.
doi:10.1186/1747-597X-3-18
PMCID: PMC2490678  PMID: 18625061
13.  Attitudes and beliefs about secondhand smoke and smoke-free policies in four countries: Findings from the International Tobacco Control Four Country Survey 
Nicotine & Tobacco Research  2009;11(6):642-649.
Introduction
This paper describes the varying levels of smoking policies in nationally representative samples of smokers in four countries and examines how these policies are associated with changes in attitudes and beliefs about secondhand smoke over time.
Methods
We report data on 5,788 respondents to Wave 1 of the International Tobacco Control Four Country Survey who were employed at the time of the survey. A cohort of these respondents was followed up with two additional survey waves approximately 12 months apart. Respondents’ attitudes and beliefs about secondhand smoke as well as self-reported policies in their workplace and in bars and restaurants in their community were assessed at all waves.
Results
The level of comprehensive smoke-free policies in workplaces, restaurants, and bars increased over the study period for all countries combined and was highest in Canada (30%) and lowest in the United Kingdom (0%) in 2004. In both cross-sectional and longitudinal analyses, stronger secondhand smoke policies were associated with more favorable attitudes and support for comprehensive regulations. The associations were the strongest for smokers who reported comprehensive policies in restaurants, bars, and their workplace for all three survey waves.
Discussion
Comprehensive smoke-free policies are increasing over time, and stronger policies and the public education opportunities surrounding their passage are associated with more favorable attitudes toward secondhand smoke regulations. The implication for policy makers is that, although the initial debate over smoke-free policies may be tumultuous, once people understand the rationale for implementing smoke-free policies and experience their benefits, public support increases even among smokers, and compliance with smoke-free regulations increases over time.
doi:10.1093/ntr/ntp063
PMCID: PMC2688606  PMID: 19454550
14.  Sexually transmitted infection testing and self-reported diagnoses among a community sample of men who have sex with men, in Scotland 
Sexually Transmitted Infections  2012;89(3):223-230.
Introduction
To examine sexually transmitted infection (STI) testing and self-reported diagnoses among men who have sex with men (MSM), in Scotland.
Methods
Cross-sectional survey of seven Glasgow gay bars in July 2010 (n=822, 62% response rate); 693 are included in the analyses.
Results
81.8% reported ever having had an STI test; 37.4% had tested in the previous 6 months; 13.2% reported having an STI in the previous 12 months. The adjusted odds of having ever tested were significantly higher for men who had 6+ sexual partners in the previous 12 months (adjusted OR=2.66), a maximum sexual health knowledge score (2.23), and had talked to an outreach worker/participated in counselling (1.96), and lower for men reporting any high-risk unprotected anal intercourse (UAI) in the previous 12 months (0.51). Adjusted odds of recent testing were higher for men who had 6+ sexual partners (2.10), talked to an outreach worker/participated in counselling (1.66), maximum sexual health knowledge (1.59), and higher condom use knowledge (1.04), and lower for men aged ≥25 years (0.46). Adjusted odds of having had an STI in the previous 12 months were higher for men who had 6+ sexual partners (3.96) and any high-risk UAI in the previous 12 months (2.24) and lower for men aged ≥25 years (0.57).
Conclusions
STI testing rates were relatively high, yet still below the minimum recommended for MSM at high risk. Consideration should be given to initiating recall systems for men who test positive for STIs, and to developing behavioural interventions which seek to address STI transmission.
doi:10.1136/sextrans-2012-050605
PMCID: PMC3625820  PMID: 23042901
Sexual Health; Gay Men; Sexual Behaviour; Testing
15.  Knowledge, attitude, practice, and toxicity symptoms associated with pesticide use among farm workers in the Gaza Strip 
Aims: To assess knowledge, attitude, practice, and toxicity symptoms associated with pesticide use and exposure among 189 farm workers in the Gaza Strip.
Methods: A cross section of agricultural farm workers in the Gaza Strip were asked to fill in a questionnaire on knowledge, attitudes, practice towards pesticide use, and associated toxicity symptoms.
Results: Farm workers reported high levels of knowledge on the health impact of pesticides (97.9%). Moderate to high levels of knowledge were recorded on toxicity symptoms related to pesticides. Most farm workers were aware of the protective measures to be used during applying pesticides. However, no one took precautions unless they knew about the measures. Burning sensation in eyes/face was the commonest symptom (64.3%). The prevalence of self reported toxicity symptoms was dependent on mixing and use of high concentrations of pesticides. The highest percentage of self reported toxicity symptoms was found among the farm workers who returned to sprayed fields within one hour of applying pesticides.
Conclusions: Farm workers in the Gaza Strip used pesticides extensively. Despite their knowledge about the adverse health impact of the pesticides, the use of protective measures was poor. Most had self reported toxicity symptoms, particularly the younger workers. It would be useful to minimise the use of pesticides and encourage alternative measures. Prevention and intervention programmes regarding the use of protective measures and monitoring the health status of farm workers should be implemented.
doi:10.1136/oem.59.6.387
PMCID: PMC1740291  PMID: 12040114
16.  Symptom experience and subsequent mortality: results from the West of Scotland Twenty-07 study 
Background
Associations between symptom experience and mortality have rarely been investigated. One study has suggested that the number of symptoms people experience may be an important predictor of mortality. This novel and potentially important finding may have important implications but needs to be tested in other cohorts.
Methods
858 people aged around 58 years were interviewed by nurses in 1990/1 as part of the West of Scotland Twenty-07 Study. They were asked about the presence of symptoms in the last month from a checklist of 33 symptoms. Measures of morbidity included symptom type (respiratory, musculoskeletal, gastrointestinal, mental health, neurological, systemic) and symptom summary measures looking at the number and impact of symptoms (total number; number participants tended to have; number participants did not tend to have; number which restricted usual activities; number which led to GP consultation). Hazard ratios for thirteen-year all-cause mortality were calculated for symptom types, symptom summary measures, and self-assessed health with and without adjustment.
Results
On unadjusted analysis, and after adjusting for gender, socio-economic status and smoking, mortality was elevated in individuals reporting respiratory, systemic and mental health symptoms. After additional adjustment for chronic conditions and self-assessed health, only the association between mental health symptoms and mortality remained significant. On unadjusted analysis, and after adjusting for gender, socio-economic status and smoking, mortality was elevated in individuals with many (≥ 6) symptoms in four of the symptom summary measures examined. These relationships were no longer significant after additional adjustment for chronic conditions and self-assessed health. A clear trend of increasing mortality as self-assessed health became poorer was observed. This pattern remained statistically significant after adjustment for gender, socio-economic status, smoking, chronic conditions and the total number of symptoms experienced.
Conclusion
Symptoms often thought of as minor may have important consequences later in life especially for those reporting mental health-related symptoms or those experiencing many symptoms. In this study however, self-assessed health appeared to be a better predictor of mortality than the type or number of symptoms experienced, even when the tendency to have and impact of the symptoms were taken into account.
doi:10.1186/1472-6963-6-158
PMCID: PMC1702541  PMID: 17156478
17.  One year of smokefree bars and restaurants in New Zealand: Impacts and responses 
BMC Public Health  2006;6:64.
Background
New Zealand introduced a smokefree bars and restaurants policy in December 2004. We reviewed the data available at December 2005 on the main public health, societal and political impacts and responses within New Zealand to the new law.
Methods
Data were collected from publicly available survey reports, and from government departments and interviews. This included data on smoking in bars, attitudes to smokefree bars, bar patronage, socially cued smoking, and perceived rights to smokefree workplaces.
Results
The proportion of surveyed bars with smoking occurring decreased from 95% to 3% during July 2004 – April 2005. Between 2004 and 2005, public support for smokefree bars rose from 56% to 69%. In the same period, support for the rights of bar workers to have smokefree workplaces rose from 81% to 91%. During the first ten months of the smokefree bars policy, there were only 196 complaints to officials about smoking in the over 9900 licensed premises. The proportion of smokers who reported that they smoked more than normal at bars, nightclubs, casinos and cafés halved between 2004 and 2005 (from 58% to 29%).
Seasonally adjusted sales in bars and clubs changed little (0.6% increase) between the first three quarters of 2004 and of 2005, while café and restaurant sales increased by 9.3% in the same period. Both changes continued existing trends. Compared to the same period in 2004, average employment during the first three quarters of 2005 was up 24% for 'pubs, taverns and bars', up 9% for cafés/restaurants, and down 8% for clubs (though employment in 'pubs, taverns and bars' may have been affected by unusually high patronage around a major sports-series).
The proportion of bar managers who approved of smokefree bars increased from 44% to 60% between November 2004 and May 2005. Bar managers also reported increased agreement with the rights of bar workers and patrons to smokefree environments. The main reported concerns of the national and regional Hospitality Associations, in 2005, were the perceived negative effects on rural and traditional pubs.
Conclusion
As in other jurisdictions, the introduction of smokefree bars in New Zealand has had positive overall health protection, economic and social effects; in contrast to the predictions of opponents.
doi:10.1186/1471-2458-6-64
PMCID: PMC1475576  PMID: 16533408
18.  Prospective study of predictors of attendance for breast screening in inner London. 
OBJECTIVE--To investigate the predictors of first-round attendance for breast screening in an inner city area. DESIGN--Prospective design in which women were interviewed or completed a postal questionnaire before being sent their invitation for breast screening. Sociodemographic factors, health behaviours, and attitudes, beliefs, and intentions were used as predictors of subsequent attendance. A randomised control group was included to assess the effect of being interviewed on attendance. SETTING--Three neighbouring health districts in inner south east London. PARTICIPANTS--A total of 3291 women aged 50-64 years who were due to be called for breast screening for the first time. The analysis of predictors was based on a subsample of 1301, reflecting a response rate of 75% to interview and 36% to postal questionnaire. MAIN RESULTS--Attendance was 42% overall, and 70% in those who gave an interview or returned a questionnaire. There was little evidence for an interview effect on attendance. The main findings from the analysis of predictors are listed below. (These were necessarily based on those women who responded to interview/questionnaire and so may not be generalisable to the full sample.) (1) Sociodemographic factors: Women in rented accommodation were less likely to go for screening but other indicators of social class and education were not predictive of attendance. Age and other risk factors for breast cancer were unrelated to attendance, as was the distance between home and the screening centre. Married or single women were more likely to attend than divorced, separated, or widowed women, and black women had a higher than average attendance rate; however, neither of these relationships was found in the interview sample. (2) Health behaviours: Attenders were less likely to have had a recent breast screen, more likely to have had a cervical smear, more likely to go to the dentist for check ups, and differed from non-attenders with regard to drinking frequency. Exercise, smoking, diet change, and breast self-examination were unrelated to attendance. (3) Attitudes, beliefs, and intentions: The two best predictors were measures of the perceived importance of regular screening for cervical and breast cancer and intentions to go for breast screening. Also predictive were beliefs about the following: the personal consequences of going for breast screening, the effectiveness of breast screening, the chances of getting breast cancer, and the attitudes of significant others (the woman's husband/partner and children). Women who reported a moderate amount of worry about breast cancer were more likely to attend than those at the two extremes. CONCLUSIONS--Attenders and non-attenders differ in two broad areas: the health related behaviours they engage in and the attitudes, beliefs, and intentions they have towards breast cancer and breast screening. The latter are potentially amenable to change, and though different factors may operate among women who do not respond to questionnaires, the findings offer hope that attendance rates can be improved by targeting the relevant attitudes and beliefs. This could be done by changing the invitation letter and its accompanying literature, through national and local publicity campaigns, and by advice given by GPs, practice nurses, and other health professionals. It is essential that such interventions are properly evaluated, preferably in randomised controlled studies.
PMCID: PMC1059897  PMID: 8138773
19.  Stigma Related to HIV among Community Health Workers in Chile 
Stigma research and action  2011;1(1):3-10.
Purpose
When healthcare workers have stigmatizing attitudes toward people living with HIV it may lead to discriminatory behavior that interferes with prevention, treatment, and care. This research examined the HIV-related stigmatizing attitudes reported by health workers in Santiago, Chile.
Methods
The study used focus group data from the first phase of a larger study to develop and test a HIV prevention intervention for Chilean health workers. Ten focus groups were conducted with Health workers in two communities in Santiago, Chile. Content analysis was used to analyze the data.
Results
Two central themes emerged: Societal stigma and discrimination towards people living with HIV and healthcare system’s policies related to HIV. Both inaccurate fears of transmission among the general public and Chilean Health workers and societal prejudices against homosexuals contributed to stigmatization and discrimination.
Conclusions
Health workers did not recognize their own stigmatizing attitudes or discriminatory behaviors, but their discussion indicated that these behaviors and attitudes did exist. Healthcare system issues identified included problems with confidentiality due to the desire to inform other health workers about client HIV status. Health workers must be sensitized to the current stigmatization and misinformation associated with HIV and its negative impacts on persons living with HIV and the general community.
Implications
All clinical and non-clinical workers at community clinics need mandatory education for HIV prevention that focuses on changing attitudes as well as sharing knowledge. Also, the Chilean law protecting people living with HIV and the confidentiality of their medical care needs to be publicized, along with guidelines for its enactment in clinics and other health facilities.
doi:10.5463/sra.v1i1.11
PMCID: PMC3115724  PMID: 21687824
Chile; community; health workers; HIV; stigma
20.  Acquired immunodeficiency syndrome/human immunodeficiency virus knowledge, attitudes, and practices, and use of healthcare services among rural migrants: a cross-sectional study in China 
BMC Public Health  2014;14:158.
Background
Today’s rapid growth of migrant populations has been a major contributor to the human immunodeficiency virus (HIV) epidemic. However, relatively few studies have focused on HIV/acquired immunodeficiency syndrome (AIDS)-related knowledge, attitudes, and practice among rural-to-urban migrants in China. This cross-sectional study was to assess HIV/AIDS-related knowledge and perceptions, including knowledge about reducing high-risk sex.
Methods
Two-phase stratified cluster sampling was applied and 2,753 rural migrants participated in this study. An anonymous self-administered questionnaire was conducted in Guangdong and Sichuan provinces in 2007. Descriptive analysis was used to present the essential characteristics of the respondents. Chi-square test and multiple logistic regression models were performed to examine the associations between identified demographic factors and high-risk sex, sexually transmitted disease (STD) symptoms, and access to HIV screening services among the seven types of workers.
Results
58.6% of participants were knowledgeable about HIV/AIDS transmission, but approximately 90% had a negative attitude towards the AIDS patients, and that 6.2% had engaged in high-risk sex in the past 12 months. Logistic regression analysis revealed sex, marital status, income, migration and work experience to be associated with high-risk sex. Among the 13.9% of workers who reported having STD symptoms, risk factors that were identified included female gender, high monthly income, being married, daily laborer or entertainment worker, frequent migration, and length of work experience. Only 3% of migrant workers received voluntary free HIV screening, which was positively associated with monthly income and workplace.
Conclusions
HIV/AIDS knowledge, attitudes, and practices among rural migrants in China remain a thorny health issue, and use of healthcare services needs to be improved. Low levels of education and knowledge regarding HIV/AIDS among housekeepers and migrant day laborers result in this population likely being engaged in high-risk sex. Government programs should pay more attention to public education, health promotion and intervention for the control of the HIV/AIDS epidemic in China.
doi:10.1186/1471-2458-14-158
PMCID: PMC3996086  PMID: 24520921
China; AIDS/HIV; Knowledge, Attitude and Practice (KAP) study; Rural migrant workers; High-risk sexual behavior; Health services use
21.  Reviewing the effect of two methods of educational package and social inoculation on changing the attitudes towards domestic violence against women 
BACKGROUND:
Domestic violence (DV) is a serious problem all over the world which had been extended to boundaries of countries, economical, cultural and racial classes. 10-69 percent of women are exposed to physical, sexual and emotional violence which has numerous physical and emotional consequences. Therefore, males’ attitude towards women is one of the strongest predicting factors of violence against women, so one of the ways to remove the violence against women is to change the men's attitude. Changing the attitude, in the basic stages of the marriage for couples who are not yet involved with marital misunderstandings, will probably influence their future relationships, therefore, the present study reviewed two attitude changing methods of educational package (EP) and social inoculation (SI) which were used to change the attitude among male volunteers participating in the premarital counseling classes.
METHODS:
This was a semi-experimental study aimed to determine the influence of two methods of supplying EP and SI on the change of attitude toward DV against women. The study subjects included male volunteers participating in Isfahan Molla Hadi Sabzevari Premarital Counseling Center, where the attitudes of 183 subjects were investigated primarily using simple sampling method. Ninety-nine subjects who had positive attitude toward DV were selected and then, randomly distributed into three 33-subject groups. The first was SI group, the second was EP supply group and the third was the control group. Data collection tool was an evaluating questionnaire of the attitude toward DV against women which consisted of two parts, demographic data and 34 attitude evaluating questions. Scientific validity was determined by content validity method and scientific reliability was determined using Cronbach's alpha. Analyzing the data was done using descriptive (frequency and mean), analytical statistical methods (paired-t, independent t-tests, ANOVA, Duncan, Kruskal-Wallis and chi-square) and SPSS software.
RESULTS:
Among 183 participants, 99 of them (54%) had a positive attitude with an average score of 46.5 and 84 of them (45%) with an average score of 29 had a negative attitude toward violence against women. Before the intervention, the highest violence attitude was in emotional, physical and sexual areas, respectively. After the intervention in the inoculation group, the highest attitude changes were in physical, sexual and emotional areas, respectively and in the EP group, in total the attitude changes score after the intervention was significant compared to prior to it, although changes were observed only in physical and sexual areas. In SI group, more attitude changes were occurred than that in EP group. In control group, the attitude score after the intervention had no significant change compared to it before.
CONCLUSIONS:
Although attitude change has no guaranty for changing the behavior, in order to change the behavior, changing the attitude is required, in which for violence against women, it is better to be started at the beginning of the marital relationship. The SI method has been successfully applied in psychology Sciences and the health programs, but the EP method is not an effective method on its own to change the attitude, so it is better to be accompanied by other methods like group discussion, etc.
PMCID: PMC3208932  PMID: 22069401
Domestic violence; attitude change; social inoculation; educational package; premarital counseling
22.  Studies on cardiac myofibrillogenesis with antibodies to titin, actin, tropomyosin, and myosin 
The Journal of Cell Biology  1988;107(3):1075-1083.
Cardiac myofibrillogenesis was examined in cultured chick cardiac cells by immunofluorescence using antibodies against titin, actin, tropomyosin, and myosin. Primitive cardiomyocytes initially contained stress fiber-like structures (SFLS) that stained positively for alpha actin and/or muscle tropomyosin. In some cases the staining for muscle tropomyosin and alpha actin was disproportionate; this suggests that the synthesis and/or assembly of these two isoforms into the SFLS may not be stoichiometric. The alpha actin containing SFLS in these myocytes could be classified as either central or peripheral; central SFLS showed developing sarcomeric titin while peripheral SFLS had weak titin fluorescence and a more uniform stain distribution. Sarcomeric patterns of titin and myosin were present at multiple sites on these structures. A pair of titin staining bands was clearly associated with each developing A band even at the two or three sarcomere stage, although occasional examples of a titin band being associated with a half sarcomere were noted. The appearance of sarcomeric titin patterns coincided or preceded sarcomere periodicity of either alpha actin or muscle tropomyosin. The early appearance of titin in myofibrillogenesis suggests it may have a role in filament alignment during sarcomere assembly.
PMCID: PMC2115289  PMID: 3047149
23.  Impact of Scotland's Smoke-Free Legislation on Pregnancy Complications: Retrospective Cohort Study 
PLoS Medicine  2012;9(3):e1001175.
An analysis of pregnancy data for the whole of Scotland demonstrates a reduction in small-for-gestational-age births and preterm delivery since the introduction of legislation banning smoking in enclosed public spaces.
Background
Both active smoking and environmental tobacco smoke exposure are associated with pregnancy complications. In March 2006, Scotland implemented legislation prohibiting smoking in all wholly or partially enclosed public spaces. The aim of this study was to determine the impact of this legislation on preterm delivery and small for gestational age.
Methods and Findings
We conducted logistic regression analyses using national administrative pregnancy data covering the whole of Scotland. Of the two breakpoints tested, 1 January 2006 produced a better fit than the date when the legislation came into force (26 March 2006), suggesting an anticipatory effect. Among the 716,941 eligible women who conceived between August 1995 and February 2009 and subsequently delivered a live-born, singleton infant between 24 and 44 wk gestation, the prevalence of current smoking fell from 25.4% before legislation to 18.8% after legislation (p<0.001). Three months prior to the legislation, there were significant decreases in small for gestational age (−4.52%, 95% CI −8.28, −0.60, p = 0.024), overall preterm delivery (−11.72%, 95% CI −15.87, −7.35, p<0.001), and spontaneous preterm labour (−11.35%, 95% CI −17.20, −5.09, p = 0.001). In sub-group analyses, significant reductions were observed among both current and never smokers.
Conclusions
Reductions were observed in the risk of preterm delivery and small for gestational age 3 mo prior to the introduction of legislation, although the former reversed partially following the legislation. There is growing evidence of the potential for tobacco control legislation to have a positive impact on health.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The risks of smoking during pregnancy, both on mother and fetus, are well established: women who smoke during pregnancy are more likely to have a miscarriage. Smoking can cause placental problems, such as placental abruption, which can result in heavy bleeding during pregnancy, which is dangerous for both mother and baby. Other dangers of smoking during pregnancy include the baby being born too early (premature birth), the baby being below average weight (small for gestational age), birth defects, and infant death. Because of the serious damage to health caused by smoking, in 2005, under the auspices of the World Health Organization, countries adopted the Framework Convention on Tobacco Control to protect present and future generations from the devastating health, social, environmental, and economic consequences of tobacco consumption and exposure to tobacco smoke. Article 8 of the treaty obliges member states who have ratified the treaty—168 so far—to protect all people from exposure to tobacco smoke in indoor workplaces, public transport, and indoor public places. As a result, many countries around the world have banned smoking in public places.
Why Was This Study Done?
Scotland was the first country in the United Kingdom to ban smoking in public places, which was implemented as part of the Smoking, Health and Social Care (Scotland) Bill on 26 March 2006. Previous studies have shown that the introduction of the legislation led directly to a reduction in smoking and also a reduction in environmental tobacco smoke exposure in adults and children. Furthermore, the Scottish legislation has been accompanied by significant reductions in both cardiovascular and respiratory disease. Because of the known risks of smoking during pregnancy, the researchers wanted to investigate whether the change in policy on smoking in public places had positive benefits on the health of mothers and babies. They evaluated this by measuring the rates of preterm delivery and small for gestational age before and after the Scottish legislation went into effect.
What Did the Researchers Do and Find?
The researchers collected information on preterm delivery and small for gestational age in all single babies born live at 22–44 weeks gestation between 1 January 1996 and 31 December 2009 by using the Scottish Morbidity Record (SMR2), which collects relevant information on all women discharged from Scottish maternity hospitals, including maternal and infant characteristics and pregnancy complications. The researchers categorized preterm delivery into mild, moderate, and extreme depending on how much before 37 weeks the baby was born. They defined small for gestational age as the smallest 10% (below the 10th centile) for sex-specific birth weight at delivery, and very small for gestational age as the smallest 3% (below the 3rd centile), for all deliveries in Scotland over the study period. As some people may have stopped smoking in anticipation of the smoking ban, in their statistical model, the researchers included two possible breakpoints for the effect of the legislation—the actual date of implementation and 1 January 2006.
The researchers found that of the 716,968 pregnancies (the number eligible for inclusion in the study), 99.9% of women had their smoking status recorded, and among these 23.9% were current smokers, 57.6% never smokers, and 8.7% former smokers. However, following implementation of the legislation the researchers noted that there was a significant reduction in current smokers to 18.8%. In their statistical model, the researchers found that following 1 January 2006, there was a significant drop in overall preterm deliveries, which remained after adjustment for potential confounding factors. Likewise, there was a significant decrease in the number of infants born small, and very small, for gestational age after 1 January 2006. Furthermore, the researchers found that these significant reductions occurred in both mothers who smoked and those who had never smoked.
What Do These Findings Mean?
These findings suggest that the introduction of national, comprehensive smoke-free legislation in Scotland was associated with significant reductions in preterm delivery and babies being born small for gestational age. These findings are plausible and add to the growing evidence of the wide-ranging health benefits of smoke-free legislation, and support the adoption of such legislation in other countries that have yet to implement smoking bans.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001175.
More information is available on the World Health Organization's Framework Convention for Tobacco Control
More information on the Smoking, Health and Social Care (Scotland) Bill is available
The US Centers for Disease Control and Prevention has more information about the risks of smoking in pregnancy, as does the UK National Health Service's smokefree web page
NHS Health Scotland has a website that summarises all the studies to date evaluating the Scottish smoke-free legislation
doi:10.1371/journal.pmed.1001175
PMCID: PMC3295815  PMID: 22412353
24.  Medical Students' Exposure to and Attitudes about the Pharmaceutical Industry: A Systematic Review 
PLoS Medicine  2011;8(5):e1001037.
A systematic review of published studies reveals that undergraduate medical students may experience substantial exposure to pharmaceutical marketing, and that this contact may be associated with positive attitudes about marketing.
Background
The relationship between health professionals and the pharmaceutical industry has become a source of controversy. Physicians' attitudes towards the industry can form early in their careers, but little is known about this key stage of development.
Methods and Findings
We performed a systematic review reported according to PRISMA guidelines to determine the frequency and nature of medical students' exposure to the drug industry, as well as students' attitudes concerning pharmaceutical policy issues. We searched MEDLINE, EMBASE, Web of Science, and ERIC from the earliest available dates through May 2010, as well as bibliographies of selected studies. We sought original studies that reported quantitative or qualitative data about medical students' exposure to pharmaceutical marketing, their attitudes about marketing practices, relationships with industry, and related pharmaceutical policy issues. Studies were separated, where possible, into those that addressed preclinical versus clinical training, and were quality rated using a standard methodology. Thirty-two studies met inclusion criteria. We found that 40%–100% of medical students reported interacting with the pharmaceutical industry. A substantial proportion of students (13%–69%) were reported as believing that gifts from industry influence prescribing. Eight studies reported a correlation between frequency of contact and favorable attitudes toward industry interactions. Students were more approving of gifts to physicians or medical students than to government officials. Certain attitudes appeared to change during medical school, though a time trend was not performed; for example, clinical students (53%–71%) were more likely than preclinical students (29%–62%) to report that promotional information helps educate about new drugs.
Conclusions
Undergraduate medical education provides substantial contact with pharmaceutical marketing, and the extent of such contact is associated with positive attitudes about marketing and skepticism about negative implications of these interactions. These results support future research into the association between exposure and attitudes, as well as any modifiable factors that contribute to attitudinal changes during medical education.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The complex relationship between health professionals and the pharmaceutical industry has long been a subject of discussion among physicians and policymakers. There is a growing body of evidence that suggests that physicians' interactions with pharmaceutical sales representatives may influence clinical decision making in a way that is not always in the best interests of individual patients, for example, encouraging the use of expensive treatments that have no therapeutic advantage over less costly alternatives. The pharmaceutical industry often uses physician education as a marketing tool, as in the case of Continuing Medical Education courses that are designed to drive prescribing practices.
One reason that physicians may be particularly susceptible to pharmaceutical industry marketing messages is that doctors' attitudes towards the pharmaceutical industry may form early in their careers. The socialization effect of professional schooling is strong, and plays a lasting role in shaping views and behaviors.
Why Was This Study Done?
Recently, particularly in the US, some medical schools have limited students' and faculties' contact with industry, but some have argued that these restrictions are detrimental to students' education. Given the controversy over the pharmaceutical industry's role in undergraduate medical training, consolidating current knowledge in this area may be useful for setting priorities for changes to educational practices. In this study, the researchers systematically examined studies of pharmaceutical industry interactions with medical students and whether such interactions influenced students' views on related topics.
What Did the Researchers Do and Find?
The researchers did a comprehensive literature search using appropriate search terms for all relevant quantitative and qualitative studies published before June 2010. Using strict inclusion criteria, the researchers then selected 48 articles (from 1,603 abstracts) for full review and identified 32 eligible for analysis—giving a total of approximately 9,850 medical students studying at 76 medical schools or hospitals.
Most students had some form of interaction with the pharmaceutical industry but contact increased in the clinical years, with up to 90% of all clinical students receiving some form of educational material. The highest level of exposure occurred in the US. In most studies, the majority of students in their clinical training years found it ethically permissible for medical students to accept gifts from drug manufacturers, while a smaller percentage of preclinical students reported such attitudes. Students justified their entitlement to gifts by citing financial hardship or by asserting that most other students accepted gifts. In addition, although most students believed that education from industry sources is biased, students variably reported that information obtained from industry sources was useful and a valuable part of their education.
Almost two-thirds of students reported that they were immune to bias induced by promotion, gifts, or interactions with sales representatives but also reported that fellow medical students or doctors are influenced by such encounters. Eight studies reported a relationship between exposure to the pharmaceutical industry and positive attitudes about industry interactions and marketing strategies (although not all included supportive statistical data). Finally, student opinions were split on whether physician–industry interactions should be regulated by medical schools or the government.
What Do These Findings Mean?
This analysis shows that students are frequently exposed to pharmaceutical marketing, even in the preclinical years, and that the extent of students' contact with industry is generally associated with positive attitudes about marketing and skepticism towards any negative implications of interactions with industry. Therefore, strategies to educate students about interactions with the pharmaceutical industry should directly address widely held misconceptions about the effects of marketing and other biases that can emerge from industry interactions. But education alone may be insufficient. Institutional policies, such as rules regulating industry interactions, can play an important role in shaping students' attitudes, and interventions that decrease students' contact with industry and eliminate gifts may have a positive effect on building the skills that evidence-based medical practice requires. These changes can help cultivate strong professional values and instill in students a respect for scientific principles and critical evidence review that will later inform clinical decision-making and prescribing practices.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001037.
Further information about the influence of the pharmaceutical industry on doctors and medical students can be found at the American Medical Students Association PharmFree campaign and PharmFree Scorecard, Medsin-UKs PharmAware campaign, the nonprofit organization Healthy Skepticism, and the Web site of No Free Lunch.
doi:10.1371/journal.pmed.1001037
PMCID: PMC3101205  PMID: 21629685
25.  Smoking in the workplace: do smoking patterns and attitudes reflect the legislative environment? 
Tobacco Control  1996;5(1):39-45.
OBJECTIVE: With regard to the workplace, to examine restrictions on smoking, smoking at work, attitudes toward and reactions to restrictions, and workplace programmes in the context of the legislative environment. DESIGN: Population-based telephone interview survey of adult residents of the jurisdictions of Metropolitan Toronto, Ontario, Canada. SUBJECTS: Workers within the City of Toronto (n = 374) were compared with other workers (n = 536), because their legislative environments with regard to workplace smoking were markedly different, with workplaces in the City of Toronto being covered by a much more stringent bylaw. RESULTS: In comparison with other workers, City of Toronto workers reported workplace restrictions to be more common and widespread. These workers were also less likely to smoke at work, and more likely to smoke less at work and to have cut down on smoking at work. Quit-smoking rates, however, were similar. There was evidence of some compensatory smoking outside work, but additional compensation in association with more stringent restrictions was not found. City workers and other workers were similar in their support for smoke-free workplaces, in their attitudes to the role of governments in regulating workplace smoking, and in their perceptions of conflict between smokers and non-smokers. Reports of quit-smoking programmes and educational interventions in the workplace were similarly uncommon, although both groups of workers indicated strong support for the role of business and industry in helping people quit. CONCLUSIONS: Restrictions on smoking and smoking patterns reflected the legislative environment; a more stringent environment was associated with more restrictions and less smoking at work. 



PMCID: PMC1759494  PMID: 8795858

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