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1.  An empirical analysis of cigarette demand in Argentina 
Tobacco control  2013;24(1):89-93.
Objective
To estimate the long-term and short-term effects on cigarette demand in Argentina based on changes in cigarette price and income per person >14 years old.
Method
Public data from the Ministry of Economics and Production were analysed based on monthly time series data between 1994 and 2010. The econometric analysis used cigarette consumption per person >14 years of age as the dependent variable and the real income per person >14 years old and the real average price of cigarettes as independent variables. Empirical analyses were done to verify the order of integration of the variables, to test for cointegration to capture the long-term effects and to capture the short-term dynamics of the variables.
Results
The demand for cigarettes in Argentina was affected by changes in real income and the real average price of cigarettes. The long-term income elasticity was equal to 0.43, while the own-price elasticity was equal to −0.31, indicating a 10% increase in the growth of real income led to an increase in cigarette consumption of 4.3% and a 10% increase in the price produced a fall of 3.1% in cigarette consumption. The vector error correction model estimated that the short-term income elasticity was 0.25 and the short-term own-price elasticity of cigarette demand was −0.15. A simulation exercise showed that increasing the price of cigarettes by 110% would maximise revenues and result in a potentially large decrease in total cigarette consumption.
Conclusion
Econometric analyses of cigarette consumption and their relationship with cigarette price and income can provide valuable information for developing cigarette price policy.
doi:10.1136/tobaccocontrol-2012-050711
PMCID: PMC4102660  PMID: 23760657
2.  Light and intermittent smoking among California's Asian Americans 
Nicotine & Tobacco Research  2009;11(2):197-202.
Introduction:
Asian Americans, along with other ethnic minorities, have been described to be more likely than Whites to be light and intermittent smokers. Characterizing Asian American smoking behavior accurately on a population level requires oversampling groups of different national origin and including non–English-speaking participants.
Methods:
We analyzed the California Health Interview Survey to compare moderate/heavy (≥10 cigarettes/day), light (0–9 cigarettes/day), and intermittent (not daily) smoking patterns in Asian Americans with those of Whites. We also examined whether social and demographic factors that had been associated with Asian American smoking prevalence also were associated with light and intermittent smoking patterns in each of the national origin groups.
Results:
Most Asian American smokers were more likely to be light and intermittent smokers (range = 36.6%–61.5% for men and 29.9%–81.5% for women) compared with Whites, with lower mean cigarette consumption. Asian American light and intermittent smokers were more likely than moderate/heavy smokers to be women (odds ratio [OR] = 2.12, 95% CI = 1.14–3.94), highly educated (OR = 3.16, 95% CI = 1.21–8.28), not Korean (compared with Chinese; OR = 0.32, 95% CI = 0.13–0.79), and bilingual speakers with high English language proficiency compared with English-only speakers (OR = 2.83, 95% CI = 1.21–6.84). Asian American intermittent smokers were more likely than daily smokers to be women (OR = 2.25, 95% CI = 1.08–4.72) and to have lower household income.
Discussion:
The predominance of Asian American light and intermittent smoking patterns has important implications for developing effective tobacco control outreach. Further studies are needed to elaborate the relationship between biological, psychosocial, and cultural factors influencing Asian American smoking intensity.
doi:10.1093/ntr/ntp013
PMCID: PMC2658910  PMID: 19246424
3.  Influence of gender role attitudes on smoking and drinking among girls from Jujuy, Argentina 
Preventive medicine  2013;57(3):194-197.
Objective
Evaluate effect of gender role attitudes on tobacco and alcohol use among Argentinean girls.
Method
Cross-sectional survey of 10th grade students attending 27 randomly selected schools in Jujuy, Argentina. Questions about tobacco and alcohol use were adapted from global youth surveys. Five items with 5-point response options of agreement-disagreement assessed attitude towards egalitarian (higher score) gender roles.
Results
2,133 girls, aged 13-18 years, 71% Indigenous, 22% mixed Indigenous/European, and 7% European responded. Of these, 60% had ever smoked, 32% were current smokers, 58% ever drinkers, 27% drank in previous month, and 13% had ≥5 drinks on one occasion. Mean response to the gender role scale was 3.49 (95% CI=3.41-3.57) out of 5 tending toward egalitarian attitudes. Logistic regression models using the gender role scale score as the main predictor and adjusting for demographic and social confounders showed that egalitarian gender role was associated with ever smoking (OR=1.25; 95% CI 1.09-1.44), ever drinking (OR=1.24; 95% CI 1.10-1.40), drinking in prior month (OR=1.21; 95% CI 1.07-1.37) and ≥5 drinks on one occasion (OR=1.15; 95% CI 1.00-1.33), but was not significant for current smoking.
Conclusion
Girls in Jujuy who reported more egalitarian gender role attitudes had higher odds of smoking or drinking.
doi:10.1016/j.ypmed.2013.05.011
PMCID: PMC3748231  PMID: 23732243
gender role; tobacco use; alcohol use; adolescents; Latin America; Indigenous
4.  Diabetes Risk in Mexican Americans: Effects of Language Acculturation, Generation and Socioeconomic Status 
Background
The effect of language acculturation, socioeconomic status (SES), and immigrant generation on development of diabetes among Mexican Americans was evaluated in the Hispanic Established Population for the Epidemiologic Study of the Elderly (HEPESE).
Methods
HEPESE is a longitudinal cohort study of 3,050 non-institutionalized Mexican Americans aged 65 years at baseline (1993–1994) from 5 Southwestern states. Diabetes incidence was ascertained in 4 follow-up surveys to 2004–05 by respondent self-reported physician-diagnosis of diabetes, high blood glucose, or sugar in the urine. Language of interview, immigrant generation, gender, age, education, family history of diabetes, smoking status, alcohol use, health insurance type and self-reported height and weight were assessed. High socioeconomic status (SES) was defined by high school graduation and non-Medicaid insurance. Cox's proportional hazards models were fit to evaluate the effects of language acculturation, generation and SES on incident diabetes.
Results
845 of 3,050 (27.7%) Mexican Americans had diabetes at baseline and were younger, more educated, and more likely to have health insurance than those without diabetes. Risk of developing diabetes increased for Spanish-speaking respondents with low SES from 1st to 3rd generation (HR = 1.76, 95% CI = 1.02–3.03) and from 2nd to 3rd generation (HR = 2.15, 95% CI = 1.20–3.84). Among English-speaking, high SES participants, generation had a protective effect on developing diabetes: HR = 0.45 (95% CI = 0.22–0.91) when comparing 3rd versus 1st generation
Conclusion
The effect of language acculturation and immigrant generation on incident diabetes is moderated by SES status in HEPESE participants.
doi:10.1007/s10823-013-9200-y
PMCID: PMC3804224  PMID: 23990075
acculturation; diabetes; Mexican Americans
5.  Association Between Cancer Risk Perception and Screening Behavior Among Diverse Women 
Archives of internal medicine  2008;168(7):728-734.
Background
We measured the perception of breast, cervical, and colon cancer risks and screening in diverse women to examine the association between risk perception and screening behavior.
Methods
Cross-sectional telephone and in-person interviews of women aged 50 to 80 years were conducted in English, Spanish, or Chinese. The women were recruited from primary care practices in San Francisco, California (academic general internal medicine, family medicine, women’s health practices, a community-based clinic in Chinatown, and the Community Health Network Clinics, which is affiliated with the San Francisco Department of Public Health), with at least 1 visit within the previous 2 years. Perceived personal risk for each cancer was measured on a word scale (no risk to very high risk) and compared with self-reported screening behavior by ethnicity.
Results
A total of 1160 women participated: 338 (29%) were White, 167 (14%) were African American, 239 (21%) were Latina, and 416 (36%) were Asian. The average participant was 61 years old and a high school graduate; 18% had a personal history of cancer, and 42% had a family history of cancer. The perceived lifetime risk of cancer varied by ethnicity. Compared with White women, Latinas had a higher perceived risk for cervical cancer (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.8–4.6) and colon cancer (OR, 3.0; 95% CI, 1.8–5.0) after multivariate adjustment, and Asians had a lower perceived risk for cervical cancer (OR, 0.6; 95% CI, 0.4–0.9) and colon cancer (OR, 0.6; 95% CI, 0.3–0.9). Higher colon cancer risk perception was associated with having undergone colonoscopy within 10 years (OR, 2.8; 95% CI, 1.4–5.4).
Conclusions
Risk perception was significantly associated with colon cancer screening behavior (P = .001). Evaluation of patients’ perceived risk of cancer may be useful to clinicians who are recommending screening tests.
doi:10.1001/archinte.168.7.728
PMCID: PMC4031902  PMID: 18413555
6.  Factors Influencing Time to Diagnosis After Abnormal Mammography in Diverse Women 
Journal of Women's Health  2013;22(2):159-166.
Abstract
Background
Abnormal mammograms are common, and the risk of false positives is high. We surveyed women in order to understand the factors influencing the efficiency of the evaluation of an abnormal mammogram.
Methods
Women aged 40–80 years, identified from lists with Breast Imaging Reporting and Data System (BIRADS) classifications of 0, 3, 4, or 5, were surveyed. Telephone surveys asked about the process of evaluation, and medical records were reviewed for tests and timing of evaluation.
Results
In this study, 970 women were surveyed, and 951 had chart reviews. Overall, 36% were college graduates, 68% were members of a group model health plan, 18% were Latinas, 25% were African Americans, 15% were Asian, and 43% were white. Of the 352 women who underwent biopsies, 151 were diagnosed with cancer (93 invasive). Median time to diagnosis was 183 days for BIRADS 3 compared to 29 days for BIRADS 4/5 and 27 days for BIRADS 0. At 60 days, 84% of BIRADS 4/5 women had a diagnosis. Being African American (hazard ratio [HR] 0.69, 95% confidence interval [CI] 0.49-0.97, p=0.03), income < $10,000 (HR 0.55, 95% CI 0.31-0.98, p<0.04), perceived discrimination (HR 0.22, 95% CI 0.09-0.52, p<0.001), not fully understanding the results of the index mammogram (HR 0.49, 95% CI 0.32-0.75, p=0.001), and being notified by letter (HR 0.66, 95% CI 0.48-0.90, p=0.01) or telephone (HR 0.62, 95% CI 0.42-0.92, p=0.02) rather than in person were all associated with significant delays in diagnosis.
Conclusions
Evaluation of BIRADS 0, 4, or 5 abnormal mammograms was completed in most women within the recommended 60 days. Even within effective systems, correctible communication factors may adversely affect time to diagnosis.
doi:10.1089/jwh.2012.3646
PMCID: PMC3573728  PMID: 23350859
7.  Immigrant Generation and Diabetes Risk Among Mexican Americans: The Sacramento Area Latino Study on Aging 
American journal of public health  2013;103(5):e45-e52.
Objectives
We examined whether acculturation and immigrant generation, a marker for assimilation, are associated with diabetes risk in an aging Mexican-origin population.
Methods
We analyzed data on 1789 adults aged 60 to 101 years from the Sacramento Area Latino Study on Aging. We ascertained type 2 diabetes on the basis of diabetic medication use, self-report of physician diagnosis, or a fasting glucose of 126 milligrams/deciliter or greater. Logistic regression modeled prevalent diabetes.
Results
Adjusting for age and gender, we observed significant but divergent associations between immigrant generation, acculturation, and diabetes risk. Relative to first-generation adults, second-generation adults had an odds ratio (OR) of 1.8 (95% confidence interval [CI] = 1.4, 2.4) and third-generation adults had an OR of 2.1 (95% CI = 1.4, 3.1) of having diabetes. Greater US acculturation, however, was associated with a slightly decreased diabetes rate. In the full model adjusting for socioeconomic and lifestyle factors, the association between generation (but not acculturation) and diabetes remained significant.
Conclusions
Our study lends support to the previously contested notion that assimilation is associated with an increased diabetes risk in Mexican immigrants. Researchers should examine the presence of a causal link between assimilation and health more closely.
doi:10.2105/AJPH.2012.300969
PMCID: PMC3686633  PMID: 23488481
8.  Using Visual Displays to Communicate Risk of Cancer to Women From Diverse Race/Ethnic Backgrounds 
Patient Education and Counseling  2012;87(3):327-335.
Objective
This study evaluated how well women from diverse race/ethnic groups were able to take a quantitative cancer risk statistic verbally provided to them and report it in a visual format.
Methods
Cross-sectional survey was administered in English, Spanish or Chinese, to women aged 50 to 80 (n=1,160), recruited from primary care practices. The survey contained breast, colorectal or cervical cancer questions regarding screening and prevention. Women were told cancer-specific lifetime risk then shown a visual display of risk and asked to indicate the specific lifetime risk. Correct indication of risk was the main outcome.
Results
Correct responses on icon arrays were 46% for breast, 55% for colon, and 44% for cervical; only 25% correctly responded to a magnifying glass graphic. Compared to Whites, African American and Latina women were significantly less likely to use the icon arrays correctly. Higher education and higher numeracy were associated with correct responses. Lower education was associated with lower numeracy.
Conclusions
Race/Ethnic differences were associated with women’s ability to take a quantitative cancer risk statistic verbally provided to them and report it in a visual format.
Practice Implications
Systematically considering the complexity of intersecting factors such as race/ethnicity, educational level, poverty, and numeracy in most health communications is needed. (200)
doi:10.1016/j.pec.2011.11.014
PMCID: PMC3359420  PMID: 22244322
risk communication; cancer screening; cancer prevention; ethnic disparities; numeracy; decision making
9.  Association of Media Literacy With Cigarette Smoking Among Youth in Jujuy, Argentina 
Nicotine & Tobacco Research  2011;14(5):516-521.
Introduction:
Latin America has the highest prevalence of tobacco use by youth. Higher media literacy, defined as the ability to analyze and evaluate media messages, has been associated with lower smoking among youth in the United States. The objective of this study was to determine whether media literacy related to smoking is independently associated with current smoking and susceptibility to future smoking in a sample of mostly indigenous youth in Jujuy, Argentina.
Methods:
In 2006, a self-administered survey was conducted among 10th grade students sampled from 27 randomly selected urban and rural schools in Jujuy. Survey items measured smoking behavior (ever, never, and current), susceptibility to future smoking among never-smokers (definitely not accept a cigarette from a friend or to smoke in the future), 5 items assessing smoking media literacy (SML), and risk factors for smoking.
Results:
Of the 3,470 respondents, 1,170 (34%) reported having smoked in the previous 30 days (current). Of the 1,430 students who had never smoked, 912 (64%) were susceptible to future smoking. High media literacy was present in 38%. Using multiple logistic regression, fully adjusted models showed that high media literacy was significantly associated as a protective factor of being a current smoker (odds ratio [OR] = 0.81; 95% CI = 0.67–0.97) and of being susceptible to future smoking (OR = 0.73; 95% CI = 0.58–0.92) among those who had never smoked.
Conclusions:
Among youth in Jujuy, higher SML was significantly associated with both lower current smoking and susceptibility to future smoking. Teaching SML may be a valuable component in a prevention intervention in this population.
doi:10.1093/ntr/ntr240
PMCID: PMC3337534  PMID: 22193569
10.  Language Barriers and Understanding of Hospital Discharge Instructions 
Medical Care  2012;50(4):283-289.
Background
Effective communication at hospital discharge is necessary for an optimal transition and to avoid adverse events. We investigated the association of a language barrier with patient understanding of discharge instructions.
Methods
Spanish, Chinese and English speaking patients admitted to two urban hospitals between 2005-2008, comparing patient understanding of follow-up appointment type, and medication category and purpose between limited English proficient (LEP) and English proficient (EP) patients.
Results
Of the 308 patients, 203 were LEP. Rates of understanding were low overall for follow-up appointment type (56%) and the 3 medication outcomes (category 48%, purpose 55%, both 41%). In unadjusted analysis, LEP were less likely than EP patients to know appointment type (50% vs. 66%; p = .01), medication category (45% vs. 54%; p = .05), and medication category and purpose combined (38% vs. 47%; p = .04), but equally likely to know medication purpose alone. These results persisted in the adjusted models for medication outcomes: LEP patients had lower odds of understanding medication category (OR 0.63; 95% CI 0.42-0.95); and category/purpose (OR 0.59; 95%CI 0.39-0.89).
Conclusions
Understanding of appointment type and medications post-discharge was low, with LEP patients demonstrating worse understanding of medications. System interventions to improve communication at hospital discharge for all patients, and especially those with LEP, are needed.
doi:10.1097/MLR.0b013e318249c949
PMCID: PMC3311126  PMID: 22411441
Interpretation; hospital discharge; patient-doctor communication
11.  Clinician Ratings of Interpreter Mediated Visits in Underserved Primary Care Settings with Ad hoc, In-person Professional, and Video Conferencing Modes 
Language interpretation ameliorates health disparities among underserved limited English-proficient patients, yet few studies have compared clinician satisfaction with these services. Self-administered clinician post-visit surveys compared the quality of interpretation and communication, visit satisfaction, degree of patient engagement, and cultural competence of visits using untrained people acting as interpreters (ad hoc), in-person professional, or video conferencing professional interpretation for 283 visits. Adjusting for clinician and patient characteristics, the quality of interpretation of in-person and video conferencing modes were rated similarly (OR=1.79; 95% CI 0.74, 4.33). The quality of in-person (OR=5.55; 95% CI 1.50, 20.51) and video conferencing (OR=3.10; 95% CI 1.16, 8.31) were rated higher than ad hoc interpretation. Self-assessed cultural competence was better for in-person versus video conferencing interpretation (OR=2.32; 95% CI 1.11, 4.86). Video conferencing interpretation increases access without compromising quality, but cultural nuances may be better addressed by in-person interpreters. Professional interpretation is superior to ad hoc (OR=4.15; 95% CI 1.43, 12.09).
doi:10.1353/hpu.0.0269
PMCID: PMC3576468  PMID: 20173271
Quality of health care; cultural competency; physician-patient communication; medical interpretation; limited English proficiency
12.  Smoking Behavior and Ethnicity in Jujuy, Argentina: Evidence from a Low-Income Youth Sample 
Substance use & misuse  2009;44(5):632-646.
Latin America is the world region with the highest rates of youth tobacco use and widest socioeconomic gaps, yet no data are available on smoking among Indigenous people, the largest disadvantaged group in the region. A self-administered survey of 3,131 8th grade youth enrolled in a random sample of 27 urban and rural schools was administered in 2004 in Jujuy, Argentina. Standard questions adapted from global surveys were used. Compared with youth of European background (11.4%; 95% CI 6.7–15.1), Indigenous (23.0%; 95% CI 21.0–25.0), and Mixed ethnicity (23%; 95% CI 18.9–27.1) youth had higher prevalence of current smoking. The odds of current smoking remained significantly elevated for Indigenous (OR 1.9; 95% CI = 1.1–3.3) and Mixed youth (OR 2.0; 95% CI 1.2–3.4) after controlling for confounders. Other risk factors that were associated with current smoking included: having any friends who smoke, repeating a grade in school, depressive symptoms in previous year, drinking any alcohol in the previous week and thrill seeking orientation. These results underscore the importance of social and cultural diversity aspects of the global tobacco epidemic.
doi:10.1080/10826080902809717
PMCID: PMC3570082  PMID: 19360537
Tobacco use; adolescents; Latin America; ethnicity
13.  Patient-Physicians’ Information Exchange in Outpatient Cardiac Care: Time for a Heart to Heart? 
Patient education and counseling  2010;85(2):173-179.
Objective
Agreement between patients and physicians is an indicator of successful communication. Concordance in domains of communication among patients with heart disease and communication barriers has not been studied.
Methods
English, Spanish, or Cantonese-speaking patients seen at a public hospital cardiology clinic were assessed with pre-visit questionnaires. Surveys of patients and their physicians immediately after the visit asked each about: (1) cardiac functional status, (2) barriers to self-management, (3) cardiac diagnoses, and (4) treatment. We assessed patient-physician concordance in these domains.
Results
179 patients and 56 physicians completed the study. Patients had low educational attainment, limited literacy and limited English proficiency. Physicians underestimated patients’ cardiac functioning status (NYHA Classes 2–4), by 1 class or more in 50% of visits. Physicians were frequently unaware of medication (38/57, 67%) and psychosocial (61/88, 69%) barriers. Patients were unable to describe even 1 matching diagnosis (72/170, 42% concordant) among 5 categories. Physicians’ reported medication changes in 106/179 (59%) but patients failed to report these changes in 55% (58/106). Multivariate logistic regression analyses showed no significant association between patient characteristics and concordance.
Conclusion
Patients and physicians often fail to communicate effectively and determinants of concordance in CVD care require further investigation.
Practice Implications
Developing strategies to improve communication within the medical encounter are critical to improving ambulatory chronic disease management.
doi:10.1016/j.pec.2010.09.017
PMCID: PMC3116945  PMID: 21035298
14.  From Online Randomized Controlled Trials to Participant Preference Studies: Morphing the San Francisco Stop Smoking Site into a Worldwide Smoking Cessation Resource 
Background
Internet interventions have the potential to address many of the health problems that produce the greatest global burden of disease. We present a study illustrating this potential. The Spanish/English San Francisco Stop Smoking Internet site, which yielded quit rates of 20% or more at 12 months in published randomized controlled trials (RCTs), was modified to make it accessible to Spanish- and English-speaking smokers 18 years of age or older anywhere in the world.
Objective
To illustrate that Internet interventions designed to conduct RCTs can be adapted to serve as universal health care resources. We also examine quit rates obtained in the current participant preference study (in which users could choose from all elements tested in previous RCTs) to determine whether they differ from the quit rates found in the RCTs.
Methods
We modified the San Francisco Stop Smoking Internet site so that, instead of being randomly assigned to a specific intervention, participants could personalize the site by choosing among nine site elements (eg, stop smoking guide, reminder emails, journal, mood management intervention, or virtual group). Participants completed a baseline assessment, and reported smoking and mood data at 1-, 3-, 6-, and 12-month follow-ups. We assessed the modified website’s reach and outcomes (quit rates), and compared the quit rates of the current participant preference study with those of the previous RCTs.
Results
In the first year of recruitment, 94,158 individuals from 152 countries and territories visited the site; 13,488 participants left some data; 9173 signed consent; 7763 completed the baseline survey; and 1955, 1362, 1106, and 1096 left 1-, 3-, 6-, and 12-month data, respectively. Observed quit rates were 38.1% (n = 668), 44.9% (n = 546), 43.6% (n = 431), and 45.4% (n = 449), respectively. The current participant preference study yielded higher observed quit rates (odds ratio 1.30) than the previous RCT when controlling for individuals’ demographic and smoking characteristics.
Conclusions
After strict RCTs are completed, Internet intervention sites can be made into worldwide health intervention resources without reducing their effectiveness.
Trial Registration
Clinicaltrials.gov NCT00721786; http://clinicaltrials.gov/ct2/show/NCT00721786 (Archived by WebCite at http://www.webcitation.org/66npiZF4y)
doi:10.2196/jmir.1852
PMCID: PMC3414852  PMID: 22739225
Internet intervention; smoking cessation; international resources; Spanish; English; outcome study
15.  Interpreting the Outcomes of Automated Internet-Based Randomized Trials: Example of an International Smoking Cessation Study 
Background
Smoking is one of the largest contributors to the global burden of disease. Internet interventions have been shown to reduce smoking rates successfully. However, improved methods of evaluating effectiveness need to be developed for large-scale Internet intervention trials.
Objective
To illustrate a method to interpret outcomes of large-scale, fully automated, worldwide Internet intervention trials.
Methods
A fully automated, international, Internet-based smoking cessation randomized controlled trial was conducted in Spanish and English, with 16,430 smokers from 165 countries. The randomized controlled trial replicated a published efficacy trial in which, to reduce follow-up attrition, 1000 smokers were followed up by phone if they did not provide online follow-up data.
Results
The 7-day self-reported abstinence rates ranged from 36.18% (2239/6189) at 1 month to 41.34% (1361/3292) at 12 months based on observed data. Given high rates of attrition in this fully automated trial, when participants unreachable at follow-up were presumed to be smoking, the abstinence rates ranged from 13.63% (2239/16.430) at 1 month to 8.28% (1361/16,430) at 12 months. We address the problem of interpreting results with high follow-up attrition rates and propose a solution based on a smaller study with intensive phone follow-up.
Conclusions
Internet-based smoking cessation interventions can help large numbers of smokers quit. Large-scale international outcome studies can be successfully implemented using automated Internet sites. Interpretation of the studies’ results can be aided by extrapolating from results obtained from subsamples that are followed up by phone or similar cohort maintenance methods.
Trial Registration
ClinicalTrials.gov NCT00721786; http://clinicaltrials.gov/ct2/show/NCT00721786 (Archived by WebCite at http://www.webcitation.org/63mhoXYPw)
doi:10.2196/jmir.1829
PMCID: PMC3374542  PMID: 22314016
Smoking cessation; tobacco use; Internet intervention; evidence-based intervention; attrition; effectiveness trial
16.  Physician Counseling of Pregnant Women About Active and Second-hand Smoking in Argentina 
Objective
Describe physicians' practices of smoking cessation and secondhand smoke (SHS) exposure counseling during prenatal visits.
Design
Cross-sectional survey
Setting
13 public and private hospitals from three cities in Argentina
Population
300 obstetrician/gynecologists
Methods
Self-administered survey included knowledge and attitudes about tobacco use during pregnancy, frequency, type and duration of smoking cessation counseling, barriers to counseling, communication skills, level of understanding, and personal smoking history.
Main Outcome Measures
Composite outcomes of 4 items, each representative of counseling on smoking cessation and SHS exposure.
Results
235 (78.3%) questionnaires were completed; 54.5% men, mean age 45, 35% current smokers. Only 22% had received training in smoking cessation counseling and 48.5% reported insufficient knowledge to provide smoking cessation advice. Although 88.9% always or almost always advised women to stop smoking, 75% believed it was acceptable for pregnant women to smoke up to 6 cigarettes per day. The risk of SHS exposure was “always or almost always discussed” by only 34.5% of physicians. Multivariate logistic regression showed that lack of training was associated with less counseling about smoking cessation (OR 0.18; 95%CI 0.04-0.82) and SHS exposure (OR 0.27; 95%CI 0.12-0.59). Current compared to never smokers had lower odds of smoking cessation counseling (OR 0.39; 95%CI 0.05-0.82). Current smokers were less likely than former smokers to counsel about SHS (OR 0.25, 95%CI 0.11-0.62).
Conclusions
Smoking cessation counseling during pregnancy in Argentina occurs infrequently, interventions are needed to assist physicians motivate and counsel women to quit smoking and avoid SHS exposure. Physicians taking care of pregnant women also need to quit smoking.
doi:10.3109/00016341003739567
PMCID: PMC3158573  PMID: 20367427
Tobacco use; adolescents; Latin America; ethnicity; pregnancy; smoking; second hand smoke; counselling
17.  Are risk factors for breast cancer associated with follow-up procedures in diverse women with abnormal mammography? 
Cancer causes & control : CCC  2005;16(3):245-253.
Objective
We evaluated the association of risk factors for breast cancer with reported follow-up procedures after abnormal mammography among diverse women.
Methods
Women ages 40–80 years were recruited from four clinical sites after receiving a screening mammography result that was classified as abnormal but probably benign, suspicious or highly suspicious, or indeterminate using standard criteria. A telephone-administered survey asked about breast cancer risk factors (family history, estrogen use, physical inactivity, age of menarche, age at birth of first child, parity, alcohol use), and self-reported use of diagnostic tests (follow-up mammogram, breast ultrasound, or biopsy).
Results
Nine hundred and seventy women completed the interview, mean age was 56, 42% were White, 19% Latina, 25% African American, and 15% Asian. White women were more likely to have a positive family history (20%), use estrogen (32%), be nulliparous (17%) and drink alcohol (62%). Latinas were more likely to be physically inactive (93%), African Americans to have early onset of menarche (53%) and Asians first child after age 30 (21%). White women were more likely to have suspicious mammograms (40%) and to undergo biopsy (45%). In multivariate models, Latinas were more likely to report breast ultrasound, physical inactive women reported fewer follow-up mammograms, and care outside the academic health center was associated with fewer biopsies. Indeterminate and suspicious mammography interpretations were significantly associated with more biopsy procedures (OR = 8.4; 95% CI = 3.8–18.5 and OR = 59; 95% CI = 35–100, respectively).
Conclusions
Demographic profile and breast cancer risk factors have little effect on self-reported use of diagnostic procedures following an abnormal mammography examination. Level of mammography abnormality determines diagnostic evaluation but variance by site of care was observed.
doi:10.1007/s10552-004-4028-y
PMCID: PMC2936818  PMID: 15947876
ethnicity; abnormal mammography; follow-up procedures; breast cancer
18.  International Spanish/English Internet smoking cessation trial yields 20% abstinence rates at 1 year 
Nicotine & Tobacco Research  2009;11(9):1025-1034.
Introduction
There are 1.1 billion smokers worldwide. Traditional smoking cessation methods, such as nicotine replacement therapy and smoking cessation groups, yield between 14% and 27% abstinence rates at 6 months. Evidence-based Internet interventions with comparable abstinence rates could be a powerful global tool to reduce tobacco-related morbidity and mortality.
Methods
We report a randomized control trial in which 500 Spanish-speaking and 500 English-speaking adult Internet users, smoking at least 5 cigarettes/day and intending to quit in the next month, were recruited online from 68 countries. Consenting participants who completed baseline measures, logged cigarettes smoked on 3 days within a week, and set a quit date were randomized to four conditions. Each condition added new elements: Condition 1 was the “Guía Para Dejar de Fumar,” a static National Cancer Institute evidence-based stop smoking guide; Condition 2 consisted of Condition 1 plus E-mail reminders to return to the site; Condition 3 consisted of Condition 2 plus mood management lessons; and Condition 4 consisted of Condition 3 plus a “virtual group” (an asynchronous bulletin board). Main outcome measures were 7-day point prevalence abstinence at 1, 3, 6, and 12 months after initial quit date.
Results
There were no significant differences among the four conditions. The overall 12-month 7-day abstinence rates were 20.2% for Spanish speakers and 21.0% for English speakers when those with missing data were assumed to be smoking.
Discussion
Internet smoking cessation interventions with such abstinence rates provided globally in additional languages could contribute substantially to tobacco control efforts.
doi:10.1093/ntr/ntp090
PMCID: PMC2725004  PMID: 19640833
19.  Use of Alternative Tobacco Products in Multiethnic Youth from Jujuy, Argentina 
This study examines alternative tobacco use among Latin American youth. A self-administered survey in a random sample of 27 schools was administered in 2004 in Jujuy, Argentina (N = 3218). Prevalence of alternative tobacco product use was 24.1%; 15.3% of youth used hand-rolled cigarettes, 7.8% smoked cigars, 2.3% chewed tobacco leaf and 1.6% smoked pipe. Among youth who never smoked manufactured cigarettes, alternative product use was rare (2.9%), except for chewing tobacco (22%). In multivariate logistic regression boys were more likely than girls to smoke pipe (OR = 3.1; 95% CI 1.1–8.7); indigenous language was associated with smoking hand-rolled cigarettes (OR = 1.4; 95% CI-1.1–1.9) and pipe (OR = 2.2; 95% CI 1.5–3.4). Working in tobacco sales was a risk factor for chewing tobacco (OR = 2.9; 95% CI: 1.7–4.9) and smoking hand-rolled cigarettes (OR = 1.4; 95% CI 1.1–1.8). Having friends who smoked was associated with chewing tobacco (OR = 1.8; 95% CI 1.0–3.2) and with smoking cigars (OR = 2.1; 95% CI 1.5–2.9). Current drinking and thrill-seeking orientation were associated with cigars and pipe smoking. Findings highlight the importance of surveillance of alternative tobacco products use and availability among youth and for addressing identified risk factors.
doi:10.1155/2010/795265
PMCID: PMC2841245  PMID: 20300454
20.  Intermittent and light daily smoking across racial/ethnic groups in the United States 
Nicotine & Tobacco Research  2009;11(2):203-210.
Introduction:
Limited research exists examining the prevalence of intermittent (nondaily) and light daily (1–5 cigarettes/day) smoking across racial/ethnic groups in the United States using nationally representative data. These analyses would be informative in guiding targeted cessation strategies.
Methods:
Using logistic regression models controlling for age, gender, and education, we examined the prevalence of intermittent and light daily consumption among current smokers across racial/ethnic groups from the 2003 Tobacco Use Supplement to the Current Population Survey. We also examined the association of these demographic factors with consumption within each racial/ethnic group separately.
Results:
Black (odds ratio [OR] = 1.82, 95% CI = 1.59–2.07), Asian/Pacific Islander (OR = 1.62, 95% CI = 1.29–2.04), and Hispanic/Latino (OR = 3.2, 95% CI = 2.75–3.74) smokers were more likely to smoke intermittently compared with non-Hispanic Whites. Black (OR = 2.69, 95% CI = 2.27–3.18), Asian/Pacific Islander (OR = 2.99, 95% CI = 2.13–4.19), and Hispanic/Latino (OR = 4.64, 95% CI = 3.85–5.58) smokers also were more likely to have light daily consumption compared with non-Hispanic Whites. Hispanic/Latino intermittent smokers smoked fewer days per month and fewer cigarettes per day compared with non-Hispanic White smokers. We found no significant gender differences across racial/ethnic groups in intermittent smoking, but male smokers were significantly less likely to have light daily consumption for all racial/ethnic groups.
Discussion:
These results have implications for the understanding of the tobacco dependence, the development of prevention and cessation strategies, and the applicability of harm-reduction techniques for racial/ethnic minorities.
doi:10.1093/ntr/ntn018
PMCID: PMC2658897  PMID: 19246433
21.  Ending Cervical Cancer Screening: Attitudes and Beliefs from Ethnically Diverse Older Women 
Background
Guidelines support ending cervical-cancer screening in women aged 65–70 years and older with prior normal testing, but little is known about older women’s attitudes and beliefs about ending screening.
Methods
We conducted face-to-face interviews with 199 women aged 65 and older in English, Spanish, Cantonese or Mandarin.
Results
Most interviewees were non-White (44.7% Asian, 18.1% Latina and 11.6% African American). Most (68%) thought lifelong screening was either important or very important, a belief held more strongly by African American (77%) and Latina (83%) women compared to women in other ethnic groups (p<0.01). Most (77%) had no plans to discontinue screening or had ever thought of discontinuing (69%). When asked if they would end screening if recommended by their physician, 68% responded “yes.”
Conclusions
The majority of these women believe that lifelong cervical-cancer screening is important. Many women, however, reported they would end screening if recommended by their physician.
doi:10.1016/j.ajog.2008.07.015
PMCID: PMC2643872  PMID: 18976734
cervix cancer screening; screening cessation; older women
22.  Tobacco Industry Strategies to Obstruct the FCTC in Argentina 
CVD prevention and control  2008;3(4):173-179.
Objective
To describe the strategies pursued by the tobacco industry (TI) to interfere with the ratification of the WHO Framework Convention on Tobacco Control (FCTC) in Argentina.
Methods
We conducted semi-structured interviews about the FCTC, the TI and the legislative process with 3 legislators, 4 public health officials, 1 representative of the tobacco growers and two tobacco-control advocates. We reviewed 6 newspapers from the 4 tobacco growing provinces, searched TI documents in the Legacy Tobacco Documents Library and reviewed 1624 documents. Proposed legislation and related documents on tobacco control from Argentina’s National Congress and the Provincial Jujuy Congress were reviewed.
Results
The principal strategy used by the TI was lobbying of provincial legislators and federal officials from the Ministry of the Economy by the tobacco growers associations. These legislators prevented the passage of comprehensive bills on tobacco control or of less comprehensive national laws. A typical legislative strategy used was to request additional analyses of the proposed bills from committees that prioritized economic issues over health. FCTC was mentioned in regional newspapers three to seven times per week in articles about alleged adverse economic effects of tobacco control. Direct physical threats to legislators who were openly supportive of FCTC ratification were made.
Conclusion
Tobacco producers and TI opposed FCTC ratification in Argentina by lobbying elected representatives and placing stories in regional media to obstruct approval of tobacco control laws. These activities have led to a delay in consideration of Argentina’s ratification of the FCTC despite the President’s signature in 2003. (250 words)
doi:10.1016/j.cvdpc.2008.09.002
PMCID: PMC2630219  PMID: 19956349
FCTC; Argentina; Tobacco Control
23.  Preferences for Human Papillomavirus Testing with Routine Cervical Cancer Screening in Diverse Older Women 
BACKGROUND
Human papillomavirus (HPV) testing is increasingly being used to determine the optimal cervical cancer screening interval in older women. Little is known about women’s attitudes toward HPV testing or how these attitudes may influence medical discussions about cervical cancer screening.
METHODS
Preferences for HPV and concomitant Papanicolaou (Pap) testing were assessed through in-person interviews with diverse women aged 50 to 80 years recruited from community and university-based practices.
RESULTS
865 women (257 White, 87 African American, 149 Latina, and 372 Asian) were interviewed. Approximately 60% of participants wanted to be tested for HPV and another 15% would undergo testing if recommended by their physician. Among those wanting HPV testing, 94% would want more frequent than annual Pap tests if they had a positive HPV test and a normal Pap test. Two thirds of those under age 65 would be willing to switch to triennial Pap testing, and half of those aged 65 and older would be willing to discontinue Pap testing, if they had a negative HPV test and normal Pap test. Preferences for testing varied by ethnicity, age, place of birth, and cancer history.
CONCLUSIONS
The majority of older women were willing to use HPV testing to make decisions about frequency and duration of cervical cancer screening, but up to one third would want at least annual, ongoing screening regardless of HPV test results. Efforts should be made to ensure that HPV testing is used to reinforce appropriate utilization of screening tests.
doi:10.1007/s11606-008-0633-x
PMCID: PMC2518007  PMID: 18506546
Human papillomavirus; cervical cancer screening; ethnicity; Papanicolaou test
24.  Smoking Behaviors Among Immigrant Asian Americans Rules for Smoke-Free Homes 
Background
Higher acculturation is associated with Asian-American smoking prevalence decreasing in men and increasing in women. Asian immigrants in California are significantly more likely than their counterparts in Asia to have quit smoking. Smoke-free environments may mediate this acculturation effect because such environments are not widespread in Asia.
Methods
In 2006, Asian-American current and former smokers were analyzed using the 2003 California Health Interview Survey. A multivariate logistic regression analysis examined how the interaction between having a smoke-free-home rule and immigrating to the U.S. is associated with status as a former smoker and lighter smoking.
Results
For recent Asian immigrants (<10 years in the U.S.) and longer-term residents (born/≥10 years in the U.S.), having a smoke-free-home rule was associated with status as a former smoker (OR 14.19, 95% CI=4.46, 45.12; OR 3.25, 95% CI=1.79, 5.90, respectively). This association was stronger for recent immigrants (p=0.02). Having a smoke-free-home rule was associated with lighter smoking only for longer-term residents (OR 5.37, 95% CI=2.79, 10.31).
Conclusions
For Asian Americans, smoke-free-home rules are associated with status as a former smoker, particularly among recent immigrants, and lighter smoking in long-term residents. Interventions encouraging Asian Americans to adopt smoke-free-home rules should be evaluated.
doi:10.1016/j.amepre.2008.03.024
PMCID: PMC2441880  PMID: 18541178
25.  Factors affecting medical students' selection of an internal medicine residency program. 
OBJECTIVE: To determine factors that influence medical student selection of internal medicine residency programs by ethnicity and gender. DESIGN/SETTING: A cross-sectional mailed survey of graduating medical students applying to four residency programs in 1999. MEASUREMENTS: A five-point (5=most important) Likert scale was used to evaluate factors and included 14 items on location characteristics, 20 on program features, six on recruitment, three on future plans and three on advising. RESULTS: Of 2,820 surveys, 1,005 were completed (36%). The most important factors to applicants were house staff morale (mean +/- SD, 4.5 +/- 0.7), academic reputation (4.5 +/-0.8), and positive interview experience (4.1 +/- 1.0). Women rated gender diversity of faculty (3.3 vs. 2.3, p=0.0001) and house staff (3.3 vs. 2.5, p=0.0001), location of residency program near spouse (4.2 vs. 3.9, p=0.0001) or spouse's job (3.8 vs. 3.5, p=0.0002) and emphasis on primary care (2.9 vs. 2.4, p=0.0001) more highly than men. Minority applicants were more likely than whites to identify the following factors as more important: ethnic diversity of patients (3.8 vs. 3.4, p=0.008), house staff (3.3 vs. 2.4, p<0.0001) and faculty (3.1 vs. 2.3, p<0.0001); service to the medically indigent (3.8 vs. 3.3, p=0.004); feeling of being wanted (3.8 vs. 3.4, p=0.002); and an academic environment supportive of ethnic minorities (3.5 vs. 2.3, p<0.0001). CONCLUSIONS: Location and program factors are most important in influencing decisions to choose a residency program. However, women and minority applicants also place significant importance on family and diversity factors. Programs need to consider differential factors in recruitment of diverse students.
PMCID: PMC2594785  PMID: 16296217

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