Impediment Profiling for Smoking Cessation:Impediment Profiling for Smoking Cessation:Breaking Down Barriers to Behavioral GoalsBreaking Down Barriers to Behavioral Goals

David L. Katz, MD, MPH, FACPM, FACPDavid L. Katz, MD, MPH, FACPM, FACPDirector, Prevention Research CenterDirector, Prevention Research Center

Yale University School of MedicineYale University School of Medicine

Art & Science of Health Promotion ConferenceArt & Science of Health Promotion Conference

Las Vegas, NVLas Vegas, NVMarch 23, 2006March 23, 2006

Key References-Key References- Katz DL. Behavior modification in primary care: the pressure Katz DL. Behavior modification in primary care: the pressure

system model. Prev Med. 2001;32:66-72system model. Prev Med. 2001;32:66-72 Katz DL, Boukhalil J, Lucan SC, Shah D, Chan W, Yeh MC. Katz DL, Boukhalil J, Lucan SC, Shah D, Chan W, Yeh MC.

Impediment profiling for smoking cessation. Preliminary Impediment profiling for smoking cessation. Preliminary experience. Behav Modif. 2003;27:524-37experience. Behav Modif. 2003;27:524-37

O'Connell M, Lucan SC, Yeh MC, Rodriguez E, Shah D, Chan O'Connell M, Lucan SC, Yeh MC, Rodriguez E, Shah D, Chan W, Katz DL. Impediment profiling for smoking cessation: W, Katz DL. Impediment profiling for smoking cessation: results of a pilot study. Am J Health Promot. 2003;17:300-3results of a pilot study. Am J Health Promot. 2003;17:300-3

O'Connell ML, Freeman M, Jennings G, Chan W, Greci LS, O'Connell ML, Freeman M, Jennings G, Chan W, Greci LS, Manta ID, Katz DL. Smoking cessation for high school Manta ID, Katz DL. Smoking cessation for high school students. Impact evaluation of a novel program. Behav Modif. students. Impact evaluation of a novel program. Behav Modif. 2004;28:133-462004;28:133-46

More papers in pressMore papers in press

Modifiable Behaviors & HealthModifiable Behaviors & Health

The leading “causes” of death are the “results” The leading “causes” of death are the “results” of risk factorsof risk factors

Nearly 50% of all deaths in the US each year Nearly 50% of all deaths in the US each year are premature and related to modifiable are premature and related to modifiable behaviorsbehaviors

Tobacco, Diet, and Physical Activity patterns Tobacco, Diet, and Physical Activity patterns are the leading causes of premature deathare the leading causes of premature death

McGinnis JM, Foege WH. Actual causes of death in the McGinnis JM, Foege WH. Actual causes of death in the United States. United States. JAMAJAMA. 1993;270:2207-12 . 1993;270:2207-12

Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. causes of death in the United States, 2000. JAMAJAMA. . 2004;291:1238-452004;291:1238-45

What Behavior Is

The “best” choice under prevailing The “best” choice under prevailing circumstances/conditionscircumstances/conditions

The Challenge of Change

Moving out of a desired or valued patternMoving out of a desired or valued pattern Moving into a rejected, or unknown patternMoving into a rejected, or unknown pattern

Leading TheoriesLeading Theories

Theory of Reasoned ActionTheory of Reasoned Action

Health Beliefs ModelHealth Beliefs Model

Social Cognitive Theory/Self-efficacySocial Cognitive Theory/Self-efficacy

Social Learning Theory/Locus of ControlSocial Learning Theory/Locus of Control

Transtheoretical Model/Stages of Change & Transtheoretical Model/Stages of Change & Processes of ChangeProcesses of Change

Institute of Medicine. Institute of Medicine. Health and Behavior: the Interplay of Biological, Health and Behavior: the Interplay of Biological, Behavioral, and Societal InfluencesBehavioral, and Societal Influences. . National Academy Press. Washington, D.C. 2001National Academy Press. Washington, D.C. 2001

Reasoned ActionReasoned Action

Consideration of pros and consConsideration of pros and cons Choice based on options and valuesChoice based on options and values

Health Belief ModelHealth Belief Model

Must believe he/she is Must believe he/she is susceptiblesusceptible Must perceive the potential Must perceive the potential seriousnessseriousness Must believe that Must believe that benefitsbenefits outweigh the costs and outweigh the costs and

inconvenienceinconvenience Must believe he/she is Must believe he/she is capablecapable There must be a There must be a “cue to action”“cue to action”

Transtheoretical ModelTranstheoretical Model

Stages of ChangeStages of Change Processes of ChangeProcesses of Change

Prochaska J, DiClemente C. PsychotherapyProchaska J, DiClemente C. Psychotherapy: Theory, Res, Pract. 1982;19:276-288: Theory, Res, Pract. 1982;19:276-288

Stages of ChangeStages of Change

PrecontemplationPrecontemplation ContemplationContemplation PreparationPreparation ActionAction Maintenance/LapseMaintenance/Lapse TerminationTermination

Processes of ChangeProcesses of Change

Consciousness RaisingConsciousness Raising Dramatic ReliefDramatic Relief Self-ReevaluationSelf-Reevaluation Environmental ReevaluationEnvironmental Reevaluation Self-LiberationSelf-Liberation Helping RelationshipsHelping Relationships CounterconditioningCounterconditioning Contingency ManagementContingency Management Stimulus ControlStimulus Control Social LiberationSocial Liberation

Prochaska JO, Redding CA, Evers KE. The Transtheoretical Model and Stages of Change. In: Glanz Prochaska JO, Redding CA, Evers KE. The Transtheoretical Model and Stages of Change. In: Glanz K, Lewis FM, Rimer BK (edsK, Lewis FM, Rimer BK (eds). Health Behavior and Health Education. Theory, Research, and ). Health Behavior and Health Education. Theory, Research, and PracticePractice. 2. 2ndnd edition. Jossey-Bass, Inc. San Fancisco, CA. 1997. edition. Jossey-Bass, Inc. San Fancisco, CA. 1997.

Getting There Requires the Right Getting There Requires the Right “M/O”“M/O”

M = maximizing motivationM = maximizing motivation O = overcoming obstaclesO = overcoming obstacles

• Katz DL. Behavior Modification in Primary Care: the Pressure Katz DL. Behavior Modification in Primary Care: the Pressure System Model. System Model. Prev MedPrev Med. 2001;32:66-72. 2001;32:66-72

Miller WR. Addict Behav. 1996;21:835-42; Miller WR. Addict Behav. 1996;21:835-42; Rollnick S. Int J Obes Relat Metabl Disord. Rollnick S. Int J Obes Relat Metabl Disord. 1996;20suppl1:s22-61996;20suppl1:s22-6

Motivational InterviewingMotivational Interviewing

General Principles:General Principles: 1) express empathy / acknowledge ambivalence1) express empathy / acknowledge ambivalence 2) develop discrepancy2) develop discrepancy 3) avoid argumentation3) avoid argumentation 4) roll with resistance4) roll with resistance 5) support self-efficacy5) support self-efficacy 6) encourage social contracting6) encourage social contracting

Decision Balance for Physical Activity. Cells in the balance show some hypothetical entries.

Increase Physical Activity

  

Advantages

Weight loss

Better health

More energy

 

 

  

Disadvantages

Hard work

Limited time

Unsure how

 

 

Maintain Current Activity Level

  

Advantages

Easy

Comfortable

Avoid risk of injuryAvoid sweating

 

  

Disadvantages

No weight loss

No health benefits

Possible weight gain 

 

Motivation can be the sound of Motivation can be the sound of one hand clapping…one hand clapping…

Overcoming ResistanceOvercoming Resistance

Acknowledge obstaclesAcknowledge obstacles Convert obstacles into Convert obstacles into

challenges/opportunitieschallenges/opportunities• Identify/surmount universal barriersIdentify/surmount universal barriers• Identify/surmount patient-specific barriersIdentify/surmount patient-specific barriers

The Inspiration for IP-The Inspiration for IP-

How stone many walls with no windows or How stone many walls with no windows or doors does it take to impede your progress?doors does it take to impede your progress?

Tailored Interventions for Tailored Interventions for Smoking Cessation (TISC)Smoking Cessation (TISC)

Study Team: Study Team: PREVENTION RESEARCH CENTERPREVENTION RESEARCH CENTER

David L. Katz, David L. Katz, MD, MPH, FACPM, FACPMD, MPH, FACPM, FACP Project PI Project PIMeghan O’Connell, MPHMeghan O’Connell, MPH Project Project

CoordinatorCoordinatorSean LucanSean Lucan Research Assistant Research Assistant

YSM*4 YSM*4 Ming-Chin Yeh, PhDMing-Chin Yeh, PhD Research Research

AssociateAssociate

Wendy Chan, MPHWendy Chan, MPH Data AnalystData Analyst

*Yale Medical School*Yale Medical School

PURPOSEPURPOSE

To establish a reliable means of identifying To establish a reliable means of identifying and quantifying the diverse impediments and quantifying the diverse impediments to smoking cessation in an individualto smoking cessation in an individual

To demonstrate that smoking cessation To demonstrate that smoking cessation interventions tailored to individualinterventions tailored to individual

impediment profiles increase one and two- impediment profiles increase one and two- year quit ratesyear quit rates

BACKGROUNDBACKGROUND

Cigarette smoking is the leading cause of preventable death Cigarette smoking is the leading cause of preventable death in the U.S. in the U.S.

The literature suggests that there are 7 commonly identified The literature suggests that there are 7 commonly identified impediments to smoking cessation: nicotine dependence; impediments to smoking cessation: nicotine dependence; stress; anxiety; depression; chemical codependency;concern stress; anxiety; depression; chemical codependency;concern about weight gain; and the presence of at least one smoker in about weight gain; and the presence of at least one smoker in the householdthe household

METHODSMETHODS

Survey DesignSurvey Design Comprehensive screening tools were developed to identify Comprehensive screening tools were developed to identify

and quantify impediments by fusing items from existing and quantify impediments by fusing items from existing and newly developed questionnairesand newly developed questionnaires

Validated instruments were located for nicotine Validated instruments were located for nicotine dependence, stress, anxiety, and depression. dependence, stress, anxiety, and depression.

Multi-item questionnaires for assessing chemical Multi-item questionnaires for assessing chemical dependency and concern about weight gain were dependency and concern about weight gain were developed from surveys used in clinical practice.developed from surveys used in clinical practice.

A single, direct question used to assess the presence of A single, direct question used to assess the presence of household members who smokehousehold members who smoke

Long Impediment Profiler: Long Impediment Profiler: Fusion Of InstrumentsFusion Of Instruments

IMPEDIMENT SCALE SCORE Nicotine addiction

Fagerstrom Scale8

3/10

Stress Perceived Stress Scale2

34/64

Anxiety Beck Anxiety Inventory3

10/63

Depression Beck Depression Inventory16

17/63

Chemical dependency

CAGE14 1/5 positive responses

Weight-concern

Smoking Situations Questionnaire15

1/7 positive responses

Household smoker

Single question positive response

RecruitmentRecruitment

Inclusion criteriaInclusion criteria::

--smoking history > 1 yearsmoking history > 1 year

-current smoking > 15 cigarettes per day-current smoking > 15 cigarettes per day

-resident of Lower Naugatuck Valley, CT. -resident of Lower Naugatuck Valley, CT.

-> 18 years of age-> 18 years of age

Exclusion criteriaExclusion criteria::

-current use of nicotine replacement products-current use of nicotine replacement products

-allergy to study medications, history of seizures -allergy to study medications, history of seizures

-participation in other cessation program-participation in other cessation program

-uncompensated medical problems-uncompensated medical problems

SUBJECTSSUBJECTS

Table 1: Characteristics of study participants Variable Overall

N=19 (Mean SD)

Male N=7

(Mean SD)

Female N=12

(Mean SD) Age (years) 46.8 + 11.1 45.6 + 11.1 47.5 + 11.6 Pack/ day 1.5 + 0.6 1.88 + 0.7 1.3 + 0.5 Years of smoking

31.7 + 10.9 31.1 + 8.6 32.1+ 12.4

(%) (%) (%) Race

White 100 100 100 Education

High school or less

38.9 28.6 50

Some college or more

61.1 71.4 50

Income 0-30,000 33.3 28.6 41.7 30,001-60,000 33.3 28.6 33.3 > 60,001 33.4 42.8 25

Intervention ApplicationsIntervention Applications

Nicotine dependenceNicotine dependence• Subjects Subjects meeting criteria on the Fagerstrom scale were given meeting criteria on the Fagerstrom scale were given

bupropion, for a total of 12 weeks started 2 weeks prior to target bupropion, for a total of 12 weeks started 2 weeks prior to target quit datequit date

• Subjects rSubjects received transdermal nicotine replacement therapy for 10 eceived transdermal nicotine replacement therapy for 10 weeks starting on the quit date (2 weeks into program)weeks starting on the quit date (2 weeks into program)

Co-morbid chemical dependenciesCo-morbid chemical dependencies• -Subjects meeting CAGE score criteria were evaluated by an -Subjects meeting CAGE score criteria were evaluated by an

addictions specialist and referred to a Chemical Dependency addictions specialist and referred to a Chemical Dependency Program Program

Intervention Applications, Cont. AnxietyAnxiety

• Subjects Subjects meeting criteria on the Beck Anxiety meeting criteria on the Beck Anxiety Inventory received the anxiolytic, buspirone, for 8 Inventory received the anxiolytic, buspirone, for 8 weeks. Therapy started 2 weeks prior to quit date.weeks. Therapy started 2 weeks prior to quit date.

DepressionDepression• Subjects Subjects meeting Beck Depression Inventory criteria meeting Beck Depression Inventory criteria

were referred for psychiatric evaluation, with treatment were referred for psychiatric evaluation, with treatment on the basis of professional discretion. on the basis of professional discretion.

Smoking by household memberSmoking by household member• Subjects with family/household members who smoke Subjects with family/household members who smoke

were invited to family group counseling dinner were invited to family group counseling dinner meetings.meetings.

Intervention Applications, Cont.

StressStress• Subjects Subjects meeting criteria on the Simple Stress and Tension Test meeting criteria on the Simple Stress and Tension Test

were enrolled in a stress- management program consisting of yoga, were enrolled in a stress- management program consisting of yoga, guided relaxation, and meditation conducted weekly throughout the guided relaxation, and meditation conducted weekly throughout the year-long program.year-long program.

Weight managementWeight management• Subjects meeting “Smoking Situations Scale” criteria enrolled in Subjects meeting “Smoking Situations Scale” criteria enrolled in

ffour 1-hour dietary counseling sessions. our 1-hour dietary counseling sessions. • Organized walking groups met 3 times per week for 20 minutes, for Organized walking groups met 3 times per week for 20 minutes, for

a period of one month.a period of one month.• Discounted membership to YMCA for subsequent 3 months.Discounted membership to YMCA for subsequent 3 months.

RESULTSRESULTSN=19N=19 Percentage of subjects with impediments: Percentage of subjects with impediments:

Nicotine dependence 100% (19) Chemical dependency 31.58% (6) Stress 31.58% (6) Anxiety 57.89% (11) Depression 36.84% (7) Weight concerns 78.95% (15) Household smoking 15.79% (3)

* percent (N)

Mean # impediments of total group Mean Std Deviation Min Max 3.5 1.5 1.0 6.0

QUIT RATE: CO measure cut off 10 3 Months 42.11% (8) 6 Months 73.68% (14) 9 Months 42.11% (8) 12 Months 63.16% (12) 24 Months 26.32% (5)

QUIT RATE: CO measure cut off 5 3 Months 31.58% (6) 6 Months 26.32 % (5) 9 Months 36.84% (7) 12 Months 47.36% (9) 24 Months 26.32% (5)

*Quit status based on carbon monoxide (CO) readings. Drop-outs assumed to be smoking SELF REPORTED QUIT RATE: 12 MONTHS=42%

24 Months=26%

 

Results, Cont.Results, Cont.

No significant difference in the proportions No significant difference in the proportions of participants that quit smoking between of participants that quit smoking between males and females at the significance level males and females at the significance level of 0.05. (p=0.9)of 0.05. (p=0.9)

Insufficient evidence to suggest that any Insufficient evidence to suggest that any single impediment predicts quit statussingle impediment predicts quit status

Intervention component

Percent of subjects using/participating

Percent of participants rating “very” or “extremely” helpful

Bupropion 47% (9) 56% NRT-Patch 74% (14) 79% NRT-Gum 11% (2) 100% Buspirone 53% (10) 80% Walking group

21% (4) 50%

YMCA 21% (4) 100% Weight management

47% (9) 44%

Stress management

26% (5) 60%

Participation/intervention Ratings

Conclusions

This novel approach resulted in 42% and 26% This novel approach resulted in 42% and 26% quit rates at one and two years respectively, a quit rates at one and two years respectively, a significant improvement over best quit rates significant improvement over best quit rates reported in literature.reported in literature.

Targeting therapies for each of the 7 commonly Targeting therapies for each of the 7 commonly reported impediments to quitting smoking may reported impediments to quitting smoking may have resulted in the high quit rates achieved in have resulted in the high quit rates achieved in the study.the study.

Conclusions, Cont.

Independent of quit rate, profiling Independent of quit rate, profiling impediments to smoking cessation served to impediments to smoking cessation served to identify otherwise ignored health problems identify otherwise ignored health problems meriting treatment in their own right.meriting treatment in their own right.

The further study of impediment profiling as a The further study of impediment profiling as a smoking cessation adjunct in larger, longer, smoking cessation adjunct in larger, longer, and randomized trials is warranted.and randomized trials is warranted.

Worksite Study-Worksite Study-

To replicate the promising results of a To replicate the promising results of a

pilot study using an approach to pilot study using an approach to

smoking cessation termed “impedimentsmoking cessation termed “impediment

profiling” in the worksite settingprofiling” in the worksite setting

BackgroundBackground Cigarette smoking is the leading cause of preventable Cigarette smoking is the leading cause of preventable

death in the U.S.death in the U.S.11

The CDC’s Community Guide to Preventive The CDC’s Community Guide to Preventive Services recommends smoking cessation Services recommends smoking cessation interventions be made availableinterventions be made available22

Worksites as an important venueWorksites as an important venue33

Potential benefits to both employees and employersPotential benefits to both employees and employers3 3

Novel “Impediment Profiling” methods applied in a Novel “Impediment Profiling” methods applied in a community hospital settingcommunity hospital setting

MethodsMethods

PLANNINGPLANNING Community hospital/PRC partnership for Community hospital/PRC partnership for

planning and implementationplanning and implementation• administration, human resources, outpatient administration, human resources, outpatient

psychiatry, dietary, volunteer services depts. psychiatry, dietary, volunteer services depts. Promotion of program for manager/supervisor Promotion of program for manager/supervisor

buy-inbuy-in Hospital/PRC resource sharingHospital/PRC resource sharing

Methods (cont’d)Methods (cont’d)

RECRUITMENTRECRUITMENT All smoking employees were invited to All smoking employees were invited to

participate via internal email, flyers, participate via internal email, flyers, informational sessions for each department, informational sessions for each department, information provided with employee benefits information provided with employee benefits package, letters sent to all employeespackage, letters sent to all employees

Methods (cont’d.) Methods (cont’d.)

IMPLEMENTATION IMPLEMENTATION Use of Impediment Profiling (IP) instrument Use of Impediment Profiling (IP) instrument

(previously validated) for barrier identification (previously validated) for barrier identification Assignment to interventions as indicated by Assignment to interventions as indicated by

measurement scales: measurement scales: • NRT; treatment for anxiety/depression; dietary counseling NRT; treatment for anxiety/depression; dietary counseling

and PA for weight gain prevention; stress reduction; family and PA for weight gain prevention; stress reduction; family support groups; referral to treatment of chemical co- support groups; referral to treatment of chemical co- dependenciesdependencies

Methods (cont’d.)Methods (cont’d.)

Specific intervention components were…Specific intervention components were… Self-reported quit status was verified with Self-reported quit status was verified with

measurement of carbon monoxide (CO) measurement of carbon monoxide (CO) concentration in expired airconcentration in expired air

Smoking cessation was defined as CO reading Smoking cessation was defined as CO reading of of << 10ppm. 10ppm.

Results55 enrolled

4 dropped out prior to study commencement, resulting in sample of 51 employees

88% of participants had previously attempted to quit

Stages of Change survey indicated subjects were in the following stages at baseline: 8% precontemplative

69% contemplative

23% action

SubjectsSubjectsTable 1: Characteristics of study participants Variable Overall

(Mean SD) Male

(Mean SD) Female

(Mean SD) Age (years) 41.9 + 11.3

N=49 35.0 + 4.2

N=2 42.2 + 11.5

N=47 Cig/ day 19.8 + 7.3

N=47 30.0 + 10.0

N=3 19.1 + 6.7

N=44 Years of smoking

25.9 + 11.3 N=49

18.5 + 6.6 N=2

26.2 + 11.4 N=47

(%) (%) (%) Race N=51 N=51 N=51

White 96 100 96 Af. American 4 0 4

Education N=48 N=3 N=45 High school or

less 31 33 31.1

Some college 42 0 44.4 College grad

or more 27 67 24.4

Income N=44 N=3 N=41 0-30,000 18 0 20 30,001-60,000 41 33 41 > 60,001 41 67 39

Percentage of subjects with impediments:

Nicotine dependence 100% (51) Chemical dependency 14% (7) Stress 14% (7) Anxiety 47% (24) Depression 18% (9) Weight concerns 78% (40) Household smoking 8% (4)

* percent (N)

Mean # impediments of total group Mean Std Deviation Min Max 2.6 1.2 1.0 6.0

ParticipationParticipation

Intervention component

Percent of subjects using/participating

Bupropion 74.5% (38) NRT-Patch 92.1% (47) Buspirone 52.9% (27) Family sessions 0% (0) Weight management 24% (12) Stress management 10% (5) N=51 Additional options: Accupuncture 35% (18) Reiki 8% (4) Sessions with ND 14% (7) N=51

Quit rate: CO measure cut off 10 3 Months 64.7%(33) 6 Months 49% (25) 12 Months 39% (20)

Quit rate: CO measure cut off 5 3 Months 58.8% (30) 6 Months 43% (22) 12 Months 37% (19)

Quit status based on carbon monoxide (CO) readings. *Drop-outs (n=11) assumed to be smoking

Quit rate excluding drop-outs: CO measure cut off 10 (N=40) 12 Months 50% (20) CO measure cut off 5 (N=40) 12 Months 48% (19) Quit status based on carbon monoxide (CO) readings.

Conclusions Conclusions This study achieved a 39% one-year quit rate, replicating This study achieved a 39% one-year quit rate, replicating

pilot findings indicating that IP and tailoring of pilot findings indicating that IP and tailoring of interventions results in a dramatic improvement over quit interventions results in a dramatic improvement over quit rates reported in the literaturerates reported in the literature

Seventy-seven percent of participants were in either the Seventy-seven percent of participants were in either the precontemplative or contemplative “stage of change” at precontemplative or contemplative “stage of change” at enrollment, suggesting that providing individualized enrollment, suggesting that providing individualized assistance may be highly effective at assistance may be highly effective at increasing/maintaining motivation to quitincreasing/maintaining motivation to quit

Conclusions (cont’d)Conclusions (cont’d)

Independent of quit rate, profiling impediments Independent of quit rate, profiling impediments to smoking cessation served to identify to smoking cessation served to identify otherwise ignored health problems meriting otherwise ignored health problems meriting treatment in their own right treatment in their own right

Further study of impediment profiling as a Further study of impediment profiling as a smoking cessation adjunct in larger, longer, and smoking cessation adjunct in larger, longer, and randomized trials is warrantedrandomized trials is warranted

Conclusions (cont’d)Conclusions (cont’d)

The study demonstrated the feasibility of The study demonstrated the feasibility of applying IP methods in a worksite setting applying IP methods in a worksite setting

Hospitals in particular are ideal settings for Hospitals in particular are ideal settings for smoking cessation interventions. By smoking cessation interventions. By capitalizing on existing resources and capitalizing on existing resources and involving stakeholders, creative programs can involving stakeholders, creative programs can be implemented to benefit the entire be implemented to benefit the entire workforceworkforce

I have a dream…I have a dream…

Impediment profiling for all: web-basedImpediment profiling for all: web-based Mapping individualized paths to behavior Mapping individualized paths to behavior

changechange Application to eating/weight control…Application to eating/weight control…

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Bibliography, cont.Bibliography, cont.17.17. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Best Practices for Comprehensive Best Practices for Comprehensive

Tobacco Control Programs-August 1999Tobacco Control Programs-August 1999. Atlanta GA: U.S. Department of Health . Atlanta GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, August 1999. Health, August 1999.

18. Wasserman, M.P. 2001. 18. Wasserman, M.P. 2001. Guide to Community Preventive Services: State and local Guide to Community Preventive Services: State and local opportunities for tobacco use reductionopportunities for tobacco use reduction. American Journal of Preventive . American Journal of Preventive Medicine: 20 (S2) pp 8-9.Medicine: 20 (S2) pp 8-9.

19. Centers for Disease Control and Prevention. 19. Centers for Disease Control and Prevention. Making Your workplace Smoke-free: Making Your workplace Smoke-free: A decision makers guide. A decision makers guide. U.S. Department of Health and Human Services, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Wellness Prevention and Health Promotion, Office on Smoking and Health, Wellness Councils of America and American Cancer Society.Councils of America and American Cancer Society.

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16. Whisman, M., Perez, J., & Ramel, W. (2000). Factor Structure of the Beck Depression Inventory-Second 16. Whisman, M., Perez, J., & Ramel, W. (2000). Factor Structure of the Beck Depression Inventory-Second Edition (BDI-II) in a Student Sample. Edition (BDI-II) in a Student Sample. J Clin Psychol, 56J Clin Psychol, 56(4), 545-551.(4), 545-551.

Bibliography, cont.Bibliography, cont.17.17. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Best Practices for Comprehensive Best Practices for Comprehensive

Tobacco Control Programs-August 1999Tobacco Control Programs-August 1999. Atlanta GA: U.S. Department of Health . Atlanta GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, August 1999. Health, August 1999.

18. Wasserman, M.P. 2001. 18. Wasserman, M.P. 2001. Guide to Community Preventive Services: State and local Guide to Community Preventive Services: State and local opportunities for tobacco use reductionopportunities for tobacco use reduction. American Journal of Preventive . American Journal of Preventive Medicine: 20 (S2) pp 8-9.Medicine: 20 (S2) pp 8-9.

19. Centers for Disease Control and Prevention. 19. Centers for Disease Control and Prevention. Making Your workplace Smoke-free: Making Your workplace Smoke-free: A decision makers guide. A decision makers guide. U.S. Department of Health and Human Services, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Wellness Prevention and Health Promotion, Office on Smoking and Health, Wellness Councils of America and American Cancer Society.Councils of America and American Cancer Society.

May you be inspired often May you be inspired often (and expire late).(and expire late).

Thank you.Thank you.

Yale Prevention Research CenterYale Prevention Research Center130 Division St.130 Division St.Derby, CT 06418Derby, CT 06418(203) 732-1265(203) 732-1265

David.katz@yale.eduDavid.katz@yale.edu

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