New Help for Teens Trying to Kick the Habit

Each day, approximately 4,000 young people between the ages of 12 and 17 years initiate cigarette smoking, and an estimated 1,140 young people become daily cigarette smokers. Approximately 2.7 million youth under the age of 18 were smokers in 2005.

Although youth are known to be particularly vulnerable to tobacco addiction, there is surprisingly little known about youth tobacco cessation. More than 54% of current high school cigarette smokers in the United States tried to quit smoking within the preceding year. However rates for failed quit attempts among younger smokers are higher than those for adults (43%). We need a greater understanding of youth and teen cessation. Researchers, tobacco control leaders, and others are currently working on this problem and adding to the list of what might help youth and teens quit successfully.

Bupropion (Zyban), approved as an adult stop-smoking aid, may help teens to quit too, researchers recently announced in the November issue of Archives of Pediatrics & Adolescent Medicine.

Bupropion was the first non-nicotine medication approved for smoking cessation, but it has not been widely tested in adolescents. To help fill the gap, Dr. Muramoto and colleagues at the University of Arizona College of Medicine enrolled 312 teens, ages 14 to 17, who smoked at least six cigarettes a day, had an exhaled carbon monoxide level of at least 10 parts per million, and had tried at least twice before to quit.

Teens were randomized to placebo, a low dose of bupropion at 150 mg a day, or a high dose of bupropion at 300 mg a day. The volunteers were treated for six weeks, with brief counseling during that time, and then they were followed for another 20 weeks, the researchers said. The primary endpoints were self-reported abstinence, verified by exhaled carbon monoxide levels and cotinine levels.

The high dose (300 mg) of bupropion resulted in significantly higher quit rates than placebo at most time points during treatment, but the low dose did not. Carbon monoxide-confirmed quit rates during treatment were 11.5 percent in the placebo group, 15.3 percent for low-dose bupropion, and 22.6 percent in the high-dose group. Cotinine-verified abstinence showed that only the high dose resulted in higher quit rates at six weeks than did placebo, at 29 percent versus 16 percent.

But the teens tended to relapse after the end of six weeks of treatment with the medication combined with brief anti-smoking counseling, Dr. Muramoto and colleagues reported. The tendency to start smoking again "suggests a need to evaluate a longer dosing regimen in adolescent smokers," Dr. Muramoto and colleagues concluded. They said results might have been better had the teens been treated for 12 weeks, which is the recommended length of treatment for adults. For more information, see http://archpedi.ama-assn.org/cgi/content/abstract/161/11/1068.

In addition to pharmacological treatments, teens may also benefit from new and emerging technologies to support their quit attempts.

The FixNixer (http://www.fixnixer.com) is a new online program developed in Colorado. Sponsored by The State Tobacco Education and Prevention Partnership of the Colorado Department of Public Health and Environment and funded with proceeds from the 2004 state tobacco excise tax, this free program provides a personalized quit plan, support, and tools to help teens quit smoking or chewing tobacco.

With input from the user, FixNixer generates a customized 21-day program. As the quit date approaches, teens have access to Quitting 101, which includes tips and tools that help the user get ready for the quit date. Once they have begun the 21-day quit journey, quitters can write about their quit experience in their QuitBlog and read what other FixNixer quitters have written about their experiences in the community forum.

The FixNixer will also send personalized text messages or emails over the course of the three-week quitting program to motivate and encourage the quitters to remain smoke-free. The messages remind them about why they use tobacco, when they use tobacco, and why they want to quit. At the end of the 21-day program, teens have the option of continuing the current quit program, or to start over.

Virtual reality is may also help some teens kick the habit. The Virtual Reality Medical Center (VRMC) has created an Internet-based Virtual Reality (VR) game that helps adolescents cease smoking (http://www.vrphobia.com/teensmoking). This interactive program uses cue exposure therapy (CET) to treat addictive behaviors.

The VRMC Teen Smoking "Virtual Environment" (VE) consists of two major regions: home and school. The home is comprised of two floors: The first floor is the garage, the one above has a bedroom, kitchen, living room and bathroom. The school environment includes the classroom, restroom, and cafeteria.

At the start of the program, the user is placed in his/her bedroom where he/she must select a quit date from the provided calendar before being able to participate in other activities. Smoking cues are placed around the teenager's home. In these cases, users can choose to "smoke," "ignore," or "throw away" objects, such as a pack of cigarettes, which increases their cravings if not removed. At school, they deal with pressure from their peers to smoke. In those scenes, the user has the option of refusing, considering, or accepting the offer to smoke.

The game includes a "craving" status bar which starts off empty. It indicates the user's current craving level to smoke. When a user approaches smoking cues like an ashtray, alcohol, or coffee, the craving bar goes up. However, when users participate in an activity in an effort to distract themselves from the desire to smoke, the result is a reduction in cravings. When the user's craving level approaches the maximum, the user's vision (the visuals on the screen) will begin to blur and flash red, acting as a warning sign. Under these circumstances, the user can either participate in an activity or take a smoke in order to alleviate the craving.

Ultimately, the goal of the program is for users to remain smoke free in both environments for as long as possible. Rewards and other forms of encouragement are awarded after the user has maintained a smoke-free regimen following certain time periods.

VRMC's teen smoking cessation program can help to educate adolescents on how to effectively avoid situations that cause cravings. In addition, repeated exposure to problematic triggers eventually leads to desensitization.

A research study was to assess the adolescent's knowledge related to the smoking cessation behaviors pre and post program participation. Overall, the data from the questionnaires suggests the development of healthier habits following program participation. After participating in the program, subjects agreed that setting a quit date helps you to quit; and keeping busy and performing physical activities can aid with distraction from smoking. For more information, see http://www.ehealthonline.org/articles/article-details.asp?articleid=1517.

These tools are just some of the cessation treatments being studied for efficacy and effectiveness in youth and teens. More research is needed to help develop a better understanding of the challenges and opportunities associated with youth tobacco cessation. This will lead to the development of more effective treatment tools and services to meet the needs of young smokers and help them quit. The Youth Tobacco Cessation Collaborative (YTCC) was formed to address the gap in knowledge about what cessation strategies are most effective in assisting youth to quit smoking. Collaborative members represent major organizations that fund research, program, and policy initiatives related to controlling youth tobacco use. For more information, visit their website at http://www.youthtobaccocessation.org/.

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Smokers Remain Unaware of the Health Effects of Smoking, New Survey Finds

Despite major efforts to educate the public on the dangers of smoking over the past 40 years, a new national survey shows that major knowledge gaps exist in what smokers believe to be true about the risks associated with smoking compared the actual realities of tobacco-related disease and death.

According to the survey, conducted by the American Legacy Foundation and GlaxoSmithKline Consumer Healthcare, while many smokers are aware that smoking can lead to serious health problems including lung cancer, many underestimate the risk of getting the disease from smoking. For example, two in three smokers underestimate the chance of developing lung cancer compared to a non-smoker and four in 10 incorrectly believe that developing lung cancer depends more on genes than anything else. Furthermore, the survey found that up to a third of smokers think that certain activities such as exercise and taking vitamins could "undo" most of the effects of smoking.

Misperceptions about the effects of nicotine found in cigarettes were also common among respondents. Almost all survey respondents (81 to 86 percent) either were unsure whether, or incorrectly believed that, nicotine caused cancer, emphysema or heart attacks. More than 76 percent of smokers surveyed wrongly believe that, or do not know whether, NRTs are more addictive than cigarettes, highlighting the need for further education as cigarettes are vastly more addictive. In fact, about half of the smokers surveyed stated they would be more likely to consider NRT if they were shown scientific evidence that prove its safety and efficacy.

"What is alarming about these survey findings is that so many smokers are still so misinformed," said Dr. Cheryl Healton, president and CEO of the American Legacy Foundation. "Proven cessation treatments like nicotine replacement therapy continue to be underutilized and we believe these misperceptions are partly to blame. These findings point to the fact that more needs to be done to educate and inform smokers."

For more information, see web link:
American Legacy Press Release November 13, 2007

Cigarette Smoking Among Adults -- United States, 2006

According to a report published in the November 9th issue of MMWR, the number of adult smokers in the United States has remained constant since 2004.

The CDC analyzed data from the 2006 National Health Interview Survey (NHIS), a questionnaire that evaluated the smoking habits of 24,275 adults 18 and older. This analysis indicates that in 2006 approximately 20.8 percent of U.S. adults were current cigarette smokers. This prevalence has not changed significantly since 2004. In 2004 and 2005, 20.9 percent of the U.S. adult population were smokers.

The analysis also found that among the 20.8 percent of individuals that currently smoked, 44.2 percent had made an effort to stop smoking in the last 12 months. Slightly more men (23.9 percent) than women (18.0 percent) still light up. Only 10.4 percent of Asians surveyed still smoked, followed by Hispanics (15.2 percent), non-Hispanic whites (21.9 percent), non-Hispanic blacks (23 percent), and American Indians/Alaskan Natives (32.4 percent).

In addition, the findings indicated that persons with a diagnosis of a smoking-related chronic disease, including certain cancers, have a significantly higher prevalence (36.9 percent) of being a current smoker than persons with other chronic diseases or persons with no chronic disease. That indicates a need for more aggressive cessation messages directed at this population, the researchers say, especially given data that shows that continued smoking has harmful effects on treatment and survival

For more information, see web link:
MMWR November 9, 2007 56(44);1157-1161

Study Finds Fewer Heart Attacks after Smoking Ban

The number of heart attacks among nonsmokers in Monroe County, Indiana, declined by more than two-thirds in the months after a countywide smoking ban took effect, according to a study by Indiana University professors.

The study, published in the current issue of the Journal of Drug Education, found heart attacks in Monroe County dropped 70 percent - from 17 in the 22 months before the ban took effect to five in the 22 months after the ban started. The researchers found that in Delaware County, which has similar demographics but had no ban during the time of the study, saw an 11 percent drop - from 18 to 16 heart patients - for the same time period.

While the researchers concede the small number of overall heart attacks is a limitation of the study, Dong-Chul Seo, an assistant professor in IU's Department of Applied Health Science and the study's lead author, believes the findings are strong. The researchers' conclusions fit with the other studies that found an immediate decrease in heart attack rates following cigarette bans, smoking cessation experts say.

"This provides really solid evidence of the benefit of the public smoking ban, and hopefully this will provide a basis for adopting a public smoking ban in many municipalities and states," said Seo.

For more information, see web link:
Journal of Drug Education, 2007, Volume 37, Issue 3

Fear of Weight Gain May Keep Women from Trying to Quit Smoking

Although there are many possible reasons for the stubborn persistence of smoking, fear of weight gain is high on the list for many women, says a University of Michigan Health System researcher Cindy Pomerleau, Ph.D.

New findings published in the October issue of Addictive Behaviors show that women who smoke tend to be further from their ideal body image, and more prone to dieting and bingeing, than those who don't smoke.

In the study, the smokers and non-smokers were asked to look at silhouette pictures of ten different body types, ranging from thinnest to fattest, and to choose which one their current body type was closest to, and which one they wanted to look most like. They were also asked questions about their self-image and their eating habits, about how concerned they were about gaining weight if they quit smoking, and about how sure they were that they could stay off cigarettes even if they gained weight.

The smokers chose an ideal body shape that was slimmer than the non-smokers chose, and further from how they perceived themselves as looking. They also had more problems with limiting their eating. Smokers who were overweight were especially doubtful about their ability to stay off tobacco if they started to gain weight.

This study, Pomerleau says, suggests that if women smokers are to succeed in quitting, they may need extra help in achieving a more realistic body image and paying attention to unhealthful eating patterns, particularly if they are already overweight.

In another study, published in the August issue of Eating Behaviors, the team found that overweight women smokers who were overweight as children were far more likely to have started smoking in their early teens than women whose weight problems started later in life. They also had worse withdrawal symptoms when they tried to quit.

In the study of 89 overweight women smokers, those who remembered being overweight before they reached junior high school reported that they had started experimenting with smoking at around age 13 -- compared with women whose weight problems didn't start until junior high or after, who hadn't tried smoking till they reached age 15. The women who were overweight as children also reported more nicotine-withdrawal symptoms when they tried to quit smoking, especially symptoms like anger, irritability and trouble concentrating.

Cigarettes are well known to suppress appetite and weight, says Dr. Pomerleau. "So it's hardly surprising that women who have trouble managing their weight or are dissatisfied with their bodies are drawn to smoking," she says.

Once they make a serious attempt to quit, evidence suggests that most weight-concerned smokers can be just as successful in kicking the habit as others. "The problem here is getting women who are concerned about their weight to be willing to try to make a quit attempt," says Pomerleau, "and then helping them gain a sense of control over their weight."

These studies, and others that the U-M team have done, all point to the importance of finding new strategies to help women quit smoking without losing control of their weight.

For more information, see web link:
U-M Health Minute, November 5, 2007

Research Shows Teenagers Start Smoking To Lose Weight

The smoking rate in teens has been down for years, but researchers have found a new trend in addiction -- teen girls picking up cigarettes in hopes of dropping pounds.

According to a recent study in the American Journal of Health Promotion, teen girls dieting during the two-year study were almost twice as likely to take up smoking than those not dieting. Conversely, the study found that teen boys turned to cigarettes after attempting and failing at dieting.

Researchers noted that dieting does not appear to be linked to trying smoking, but that female teens who initiate dieting appear at risk for beginning regular smoking.

JaNan Less, community health consultant for the Scott County Health Department, Iowa, said she thinks the increase in teen girls smoking found in the research is linked to high obesity rates and girls looking to tobacco to lose weight.

Although there are many successful efforts to curb teenage smoking, young people certainly have not kicked the habit completely and need more support to successfully quit tobacco.

For more information, see web link:
Medical News Today, October 29, 2007

Community Guide Recommendations and State Level Tobacco Control Programs: 1999-2004

A recent study published in Tobacco Control documents the level of effort by state tobacco control partners working on recommended tobacco control programs and interventions. Using the Strength of Tobacco Control survey responses in 1999, 2002 and 2004, researchers were able to calculate the mean proportion of state tobacco control partners working on recommended interventions and analyzed changes in effort over time.

The researchers were able to document that the proportion of state tobacco control partners working to promote clean indoor air legislation remained at more than 70 percent in all three years. The proportion working to increase taxes on tobacco rose significantly between 1999 and 2002 (from 54 percent to 70 percent), and those working to reduce patient costs for tobacco cessation treatments never exceeded 31 percent in any year. Use of mass media targeting youths decreased significantly in all years (from 40 percent to 32 percent to 26 percent), and the proportion of state tobacco control partners participating in a quitline has increased steadily and significantly in all years (from 24 percent to 36 percent to 41 percent). The level of effort in each area varied widely between states and over time.

Researchers suggest that although state tobacco control partners are implementing evidence based interventions, more focus is needed on the tobacco cessation and mass media campaign components of comprehensive tobacco control programs.

For more information, see web link:
Tobacco Control, 2007, Volume 16, Issue 5

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American Legacy Foundation Campaign Focuses on Nation's Number-One Cancer Killer

Earlier this year, Legacy Foundation launched a new national public service campaign, Code Blue for Lung Cancer. Code Blue for Lung Cancer is designed to raise awareness of the deadly toll of lung cancer in our country.

Code Blue includes a 30-minute documentary that explores the devastating impact of lung cancer on four families and discusses how to reduce lung cancer deaths, primarily through early diagnosis and by quitting smoking. The campaign, in both English and Spanish, also includes radio and television public service announcements, a guidebook for local broadcasters, and an accompanying online component.

Lung cancer accounts for 28 percent of all cancer deaths in the United States. More Americans lose their lives to lung cancer annually than breast, prostate and colon cancers combined. According to a study released by Legacy, two-thirds of women inaccurately believed breast cancer to be the leading cause of cancer death among women.

Eighty-five percent of people diagnosed with lung cancer are current or former smokers, whom many perceive as having had the power to avoid a lung cancer diagnosis if only they had been able to quit. However, research shows two things: that nicotine is highly addictive, and that while 70 percent of smokers want to quit, many lack the tools and resources to quit for good.

"Lung cancer takes a huge social and economic burden on our country each year," said Dr. Cheryl Healton, President & CEO of the American Legacy Foundation. "We need to be more supportive of smokers trying to quit, more empathetic to people and families suffering from lung cancer, and more vigilant in ensuring more research and funding is devoted to lung cancer."

For more information, see web link:
American Legacy Foundation "Code Blue"

Growing Social and Economic Burden of Lung Disease Underscores Need For Action: The Lung Association, Canada

The Lung Association of Canada announced that the release of an important new report on lung disease in Canada demonstrates the growing burden and deadly impact of lung diseases including asthma, COPD, sleep apnea and lung cancer. "Life and Breath: Respiratory Disease in Canada" released by The Public Health Agency of Canada, highlights the most recent data available for certain major lung diseases. The report also cites the important risk factors of tobacco and the environment, and their impact on the lung health of Canadians.

Among the highlights of the report:

• Respiratory diseases place a considerable economic burden on the health care system, accounting for approximately 6.5 percent - $12 billion - of total direct health care costs;
• Both indoor and outdoor air quality are recognized as significant contributors to respiratory diseases. This underlines the very real need to address air quality issues in order to lower the increasing rate of lung disease in Canada;
• The increase in smoking among women over the last 50 years has resulted in an increased prevalence of diseases such as lung cancer and Chronic Obstructive Pulmonary Disease (COPD) among women;
• Tobacco usage remains the most important preventable risk factor for chronic lung diseases, demonstrating the need for active smoking cessation policies and programs designed to reduce tobacco-related lung diseases such as lung cancer and COPD.

"This report provides Canadians with a snapshot of the burden that lung disease is placing on them socially and economically," said Nora Sobolov, President and CEO of The Lung Association, "As The Lung Association and stakeholders nationwide continue to move forward on building Canada's first-ever Lung Health Framework, research such as this serves to underscore the very real need for concrete action to decrease incidence of lung disease in our country."

For more information, see web link:
Medical News Today, November 23, 2007

AAFP Use Guide to Plan, Conduct Tobacco Cessation Group Visits

The AAFP's tobacco cessation program has recently added a guide to tobacco cessation group visits to its online Ask and Act Practice Toolkit.

The step-by-step guide, available in a PDF, covers preparing for a tobacco cessation group visit, conducting the visit and billing for it. Sample forms include an invitation letter, a script to use when calling potential participants, a group visit payment and confidentiality form, a sample SOAP (subjective, objective, assessment and plan) note, a staff task checklist, and a list of materials and equipment needed for the visit. It also offers a suggested group visit room layout and tips for dealing with challenging group visit participants.

For more information, see external PDF:
AAFP "A Guide to Tobacco Cessation Group Visits"

Maryland Cigarette Tax Increase Delivers Victory for Kids and Taxpayers

The Maryland House of Representatives recently approved a bill to double the cigarette tax, which is currently set at $1 a pack. The price hike, which will raise revenue for health care programs, will take effect on Jan. 1. Officials are hopeful the increased cost will deter smokers, as the average pack will cost a little more than $5.

According to a statement from Campaign for Tobacco Free Kids, increasing the cigarette tax is one of the most effective ways to reduce smoking, especially among kids. Studies show that every 10 percent increase in the price of cigarettes reduces youth smoking by 7 percent and overall cigarette consumption by about 4 percent. Maryland can expect the $1 cigarette tax increase to prevent some 52,000 Maryland kids alive today from smoking; spur 28,000 Maryland smokers to quit for good; save nearly 24,000 Maryland residents from smoking-caused deaths; produce more than $1.1 billion in long-term health care savings; and raise about $220 million a year in new state revenue, as estimated by Maryland's Department of Legislative Services.

While the new revenue generated by the tax increase will go into the state's general fund, the Legislature plans to use a portion of the revenue to expand access to health care for more than 100,000 uninsured Marylanders by making health insurance more affordable to small businesses and expanding Medicaid eligibility to lower income parents and other adults.

With Maryland's tax increase, the average state cigarette tax is now $1.11 per pack. Since January 1, 2002, 44 states have increased cigarette taxes, some more than once. Maryland is now one of nine states with cigarette taxes of $2 or more. Twenty-six states have taxes of $1 or more.

For more information, see web link:
Campaign for Tobacco Free Kids Press Release November 19, 2007"

Campaign Aimed At Getting Massachusetts Smokers to Quit

Earlier this month, Massachusetts' first tobacco cessation campaign in six years was launched. The statewide "Fight for Your Life" campaign, which will run from November through April 2008, will feature advertising on television, the Internet, buses and trains, as well as a companion Web site www.fight4yourlife.org.

The television ads are powerful, emotional and, according to the Massachusetts Department of Public Health, they are effective at getting people to quit smoking. The ads are the main theme of the campaign. Similar ads ran during a successful campaign in 2003, until massive budget cuts stopped them.

"Funding for protecting youth was greatly curtailed, the number of compliance checks was reduced, and we found that illegal sale rates to minors more than doubled," said Dr. Lois Keithly, director of the Massachusetts Tobacco Control Program.

But the campaign is back thanks to $4.5 million in funding approved by the Governor Deval Patrick administration.

"This is an exciting day for public health in Massachusetts," said Dr. JudyAnn Bigby, Massachusetts Secretary of Health and Human Services. "Over the last several years, the state has lost much of the momentum in the fight against tobacco. Today, we begin a new era that we hope will help thousands of people live healthier lives."

Aside from the revised ads, the campaign will help increase awareness about resources available to smokers with hopes of getting as many people to quit as possible.

For more information, see web link:
The Boston Channel November 14, 2007

Aetna's New Toolkit Helps Physicians Work with Patients to Quit Smoking

Aetna recently announced that it is distributing 'Advising Smokers To Quit' toolkits to more than 8,500 family-practice and internal-medicine physician offices in Southern New Jersey, Ohio, Pennsylvania and Texas. The kits are intended to not only encourage a dialogue between physicians and patients on smoking cessation, but also to provide information and tools to aid physicians with management of their patients who smoke. While the negative health impact of smoking is well-documented, it can still be a difficult topic for patients and physicians to discuss. Working with the American Cancer Society and Department of Health offices in the selected states, Aetna collected information and resources that could help both sides discuss quit-smoking actions more easily and effectively.

The materials being sent to physicians include:

• An action plan sheet that will help the physician and patient put a defined strategy on paper, such as the official 'quit date,' whom the patient can turn to for help, the proper medication plan and tips on how to avoid a relapse.
• A fact sheet that offers patients reasons to quit, as well as tips to help them quit.
• A cover letter underscoring the importance of physician intervention that offers three simple steps for physicians - ask patients about their tobacco use; advise them to quit; and refer them to the 1-800-QUIT NOW Quitline for support.
• A poster for physicians that describes how a 30-second conversation on this topic can help save a life, as well as an examination room poster referring patients to the Quitline.
• A 'prescription note' that also refers patients to the Quitline.

In addition to distributing these materials to selected physicians, the Aetna provider website will also contain information on this toolkit, providing any physician user with the opportunity to review the materials and resources.

"This outreach emphasizes the important role that physicians can play in helping their patients quit smoking," said Dr. Dexter Campinha-Bacote, Aetna's medical director for the North Central region. "Studies have shown that smokers are almost twice as likely to successfully quit for five or more months if they have a physician help them with the process."

This new program is part of Aetna's larger effort to help members with the difficult process of quitting smoking. This includes the company's Quit Tobacco smoking cessation program, a voluntary, one-year program that offers personal coaching and support by certified tobacco cessation specialists.

For more information, see web link:
Business Wire October 29, 2007

TReND Announces Release of Journal Supplement on Conceptual and Methodological Issues for Research on Tobacco-Related Health Disparities

The Tobacco Research Network on Disparities (TReND) (http://dccps.nci.nih.gov/tcrb/trend/index.html), which is sponsored by the National Cancer Institute and the American Legacy Foundation, is pleased to announce the release of Conceptual and Methodological Issues for Research on Tobacco-Related Health Disparities, a supplemental journal issue published by Addiction. The papers represent multidisciplinary collaborations among health disparities and tobacco control researchers.

Many communities and policy makers recognize that the disproportionate burden of tobacco-related disease and deaths among racial/ethnic minority and low socioeconomic group have existed much too long. Although progress has been made to reduce tobacco use overall, methods and frameworks that increase our understanding of the factors linked to tobacco use, and its consequences, and interventions to reduce disparities are lacking. The articles highlight key conceptual and methodological issues for practitioners and policy makers to consider when seeking to reduce tobacco-related disparities in communities.

These articles examine:

• The importance of developing research and capacity building frameworks that address disparities, diversity, inequities and resource inequalities.
• The promising potential of frameworks that inform prevention and cessation programs and address the tobacco use addiction cycle and biopsychosocial and contextual factors across the human lifespan.
• The need to broaden the research methods, data sets, and instruments used to assess TRHD and consider both inter- and intra-group level differences when evaluating the validity and generalizability of such approaches.
• The need to evaluate existing and novel intervention efforts that are culturally appropriate and address issues such as access, demand, and receipt of care.

For more information, see web link:
Addiction, 2007, Volume 102, Issue S2

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