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The potential benefits from mHealth interventions are tempered by several challenges, including (1) inconsistent access to cell phones among low-income populations (despite the increasing adoption of cell phones, low-income populations may still struggle to maintain cell phone contracts, have regular access to minutes, and have data plans that allow for repeated use of interventions), (2) different types of devices. At this time, optimal methods are not in place to fully assess the expanding array of available mHealth cessation interventions. In addition, assessing the comparative effectiveness and cost-effectiveness of mHealth cessation interventions relative to other modalities, such as in-person and quitline interventions, will be important. Because of the rapid cycle of technological development, the use of adaptive and iterative research methods in assessing development and performing evaluations may be necessary. A series of three studies from New Zealand and the United Kingdom provided the initial evidence supporting the use of this platform for delivering smoking cessation interventions (Rodgers et al. Although the findings from studies of cessation texting interventions are generally encouraging, a review of these interventions found that, while smoking cessation outcomes measured at less than 6 months were better than those for controls, outcomes measured at 6 months or longer often failed to show differences between treatment and control groups (Scott-Sheldon et al. One reason for these mixed findings may be the substantial variation in key features of the interventions, including frequency of messages per day and per week; Interventions for Smoking Cessation and Treatments for Nicotine Dependence 507 A Report of the Surgeon General length of programs; use of unidirectional versus bidirectional messages; and, to a lesser extent, message content. Another reason may be variation in study design, such as the endpoint used for measuring abstinence (Free et al. This variability has presented a challenge when interpreting findings from specific studies. Nevertheless, the overall evidence supports the efficacy of text-based smoking cessation treatment programs. However, to inform the optimization of treatment, more research is needed to better understand the contributions of various treatment elements. However, evidence on the effectiveness of webbased smoking cessation interventions is mixed. Such interventions date back to the early 2000s, with studies exploring several approaches for delivering treatment and examining user behavior (Etter 2005; Stoddard et al. Initial research findings were inconsistent, and several reports found that websites frequently failed to deliver recommended elements of behavioral treatment for smoking cessation (Bock et al. In its 2011 review, the Community Preventive Services Task Force found insufficient evidence to determine the effectiveness of Internet-based interventions in increasing tobacco cessation (The Community Guide 2011a). Later, a study on web-based tobacco cessation interventions by Civljak and colleagues (2013) concluded that some Internet-based interventions, particularly interventions that are interactive and tailored to individuals, can assist in achieving longer term smoking cessation. However, trials that compared Internet interventions with usual care or self-help did not show consistent effects. As web-based interventions have grown more sophisticated, incorporating better website design and improved functionality, the efficacy of such interventions for smoking cessation has improved significantly (Graham et al. Comparisons of web-based cessation interventions with face-to-face counseling and quitline counseling suggest that these different modalities have the potential to produce similar cessation outcomes (Graham et al. Interventions that included goals and planning, social support, natural consequences, comparison of outcomes, reward and threat, or regulation were significantly associated with increased intervention effectiveness in the short and long terms, when compared with study arms that did not include the domain(s). The fact that web technologies and web-based cessation interventions continue to evolve, along with the potential reach and customizability of web-based technologies, suggests that future interventions could further improve on current ones. For example, advances in web technologies could improve user experience, enhance content management, better incorporate interactive elements, and better integrate various types of media. The increasing penetration of smartphones and the broad availability of free Wi-Fi may also allow for access to the web in many nontraditional settings. In response to this changing landscape, many websites are using adaptive design. Such sites have the potential to achieve broad population-level reach and widespread engagement with target audiences. Taken as a whole, the available evidence suggests that web interventions with interactive components can increase abstinence to tobacco. As with text-based cessation programs, more research is needed to better understand the specific components that can further enhance the effectiveness of web-based interventions for smoking cessation. Although most mobile phone interventions have traditionally relied on text messaging platforms (Whittaker et al. The review then analyzed nearly 100 of the most popular 508 Chapter 6 Smoking Cessation cessation apps and their adherence to an index criteria based on the Clinical Practice Guideline (Fiore et al. However, smartphone apps for smoking cessation continue to evolve, both as standalone interventions and in combination with other approaches to cessation interventions. These federally funded apps provide opportunities to learn more about the components that make a smoking cessation smartphone application effective.
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If an inadequate comprehensive assessment is done there is a risk that the nurse will not be correctly matched to the appropriate treatment, which could result in treating the wrong set of problems or missing other problems altogether. It must also include present and past psychiatric treatment, current medications and any suicide attempts. The assessor must observe appearance and thought processes of the nurse and evaluate for current suicidal ideation. The family and social history must include the history of alcohol or drug use in the family and identify the specific family members. The assessment must be done face to face and be conducted in accordance with acceptable professional standards for clinical diagnostic evaluations. The assessment is used to determine whether the participant has a substance use disorder, mental health or dual-diagnosis problem. The assessor can also determine in his/her expert opinion whether or not the participant is determined to be a threat to themselves or the public. If entry into the alternative program is indicated, the nurse must be asked to complete a selfassessment and sign appropriate releases of information that allow release of information from the treatment program to contact the board under appropriate circumstances. All information gathered in the initial screening process is reviewed by the alternative program staff. The alternative program staff also assures that the treatment program referrals are made on the basis of identified needs of the nurse and that conflict of interest situations do not occur in the referral process. The alternative program staff needs to be generally available to consult with nurse employers and other referring parties to discuss individual nurses who may have a substance use disorder that can potentially compromise patient care. The alternative program staff may also assist the nursing employer (such as a nurse manager or nurse administrator) in developing a strategy for any work-related situations. This consultation may include, but is not limited to, techniques for intervention, proper documentation of work-related behaviors and a plan for arranging a referral and transition to the alternative program. All alternative programs need to provide referral information for treatment and a list of assessors as well as criteria for evaluating the quality and integrity of assessors and treatment programs. A referral list of approved assessors can be developed and maintained by each alternative program. Each alternative program needs to develop minimum education and licensure requirements for approved assessors based on the needs of the individual program. Criteria may include licensed physicians who are certified as addictionologists or psychiatrists specializing in addiction medicine. Some advanced practice registered nurses may have a specialty in substance use disorder as well. Licensed psychologists and social workers can also have a specialty certification in addiction treatment or experience that qualifies them as appropriate assessors. Program Entry 99 Some assessors may be masters level therapists or advanced practice nurses who have either certification or advanced training in substance use disorder assessment and treatment. The assessor must not have a financial relationship, personal relationship, business relationship or any other interest that would interfere with providing an unbiased, independent evaluation. Maintaining Current and Effective Treatment Referrals in the Community Boards and alternative programs must maintain current and effective treatment referrals in the community in the interest of helping to facilitate nurses to enter and maintain ongoing recovery that is consistent with patient safety. Boards can more efficiently manage the vast numbers of investigative issues dealing with a substance use disorder that potentially impact patient safety by identifying and working with programs and approved treatment providers. Therefore, to maintain integrity of the system the programs must not only be able to rely on the diagnosis and subsequent treatment recommended and provided to the nurse they must also be able to effectively and in a timely manner refer the nurses to treatment. Since treatment is most effective when initiated upon entry, it follows that whatever increases the opportunity for treatment must be pursued (Darbro, 2009). It has been further suggested that to achieve the best outcome, the nurse needs to be referred to a treatment provider with an expertise in working with health care professionals (Angres, Bettinardi-Angres, & Cross, 2010). The barriers and limitations to effective treatment referrals, whether perceived or actual, can delay or otherwise compromise evaluation and treatment and in turn endanger patient safety. A timely referral and effective treatment are critical components of ensuring patient safety and require that programs know and maintain a current list of available treatment providers approved for use within their programs. The list must be readily accessible, including being available on the Internet (Alexander & Wells, 2008).
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Clinical interventions may also play an important role in helping youth quit smoking cigarettes. Although screening for tobacco use among 11- to 17-year-olds is fairly high in ambulatory care settings (71. The 2008 update of the Clinical Practice Guideline on Treating Tobacco Dependence recommends that clinicians provide counseling interventions to aid youth smokers in quitting (Fiore et al. Far less is known about how to help youth quit compared with how to help adults, and use of effective cessation strategies is lower among youth than adults (Fiore et al. Because many youth, like the young adults discussed previously, are some-day smokers, more research is needed on how to address these occasional users and on effective and appropriate clinical interventions for youth overall. Data presented in this chapter suggest that fewer than 2 of every 3 of adult smokers who saw a healthcare provider in the past year were advised to quit smoking, fewer than 1 of every 3 reported using cessation medications to help them quit, and fewer than 1 of every 10 reported using counseling. Taken together, these findings reinforce the need for the implementation of additional public health interventions that aim to increase cessation counseling in clinical settings and the number of quit attempts among adults and youth (Fiore et al. Encouraging and helping tobacco users to quit remains the quickest approach to reducing tobacco-related disease, death, and healthcare costs (Institute of Medicine 2007), including through both individual (see Chapter 6) and population-based (see Chapter 7) interventions. However, as is noted in this chapter, use of tobacco cessation resources among persons who use tobacco remains low: among adults, 18 years of age and older, only 29. To further increase cessation among adults and youth, public health efforts can continue the aforementioned strategies and encourage healthcare providers to consistently identify smokers, advise them to quit, and offer them cessation treatments (Fiore et al. Nevertheless, it is also important to recognize that a majority of cigarette smokers who quit do so without using evidencebased treatments. As is described in Chapter 6, identifying ways to continue to promote quit attempts to help cigarette smokers in quitting, even among those who do not intend to use treatment or are not interested in using treatment, is still needed. Therefore, many of the analyses centered on cigarettes may underestimate the impact that the use of other tobacco Patterns of Smoking Cessation Among U. Adults, Young Adults, and Youth 103 A Report of the Surgeon General products, such as little cigars and e-cigarettes, has on tobacco cessation. Polytobacco use, which is the use of two or more tobacco products, is now common (3. However, comprehensive surveillance of all of the diverse tobacco products being used by the American public is essential to effectively inform tobacco control policies, planning, and practices. In addition, continued surveillance of the use of switching to other tobacco products by smokers who are trying to quit cigarettes is needed. Switching to smokeless tobacco and cigars as a quit strategy is relatively uncommon (see "Other Tobacco Products: Use and Cessation" in this chapter). For example, switching to e-cigarettes in an attempt to quit cigarette smoking is the most prevalent cessation strategy among all demographic groups, despite the lack of clear evidence for the long-term effectiveness and safety of e-cigarettes as a cessation approach (Hartmann-Boyce et al. More research is needed to better understand the patterns of usage of noncigarette products and their relationship with quitting cigarettes and all tobacco use. In addition, research is needed to understand long-term outcomes among cigarette smokers who report switching to noncigarette products to quit cigarette smoking, including dual usage, the substitution of noncigarette products use for cigarette smoking, and the potential use of noncigarette products as temporary cessation aids with eventual cessation of all tobacco use. The findings on the use of switching to another tobacco product to quit conventional cigarettes underscore the pressing need to (a) consider more effective and efficient ways to reach smokers with evidence-based cessation support and (b) continue to research the efficacy of emerging strategies to reduce combustible tobacco use. Past-year quit attempts and recent and longer term cessation have increased over the past 2 decades among adult cigarette smokers. Advice from health professionals to quit smoking has increased since 2000; however, four out of every nine adult cigarette smokers who saw a health professional during the past year did not receive advice to quit. A large proportion of adult smokers report using non-evidence-based approaches when trying to quit smoking, such as switching to other tobacco products. Can e-cigarettes and pharmaceutical aids increase smoking cessation and reduce cigarette consumption? Policy Memorandum 16-001, Department of Defense Tobacco Policy, April 8, 2016; <. Point-of-Sale Report to the Nation: Realizing the Power of States and Communities to Change the Tobacco Retail and Policy Landscape. Louis and the National Cancer Institute, State and Community Tobacco Control Research Initiative, 2016. Updated guidelines for evaluating public health surveillance systems: recommendations from the Guidelines Working Group.
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Symptoms Sudden onset with fever, vomiting, intense headache, and stiffness of the neck. Mode of Transmission Spread by close contact with droplets and discharge from nose, throat or saliva of an infected person. Period of Communicability Usually 24 hours after the initiation of appropriate therapy Exclusion (Yes or No) and Control Measures Yes. Control measures: Follow local health department recommendations for prophylaxis and surveillance for close contacts, including household, child care contacts, others with saliva contact with case. A vaccine is available for certain types of meningococcal disease, and is required by law for certain risk groups. Other Information A case or outbreak must be reported to the local health department immediately by telephone. Smooth surfaced, spherical papules on skin, sometimes appears in linear orientation, can be itchy. For contact sports or sports with shared equipment that comes in contact with skin (such as gymnastics, etc. Mode of Transmission Spread by close personal contact via saliva; also may be transmitted by blood transfusion. Exclusion (Yes or No) and Control Measures General exclusion: No, exclusion not routinely recommended. Contact sports: Yes, until acute illness is resolved and cleared by a health care provider. Control measures: Use general hygienic measures, including handwashing to prevent salivary contamination from infected individuals; minimize contact with saliva (such as, avoiding drinking beverages from a common container). Regarding contact sports, health care provider must clear athletes to reduce risk of splenic rupture. Acute onset of cough becomes repeated and violent within 1-2 weeks, can persist for several months. Mode of Transmission Spread by droplet contact and direct contact from nose and throat discharge of an infected person. Highly contagious among unvaccinated children in school, child care, or camp settings. Period of Communicability From 3 days before salivary gland enlargement to 5 days after. Refer case to health care provider and contact local health department for guidance managing contacts of cases. Beginning from just before onset of symptoms to up until 3 weeks after start of symptoms. Confirmed cases should be excluded until completion of 5 days of recommended antibiotics. Infants, elderly and immunocompromised individuals at increased risk for complications. Symptoms Perianal itching (usually worse at night), irritability, disturbed sleep, secondary infection of the scratched skin. Mode of Transmission Transfer of Enterobius eggs from fingers of infected person to mouth of uninfested person. Period of Communicability Eggs are communicable in the environment at room temperature about 2-3 weeks. Exclusion (Yes or No) and Control Measures No, exclusion is generally not recommended. Daily for several days after treatment: change to clean underwear and bed sheets after bathing, wash linens in hot (131F) water, clean and vacuum living and sleeping areas. Other Information this should be handled and on a case-by-case basis by the appropriate school or regulatory authority. Various symptoms, depending on location of infection: ear, eye, sinus, lungs, blood, joints, or spinal fluid spaces. Outbreaks or cases of invasive disease must be reported to the local health department.
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Ongoing efforts to improve vaccine uptake across the lifespan and among persons at increased risk for vaccine-preventable diseases or their complications should be sustained. Increasing uptake of currently available vaccines supports investments in new vaccines by increasing the projected market for new products. Historically, vaccine innovation has been driven by disease epidemiology, burden, and severity. However, for some high priority vaccine 18 Encouraging Vaccine Innovation: Promoting the Development of Vaccines that Minimize the Burden of Infectious Diseases in the 21st Century targets, public-private partnerships are central to facilitating development. Vaccines for pandemic influenza preparedness or biodefense, such as smallpox and anthrax vaccines, are purchased solely by the government as there is no viable commercial interest or market. Public-private partnerships are important to facilitate development of high-priority products. Conclusion Much progress has been made in understanding the complex scientific issues inherent in making a vaccine; adapting regulatory needs to a changing environment; and supporting policies that facilitate progress and innovation. Catalytic investments in some areas as identified above may further propel innovations toward licensure and delivery. For example, a systematic, evidence-based process to assess and communicate public health needs for new and improved vaccines, including a critical review of disease epidemiology, the merits of individual targets, gaps in information, and efforts to address these gaps could spur innovation. Understanding the issues facing key stakeholders and their respective roles and contributions to the vaccine network could also help unify and focus efforts on several vaccine targets while strengthening the U. As a result of continuous development and innovation, vaccines have had a profound impact, protecting Americans across the lifespan. This report outlines challenges and opportunities facing the vaccine enterprise that, if addressed, could spur continued progress and innovation toward the availability of future vaccines to improve public health in the 21st century. Vaccine Enterprise Components Basic & Applied Research Description Improve the knowledge base regarding the antigenic components of infectious agents, underlying mechanisms of infectious disease, the human immune system, and host-pathogen interactions. Develop the "target product profile", a high level summary of characteristic traits and key features of the product. Develop a clinical program that involves studies in humans to determine the effects of vaccines for safety, immunogenicity, and efficacy through a staged process. Product Development* Regulatory Evaluation and Licensure Recommendations Provide recommendations for use to indicate which civilian populations for Introduction should receive a vaccine and under what conditions. Vaccine Uptake Support the immunization delivery system to ensure all individuals across the lifespan have access to the Advisory Committee on Immunization Practice-recommended vaccines and vaccinations and monitor the impact of vaccine uptake, safety, and effectiveness. The entire portfolio of vaccines in clinical development in the United States is available at clinicaltrials. The table provided here is reproduced from the source and include only infectious disease vaccine candidates. In order to receive an orphan designation, a qualifying drug or biologic must be intended for the treatment, diagnosis, or prevention of a rare disease or condition that affects usually fewer than 200,000 people in the United States. Phase 1-Researchers test the investigational drug or biologic in a small group of people, usually between 20 and 100 healthy adult volunteers, to evaluate its initial safety and tolerability profile, determine a safe dosage range, and identify potential side effects. Phase 2-The investigational drug or biologic is given to volunteer patients, usually between 100 and 500, to determine whether it is effective, identify an optimal dose, and to further evaluate its short-term safety. Phase 3-The investigational drug or biologic is given to a larger, more diverse patient population, often involving between 1,000 and 5,000 patients (but sometimes many more), to generate statistically significant evidence to confirm its safety and effectiveness. Breakthrough Therapy designation is based on the Designation following criteria: 1) the product is intended to be used alone or in combination with one or more drugs to treat a serious or life-threatening disease or condition and 2) Preliminary clinical evidence indicates that the product may demonstrate substantial improvement on a clinically significant study endpoint(s) over available therapies. The Food and Drug Administration Modernization Act of 1997 mandates the Agency to, at the request of the sponsor, facilitate the development and expedite review of drugs, including biological products, intended to treat serious or life-threatening diseases or conditions and that demonstrate the potential to address unmet medical needs. Fast Track adds to existing programs, such as accelerated approval, the possibility of a "rolling review" for an application. Numerous vaccines have been approved that received Fast Track Designation, including vaccines for the prevention of cervical cancer and cholera. Numerous vaccines have been approved that had Priority Review status, including vaccines to prevent cervical cancer, invasive meningococcal serogroup B disease, cholera, and pneumococcal conjugate vaccines. Such approval may be subject to verification of clinical benefit through additional studies conducted after approval (Phase 4 studies). Since its creation, the accelerated approval program has been used to approve numerous vaccines, including those to prevent influenza, Haemophilus influenzae Type b (Hib) and invasive meningococcal disease caused by Neisseria meningitidis serogroup B. Table 4: Innovative Regulatory Mechanisms Mechanism Animal Rule Description In 2002, a rule was promulgated that allows animal efficacy data to be used as a basis for approval, when human efficacy studies are not ethical or feasible to conduct. The use of anthrax vaccine for the prevention of anthrax after suspected or confirmed exposure to Bacillus anthracis when used with recommended antimicrobial therapy was approved using the Animal Rule pathway.
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An intestinal disorder characterized by watery diarrhea and abdominal cramps in the majority of cases, Isolation of Vibrio parahaemolyticus from a and sometimes with nausea, vomiting, fever and headache. The disease appears 12 hours to 3 days after eating raw or undercooked seafood, especially oysters. One third of patients are in shock when they present for care or develop hypotension within 12 hours after hospital admission. Three quarters of patients have distinctive bullous skin lesions; thrombocytopenia is common and there is often evidence of disseminated intravascular coagulation. Vibriosis, other or unspecified 1, 8 An infection of variable severity characterized by diarrhea and vomiting, primary septicemia, or wound Isolation of a species of the family Vibrionaceae 11540 infections. Asymptomatic infections can occur, and the organism can cause extraintestinal infections (other than Vibrio parahaemolyticus, Vibrio Probable: A clinically compatible case that is epidemiologically linked to a confirmed case Confirmed: A case that meets the laboratory criteria for diagnosis Probable: A clinically compatible case that is epidemiologically linked to a confirmed case vulnificus, and toxigenic Vibrio cholerae) from a clinical specimen. Genera in the family Vibrionaceae currently include Aliivibrio, Allomonas, Catenococcus, Enterovibrio, Grimontia, Listonella, Photobacterium, Salinivibrio, and Vibrio. Confirmed: A clinically compatible case that is laboratory confirmed Probable: A clinically compatible case with supportive serology: Stable elevated antibody titer to yellow fever virus. The case definitions and criteria are partially or fully taken from the following sources as noted: 1 Centers for Disease Control and Prevention web. An initial focused review of the history and physical examination, followed by a detailed history, investigations and management, is necessary to identify the etiology of the bleeding and aid in its treatment. Occult bleeding presents with fatigue, iron-deficiency anemia, or is identified when stool is tested in a child with other symptoms, such as abdominal pain or vomiting. Evaluation by the emergency physician begins with a quick assessment of the patient to decide the level and urgency of the intervention. An important consideration is to make sure that what appears to be blood, really is blood. Certain foods and medications can certainly alter the color of the emesis or stool, and even an experienced individual could mistake this for blood and prompt unnecessary investigations in a child. Substances that may give red color to stool or vomitus include ingested red candies, fruit punch, beets and medications such as rifampin, whereas black color could be from bismuth, iron, charcoal and foods such as spinach and blueberries . Stool or vomitus is tested for blood by using the widely available guaiac test, which changes color in the presence of hemoglobin. Early consultation with a pediatric gastroenterologist, either in the emergency department or after admission to the hospital, should be considered for a child with significant bleeding, which is defined as: the presence of large clots in the emesis or stool, in addition to melena; a drop of hematocrit by more than 10%; or tachycardia, diaphoresis, orthostatic changes or any suggestion of portal hypertension or liver disease. However, they should also have carried out a quick assessment of symptoms, such as abdominal pain, weight loss or jaundice, and also be aware of any significant family history, such as inflammatory bowel disease in a hospitalized child. Different etiologies cause bleeding at different ages in children, from newborn to adolescents. In patients who present with hematemesis, a history of heartburn, chest pain, epigastric pain or frequent regurgitation may suggest erosive esophagitis or peptic ulcer disease. A history of liver disease, such as biliary atresia, could point towards variceal bleeding. The differential diagnoses of rectal bleeding depend on the character of blood, age of the patient, and other associated symptoms. In a younger child who presents with intermittent crying, lethargy and vomiting with acute hematochezia, it may suggest intussusception. Vomiting, frequently bilious, with rectal bleeding suggests mid-gut volvulus from malrotation. A child who presents with diarrhea and rectal bleeding may have colitis of infectious etiology, or as a result of inflammatory bowel disease. Rectal bleeding is a frequent presentation of allergic colitis from milk-protein intolerance in infancy .
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Smoking Cessation and Cerebrovascular Disease Cerebrovascular disease results from interruptions in the flow of arterial blood to the brain, resulting in a syndrome of mild-to-severe neurologic deficits. In the United States, cerebrovascular disease is the fifth leading cause of death (Kochanek et al. Ischemic stroke, which results from an obstruction in a blood vessel that blocks the supply of blood to the brain, accounts for an estimated 87% of strokes in the United States (Benjamin et al. From 2014 to 2015, the annual direct (medical) plus indirect costs of stroke in the United States was estimated to be $45. Heidenreich and colleagues (2011) projected that the direct (medical) cost of stroke will increase by 238% from 2010 to 2030. Several pooled studies or meta-analyses have found that smoking cessation is associated with a reduced risk of stroke or stroke mortality (Table 4. Peters and colleagues (2013), in a metaanalysis of prospective cohort studies from around the world that were published between January 1, 1966, and the Health Benefits of Smoking Cessation 239 A Report of the Surgeon General Table 4. There was no evidence of a difference in the benefit of smoking cessation between women and men. This analysis did not evaluate the relationships between risk of stroke and smoking duration or time since quitting. Compared with current smokers, there was a dose-response relationship, with risk decreasing among former smokers as years since cessation increased (Table 4. Similarly, Thun and colleagues (2013a) reported that smoking cessation reduced rates of death from stroke in two older and five contemporary cohorts restricted to men and women 55 years of age or older (Table 4. Risk of stroke mortality among former smokers tended to decrease as time since cessation increased. Similarly, in a large cohort study of women in the United Kingdom, most of the benefit from cessation occurred among those who had quit at younger ages (Table 4. Compared with current smokers, risk of cerebrovascular-disease mortality decreased among former smokers with increased time since cessation (from fewer than 5 years to 20 or more years). The Strong Heart Study, a population-based cohort recruited from 13 American Indian tribes/communities, found that current and former smokers had an increased adjusted hazard of stroke compared with never smokers (Zhang et al. In a meta-analysis of persons with diabetes mellitus, former smokers did not have an increased risk of stroke compared with never smokers (Pan et al. In a fixed-effects model, they estimated that the excess risk of stroke associated with smoking decreased by 50% after 4. There was considerable unexplained heterogeneity in the results, however, making a definitive conclusion challenging; the random-effects estimate for a 50% reduction was 3. Some of the studies in this meta-analysis assessed amount smoked or time since cessation or examined subtypes of stroke. Those the Health Benefits of Smoking Cessation 243 A Report of the Surgeon General Table 4. This study also found a pattern of lower risk for former smokers with lower levels of prior smoking intensity. The study, however, may have been biased because of faulty recall of smoking history and selection of controls who were siblings, friends, or neighbors. A similar pattern, although not statistically significant, was observed for hemorrhagic stroke. Compared with heavy smokers, former smokers who had stopped smoking for a longer period of time had lower adjusted hazards of all types of strokes. In a hospital-based case-control study comparing patients with ruptured aneurysms against controls with unruptured aneurysms, the adjusted odds of ruptured cerebral aneurysm were 1. After 10 years of cessation, former smokers tended to have the same hazard of these cerebrovascular-disease outcomes as never smokers (not shown in table).