An Ounce of Prevention

Preventive health is one of the most important and most neglected topics in modern health care. We can save millions of lives and millions of dollars by helping patients change unhealthy behaviors, but most medical schools provide inadequate teaching in preventive health. Prevention is an especially important part of primary care; generalist physicians have many opportunities to identify disease risk factors and encourage patients to change their behavior so they can live longer, healthier lives. In order to provide a foundation in the basics of prevention and a framework in which to apply preventive medicine in our clinical experiences, this Project-in-a-Box will answer the following questions:

• What is preventive health?
• Is prevention important? Is it effective?
• How can medical students practice prevention?
• Student Organizer's Guide

Along with information about preventive health, this Project-in-a-Box provides suggestions for activities designed to teach medical students about the basics of prevention and help them to understand and practice preventive medicine. It also gives tips on how to find speakers for your activities, key questions to ask them and where to find more information on the topic. Use your own ideas and the suggestions below to create a fun and informative preventive health activity.

Suggested Activities
Take a look at your school's curriculum and activities and decide what is missing in terms of preventive health. You may decide that a general preventive framework may be the missing link or that specific preventive topics, such as breast feeding, substance abuse and lead poisoning, are not being addressed. The following activities can help fill these gaps.

• Organize a talk over lunch or dinner with generalists involved in preventive care. Invite primary care physicians (pediatricians, family physicians, obstetricians/gynecologists and general internists) to discuss how they practice preventive medicine. Ask a panel of physicians to discuss their different experiences with prevention or ask individual physicians to discuss their approach to prevention in detail. Consider including an interactive component in these presentations, such as a discussion of the case studies in this Project-in-a-Box, or role plays with sample patients. Don't forget food; if you can provide it, it will increase attendance dramatically.
• Plan a seminar series focusing on information and skills important in preventive care. Teach the basics of prevention and then apply this knowledge to clinical situations. Each part of your preventive health series can build on the last event by teaching students the philosophy of prevention and providing tools for its integration into clinical medicine. Organize discussions and workshops on any combination of the following:

1. The importance and impact of preventive care as well as the basic skills needed to integrate prevention into clinical practice.
2. The epidemiology of risk factors and how to target appropriate preventive messages to specific populations.
3. The implementation of prevention using case studies, role plays and discussions. See the case studies later in this Project-in-a-Box.
4. The different strategies for helping patients change behavior. There are specific tools that can improve results with preventive messages. Learn about them, and then practice with cases or role plays.

• Develop a project focusing on preventive health, such as smoking cessation, HIV/AIDS or violence prevention. This can be based in your community or dedicated to educating other medical students about these topics. Contact the AMSA Resource Center at (703) 620-6600, ext. 217, for materials that can help you start up any of these projects. Also contact any of AMSA's issue-oriented task forces at (703) 620-6600, ext. 212, to receive more information on specific preventive health topics, such as Nutrition and Preventive Medicine or Child and Adolescent Health.
• Advocate for prevention in your school's curriculum. Does your school teach enough about prevention? Preventive medicine and public health will be fundamental to medicine in the 21st century and our schools have a responsibility to prepare us to be competent, responsible physicians. Talk with faculty members interested in preventive medicine, get a group of students together to investigate prevention and curricular reform, do some research on how other medical schools teach prevention, and present your ideas to administrators in charge of curricula.
• Host a slide show on careers in preventive medicine. The American College of Preventive Medicine (ACPM) has developed a slide show on professional opportunities in preventive medicine. It was sent to a faculty contact at each U.S. medical school; call the ACPM at (202) 466-2044 for the name of your school's contact person.
• Learn about preventive health policy. Find out about important preventive health issues that are included in local, state or federal legislation. You can educate your fellow students about current legislation, lobby for state or federal support of preventive medicine, or get involved in preventive projects in your state. Call the AMSA Legislative Affairs Director at (703) 620-6600, ext. 211, for more information.

Topics for Speakers

• Prevention success stories
• How they integrate prevention into their practices
• Particular areas of interest, such as adolescent pregnancy, smoking cessation, cardiovascular health, cancer prevention, depression, injury prevention or HIV/AIDS
• Characteristics of the community and preventive messages especially important in their particular community
• How students can learn more about prevention

Additional Speakers
In addition to generalists, you can invite other health professionals who are knowledgeable in preventive health topics, such as:

• Psychiatrists and psychologists, who often have expertise in behavior modification
• Behavioral medicine specialists, who can provide you with specific strategies to use in helping patients change their behavior
• Social workers, public health nurses and health educators
• Local health department staff, who can talk about the department's preventive projects and how students can get involved
• Community outreach workers or local clinic staff who work in the community teaching about preventive care

Definition

Preventive medicine: encompasses health promotion and disease prevention, as well as epidemiology aimed at identifying risk factors within communities and populations so that they can be targeted for clinical intervention.

Epidemiology: an investigation of the occurrence and distribution of disease.

Health promotion: anything that supports behavior or an environment conducive to health; encouraging all patients to exercise regularly is a form of health promotion.

Disease prevention: includes primary, secondary and tertiary prevention.

Primary prevention: reducing potential for disease in someone who does not have a specific disease but may develop it in the future; for example, routine immunizations in healthy children.

Secondary prevention: identifying and treating a person who has no symptoms of disease but who has risk factors or very early stages of disease that cannot be detected by the patient; for example, pap smears to detect early forms of cervical cancer.

Tertiary prevention: treating symptomatic patients in an effort to decrease complications or severity of disease; for example, antibiotics given to prevent wound infections, and careful sugar control in a diabetic in order to prevent vision, kidney and nerve problems.1

What is preventive health?
Prevention is based on the belief that it is better to avoid having a disease or disability than to treat one. It makes sense to encourage patients to quit smoking now rather than to say nothing and treat them for lung cancer in 20 years. It is medically and financially advantageous to keep a diabetic's blood glucose in careful control to minimize the complications of diabetes rather than allow big swings in glucose levels with the knowledge that patients will suffer in the future as a result. And it is good medicine to recommend that all patients use seat belts and car seats because auto accidents are a significant cause of death and disability, especially in children and young adults.

Prevention takes many forms: public service announcements, screening questions asked by a health professional at an office visit, routine labs performed during a periodic exam. Physicians can play an active role in many components of preventive medicine, from encouraging all patients to exercise and eat a healthy diet to appearing on radio talk shows to discuss the health hazards of smoking or talking with parents about how to make a home safer for a toddler.

As medical students, we can learn the basics of prevention and integrate a preventive perspective into our every-day clinical encounters. This will help ensure that when we enter a busy clinical practice, we will consider prevention an important part of basic health care. Working closely with partners in nursing, public health, social services and other health professions, we will identify patients at risk for disease in order to recommend behavior modifications and medical therapies designed to minimize their risk.

Preventive Medicine and Public Health
Preventive medicine is rooted in public health: taking a population-based perspective in order to identify risk factors for disease and populations who commonly have these risk factors. Physicians then apply this population perspective to individual patients by screening for those risk factors and diseases most likely to affect the patient given age, gender, race and other demographic and lifestyle characteristics.

For example, lead poisoning is caused by ingestion or inhalation of lead paint dust and is most commonly found in children who live in housing built before 1950. Physicians familiar with their communities know the relative risk of lead poisoning. In the western U.S., where most houses were built after World War II, lead poisoning is uncommon. This is in contrast to New England, where lead poisoning is very common, especially in poor neighborhoods where older houses have not been replaced or repaired. Physicians practicing in high-risk areas can ensure that patients receive regular screening blood tests, the frequency of which are usually mandated by state law or the local Department of Health. Doctors can also be especially vigilant for signs of lead poisoning and ask families the age of their home and if there are any signs of peeling paint.

Epidemiology also plays an important role in recommendations for cancer screening. For example, because breast cancer most often occurs in older women, experts recommend mammography every one or two years for this population. Although the age at first mammography is currently under debate, all experts recommend that women receive regular mammography after the age of 50. This recommendation is based on clinical research: there is conclusive evidence that mammography in women over 50 years of age is beneficial, resulting in a 20-30% reduction in breast cancer deaths. The evidence of a benefit from mammography in younger women is less conclusive.2 Therefore, some professional groups recommend mammography beginning before age 50,3,4 and others recommend a first mammography at 50 years of age unless a patient has other reasons for early mammography, such as breast cancer risk factors.1

Prevention and Medical Education
In a 1993 study conducted by the Association of American Medical Colleges, 44% of graduating medical students reported inadequate exposure to health promotion and disease prevention, and 46% found deficiencies in the public health and community medicine curriculum.5

Medical schools continue to give inadequate attention to prevention, despite the rising importance of preventive care in all areas of medicine. Medical students will be unprepared to practice the type of medicine that is demanded of them upon graduation. Furthermore, if they are not taught to include preventive care in their basic definition of medical care, they will be unable to advocate for a stronger emphasis on prevention. As a result, millions of patients will continue to suffer from preventable disease and disability because their physicians are not trained to focus on prevention.

Students must learn prevention as a foundation of medicine instead of as an "add-on." In the rare instances that schools address preventive medicine, it is often presented in classes separate from the basic medical sciences rather than integrated into the overall curriculum. Diagnosis and treatment of illness is still emphasized above all other clinical strategies.

Preventive Guidelines and Goals
Preventive guidelines help us deliver the right preventive messages to the right population. The United States Preventive Services Task Force has studied the efficacy of different preventive measures and published the Guide to Clinical Preventive Services. This guide summarizes which preventive efforts are scientifically proven to be important for health promotion and disease prevention and which strategies are most effective in encouraging healthy behaviors.

Many medical societies also publish prevention guidelines. Although each group's specific recommendations vary, the overall message is clear: prevention is fundamental to good health and physicians must ensure that patients receive appropriate screening and counseling.

Healthy People 2000, published by the U.S. Department of Health and Human Services (DHHS), details the preventive goals for the year 2000. For example, a mental health goal is to "increase to at least 45% the proportion of people with major depressive disorders who obtain treatment (baseline: 31% in 1982)."7 A maternal and infant health goal is to "reduce the infant mortality to no more than 7 per 1,000 live births (baseline: 10.1 per 1,000 live births in 1987)."7 The U.S. Public Health Service has created the Put Prevention Into Practice initiative, which provides preventive health materials to patients and physicians.

Prevention and Managed Care
Preventive medicine has a complex relationship with managed care. On the one hand, it is in a managed care organization's best interest to prevent disease in patients in order to minimize disease and disability and therefore decrease long-term costs. On the other hand, a managed care organization may not see a return on its investment because the patient may no longer be a part of that organization by the time the patient requires care for a preventable disease. In this case, the time and money invested in counseling patients about prevention could have been used to increase the organization's profit.

Some managed care organizations choose not to emphasize prevention, while others integrate prevention into all patient care. Those organizations that emphasize preventive care have many opportunities to improve the effectiveness of prevention, both within their organizations and throughout the U.S. health care system. The structure of managed care can increase use of preventive services: a computerized system can remind practitioners of appropriate preventive messages for each patient; a patient's risk factors and behavior change can be tracked; and the large population served facilitates studies of the efficacy of preventive measures.

Is prevention important? Is it effective?
Preventable disease and disability exact an enormous toll on our patients and our society. Nearly one million people die a year from preventable causes, and many more are disabled by preventable disease and injury. The financial impact of preventable disease and disability is also enormous. According to one study, tobacco, alcohol and illicit drug use cost a total of $238 billion in the United States in 1990.12 This figure included medical expenses, lost productivity and other costs attributable to substance use.

Smoking is considered the single most important prevention issue. If physicians have to choose one preventive message, it should be smoking cessation. Smoking is a primary cause in 87% of all lung cancers, and lung cancer is the leading cause of cancer death in men and women.13 Smoking has also been associated with cancer of the mouth, pharynx, larynx, esophagus, pancreas, bladder and kidney, and with respiratory illnesses, including chronic obstructive pulmonary disease, pneumonia and asthma. Children who are frequently exposed to second-hand smoke also suffer unnecessary illness, with higher long-term rates of lung cancer and increased susceptibility to respiratory infections.14

Does behavior change make a difference?
Changes in lifestyle can have a dramatic effect on a patient's risk of serious disease. The Lifestyle Heart Trial studied the impact of behavior modification on heart disease. Recommendations designed to minimize risk factors for heart disease included a low-fat vegetarian diet, moderate aerobic exercise, stress management training, smoking cessation, and group support. When compared to controls, patients who followed these recommendations experienced less frequent and less severe angina, their serum cholesterol decreased, and the blockage of their coronary arteries decreased significantly.15

Prevention can also save money. Immunizing children against measles, mumps and rubella can save about $14 in treatment for every dollar spent on immunizations.16 By increasing use of bicycle helmets, which dramatically reduce the incidence of head trauma, approximately $200 million can be saved a year.17 Programs that reduce smoking during pregnancy can save more than $6 for each dollar spent by decreasing the number of babies born with low birth weight or developmental delays.18 In the long run, quitting smoking also saves money: lifetime medical costs for cigarette smokers are approximately $10,000 more than for nonsmokers.

Do physicians practice prevention?
Despite the proven medical and economic benefits of preventive care, physicians do not practice adequate prevention. Some aspects of prevention seem to be well incorporated into every-day medical practice, but in fact, not all physicians perform the most basic of preventive services all the time. Immunizations, which seem to be an automatic part of all child health care, are administered to approximately 90% of children in the U.S. In 1991, the percentage of infants who had received the appropriate immunizations against diphtheria, tetanus and pertussis (DTP) were lower in the United States than in any other industrialized country, with the exception of Ireland and Greece.19 In 1993, 88% of children ages 19-35 months had received adequate DTP immunizations, and 79% had been immunized against polio.9 Clearly, there is room for improvement with even the most basic preventive issues.

Adult patients also receive inadequate preventive services. In 1993, only 71% of all adults had ever had their cholesterol checked, and cholesterol screening rates were even lower among some minority patients: 55% for low-income adults and 60% for Native Americans.9 In addition, a single dose of a vaccine against pneumoccocus, which causes pneumonia and other diseases, is recommended for everyone over age 65. In 1993, 28% of people over 65 had received the vaccination; and only 18% of low-income patients, 14% of African Americans and 13% of Hispanic Americans had received the vaccination.9

Success with smoking counseling is equally poor: 44-72% of patients who smoke are advised to cut down or quit smoking by their physician.20,21,22 In one study, even if patients saw a doctor more than 10 times in a year, only 53% of them had been advised to quit. Patients with cardiovascular risk factors, including obesity, diabetes and hypertension, were no more likely to have been advised to quit smoking.21

History of Prevention
Prevention has had a dramatic influence on health and disease in the United States. During the early 1900s, infectious diseases were the main causes of death and disability throughout the world. As a result of the discovery of antibiotics, the wide use of immunizations, and better sanitation and housing conditions in the U.S., we have controlled some deadly infections and eradicated others, such as polio and small pox. Injuries, cardiovascular diseases and cancer are now the leading causes of morbidity and mortality in the U.S.

We have made significant progress in other areas of preventive health in the last 30 years. In 1964, 40% of the U.S. population smoked cigarettes; as of 1993, only about one fourth of the population smoked.8 In addition, cancer screening has become more common. The number of women over age 50 who had a mammogram in the last two years doubled between 1988 and 1993; and in 1993, 95% of women over 18 had a gotten pap smear during their lifetime, compared to 88% in 1988.8,9

Health statistics in the United States have paralleled this increase in prevention. Between 1940 and 1992, life expectancy at birth increased from 63 to almost 76 years, and between 1950 and 1992, infant mortality rates fell from 29 per 1000 live births to 8.5 per 1000 live births.10 Between 1979 and 1992, behavior changes contributed to decreases in the age-adjusted death rates for heart disease (28% reduction), cerebrovascular disease (37% reduction) and injuries (32% reduction).9

Do preventive messages make a difference?
Physician advice and counseling have a demonstrable effect on patient behavior. For example, brief smoking cessation counseling from physicians has been shown to result in a 5% to 10% long-term quit rate. Patients who drink excessive amounts of alcohol reduced their alcohol consumption 6% to 19% after one 10-minute counseling session with their physician.23

The most important thing we can do for our patients is integrate preventive messages into our daily practice and stay consistent in those messages. One study that reviewed smoking cessation efforts across the U.S., found that the continuous and consistent message to quit was the best predictor of the patient's success; "Success...was the product of personalized smoking cessation advice and assistance, repeated in different forms by several sources over the longest feasible period."24 There was no evidence that "any particular intervention strategy is uniformly more effective than firm, consistent, and repeated help and advice to stop smoking."24

How can medical students practice prevention?
As students, we have many opportunities to apply the tools of prevention. During a medical interviewing course, we can include questions about preventive topics such as smoking, family violence, diabetes control and injury prevention. During a physical diagnosis class, we can ask similar questions as well as identify the physical findings that are manifestations of preventable disease and disability, including asthma exacerbation in children of smokers, cardiac murmurs from infection of the heart valves in an intravenous drug user, and malignant melanoma due to unprotected sun exposure. The clinical years offer a wealth of opportunities to practice prevention, from discussing cancer risk factors with patients to explaining the risks and benefits of immunizations with parents and discussing contraceptive options with adolescents. In addition, we can learn more about prevention through electives in preventive and behavioral medicine.

In order to be effective physicians, we must learn to integrate the philosophy of prevention into our basic approach to medicine. Prevention should be an integral part of every patient encounter. Even when a patient comes to us for a sick visit, we can discuss preventive issues for a minute or two after we have addressed the acute complaint. Many patients only see physicians when they are sick, so these encounters are important opportunities to discuss prevention. During patients' periodic physicals, we can include an analysis of their current risk factors and discuss how behavior change can lead to a longer and healthier life.

A comprehensive approach to preventive medicine includes:

• Epidemiology of preventable disease and disability
• Identification of risk factors through history taking, physical exam and lab tests
• Counseling patients about the importance of prevention
• Counseling in specific strategies for behavior modification

The basic approach we take to working with patients is more important than the specific strategies used. In order to motivate patients to change, we must thoroughly understand their concerns and work to design preventive strategies to meet their specific needs. This "patient-centered approach" will be more effective and more rewarding for patients and physicians alike.

Barriers to Practicing Prevention
If preventive medicine is so effective in improving patients' health, why don't more physicians include comprehensive preventive care in their practices?

• Many physicians have little knowledge and minimal training in prevention. They are unaccustomed to asking screening questions during routine office visits and are unaware of the appropriate questions to ask different patients and the schedule for screening tests.
• The office environment is not designed to maximize prevention opportunities. Patients often come to the doctor because they are sick and during the visit, physicians focus only on the immediate problem. Unless patients return for a general exam, they are never evaluated or counseled regarding risk factors for preventable disease.
• Many physicians doubt the effectiveness of preventive medicine. They are unaware that multiple studies have demonstrated that preventive screening and counseling have a significant impact on patient behavior and health.
• Prevention activities are not reimbursed at the same rate as procedures and laboratories. Many physicians in a busy office practice feel unable to devote the time necessary to make prevention effective.9

There are many tools designed to overcome the barriers to prevention in clinical practice. Computerized reminder systems track practice patterns and ensure that patients receive appropriate screening and counseling at the right time. Health-risk appraisals summarize a patient's modifiable risks based on a survey filled out by the patient. Chart reminders call attention to patient risk factors and routine preventive messages that need to be addressed. Many of these tools are new to clinical practice and will be refined as prevention becomes a more integral part of clinical practice. Although helpful, these tools are not a panacea for the current lack of attention paid to preventive medicine. In order to apply the tools effectively, physicians must consider prevention an integral part of medical practice and include preventive care in every patient encounter.

Tools for Implementing Prevention
When we enter practice, we will be part of a team delivering preventive care. Nurses, nurse practitioners, physicians assistants, social workers and other health professionals can also assess patient risk and provide counseling about preventive issues. The most effective strategy for preventive care ensures that all care providers deliver consistent and strong preventive messages.

When discussing prevention with a patient, we can use the following "5As," developed at Brown University School of Medicine:

Address Agenda

• Attend to the patient's agenda
• Explain that you would like to talk about preventive health

Ask

• What does the patient know about the risky behavior and potential for disease?
• How does the patient feel about the behavior?
• Is the patient interested in changing the behavior?
• What are the patient's fears about change?
• Has the patient tried to change the behavior before? What did and didn't work?

It is important to spend adequate time in this stage. Patient counseling is more effective when patients know that the physician understands their perspective. If you have limited time, spend most of it on assessment and then incorporate what you learn into a few words of advice.

Advise

• Tell the patient that you strongly advise behavior change
• Personalize reasons for change (e.g., "By quitting smoking you will help your daughter have fewer asthma attacks.")
• Discuss the immediate and long-term benefits of change

Assist

• Provide accurate, complete information about risk and give the patient written materials to take home
• Address the patient's feelings and provide support
• Address barriers to change
• Discuss steps toward behavior change
• Get attending physicians, residents or preceptors involved for additional support, more extensive advice and referrals

Arrange Follow-up

• Reaffirm the plan
• Schedule follow-up appointment or phone call

For More Information

1. Woolf SH, Jonas S, Lawrence RS. Health Promotion and Disease Prevention in Clinical Practice. Baltimore, MD: Williams & Wilkins, 1996
2. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd Edition. Baltimore, MD: Williams & Wilkins, 1996.
3. U.S. Department of Health and Human Services Public Health Service. Put Prevention Into Practice. National Health Information Center, P.O. Box 1133, Washington, D.C. 20013-1133.
4. American College of Preventive Medicine, (202) 466-2044, 1660 L Street, NW, Suite 206, Washington, DC 20036-5603.

Clearinghouses and Hotlines

Aerobic and Physical Fitness Foundation

(800) BE FIT 86

 

Cancer Information Service

(800) 4-CANCER

 

CDC National AIDS Hotline

(800) 342-AIDS

 

Consumer Product Safety Commission (Injury Prevention)

(800) 638-CPSC

 

National Child Abuse Hotline

(800) 422-4453

 

National Clearinghouse for Alcohol and Drug Information

(800) 729-6686

 

National Council on Aging

(800) 424-9046

 

National Heart, Lung and Blood Institute, Education Programs Center

(301) 951-3260

 

National Highway Traffic Safety Administration, Auto Safety Hotline

(800) 424-9393

 

National Institute for Occupational Safety and Health

(800) 356-4674

 

National Maternal and Child Health Clearinghouse

(703) 821-8955 x254

 

National Mental Health Association

(800) 969-6642

Case Studies
Use these case studies to apply what you have learned about preventive health. You can use them as small group cases in which you discuss the questions listed, or as role plays in which you practice discussing preventive issues with these patients.

If at all possible, have physicians help facilitate your discussion. They can give you a better idea of the challenges encountered when discussing these topics as well as specific medical information about the preventive issues in each case.

Geeta Patel is an obese ,59 year-old woman who comes to your office with a history of severe headaches.

• What additional information do you want from Mrs. Patel?
• What will you do to diagnose and/or treat her headaches?
• What are the preventive issues you want to address in this visit?
• Given her age, gender and obesity, what preventive issues are you particularly concerned about?

Gina, a 14-year-old girl, is beginning high school and needs a general physical exam in order to play field hockey.

• What additional information do you want from Gina?
• What are the most common causes of death, disease and disability in this age group? Is Gina at risk for any of these?
• What preventive topics do you need to discuss with Gina?

Joseph Levno is a 40-year-old man who is changing jobs and needs a physical exam. He quit smoking eight months ago, after smoking a pack a day for 20 years. He drinks occasionally.

• What additional information do you want from Joseph?
• What preventive issues will you address with Joseph?
• Given his age and gender, and the common causes of death, disease and disability in this age group, which preventive topics are especially important?

Sue-lin and Giang bring Alan, their 18-month-old child, in for a well-child check.

• What additional information do you want from Sue-lin and Giang?
• By this age, what immunizations should Alan have received? Is he due for any at this visit?
• What are the common causes of death, disease and disability in this age group? How can you counsel Alan's parents to prevent them?
• What injuries are most common in this age group? How can Sue-lin and Giang make their house safer for a toddler?
• What other preventive issues should you discuss regarding the health of the entire family?

References

1. Adapted from U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams & Wilkins, 1996.
2. Kerlikowske K, Grady D, Rubin SM, Sandrock C, Ernster VL. Efficacy of screening mammography: a meta-analysis. JAMA 1995;273:149-154
3. American College of Obstetricians and Gynecologists. The Obstetrician-Gynecologist and Primary-Preventive Health Care. Washington, DC: American College of Obstetricians and Gynecologists, 1993.
4. American Academy of Family Physicians. Age Charts for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians, 1994.
5. Association of American Medical Colleges. Roles for Medical Education in Health Care Reform. Acad Med 1994;69:512-515
6. Scutchfield FD, Hartman KT. Physicians and preventive medicine. JAMA 1995;273:1150-1151
7. U.S. Department of Health and Human Services, Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: U.S. Government Printing Office; 1990.
8. McGinnis JM, Lee PR. Healthy People 2000 at the mid decade. JAMA 1995;273:1123-1129
9. Woolf SH, Jonas S, Lawrence RS. Health Promotion and Disease Prevention in Clinical Practice. Baltimore, Md: Williams & Wilkins, 1996.
10. Kochanek KD, Hudson BL. Advance report of final mortality statistics, 1992. Monthly Vital Statistics Report April 1995;43(suppl):1-73
11. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 993;270:2207-2212
12. Brady K. Prevalence, consequence and costs of tobacco, drug and alcohol use in the U.S..Training About Alcohol and Substance Abuse for All Primary Care Physicians Conference Proceedings. New York, NY: Macy Foundation, 1995
13. American Cancer Society. Cancer Facts and Figures 1992. Atlanta, Ga: American Cancer Society, 1992
14. Janerich D, Thompson W, Varela L. Lung cancer and exposure to tobacco smoke in the household. N Engl J Med 1990;323:632-636
15. Ornish, D, Brown SE, Scherwitz LW. Can lifestyle changes reverse coronary heart disease? Lancet 1990;336:129-133
16. White CC, Koplan JP, Orenstein WA. Benefits, risks and costs of immunization for measles, mumps and rubella. Am J Public Health 1985;75:739-744
17. Rice DP, MacKenzie EJ, and associates. Cost of Injury in the United States: A Report to Congress. San Francisco, Calif and Baltimore, Md: Institute for Health and Aging, University of California, and Injury Prevention Center, The Johns Hopkins University, 1989.
18. Marks JS, Koplan JP, Hogue CJR, Dalmat ME. A cost-benefit/cost-effectiveness analysis of smoking cessation for pregnant women. Am J Prev Med 1990;6:282-289
19. World Bank. World development report 1993. Washington, DC: World Bank, 1993.
20. Anda RF, Remington PL, Dienko DG, Davis RM. Are physicians advising smokers to quit? The patient's perspective. JAMA 1987;257:1916-1919
21. Frank E, Winkleby MA, Altman DG, et al. Predictors of physicians' smoking cessation advice. JAMA 1991;266:3139-3144
22. Gilpin EA, Pierce JP, Johnson M, Bal D. Physician advice to quit smoking: results from the 1990 California tobacco survey. J Gen Intern Med 1993;8:549-553
23. Anderson S, Scott E. The effect of general practitioners' advice to heavy drinking men. Br J Addict 1992;87:891-900
24. Kottke TE, Battista RN, DeFriese GH, et al. Attributes of successful smoking cessation interventions in medical practice: a meta-analysis of 39 controlled trials. JAMA 1988;259:2883-2889

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