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Try out PMC Labs and tell us what you think. Learn More. Little smoking research in the past 20 years includes persons 50 and older; herein we describe patterns of clinician cessation advice to US seniors, including variation by Medicare beneficiary characteristics. We estimated smoking rates and the proportion of smokers whose clinicians encouraged cessation. Smoking cessation advice to seniors is variable.

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Providers may focus on groups or areas in which smoking is less common or when they are most comfortable giving advice. More consistent interventions are needed, including cessation advice from clinicians.

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Quitting smoking at any age reduces morbidity and mortality associated with smoking Allen, ; National Cancer Institute, ; Taylor et al. Cessation for older smokers is associated with greatly reduced risk of myocardial infarction and cerebrovascular accidents, and has other short-term benefits e. An important public health goal, then, is to assist older smokers with quitting. While some have found that smokers over 50 are as motivated to quit as younger smokers Hall et al.

Brief cessation interventions by physicians or other health care providers can effectively help older smokers quit Morgan et al. However, most providers do not offer smoking cessation treatments Centers for Disease Control and Prevention,especially for older smokers Allen, and those suffering from a smoking-related disease like lung cancer Wassenaar et al. Barriers to physician adherence to clinical practice guidelines include lack of awareness and familiarity with guidelines, poor self-efficacy, belief that recommendation will not lead to desired outcome, little office support, limited counseling skills, and inability to overcome the inertia of practice; patient barriers include lack of motivation or interest in quitting Cabana et al.

More research on the national prevalence of provider cessation advice is needed. Past research has used convenience samples of smokers already enrolled in smoking cessation trials Ossip-Klein et al. In this study we examine the prevalence of smoking and predictors of clinician smoking cessation advice in a nationally representative sample of US adults age 65 and older. These analyses focus on a nationally representative sample of Medicare beneficiaries age 65 and older living in the 50 states and Washington, DC.

We describe patterns of current smoking and assess whether smokers were advised to quit during medical visits. Among smokers, responses regarding cessation advice were linearly rescaled to a 0— possible range. Smokers with no medical visits in the past 6 months were excluded from the cessation advice analyses. Among current smokers with a recent medical visit, we estimated the mean of the cessation advice item by the beneficiary characteristics listed above, as well as by confidence in the ability to identify need for medical care, health characteristics self-reported general and mental health, history of six specific chronic conditions and smoking intensity daily versus less often than daily.


A sensitivity analysis included interactions of beneficiary characteristics with the daily smoking indicator to test whether predictors of cessation advice differed for those who smoked daily versus less frequently. Analyses were completed in Data fromsenior Medicare beneficiaries are used for the analyses, of whom 9. The plan-level intraclass correlation ICC coefficient for the cessation advice item is 0. Table 1 presents smoking rates by beneficiary and coverage characteristics. Men are more likely to smoke Smoking decreases with age from Rates are highest among American Indians Rates are highest in the East South Central census division Low-income seniors eligible for Medicaid smoke more often The small proportion of seniors without a personal physician had a higher smoking rate Beneficiary and coverage characteristics and differences in smoking prevalence by these characteristics a.

Eight percent of smokers had no medical visits in the past 6 months. Table 2 presents unadjusted means of the 0— advised-to-quit scale by socio-demographic, coverage and health characteristics.

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Means and regression coefficients for advised-to-quit smoking scale 0— a by demographic, coverage, and health characteristics bc. Table 2 also presents from simple and multivariate linear regressions of the advised-to-quit item. After adjusting for all other beneficiary and coverage characteristics, differences associated with gender, age, region, having a personal physician, and smoking frequency remain ificant and are similar in size to the differences in the unadjusted means.

The figure also includes the two associated regression lines. For example, API women and New England residents have among the lowest smoking prevalence but those who do smoke in those groups receive especially frequent cessation advice. While women are more likely to receive cessation advice, models stratified by smoking frequency suggest that pattern is limited to occasional smokers.

Similarly, the tendency for more cessation advice for those in worse health is strongest among less frequent smokers. Beneficiaries without a regular physician are much less likely to receive cessation advice; the gap is especially large for daily smokers.

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In this study, 9. These rates are lower than other studies have reported for older adults Schiller et al. Rates were higher among men, younger and low-income Medicaid-eligible seniors, those without a personal physician, and those with less than a high school degree. While these patterns generally mirror those in younger adults, the gender difference is more pronounced than for younger adults Schiller et al. Cessation advice is more frequent for daily smokers perhaps because of greater perceived risk, or because they are more likely to identify themselves as smokers to providers Berg et al.

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These findings replicate other studies Doolan and Froelicher, ; Wassenaar et al. This pattern might indicate that providers are less comfortable challenging smoking they perceive as normative He et al. Alternatively, these negative correlations may simply reflect the greater incidence and effectiveness of cessation advice in certain regions. Given evidence of the efficacy of smoking cessation advice to seniors Rimer and Orleans, and their access to providers through Medicare, these suggest the need for more targeted smoking interventions including provider cessation advice Richmond and Anderson,which is not always emphasized in current physician training Zwar and Richmond, Smokers with lower levels of education 8th grade or less reported receiving less advice from physicians to quit, consistent with other studies finding less access to cessation treatment for such seniors Shiffman et al.

In addition, smoking rates are highest Centers for Disease Control and Prevention, and cessation rates are lowest Barbeau et al.

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Existing brief treatments and pharmacotherapies can be effective in low-education populations Fiore et al. Clinicians should be trained and encouraged to deliver combined brief counseling and pharmacological interventions to all of their patients, particularly those with less education. In addition, clinicians should be informed about the best ways to elicit smoking information, especially from light smokers Berg et al.

Clinicians should be reminded that the population-level effects of brief, consistent cessation advice can be substantial Abrams et al. Incorporating non-physician members of the primary-care team to deliver cessation advice might help overcome the barrier of limited physician time with patients Fiore et al. This study has several limitations. First, measures were self-reported and could be subject to recall biases Hammersley, Recordings of encounters revealed high specificity but lower sensitivity in patient reports of receiving cessation advice Ward and Sanson-Fisher,suggesting that only advice clear enough to be perceived by patients was reported.

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Advice both given and perceived, however, may be the relevant construct, since there is evidence that only physician communication that patients perceive and recall has effects Beckett et al. Second, cessation advice may vary by chronic conditions known to the physician, including terminal illnesses, not measured on the MCAHPS survey.

Third, the optimal frequency of cessation advice is unknown, so the 0— scale used as the primary outcome might not be optimal. Nevertheless, sensitivity tests using a binary never-advised-to-quit indicator resulted in similar findings data not shown. Fourth, the cessation advice item only asks about the consistency of advice in the preceding six months, but does not indicate the frequency of patient counseling for patients with different visit frequencies. Finally, some have speculated that smokers might be less likely to respond to a survey specifically about smoking than non-smokers Davis,but such concerns are unlikely to apply to Medicare CAHPS, a survey of general healthcare experiences.

In addition, we adjusted for the modest differences between responders and non-responders on observed characteristics using nonresponse weighting. This research provides important information about smoking prevalence and cessation advice among adults age 65 and older.

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Inconsistent cessation advice from clinicians indicates a need to emphasize smoking cessation for seniors in clinician training and more intervention with older smokers. No financial disclosures were reported by the authors of this paper. Authors are employed by their deated institutions and have received no further financial support from any organization that might have an interest in the submitted work. Conflict of interest statement. National Center for Biotechnology InformationU. Prev Med. Author manuscript; available in PMC May William G. Shadela Marc N.

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