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Arrieta, Ohlendorf set to square off at Wrigley
Cubs righty making third start with new team; Nats righty back from DL
After an 11-run outburst in their series opener with the Nationals, the Cubs returned to their recent ineffectiveness on Tuesday. They scored two runs on six hits in a 4-2 loss to Washington and fell to 4-13 in their past 17 games at Wrigley Field.
"It's frustrating, to be honest with you," general manager Jed Hoyer said. "I don't know why we haven't played well here."
Perhaps Jake Arrieta will be able to buck the trend on Wednesday. Since being acquired from the Orioles in the deal that sent Scott Feldman to Baltimore, Arrieta has notched two quality starts and is holding opposing hitters to a .095 batting average. In his last outing, a 7-0 win against the Cardinals, he threw seven scoreless innings and only allowed two hits.
"For me, there's no question that this change of scenery and this trade was huge for me and my career. And not only for me, but for the Cubs as well," Arrieta said. "I couldn't be more excited to be here."
Ross Ohlendorf will be activated from the 15-day disabled list to start for the Nationals. The right-hander has been a valuable long reliever in the second half of the season, but he will now start every fifth day in place of Taylor Jordan, who was shut down after his last start as a precautionary measure following Tommy John surgery in 2011. Ian Krol was optioned to Triple-A Syracuse on Tuesday night to make room for Ohlendorf on the 25-man roster.
With a 1.85 ERA, Ohlendorf has been one of the team's most notable bright spots this season. He is 2-0 with a 2.75 ERA in six career starts against the Cubs, but he has a 5.06 ERA in three career starts at Wrigley Field.
"Just trying to do as well as I can whenever I go in," he said. "I feel good and my command has been good."
Cubs: Rizzo, Castro becoming de facto leaders
The Cubs lost another veteran on Monday when 33-year-old David DeJesus was traded to the Nationals. As Chicago has grown younger, two-time All-Star Starlin Castro, 23, and first baseman Anthony Rizzo, 24, have suddenly become two of the more established players on the team.
Rizzo, who signed a seven-year, $41 million contract in May, said that he is not worried about taking on more of a leadership role.
"You just go about your business every day. Work hard, prepare like I always do. And that gains the respect right there in itself," he said. "I'm just going to play hard and gain the respect on the field and in the clubhouse. I'm still young. So you respect your elders and what they've done in this game, and just keep playing the game hard."
Nationals: No suspensions for Strasburg, Johnson
Manager Davey Johnson and Stephen Strasburg will not be suspended after the right-hander's actions Saturday night, according to a league source.
Strasburg plunked Braves outfielder Justin Upton in the first inning and then threw two pitches behind Andrelton Simmons in the second after Nationals outfielder Bryce Harper was hit twice on Friday. However, the Commissioner's office ruled that there wasn't evidence that Strasburg intentionally threw at Simmons, according to the source.
The decision came on the same day that Major League Baseball suspended Red Sox pitcher Ryan Dempster for five games after he hit Alex Rodriguez with a pitch.
"I think that's a great decision," Johnson said. "I was happy to hear that they made a decision on Dempster, and he [hit Rodriguez] on Sunday night and [our game] happened on Saturday, so I figured we weren't probably going to get suspended, at least."
Worth noting
• After blasting five home runs on Monday night, the Cubs joined their opponents -- the Nationals -- as the only National League teams with a five-homer game this season.
• With Tuesday night's victory, the Nationals won their 300th game over the Cubs. In the history of the franchise, they only have more wins against the Mets (375) and Phillies (356).
Tom Schad is an associate reporter for MLB.com. This story was not subject to the approval of Major League Baseball or its clubs.


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Violin: Works for all violin sizes.Viola/Cello: Works for all viola and cello sizesBass: Works for 3/4-1/2 basses.
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Today is: Wednesday, May 6, 2015
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Here at Naturepedic we love babies and want all babies to sleep well. We know a lot about crib mattresses and we're committed to providing safer and healthier mattresses and bedding accessories for our children and our planet.
But we also know that a healthy crib mattress is just the first step in getting a healthy sleep. There are a lot of other factors involved – schedule, sleeping habits, feeding, other environmental issues and other toxics or allergens they may be exposed to, and so on.
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Still hot. And getting more humid, too. But no precipitation.
Still hot. And getting more humid, too. But no precipitation.
"That's what Sheev said."
High 90's, muggy....
[edit] We made it to 100ºF today. That's the 33rd time we've hit that temp (or higher) this year. Very typical for a summer in the San Joaquin Valley.
¡Que la fuerza te acompañe!
Friday is projected to hit at least 106 here, with 100+ temps every day this week except tomorrow (99... gee, thanks Momma Nature). If it's as humid as it's been, plus outrageous temps, I may just quit.
"That's what Sheev said."
Got up to 102ºF today but at least the humidity was down.
¡Que la fuerza te acompañe!
It's saying it's going to be upper 70s and the last day for the foreseeable future like that, so I'm hitting the pool.
Darth Vader is becoming the Mickey Mouse of Star Wars.
"In Brooklyn, a castle, is where dwell I"
The use of a lightsaber does not make one a Jedi, it is the ability to not use it.
Around here, our LOWS are in the low-/mid-70s at night. That's bad, Louie, bad. Might even be a thunderstorm tomorrow. Really?
"That's what Sheev said."


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Federal Power-Shok Centerfire Rifle Ammunition .243 Win 80 gr SP 3330 fps - 20/box
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Summary of Evidence
Note: A separate PDQ summary on Levels of Evidence for Cancer Screening and Prevention Studies is also available.
The cancer prevention summaries in PDQ refer to cancer prevention, defined as a reduction in the incidence of cancer. The PDQ includes summaries generally classified by histological type of cancer, especially when there are known risk factors for the specific types of cancer. This summary addresses a specific risk factor, tobacco use, which is associated with a large number of different cancers (and other chronic diseases) and unequivocally contains human carcinogens.[1] The focus of this summary is on clinical interventions by health professionals that decrease the use of tobacco.
Effects of Smoking Cessation
Based on solid evidence, cigarette smoking causes cancers of the lung, oral cavity and pharynx, larynx, esophagus, bladder, kidney, pancreas, stomach, uterine cervix, and acute myeloid leukemia.[2] Smoking avoidance and smoking cessation result in decreased incidence and mortality from cancer.
Description of the Evidence
- Study Design: Evidence obtained from a randomized controlled trial.
- Internal Validity: Good.
- Consistency: Good.
- Magnitude of Effects on Health Outcomes: The relative risk (RR) of several cancers is much greater in cigarette smokers compared with nonsmokers (depending on the anatomical site of the cancer and the intensity and duration of smoking, the RR can range from twofold to tenfold or greater in smoking populations). A reduction of 15% is seen in the RR of all-cause mortality in heavy smokers subjected to intensive clinical cessation interventions.
- External Validity: Good.
Counseling and Smoking Cessation
Based on solid evidence, counseling by a health professional improves smoking cessation rates.
Description of the Evidence
Physician Advice and Smoking Cessation
Based on solid evidence, simple advice from a physician to stop smoking improves smoking cessation rates.
- Study Design: Evidence obtained from randomized controlled trials.
- Internal Validity: Good.
- Consistency: Good.
- Magnitude of Effects on Health Outcomes: Physician advice improves cessation rates (relative risk [RR], 1.66; 95% CI, 1.42–1.94).[3]
- External Validity: Good.
Drug Treatment and Smoking Cessation
Based on solid evidence, drug treatments, including nicotine replacement therapies (gum, patch, spray, lozenge, and inhaler), selected antidepressant therapies (e.g., bupropion), and nicotinic receptor agonist therapy (varenicline), result in better smoking cessation rates than placebo.
Description of the Evidence
- Study Design: Evidence obtained from randomized controlled trials.
- Internal Validity: Good.
- Consistency: Good.
- Magnitude of Effects on Health Outcomes: Nicotine replacement therapy treatments, alone or in combination, improve cessation rates over placebo after 6 months (RR, 1.58; 95% CI, 1.50–1.66).[5] Treatment with bupropion improves cessation rates over placebo after 6 months (OR, 1.94; 95% CI, 1.72–2.19).[6] Varenicline therapy treatment improves cessation rates over placebo after 6 months (RR, 2.33; 95% CI, 1.95–2.80).[7]
- External Validity: Good.
- IARC Working Group on the Evaluation of Carcinogenic Risks to Humans: Tobacco smoke and involuntary smoking. IARC Monogr Eval Carcinog Risks Hum 83: 1-1438, 2004. [PUBMED Abstract]
- U.S. Department of Health and Human Services: The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, Ga: U.S. Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available online. Last accessed April 24, 2015.
- Lancaster T, Stead L: Physician advice for smoking cessation. Cochrane Database Syst Rev (4): CD000165, 2004. [PUBMED Abstract]
- Lemmens V, Oenema A, Knut IK, et al.: Effectiveness of smoking cessation interventions among adults: a systematic review of reviews. Eur J Cancer Prev 17 (6): 535-44, 2008. [PUBMED Abstract]
- Silagy C, Lancaster T, Stead L, et al.: Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev (3): CD000146, 2004. [PUBMED Abstract]
- Hughes JR, Stead LF, Lancaster T: Antidepressants for smoking cessation. Cochrane Database Syst Rev (1): CD000031, 2007. [PUBMED Abstract]
- Cahill K, Stead LF, Lancaster T: Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev (3): CD006103, 2008. [PUBMED Abstract]
In the United States, smoking-related illnesses accounted for an estimated 480,000 deaths each year.[1,2] (Also available online.) On average, these deaths occur 12 years earlier than would be expected, so the aggregate annual loss exceeds 5 million life-years.[3] These deaths are primarily due to smoking's role as a major cause of cancer, cardiovascular diseases, and chronic lung diseases. The known adverse health effects also include other respiratory diseases and symptoms, nuclear cataract, hip fractures, reduced female fertility, and diminished health status. Maternal smoking during pregnancy is associated with fetal growth restriction, low birth weight, and complications of pregnancy.[4] It has been estimated that about 30% of cancer deaths and 20% of all premature deaths in the United States are attributable to smoking.[1]
Tobacco products are the single, major avoidable cause of cancer, causing more than 155,000 deaths among smokers in the United States annually due to various cancers.[5] The majority of cancers of the lung, trachea, bronchus, larynx, pharynx, oral cavity, nasal cavity, and esophagus are attributable to tobacco products, particularly cigarettes. Smoking is also causally associated with cancers of the pancreas, kidney, bladder, stomach, and cervix and with myeloid leukemia.[4,6]
Smoking also has substantial effects on the health of nonsmokers. Environmental or secondhand tobacco smoke is implicated in causing lung cancer and coronary heart disease.[7] Among children, secondhand smoke exposure is causally associated with sudden infant death syndrome, lower respiratory tract illnesses, otitis media, middle ear effusion, exacerbated asthma, and respiratory effects such as cough, wheeze, and dyspnea.[7]
Environmental tobacco smoke has the same components as inhaled mainstream smoke, although in lower absolute concentrations, between 1% and 10%, depending on the constituent. Carcinogenic compounds in tobacco smoke include the polycyclic aromatic hydrocarbons (PAHs), including the carcinogen benzo[a]pyrene (BaP) and the nicotine-derived tobacco-specific nitrosamine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK).[8] Elevated biomarkers of tobacco exposure, including urinary cotinine, tobacco-related carcinogen metabolites, and carcinogen-protein adducts, are seen in passive or secondhand smokers.[7,9-11]
In 2013, 20.5% of adult men and 15.3% of adult women in the United States were current smokers.[2] (Also available online.) Cigarette smoking is particularly common among American Indians and Alaska Natives. The prevalence of smoking also varies inversely with education, and was highest among adults who had earned a General Educational Development diploma (41.4%) and generally decreased with increasing years of education.[2] (Also available online.) From 2000 to 2011, significant declines occurred in the use of cigarettes among middle school (10.7% to 4.3 %) and high school (27.9% to 15.8%) students.[12] (Also available online.) Cigarette smoking prevalence among male and female high school students increased substantially during the early 1990s in all ethnic groups but appears to have been declining since approximately 1996.[13,14] (Also available online.)
The effect of tobacco use on population-level health outcomes is illustrated by the example of lung cancer mortality trends. Smoking by women increased between 1940 and the early 1960s, resulting in a greater than 600% increase in female lung cancer mortality since 1950. Lung cancer is now the leading cause of cancer death in women.[13,15] In the last 30 years, prevalence of current cigarette use has generally decreased, though far more rapidly in males. Lung cancer mortality in men peaked in the 1980s, and has been declining since then; this decrease has occurred predominantly in squamous cell and small cell carcinomas, the histologic types most strongly associated with smoking.[13] Variations in lung cancer mortality rates by state also more or less parallel long-standing state-specific differences in tobacco use. Among men, the average annual age-adjusted lung cancer death rates from 2001 to 2005 were highest in Kentucky (111.5 per 100,000), where 29.1% of men were current smokers in 1997, and lowest in Utah (33.7 per 100,000), where only 10.4% of men smoked. Among women, lung cancer death rates were highest in Kentucky (55.9 per 100,000), where 28.0% of women were current smokers, and lowest in Utah (16.9 per 100,000), where only 9.3% of women smoked.[13]
- American Cancer Society: Cancer Facts and Figures 2015. Atlanta, Ga: American Cancer Society, 2015. Available online. Last accessed April 1, 2015.
- Jamal A, Agaku IT, O'Connor E, et al.: Current cigarette smoking among adults--United States, 2005-2013. MMWR Morb Mortal Wkly Rep 63 (47): 1108-12, 2014. [PUBMED Abstract]
- Nelson DE, Kirkendall RS, Lawton RL, et al.: Surveillance for smoking-attributable mortality and years of potential life lost, by state--United States, 1990. Mor Mortal Wkly Rep CDC Surveill Summ 43 (1): 1-8, 1994. [PUBMED Abstract]
- U.S. Department of Health and Human Services: The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, Ga: U.S. Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available online. Last accessed April 24, 2015.
- Centers for Disease Control and Prevention: Targeting Tobacco Use: The Nation's Leading Cause of Death 2005. Atlanta, Ga: CDC, 2005.
- Ontario Task Force on the Primary Prevention of Cancer: Recommendations for the Primary Prevention of Cancer. Toronto, Canada: Queen's Printer for Ontario, 1995.
- U.S. Department of Health and Human Services: The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, Ga: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. Also available online. Last accessed January 30, 2015.
- Cinciripini PM, Hecht SS, Henningfield JE, et al.: Tobacco addiction: implications for treatment and cancer prevention. J Natl Cancer Inst 89 (24): 1852-67, 1997. [PUBMED Abstract]
- Finette BA, O'Neill JP, Vacek PM, et al.: Gene mutations with characteristic deletions in cord blood T lymphocytes associated with passive maternal exposure to tobacco smoke. Nat Med 4 (10): 1144-51, 1998. [PUBMED Abstract]
- Benowitz NL: Cotinine as a biomarker of environmental tobacco smoke exposure. Epidemiol Rev 18 (2): 188-204, 1996. [PUBMED Abstract]
- Hecht SS: Human urinary carcinogen metabolites: biomarkers for investigating tobacco and cancer. Carcinogenesis 23 (6): 907-22, 2002. [PUBMED Abstract]
- Centers for Disease Control and Prevention (CDC): Current tobacco use among middle and high school students--United States, 2011. MMWR Morb Mortal Wkly Rep 61 (31): 581-5, 2012. [PUBMED Abstract]
- Jemal A, Thun MJ, Ries LA, et al.: Annual report to the nation on the status of cancer, 1975-2005, featuring trends in lung cancer, tobacco use, and tobacco control. J Natl Cancer Inst 100 (23): 1672-94, 2008. [PUBMED Abstract]
- Johnston LD, O'Malley PM, Bachman JG: Monitoring the Future: National Survey Results on Drug Use, 1975-2001. Volume I: Secondary School Students. Bethesda, Md: National Institute on Drug Abuse, 2002. NIH Pub. No. 02-5106. Also available online. Last accessed February 9, 2015.
- U.S. Preventive Services Task Force: Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. 2nd ed. Baltimore, Md: Williams & Wilkins, 1996.
Evidence of Benefit
Many health risks related to tobacco smoking can be reduced by smoking cessation. Smokers who quit smoking before age 50 years have up to half the risk of dying within 15 years compared with people who continue to smoke, and the risk of dying is reduced substantially even among persons who stop smoking after age 70 years.[1] The risk of lung cancer is 30% to 50% lower than that of continuing smokers after 10 years of abstinence, and the risk of oral and esophageal cancer is halved within 5 years of cessation.[1] Smokers who quit also lower their risk of cervical, gastric, and bladder cancer.[1-3]
In a randomized trial of heavy smokers, the long-term follow-up results demonstrated that compared with the nonintervention group (n = 1,964), those randomly assigned to a smoking cessation intervention (n = 3,923) experienced a 15% reduction in all-cause mortality rates (8.83 vs. 10.38 per 1,000 person-years; P = .03).[4] The smoking cessation intervention consisted of a strong physician message plus 12 group sessions and nicotine gum administered during a 10-week period. Decreases in the risk of lung and other cancers, and coronary heart disease, cardiovascular disease, and respiratory disease contributed to the benefit in the group randomly assigned to the smoking cessation intervention.
A number of approaches at the policy, legislative, and regulatory levels have been attempted to effect widespread reduction in or prevention of commencement of tobacco use. Various efforts at the community, state, and national level have been credited with reducing the prevalence of smoking over time. These efforts include, reducing minors' access to tobacco products, disseminating effective school-based prevention curricula together with media strategies, raising the cost of tobacco products, using tobacco excise taxes to fund community-level interventions including mass media, providing proven quitting strategies through health care organizations, and adopting smoke-free laws and policies.[5,6] School-based interventions alone have not demonstrated long-term impact for smoking prevention.[7] One of the highest quality studies was a large, randomized trial in which children received a theory-based program that incorporated various social-influence approaches from grade 3 through grade 12, with no difference in smoking outcomes observed either at grade 12 or at 2 years after high school between school districts receiving the intervention and those in the control arm.[8]
The Community Intervention Trial for Smoking Cessation (COMMIT) was a National Cancer Institute-funded large-scale study to assess a combination of community-based interventions designed to help smokers cease using tobacco. COMMIT involved 11 matched pairs of communities in North America, which were randomly assigned to an arm offering an active community-wide intervention or a control arm (no active intervention).[9] The 4-year intervention included messaging through existing media channels, major community organizations, and social institutions capable of influencing smoking behavior in large groups of people. The interventions were implemented in each community through a local community board that provided oversight and management of COMMIT activities.
In COMMIT, there was no difference in the mean quit rate of heavy-smokers in the intervention communities (18.0%) compared with the control communities (18.7%). The light-to-moderate smoker quit rates were statistically significantly different: averages of 30.6% and 27.5% for the intervention and control communities, respectively (P = .004). Although no significant differences in quit rates between the sexes were observed, less-educated light-to-moderate smokers were more responsive to the intervention than were college-educated smokers with a light-to-moderate habit.[10,11]
Clinical interventions targeted at individuals have shown more promising results. A meta-analysis of randomized controlled trials shows that 6-month cessation rates are significantly improved with use of nicotine replacement therapy (NRT) products compared with placebo or no intervention (summary relative risk [RR], 1.58; 95% confidence interval [CI], 1.50–1.66).[12] The benefits of nicotine replacement therapy product use have been consistently observed regardless of whether the product used was the patch, gum, nasal spray, inhaler, or lozenge.[12] Smoking cessation counseling alone is also effective;[13] even a brief intervention by a health care professional significantly increases the smoking cessation rate.[14]
An important issue is whether pharmacotherapies are more effective in the presence of counseling. A randomized trial compared the following three levels of intervention that combined free pharmacotherapy (nicotine patch or bupropion) with or without counseling: 1) pharmacotherapy alone; 2) pharmacotherapy plus up to two counseling sessions every 6 months; and 3) pharmacotherapy plus up to six counseling sessions every 6 months. During the 24-month study, each group was offered a randomly assigned intervention at baseline, 6 months, 12 months, and 18 months later. For the primary study endpoint of 7-day point prevalence of smoking abstinence after 24 months of follow-up, no statistically significant differences were observed among the interventions.[15] The results of this study suggest that the combination of pharmacotherapy plus counseling is no better than intervention alone.
Promoting smoking cessation among cancer survivors is essential because the deleterious health effects of cigarette smoking may impact prognosis in both the short term and long term. In a randomized controlled trial of a peer-delivered smoking cessation intervention among childhood cancer survivors, a significantly higher 12-month quit rate was observed in the intervention group (15% vs. 9%; P < .01).[16]
Tobacco Cessation Guidelines
In 1996, the Agency for Health Care Policy and Research (AHCPR), now the Agency for Healthcare Research and Quality released a landmark set of clinical smoking-cessation guidelines for helping nicotine-dependent patients and healthcare providers. Now sponsored by the Public Health Service, the updated 2008 guidelines, "Treating Tobacco Use and Dependence" are available online.[17] The broad elements of these guidelines are:
- Clinicians should document the tobacco-use status of every patient.
- Clinicians should assess the readiness to quit of patients who use tobacco and assist those who wish to quit in setting a quit date.
- Patients using tobacco should be provided with at least one of the effective brief cessation interventions that are available.
- In general, more intense interventions are more effective than less intense interventions in producing long-term tobacco abstinence, reflecting the dose-response relationship between the intervention and its outcome.
- One or more of the three treatment elements identified as being particularly
effective should be included in smoking-cessation treatment:
- Social support from clinicians in the form of encouragement, assistance.
- Skills training/problem solving (cessation/abstinence techniques).
- Pharmacotherapy, such as nicotine-replacement (e.g., patches, gum).
- To be effective, health care systems must make institutional changes resulting in systematic identification of tobacco users and intervention with these patients at every visit.
For individual interventions, the guidelines [17] suggest a model based on outcomes from six major clinical trials of physician-delivered smoking intervention conducted in the late 1980s:[18] the ASK, ADVISE, ASSESS, ASSIST, and ARRANGE model. The physician provides a brief intervention that entails asking about smoking status at every visit, advising abstinence, assisting by setting a quit date, providing self-help materials and recommending use of nicotine replacement therapy, and arranging for a follow-up visit. See below for brief and expanded intervention outlines. The recommendations also strongly support the value of referral to more intensive counseling.
Ask, Advise, Assess, Assist, Arrange: Key Elements
- Ask
- Screen for smoking status at every visit or admission.
- Advise
- Minimal Advice: "As your physician, I must advise you that smoking is bad for your health, and it would be important for you to stop."
- Augmented Advice: "Because of your (__________) condition, it is particularly important for you to stop. If you stop now, (briefly educate patient about basic health benefits from quitting)."
- Assess
- Minimal Assessment: Ask every tobacco user if he/she is willing to make a quit attempt at this time.
- Augmented Assessment: Assess characteristics of smoking history and
- Amount smoked.
- Quit history.
- Stage of Change:
- Precontemplator: Is not seriously considering stopping smoking.
- Contemplator: Is seriously considering stopping within 3 to 6 months.
- Preparation: Is seriously considering stopping within the next week to month and has already made changes such as cutting back.
- Action: Has recently stopped smoking (within last 6 months).
- Relapse: Has quit for at least 48 hours but is smoking again.
- Maintenance: Has quit for at least 6 months but may still be vulnerable to a relapse up to 1 year.
- Nicotine Addiction: Fagerstrom Test for nicotine dependency.
- Behavioral Patterns: "Why Do You Smoke?" Scale.
- Assist/Counsel
- Minimal Assistance: Provide self-help materials; assess interest in quitting; and assess interest in and appropriateness of pharmacological aids.
- Augmented Assistance: Provide brief 5 to 7 minute patient-centered counseling. See below for an outline of the counseling content.
- Arrange Follow-up Support
- Minimal Follow-up Support: Arrange for single follow-up contact by visit or by telephone in about 2 weeks; provide referral to a smoking counselor or group.
- Extended Follow-up Support: Establish "quit smoking" contract with quit date. Arrange three or more follow-up contacts by visit or by telephone.
Patient-Centered Counseling: Key Elements
- Motivation
- Basic Question:
- "How do you feel about smoking?"
- Follow-up Questions:
- "How do you feel about stopping smoking?"
- "Have you ever tried to stop before?" "What happened?"
- "What do you like about smoking?"
- "What do you not like about smoking?"
- Basic Question:
- Anticipated Problems
- Basic Question:
- "What problems will you have if you stop smoking?"
- Follow-up Questions:
- "Anything else?"
- "On the 'Why Do You Smoke?' questionnaire, you scored high on (_______). How do you think you can handle that type of situation?"
- Basic Question:
- Resources for Coping with Problems
- Basic Question:
- "How do you think you can handle that?"
- Follow-up Questions:
- "What else could you do?"
- "How do you expect your (family/spouse/friends) to help you?"
- Basic Question:
Pharmacotherapy for Smoking Cessation
Pharmacological agents have been used successfully to aid in the cessation of smoking in the general population.[19] Since the original AHCPR guidelines [20] were published in 1996, various nicotine replacement products have been approved for over-the-counter sale, and additional evidence of the effectiveness of therapies for smoking cessation has been published.[21-24] Pharmacotherapy of smoking, including nicotine replacement therapies (gum, patch, spray, lozenge, and inhaler) and nonnicotine medications (e.g., bupropion and varenicline) result in statistically significant increases in smoking cessation rates compared with a placebo. Based on a synthesis of the results of 110 randomized trials, nicotine replacement therapy treatments, alone or in combination, improve cessation rates over placebos after 6 months (RR, 1.58; 95% CI, 1.50–1.66).[12]
There are also nonnicotine pharmacotherapies that have been efficacious for smoking cessation, including bupropion and varenicline. Based on the results of 31 randomized trials that compared the antidepressant bupropion to placebo, after 6 months of follow-up, bupropion was associated with a statistically significant increase in the likelihood of quitting smoking (summary odds ratio [OR], 1.94; 95% CI, 1.72–2.19).[25] There is insufficient evidence to support the idea that combining bupropion plus NRT increases smoking cessation rates compared to NRT alone (summary OR, 1.37; 95% CI, 0.65–2.91).[25]
Varenicline is a selective alpha-4-beta-2 nicotinic acetylcholine receptor partial agonist. In two randomized controlled trials for smoking cessation, varenicline titrated to a dose of 1.0 mg twice a day and was compared with bupropion sustained-release (SR) 150 mg twice a day and with a placebo group.[26,27] Treatment lasted for 12 weeks, with an additional 40 weeks of posttreatment follow-up. In both studies, varenicline was more efficacious than bupropion and placebo for continuous abstinence from smoking at 9 to 12 weeks and at 9 to 24 weeks of follow-up. For 9 to 52 weeks of follow-up, varenicline was more efficacious than placebo in both studies.[26,27] At 52 weeks of follow-up, the 7-day point prevalence of smoking abstinence was 46% higher in the varenicline group than in the bupropion SR group (OR, 1.46; 95% CI, 1.04–2.06).[26] The other study also showed a 46% higher continuous abstinence in the varenicline group (OR, 1.46; 95% CI, 0.99–2.17).[27] Approximately 30% of the participants who were randomly assigned to receive varenicline reported nausea, more than double that in the bupropion groups, and triple that seen in the placebo groups. In a randomized trial comparing varenicline with transdermal nicotine, continuous abstinence was greater in the varenicline group than in the transdermal nicotine group at the end of treatment (56% vs. 43%; P < .001) and during posttreatment follow-up (26% vs. 20%; P = .06).[28] The prevalence of nausea in the varenicline group (37%) was more than triple that in the transdermal nicotine group (10%).
Based on postmarketing surveillance, on July 1, 2009, the U.S. Food and Drug Administration (FDA) required additions to the Boxed Warnings for both bupropion and varenicline to describe the risk of serious neuropsychiatric symptoms associated with these products. Symptoms include: "changes in behavior, hostility, agitation, depressed mood, suicidal thoughts and behavior, and attempted suicide."[29] The FDA goes on to advise that the important health benefits of quitting smoking "should be weighed against the small, but real, risk of serious adverse events with the use of varenicline or bupropion."[29] A meta-analysis of double-blind, placebo-controlled, randomized trials of varenicline administered for at least 1 week (N = 14 trials) indicated that varenicline was associated with an increased risk of serious adverse cardiovascular events (RR, 1.72; 95% CI, 1.09–2.71).[30] This finding is particularly noteworthy because almost all of the randomized trials included in the meta-analysis had the following in common: they excluded patients with cardiovascular disease (CVD) at baseline; the usual average age of the patient populations (early 40s) was young for CVD; varenicline was usually administered for only 12 weeks or less; and, varenicline is efficacious for smoking cessation, which would act to decrease CVD risk.
There is a growing number of smoking cessation pharmacotherapies that have been shown to be efficacious in significantly increasing rates of smoking cessation. The choice of therapy should be individualized based on a number of factors, including past experience, patient and/or physician preference, and potential agent side effects. As more is learned about specific genetic variants that influence a smoker's response to smoking cessation pharmacotherapies—such as polymorphisms in genes encoding enzymes involved in nicotine metabolism—this information could eventually be integrated into smoking cessation treatment planning.[31] Presently, the evidence is not yet sufficient to be integrated into clinical practice.
The following sections summarize available pharmacologic interventions to assist in tobacco cessation. More comprehensive information is available from product package inserts.
Pharmacologic interventions to assist in tobacco cessation
Nicotine replacement therapy
These products are designed to aid in the withdrawal symptoms associated with nicotine. Several precautions are warranted before initiating therapy, but it should be noted that these precautions do not constitute absolute contraindications. In particular, special considerations are necessary in some patient groups (e.g., those with medical conditions such as arrhythmias, uncontrolled hypertension, esophagitis, peptic ulcer disease, insulin-treated diabetes, or asthma, pregnant or breast-feeding women, and adolescent smokers).[32]
Brand | Dose | Side Effects | Comments | |
d = day; OTC = over the counter; Rx = prescription; wk = week. | ||||
Rx | Habitrol | 7–21 mg/d | Erythema | Use for 6–12 wk |
OTC | Nicoderm CQ | 7–21 mg/d | Pruritus | Use for 6–12 wk |
OTC | Nicotrol | 5–15 mg/d | Burning at site | Use for 14–20 wk |
Rx | ProStep | 11–22 mg/d | Local irritation | Use for 6–12 wk |
Current guidelines recommend 8 weeks of transdermal nicotine therapy. Findings from two randomized placebo-controlled trials of transdermal therapy are divergent in their findings as to whether extended therapy (22–24 weeks vs. 8 weeks) improves quit rates.[33,34]
Brand | Dose | Side Effects | Comments | |
d = day; OTC = over the counter. | ||||
OTC | Nicorette | 18–24 mg/d | Stomatitis, sore throat | Max 30 pieces/d; decrease 1 piece every 4–7 d |
OTC | Nicorette DS | 36–48 mg/d | Jaw ache | Max 20 pieces/d; decrease 1 piece every 4–7 d |
Brand | Dose | Side Effects | Comments | |
d = day; h = hour; OTC = over the counter; wk = week. | ||||
OTC | Commit | 40–80 mg/d | Local irritation (warmth and tingling) | Use for 12 wk; max 20 pieces/d. Wk 1–6: 1–2 lozenges every 1–2 h; wk 7–9: 1 lozenge every 2–4 h; wk 10–12: 1 lozenge every 4–8 h |
Brand | Dose | Side Effects | Comments | |
Rx = prescription; wk = week. | ||||
Rx | Nicotrol Inhaler | Individualized | Local irritation | Use up to 24 wk |
Brand | Dose | Side Effects | Comments | |
d = day; mo = month; Rx = prescription. | ||||
Rx | Nicotrol NS | Max 40 mg/d | Nasal irritation | Max use 3 mo |
Nonnicotine products
Bupropion HCl
Also used as an antidepressant, bupropion HCl is a nonnicotine aid to smoking cessation. It is a relatively weak inhibitor of the neuronal uptake of norepinephrine, serotonin, and dopamine, and does not inhibit monoamine oxidase. The exact mechanism by which bupropion HCl enhances the ability of patients to abstain from smoking is unknown; however, it is presumed that this action is mediated by noradrenergic or dopaminergic mechanisms.
Brand | Dose | Side Effects | Warning/Precaution | |
d = day; Rx = prescription; wk = week. | ||||
Rx | Zyban | 150 mg/d X 3 d then increase to 300 mg/d X 7–12 wk | Insomnia, dry mouth, dizziness, rhinitis | Do not take with Wellbutrin or Wellbutrin SR |
Higher incidence of seizures in patients treated for bulimia, anorexia | ||||
Do not prescribe >300 mg/d for patients being treated for bulimia |
Brand | Dose | Side Effects | Warning/Precaution | |
d = day; Rx = prescription; wk = week. | ||||
Rx | Chantix | 0.5 mg/d, d 1–3; 0.5 mg twice a d, d 4–7; then 1.0 mg twice a d through wk 12 | Nausea, insomnia | Risk of toxicity greater in patients with impaired renal function |
Not tested in children and pregnant women |
Although Zyban (bupropion HCl) is the only antidepressant approved by the FDA for smoking cessation, Prozac (fluoxetine HCl) has been shown to be effective.[35]
Brand | Dose | Side Effects | Comments | |
d = day; Rx = prescription. | ||||
Rx | Prozac | 30–60 mg/d | Insomnia, dizziness, anorexia, sexual dysfunction, confusion | Limited data available on its use in combination with cognitive-behavioral therapy |
Lobeline (Bantron) is classified as a category III agent by the FDA, safe but no proven effectiveness. This product is not recommended for use in any smoking cessation program due to its lack of efficacy.[36]
Other Agents
Clonidine and nortriptyline have been suggested as possibly useful second-line pharmacotherapies, but are not approved for smoking cessation by the FDA. Nortriptyline is an antidepressant that does not contain nicotine. A meta-analysis of five randomized controlled trials found that smokers who received nortriptyline were 2.4 times more likely (95% CI, 1.7–3.6) than smokers who received a placebo to remain abstinent from smoking after 6 months.[37]
Smoking Reduction
Among dependent smokers, complete abstinence from smoking is the ultimate goal. Even in instances when complete abstinence from smoking is not achieved, smoking cessation pharmacotherapies may benefit individual health—and ultimately the public's health—if the smoker reduces the number of cigarettes smoked. The relationship between cigarette smoking and lung cancer, and other smoking-associated malignancies, is strongly dose-dependent. Thus, an individual smoker who is unable to achieve abstinence or who is not motivated to quit smoking may benefit by using pharmacotherapies (or other means) to reduce the number of cigarettes smoked per day. NRT has thus generated attention as a viable means of "harm reduction." In studies that randomly assigned smokers who were not trying to quit to NRT or placebo, a greater proportion of those randomly assigned to NRT compared with placebo reduced the number of cigarettes per day.[38,39] However, the impact of NRT on smoking reduction appears not to be sustained in the long run.[40] Less evidence is available for bupropion, varenicline, and psychosocial interventions as a means of harm reduction. A potential problem with such a harm reduction strategy would be if it prevented cessation among smokers who would have otherwise quit smoking. Evidence shows that smoking reduction is actually associated with increased likelihood of future cessation.[39,41] Another potential negative aspect of harm reduction would be if smokers reduced the number of cigarettes smoked per day but modified the way the cigarettes were smoked in such a way that exposure to tobacco toxins was not actually reduced (e.g., by inhaling more deeply). Compensatory behaviors such as inhaling more deeply or smoking more of a cigarette are attempts by the smoker to try to maintain nicotine levels, so the use of supplemental NRT presumably safeguards against this. Evidence from studies of smoking reduction with NRT that measured smoking biomarkers indicates that compensation occurs, but not to such an extent that it would be expected to outweigh the reduction in exposure from the reduced number of cigarettes per day.[38]
A Changing Marketplace for Tobacco Products and Nicotine-Delivery Devices
The expansion in the marketplace of tobacco products and devices that deliver nicotine poses new challenges to tobacco control.[42-46] Examples of nontraditional tobacco products in the U.S. market include small cigars, water pipe tobacco smoking ("hookah"), and new types of flavored, smokeless tobacco products modeled after Swedish snus. Prominent among non–tobacco-containing nicotine delivery devices are electronic cigarettes (or "e-cigarettes") that have experienced a rapid upsurge in use and are now marketed by the major U.S. tobacco companies.[42,43] Monitoring this expansion in products, how the products are used (e.g., product switching, multiple use, and use for tobacco cigarette smoking cessation), and the harms and benefits associated with their use compared to tobacco cigarettes is critical to the development of more effective tobacco control strategies.
Research to determine the potential risks and benefits of these new products is just beginning to emerge. In a three-arm trial in New Zealand, 657 adult tobacco cigarette smokers who wanted to quit smoking were all referred to a smoking cessation quit line and randomly assigned to receive nicotine e-cigarettes, nicotine patches, or placebo e-cigarettes.[47] After 3 months of intervention and 3 additional months of follow-up, the primary outcome of 6-month continuous abstinence was 7.3%, 5.8%, and 4.1%, respectively. These quit rates were low in all three arms of the study, and the differences were not statistically significant but provide preliminary evidence that e-cigarettes resulted in rates of smoking cessation comparable to those of the nicotine patch, a smoking cessation pharmacotherapy of established efficacy. The trial results also suggested that nicotine e-cigarettes could expand the reach of smoking cessation interventions. Compared with the group assigned to the nicotine patch, the group assigned to e-cigarettes had higher adherence to treatment (78% vs. 46%; P < .0001) and were more likely to report that they would recommend their assigned product to a friend wanting to quit (88% vs. 56%; no P-value reported).[47]
- U.S. Department of Health and Human Services: The Health Benefits of Smoking Cessation. A Report of the Surgeon General. Rockville, Md: 1990. DHHS Publ No. (CDC) 90-8416.
- U.S. Preventive Services Task Force: Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. 2nd ed. Baltimore, Md: Williams & Wilkins, 1996.
- U.S. Department of Health and Human Services: The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, Ga: U.S. Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available online. Last accessed April 24, 2015.
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- Koh HK: The end of the "tobacco and cancer" century. J Natl Cancer Inst 91 (8): 660-1, 1999. [PUBMED Abstract]
- Thomas R, Perera R: School-based programmes for preventing smoking. Cochrane Database Syst Rev 3: CD001293, 2006. [PUBMED Abstract]
- Peterson AV Jr, Kealey KA, Mann SL, et al.: Hutchinson Smoking Prevention Project: long-term randomized trial in school-based tobacco use prevention--results on smoking. J Natl Cancer Inst 92 (24): 1979-91, 2000. [PUBMED Abstract]
- Community Intervention Trial for Smoking Cessation (COMMIT): summary of design and intervention. COMMIT Research Group. J Natl Cancer Inst 83 (22): 1620-8, 1991. [PUBMED Abstract]
- Community Intervention Trial for Smoking Cessation (COMMIT): I. cohort results from a four-year community intervention. Am J Public Health 85 (2): 183-92, 1995. [PUBMED Abstract]
- Community intervention trial for smoking cessation (COMMIT): II. Changes in adult cigarette smoking prevalence. Am J Public Health 85 (2): 193-200, 1995. [PUBMED Abstract]
- Silagy C, Lancaster T, Stead L, et al.: Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev (3): CD000146, 2004. [PUBMED Abstract]
- Lemmens V, Oenema A, Knut IK, et al.: Effectiveness of smoking cessation interventions among adults: a systematic review of reviews. Eur J Cancer Prev 17 (6): 535-44, 2008. [PUBMED Abstract]
- Lancaster T, Stead L: Physician advice for smoking cessation. Cochrane Database Syst Rev (4): CD000165, 2004. [PUBMED Abstract]
- Ellerbeck EF, Mahnken JD, Cupertino AP, et al.: Effect of varying levels of disease management on smoking cessation: a randomized trial. Ann Intern Med 150 (7): 437-46, 2009. [PUBMED Abstract]
- Emmons KM, Puleo E, Park E, et al.: Peer-delivered smoking counseling for childhood cancer survivors increases rate of cessation: the partnership for health study. J Clin Oncol 23 (27): 6516-23, 2005. [PUBMED Abstract]
- Fiore MC, Jaén CR, Baker TB: Treating Tobacco Use and Dependence [Electronic Resource] : 2008 Update. Rockville, Md: Public Health Service, U.S. Department of Health and Human Services, 2008. Available online. Last accessed February 9, 2015.
- Glynn TJ, Manley MW, Pechacek TF: Physician-initiated smoking cessation program: the National Cancer Institute trials. Prog Clin Biol Res 339: 11-25, 1990. [PUBMED Abstract]
- Okuyemi KS, Ahluwalia JS, Harris KJ: Pharmacotherapy of smoking cessation. Arch Fam Med 9 (3): 270-81, 2000. [PUBMED Abstract]
- Fiore MC, Bailey WC, Cohen SJ, et al.: Smoking Cessation: Clinical Practice Guideline No 18. Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1996. AHCPR Publ No 96-0692.
- Tang JL, Law M, Wald N: How effective is nicotine replacement therapy in helping people to stop smoking? BMJ 308 (6920): 21-6, 1994. [PUBMED Abstract]
- Hurt RD, Sachs DP, Glover ED, et al.: A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med 337 (17): 1195-202, 1997. [PUBMED Abstract]
- Jorenby DE, Leischow SJ, Nides MA, et al.: A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med 340 (9): 685-91, 1999. [PUBMED Abstract]
- Hughes JR, Goldstein MG, Hurt RD, et al.: Recent advances in the pharmacotherapy of smoking. JAMA 281 (1): 72-6, 1999. [PUBMED Abstract]
- Hughes JR, Stead LF, Lancaster T: Antidepressants for smoking cessation. Cochrane Database Syst Rev (1): CD000031, 2007. [PUBMED Abstract]
- Jorenby DE, Hays JT, Rigotti NA, et al.: Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial. JAMA 296 (1): 56-63, 2006. [PUBMED Abstract]
- Gonzales D, Rennard SI, Nides M, et al.: Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial. JAMA 296 (1): 47-55, 2006. [PUBMED Abstract]
- Aubin HJ, Bobak A, Britton JR, et al.: Varenicline versus transdermal nicotine patch for smoking cessation: results from a randomised open-label trial. Thorax 63 (8): 717-24, 2008. [PUBMED Abstract]
- U.S. Food and Drug Administration: Information for Healthcare Professionals: Varenicline (Marketed as Chantix) and Bupropion (Marketed as Zyban, Wellbutrin, and Generics). Rockville, Md: U.S. Food and Drug Administration, 2009. Available online. Last accessed February 9, 2015.
- Singh S, Loke YK, Spangler JG, et al.: Risk of serious adverse cardiovascular events associated with varenicline: a systematic review and meta-analysis. CMAJ 183 (12): 1359-66, 2011. [PUBMED Abstract]
- Ray R, Schnoll RA, Lerman C: Pharmacogenetics and smoking cessation with nicotine replacement therapy. CNS Drugs 21 (7): 525-33, 2007. [PUBMED Abstract]
- Fincham JE: Smoking cessation products. In: Covington TR, Berardi RR, Young LL, et al., eds.: Handbook of Nonprescription Drugs. 11th ed. Washington, DC: American Pharmaceutical Association, 1996, pp 715-723.
- Schnoll RA, Patterson F, Wileyto EP, et al.: Effectiveness of extended-duration transdermal nicotine therapy: a randomized trial. Ann Intern Med 152 (3): 144-51, 2010. [PUBMED Abstract]
- Tønnesen P, Paoletti P, Gustavsson G, et al.: Higher dosage nicotine patches increase one-year smoking cessation rates: results from the European CEASE trial. Collaborative European Anti-Smoking Evaluation. European Respiratory Society. Eur Respir J 13 (2): 238-46, 1999. [PUBMED Abstract]
- Drug Facts and Comparisons. 54th ed. St. Louis, Mo: Facts and Comparisons, 2000.
- Drug Facts and Comparisons. St. Louis, Mo: Facts and Comparisons, 1998.
- Wagena EJ, Knipschild P, Zeegers MP: Should nortriptyline be used as a first-line aid to help smokers quit? Results from a systematic review and meta-analysis. Addiction 100 (3): 317-26, 2005. [PUBMED Abstract]
- Hughes JR, Carpenter MJ: The feasibility of smoking reduction: an update. Addiction 100 (8): 1074-89, 2005. [PUBMED Abstract]
- Batra A, Klingler K, Landfeldt B, et al.: Smoking reduction treatment with 4-mg nicotine gum: a double-blind, randomized, placebo-controlled study. Clin Pharmacol Ther 78 (6): 689-96, 2005. [PUBMED Abstract]
- Etter JF, Laszlo E: Postintervention effect of nicotine replacement therapy for smoking reduction: a randomized trial with a 5-year follow-up. J Clin Psychopharmacol 27 (2): 151-5, 2007. [PUBMED Abstract]
- Hughes JR, Carpenter MJ: Does smoking reduction increase future cessation and decrease disease risk? A qualitative review. Nicotine Tob Res 8 (6): 739-49, 2006. [PUBMED Abstract]
- Popova L, Ling PM: Alternative tobacco product use and smoking cessation: a national study. Am J Public Health 103 (5): 923-30, 2013. [PUBMED Abstract]
- Kamerow D: Big Tobacco lights up e-cigarettes. BMJ 346: f3418, 2013. [PUBMED Abstract]
- Schuster RM, Hertel AW, Mermelstein R: Cigar, cigarillo, and little cigar use among current cigarette-smoking adolescents. Nicotine Tob Res 15 (5): 925-31, 2013. [PUBMED Abstract]
- Jawad M, McEwen A, McNeill A, et al.: To what extent should waterpipe tobacco smoking become a public health priority? Addiction 108 (11): 1873-84, 2013. [PUBMED Abstract]
- Centers for Disease Control and Prevention (CDC): Consumption of cigarettes and combustible tobacco--United States, 2000-2011. MMWR Morb Mortal Wkly Rep 61 (30): 565-9, 2012. [PUBMED Abstract]
- Bullen C, Howe C, Laugesen M, et al.: Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet 382 (9905): 1629-37, 2013. [PUBMED Abstract]
Changes to This Summary (02/13/2015)
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Added American Cancer Society and Jamal et al. as references 1 and 2, respectively.
Revised text to state that in 2013, 20.5% of adult men and 15.3% of adult women in the United States were current smokers.
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About This PDQ Summary
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the prevention and cessation of cigarette smoking and the control of tobacco use. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
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text:
Kenmore Elite 24 cu. ft. Bottom-Freezer Refrigerator - Stainless Steel
Item# 04678043000 | Model# 78043Specifications & Dimensions
Ratings & Reviews
Product Description
Kenmore is America's #1 Refrigerator brand
The Kenmore Elite 78043 bottom-freezer refrigerator delivers more capacity in less space and features a swing-open freezer door. The design also includes a full-width gourmet pantry drawer so you can stock up for entertaining. Multi Air Flow technology keeps food fresh.
The stainless steel Kenmore Elite 7804 has adjustable shelves and door bins, including 2 split shelves and the Tilt-N-Store flip-up door bin, allow for flexible fridge arrangements. The 7804 also features 2-tier freezer organization and a convenient factory-installed icemaker.
- The 7804 refrigerator has so much space, no other 2-door bottom-freezer refrigerator has more capacity*
- The full-width door bin on the 7804 holds an impressive twenty-five 12-oz. cans making this refrigerator perfect for entertaining
- The 24" full-width gourmet pantry drawer has room for extra large items like veggie trays and party platters and has enough space to hold sixty-five 12-oz. packages of sliced cheese**
- With Multi Air Flow technology, strategically placed vents distribute cool air evenly throughout the entire refrigerator to maintain ideal temperatures in every nook and cranny to keep food fresh
- Both super-sized crisper bins feature humidity-control so produce stays fresh and less food is wasted
- Enjoy automatic ice that is always ready with the factory-installed icemaker
- The Tilt-N-Store door bin flips up and out of the way to create more vertical space to store taller items with ease, such as wine bottles and pitchers
- The swing-door freezer features a new, deluxe 2-tier drawer design that lets you organize frozen food in the top drawer and bulky items in the deep divided bin
*Among leading brands refrigerator capacity measured through Association of Home Appliance Manufacturers (AHAM) Standards.
**Using 12oz. American Cheese Singles 16 slice pkg.
Added on November 24, 2013
Overall, others give this:
Aurora, CO
via sears.com
Great fridge, led lighting inside, roomy. Ice maker works well. Wish I had more space in my kitchen for a bigger version of this refrigerator but fits well in a very small space.
The reviewer indicated they are affiliated with this product.
Bogart, GA
via sears.com
Like the headline states...I Love this refrigerator!. Largest capacity for the refer side and also freezer. The door on the bottom opens to the side and the trays pull out this allows the trays to be larger without the pull out door in the way, It also works if you have an older home that only alows for 33 inch spaces. Every inch on the inside is usable space!! I love the LED lights on the inside The ice maker is on the inside but it doesnt use much space.
Mesa, AZ
via sears.com
We have had this fridge 2 weeks and it is big and holds a lot of food. The freezer is smaller than I like, the ice maker is fabulous, the pullout pantry drawer is my favorite. I like that all the shelves have no dividers so you can use the space how you like. I neglected to measure the depth and it sticks out too far; my fault. Love it!
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TOPIC: SummerThunder's Race Moved 1 Week
SummerThunder's Race Moved 1 Week 3 years 11 months ago #348
Hi District 4,
I just wanted to let everyone know that the SummerThunder Race has been rescheduled for this Coming Sunday May 22nd 2011. This past weekend we sat out in the 40 degree weather with 40 MPH winds and rain waiting for any break in the weather and none was happening. So with a Vote from all the racers present the race was canceled and as of tonight has been rescheduled for May 22nd 2011. The race was pre registration but if you cant call John Kubitz and let him know you will be there please just bring a boat and lets have some fun racing. John Kubitz (630) 495-1829 Paul Bychowski (847) 593-7769 Thank You, Paul |
The administrator has disabled public write access.
Moderators: Alan Archer
Time to create page: 0.141 seconds


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Top Definition
Cana butter is butter that has gone through a prosses that extracts the THC in marijuana. By extracting the THC in marijuana you can do much more with it then just put it in Brownies. Instead of trying to put actual leafs in your brownies that will get stuck in your teeth you can cook with it.
Damn, pass that cana butter and start up that oven.
Beküldő: Brandon
2004. szeptember 7.


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text: All of this is quite interesting except for the fact the Lee Harvey Oswald was a committed leftist (that should have been committed by the way) . At the time Kennedy was hardly a lion of the Civil Rights movement , being dragged in by events and his brother, not much less than kicking and screaming. I cannot believe that the DMN editorial page , as much as I dislike it , had one thing to do in reality with JFK's assassination here.


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Nursery Pillows are extremely soft pillows which are perfect for mommies with growing tummies. Nursery Pillows are also great for after the child is born as they provide an extremely soft area for child to place his head. There are many different variety of nursery pillows and we carry a good portion of them.
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Give to McCombs
Home · Executive Education Home · Open Enrollment Programs · Partner Program
Texas Executive Education has partnered with the Human Dimensions of Organizations (HDO), a new professional program in UT's College of Liberal Arts to offer you additional executive education choices. Human Dimensions of Organizations offers programs focused on understanding the people inside and outside organizations who drive performance in today's diverse global marketplace. HDO is organized exclusively for professionals in a variety of sectors, including those in business and nonprofit management. Their unique curriculum combines scholarly study and real-world application. HDO emphasizes the practical value of the humanities and the social and behavioral sciences for solving real-world problems. Their seminars provide depth in an area of study as well as practical exercises to improve the way you do business. HDO offers one-day Professional Seminars, beginning in April 2012, that are aimed at improving individuals' understanding of specific issues affecting the modern workplace: global enterprise, culture, marketing psychology, leadership skills, communication effectiveness, and more.
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IETF Opus codec now ready for testing, That's CELT 0.11 |
IETF Opus codec now ready for testing, That's CELT 0.11 |
Feb 4 2011, 17:36
Xiph.org Speex developer Group: Developer Posts: 487 Joined: 21-August 02 Member No.: 3134 |
We'd like to announce that the Opus codec is now ready for testing. The bit-stream is now is a "pseudo-freeze", which means that unless a problem is found during testing/review, there are no longer any changes planned. The only exception to this are the SILK-mode FEC and the stereo SILK mode, which should be landing in the next few days. Considering that these are not critical features, we felt like the testing phase could already begin.
You can get the source code in two different ways. There is a release tarball at http://jmvalin.ca/opus/opus-0.9.0.tar.gz . You can also extract the source directly from the I-D ( http://www.ietf.org/id/draft-ietf-codec-opus-02.txt ) with the following command: cat draft-ietf-codec-opus-02.txt | grep '^\ \ \ ###' | sed 's/\s\s\s###//' | base64 -d > opus_source.tar.gz Now the Opus codec supports three mores, one of which is identical to CELT 0.11, which was just released (not announced officially yet). It would be nice if the HA community could help test this codec. Opus targets a very wide range of bit-rates, from 6 kb/s narrowband speech up to 510 kb/s stereo music. Perhaps a 64-96 kb/s stereo music test would be interesting to do. Anyone would like to help? |
Jun 1 2012, 23:09
Group: Members Posts: 189 Joined: 31-May 05 From: Netherlands Member No.: 22417 |
Does Opus have, or will Opus get an option equivalent to Vorbis's --ignorelength for use with Foobar?
Works fine on WinXP! -------------------- DC-Bass Source Mod: http://reino.degeelebosch.nl
Lo-Fi Version | Time is now: 7th May 2015 - 10:53 |


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©2007-2009 Aimee Stewart, Foxfires – please see my CC Terms of Use before considering using this image for any personal or commercial use. Click Here
The journey's end….is really only a beginning.
Tucked away in the Secret Harbor, enchantment drifts as easily as mist from the quiet mountains.
red, mountain, boat, palace, fantasy, castle, magic, ship, sail, enchanted, exotic, fortress, foxfires, aimee stewart, secret harbor, journeys end, landscape, chinese junk
red, mountain, boat, palace, fantasy, castle, magic, ship, sail, enchanted, exotic, fortress, foxfires, aimee stewart, secret harbor, journeys end, landscape, chinese junk
Aimee's artwork has been featured in Advanced Photoshop Magazine, ImagineFX, and others. Her work can be found internationally as a greeting cards through Tree Free Greetings, cross stitch patterns through HAED, and jigsaw puzzles by such companies as Buffalo Games, Mega Puzzles, and more! These are now available at Walmart, Fred Meyer, and more. Aimee is currently working on her first children's book featuring whimsical animals, slated for release in 2012.
View Full ProfileAnother beautiful work of art of yours. I simply love your imagination. Your colors and tone just pull me tight into your world that you just created.
Thank you so much Melinda! I so enjoy creating this world, and inviting others to wander into it with me!
– Aimee Stewart
It's dreamy – I love it :o)
Thank you Kira!!
– Aimee Stewart
Gorgeous! I love this :)
Thank you Stacy!!
– Aimee Stewart
Wow, beautiful .. I wish I could go there!
thank you so much Lisa! I wish I could too! :D
– Aimee Stewart
Gorgeous fantasy world you have created here. You sure have some talent.
Thank you very much Bob!! It was a true pleasure escaping into this scene while I worked on it.
– Aimee Stewart
Thank you so much Sky!! We must reconnect soon!
– Aimee Stewart
Love this!
Thank you Susan!
– Aimee Stewart
it's crazy that you can just create another world like this… it's awesome.
Thank you so much! I plan to do a lot more of this world and share it here. :D
– Aimee Stewart
Beautiful, the blue is just stunning!!
Thank you Donna!
– Aimee Stewart
Nice little fantasy world you created there for yourself Aimee. Love to go to these places from time to time.
Thank you so much Cos! These are definitely wonderful places to drift to. It's been a fun challenge seeing if I can translate what I see in my mind, to the 'page' so to speak. :D
– Aimee Stewart


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How To Obtain Publicly Available Documents from the FCC
June 28, 2011 (Published)
How do I obtain publicly available documents and other materials from the FCC? Many of these...
How to Report a Suspected Violation of Ex Parte Rules
March 22, 2011
Section 1.1214 of the Commission's Rules provides:Any party to a proceeding or any Commission...
How to File a Notice of an Ex Parte Presentation
May 10, 2011 (Published)
When are Ex Parte Presentations Allowed?For the purposes of the Ex Parte rules, FCC proceedings are...
Media Bureau General Questions
May 27, 2011 (Published)
Ownership Report for Commercial Broadcast Station (Form 323)...
September 29, 2011 (Published)
The biennial filing deadline for licensees and other entities required to file the FCC Form 323 has...
Children's Educational Television (KidVid)
February 14, 2011
This page provides information about the Children's Television Programming Report (FCC Form 398)....
Form 323 Spreadsheet Instructions for Respondents
February 14, 2011
What Is The Spreadsheet Used For? Question 3(a) on the revised For 323 requires you to enter in the...
Biennial Form 323 Frequently Asked Questions
September 29, 2011 (Published)
If your question is not addressed in the FAQs, please submit your detailed question to Form323@fcc....
International Roaming: Using Your Mobile Phone in Other Countries
October 22, 2014 (Updated)
Before you travel abroad, find out if your mobile phone will work abroad. Mobile telephone...
FCC's Review of the Broadcast Ownership Rules
July 30, 2014 (Updated)
The Federal Communications Commission (FCC) sets limits on the number of broadcast stations (...


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Out of Stock
Item # SNZ0346
Don't worry though, we have a lot more All-Mountain & Trail Bikes - Full Suspension in stock than that.
Santa Cruz Bicycles Bronson R AM Complete Mountain Bike $0.00
Reviews & Community
What do you think of the
Santa Cruz Bicycles Bronson R AM Complete Mountain Bike
? Share a...
sick bike
Why is the brake set listed as Avid Elixir...
Why is the brake set listed as Avid Elixir 5 , but Santa Cruz lists the R AM build kit as coming with Shimano (Deore)?
Kevin K
Hi Ryan,
Unfortunately Santa Cruz's build specs are subject to change at any time. You have picked out a rolling change that they have made on this particular build. They started specing this bike with Avid Elixir 5's, but then moved to Shimano Deore brakes. Sadly, there is not an efficient way to tell specifically which brakes are on the color/sizes that we have currently. If you are interested in this bike, please feel free to contact our customer service department at 888-276-7130 and they will be able to assist with which brake spec we have in stock.
franz doppelhofer
Could you send this bike to...
Could you send this bike to Austria?
Kevin K
Hi Franz,
Unfortunately we are unable to ship any Santa Cruz products outside of the United States.
Where can I buy this bike. in New...
Where can I buy this bike. in New YOrk??thanks a email@example.com
Mike D Hilverda
I have great news Jorge, we definitely can ship this bike to New York. Feel free to hit up one of our Gearheads by phone or chat and we can put that order together for you and get you the best shipping options possible.


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$77.99 to $275.99
Show & Go natural supplements for horses contain 100% natural human grade ingredients. Protein Synthesis - for repair and growth of muscle. Joint Strength - supports tissue repair and growth, reduces... Read More
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I have a 15yr Quarab mare that I've had all her life. She requires hoof supplements and front shoes to maintain functioning hooves. We had one product for years that we relied on but I went on a hunt when we lost access to it. With really no chance to screw up, I purchased Show&Go. My farrier was absolutely amazed at the response he saw in her feet a few months later. During those few months, I saw major improvement in her coat, I was able to take her off of other joint support supplements as well. I was so pleased with the results. She was on it for several years and was only taken off due to personal problems of my own. She will be back on them again soon (along with my 2 new older kids). I highly recommend this product. Worth every penny.
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I have a 12 yr old paint gelding that I purchased and found out that he has navicular. For almost two years I have been trying different supplements in hopes of helping his lamness issues. I don't usually write reviews, but I have been giving Show and Go for a little over a month now and last weekend we had our first show that he was able to make it all day without being sore and going lame. We have been training almost every day with no soreness and he is doing great. His coat also looks better and he is more focused. I know not all supplements help all horses, but Show and Go has done a great job for this one and I recommend giving it a try!


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Dishwasher door seal leaking Wade F. • Belton, TX • June 29, 2014 My Repair & Advice Ordered the part from AppliancePartsPros.com and installed it. Just ordered the part and watched the video. I consider myself a moderately experienced repair guy, but this was so simple. Sometimes repairs seem easier than they actually are, but this was super easy and made all the easier by the great video that came with the part I ordered. Was this review helpful to you?
Rusted lower rack Bruce W. • Bayville, NJ • March 31, 2014 My Repair & Advice Replaced rack with new from AppliancePartsPros.com Item was shipped and arrived 1 day after order. Was this review helpful to you?
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Several of the rollers on the lower rack of my dishwasher we damaged by heat or missing Marcus C. • Melrose, FL • October 11, 2014 My Repair & Advice I went to appliancepartspros.com and searched "dishwasher rack rollers" and found mine immediately using only the make of the machine. It took me another 5 minutes to order the parts and check out. I received the parts in two days using the most economical shipping method. It took less than ten minutes to make my dishwasher as good as new! A very simple job made more simple by using appliancepartspro.com. Was this review helpful to you?
Water spewing from dishwasher door Mary M. • Ridgway, PA • August 23, 2014 Appliance: Frigidaire Dishwasher FDB636GFR5 My Repair & Advice Turns out the bottom sprayer arm had somehow become lodged against the bottom heating element resulting in a sizable hole on the underside of the arm. This caused water to shoot directly at the door and leak out. Appliance Parts Pros had the replacement spray arm and shipped it super quick. My very old dishwasher works like a pro again! Was this review helpful to you?


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An astounding VISUAL card change- in the same "WOW Factor" category as Knock Out Card and Card Warp!
After your spectator selects a card and it's shuffled back in the deck, you pull out a card. Of course, it's the wrong card! But wait- you simply slide the card through the deck, and instantly it changes to the spectator's chosen card!
And this one even comes with a BONUS! Buy the Bicycle Drawer Deck from MagicTricks.com, and you'll get the password to an EXCLUSIVE video in which Peter Monticup teaches you his secret tips and techniques that he's developed to make this a smooth and foolproof trick! You won't get that anywhere else!


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Nixon's the One
The '68 Election | Sunday, 10 p.m.Narrated by Dick Cavett, this program chronicles not only Richard Nixon's stunning victory in the 1968 presidential race, but the ways in which that historic election gave rise to Red State-Blue State America. Combining archival footage and original interviews with, among others, activist Tom Hayden, former Nixon advisor Kevin Phillips, Pulitzer Prize-winning journalist and historian David Maraniss, and bestselling author Rick Perlstein, Nixon's the One is anything but a nostalgic trip through the "flower power" decade. Rather, it's a sobering, wry look at how the Sixties divided us-and how Nixon stepped into the breach to claim the biggest prize of all.
Mr. Selfridge
Season 3, Episode 3 | Monday, 8 p.m.Surprising accomplices turn up in the search for Kitty's assailants. Agnes and Henri call it quits, and Harry and Nancy reach an understanding.
Episode 2 | Saturday, 9 p.m.Sidney's former flame throws an engagement party that leads to murder. To crack the case, Sidney and Geordie must break a code of silence.
Motown 25
Yesterday, Today, Forever | Sunday, 10 p.m.Hosted by legendary comedian Richard Pryor, Motown 25: Yesterday, Today, Forever celebrates the 25th anniversary of Motown, with reunions of Smokey Robinson & The Miracles, Diana Ross & The Supremes, The Jackson 5, The Temptations, Four Tops, Marvin Gaye, Stevie Wonder, Martha Reeves, Mary Wells, Jr. Walker and more! Not seen on broadcast TV in more than 20 years, this incredible MY MUSIC special presentation finally comes to public television for one amazing night!
Is WEIU important to you? Become a member today! Also, send us a message and let us know what WEIU means to you!
A Night of Giving
Thursday, Nov. 20 | 7 p.m.Showcasing Local Artists -- Supporting Local Public Television
Local artists include:
- Randy & Joy Turner from Larkfield Glass (Paris, IL)
- Jerry Rhoads (St. Joseph, IL) - Woodtuning
- Jeanette Huisinga (Casey, IL) - The Yarn Shop
- Pottery from Dwain Naragon (EIU Faculty)
This night of giving allows our viewers to give to their local public television station and in return WEIU will offer viewers a wonderful handmade thank you gift from a local artist.
Is WEIU important to you? Become a member today! Also, send us a message and let us know what WEIU means to you!
A Chef's Life
Blueberries and Boiling Over | Monday, 7:30 p.m.After a year recovering from a restaurant fire and re-opening Chef and the Farmer, Vivian and Ben open a burger/oyster bar called the Boiler Room. Vivian boils over with the stress of staffing adjustments, testing new menu concepts and the task of putting 500 pounds of blueberries to good use. She dons a hairnet and bubbles with excitement at the sight of her blueberry BBQ sauce hitting the assembly line. The staff of Chef and the Farmer finally lets off some steam with a growler cocktail and a blueberry BBQ water park extravaganza.
Austin City Limits
The Shins/Dr. Dog | Friday, 10 p.m.ACL presents alternative rock with the Shins and Dr. Dog. The Shins play songs from their latest record Port of Morrowe, while Dr. Dog highlights Be the Void.
America's Generations with Chuck Underwood
Millenials: The New World | Wednesday, 9 p.m.Whenever American youth – of ANY generation – come of age during some "revolution" that creates widespread and presumably permanent change – Depression, War, Prosperity, Social Activism, Family Breakdown, and in the case of Millennials the Technology Revolution – there is ALWAYS good and bad to come from it. Sure enough, Mils possess good and bad qualities because of tech. They've come of age nurtured, coddled, and protected by extreme Over-Parenting, which has delivered good and bad. Chuck will explain that they're going to be a great career generation but are driving their bosses nuts right now. Flawed sense of entitlement, unrealistic expectations. But this generation has lots of Boomer in them, which makes sense because many of them have Boomer parents: idealistic; empowered; engaged; cocky; sassy; think they're gonna change the world for the better, so they probably will. Battered by The Great Recession. Permanently re-defining what it is like to live life in one's 20's, and it has a name: Extended Adolescence.
Globe Trekker
Poland | Saturday, 7 p.m.Megan McCormick discovers the rich folklore and history of Poland. She visits the humble church where Pope John Paul II served as a young priest, discovers anti-Communist sculptures in Wroclaw, and hunts for amber on the Pomeranian coast. She explores the baroque streets of Gdansk, boards a galleon along the River Motlawa and re-enacts the ancient battles in Gniew. She explores Hitler's command post in Ketzryn and kayaks through the Augustow canal to the Belarussian border.
Wolf Hall
Episode 2 | Monday, 9 p.m.Cardinal Wolsey has been forced to move to York. Cromwell remains in London, seeking to return the cardinal to the king's favor. As Cromwell's relationship with Henry deepens, there is unexpected news from the north.
Sandy Roberts - Champaign, IL
"I love the fact that on Saturday nights from 8 p.m. til midnight you have movies!"
WEIU membership is important to Sandy, and you can also be a proud member! Also, send us a message and let us know what WEIU means to you!
Sandy Roberts - Champaign, IL
"I enjoy watching Heartland Highways because the two women on that show take you all over the state. You always learn a lot by watching that show."
WEIU membership is important to Sandy, and you can also be a proud member! Also, send us a message and let us know what WEIU means to you!
Andrea McKenna - Program Manager
When Did You Start at WEIU? June 2012
Favorite Show on WEIU-TV: Masterpiece Classic, such as Downton Abbey, Birdsong and Mr. Selfridge and Masterpiece Mystery such as Sherlock, Inspector Lewis and Wallender. The best of British television drama comes right to your TV without commercial interruption! What's not to like?
What have you learned while working at WEIU? Coming from a very different market in Texas, I've had to quickly learn about the community that WEIU serves, and I've become very fond of it. As I've gotten to know the staff at WEIU, I've learned how dedicated they are to bringing the kind of quality television that has relevance to the community, but still entertains and stimulates viewers — no easy feat in the age of 200 channels.
Why should someone become a member of WEIU? The question should be "Why wouldn't someone become a member of WEIU?" If you've ever enjoyed the wide range of programming WEIU provides; if your children or grandchildren have ever learned about letters or numbers or even social skills from the 11.5 hours of stimulating, non-violent and educational kids' programming WEIU provides each day; if you've been able to experience an opera or a Shakespearean play or a rock concert or a Broadway show that you wouldn't otherwise have had access to; if you've learned to knit or do woodworking or to cook by watching WEIU's programming, then why shouldn't you be a member of WEIU?
Is WEIU as important to you as it is to Andrea? Become a member today! Also, send us a message and let us know what WEIU means to you!
We love to hear from you!
Most of TV is pathetic. I think your offering is outstanding and a lovely way spend an evening. Please, oh please, keep it up.
-- Nancy, Sigel
Is WEIU as important to you as it is to Nancy? Become a member today! Also, send us a message and let us know what WEIU means to you!
Chris Considine - Mattoon: A Baseball Town
Chris Considine talks about why Mattoon is a baseball town.
Chris would love for you to tune in to Effingham: This is Our Story on Thursday, Oct. 2, at 7 p.m. We hope you'll join us!
Aaron Walk - How Mattoon Got Its Name
Wonder how Mattoon got its name? Storyteller Aaron Walk gives us the details.
Aaron would love for you to tune in to Effingham: This is Our Story on Thursday, Oct. 2, at 7 p.m. We hope you'll join us!