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Smoking and environmental characteristics of smokers with a mental illness, and associations with quitting behaviour and motivation; a cross sectional study
Alexandra P. Metse1,2,
John Wiggers1,2,3,
Paula Wye1,2,3,
Lyndell Moore1,2,
Richard Clancy1,2,4,
Luke Wolfenden1,2,3,
Megan Freund1,2,
Tara Van Zeist1,2,
Emily Stockings5 &
Jenny A. Bowman1,2
Persons with a mental illness are less likely to be successful in attempts to quit smoking. A number of smoking and environmental characteristics have been shown to be related to quitting behaviour and motivation of smokers generally, however have been less studied among smokers with a mental illness. This study aimed to report the prevalence of smoking characteristics and a variety of physical and social environmental characteristics of smokers with a mental illness, and explore their association with quitting behaviour and motivation.
A cross-sectional descriptive study was undertaken of 754 smokers admitted to four psychiatric inpatient facilities in Australia. Multivariable logistic regression analyses were undertaken to explore the association between smoking and environmental characteristics and recent quitting behaviour and motivation.
Participants were primarily daily smokers (93 %), consumed >10 cigarettes per day (74 %), and highly nicotine dependent (51 %). A third (32 %) lived in a house in which smoking was permitted, and 44 % lived with other smokers. The majority of participants believed that significant others (68–82 %) and health care providers (80–91 %) would be supportive of their quitting smoking. Reflecting previous research, the smoking characteristics examined were variously associated with quitting behaviour and motivation. Additionally, participants not living with other smokers were more likely to have quit for a longer duration (OR 2.02), and those perceiving their psychiatrist to be supportive of a quit attempt were more likely to have had more quit attempts in the past six months (OR 2.83).
Modifiable characteristics of the physical and social environment, and of smoking, should be considered in smoking cessation interventions for persons with a mental illness.
A decreased likelihood of successfully quitting [1, 2] contributes to the persistently higher prevalence of smoking among persons with a mental illness [3–6]. This in turn is reflected in greater morbidity and mortality from tobacco-related diseases and a reduced life expectancy [7, 8].
Successful smoking cessation is often preceded by multiple quit attempts [9, 10], a motivation to quit [9, 11], and a greater capacity to identify as a potential non-smoker [12–14]. The likelihood of being motivated and attempting to quit has been suggested to be a function of an individual's smoking characteristics such as level of nicotine dependence [15, 16], number of cigarettes smoked per day [17, 18], age of smoking initiation [10, 19], and number of years smoking [20]. While research among smokers with a mental illness specifically has consistently demonstrated high levels of nicotine dependence and heavy smoking (in terms of cigarettes per day) [3, 5, 6], far less research has explored the associations of such characteristics with quitting behaviour and motivation. That which has been undertaken however suggests the same patterns of association as found among smokers generally [11, 21, 22]. For instance, lower levels of nicotine dependence have been associated with quit attempts of longer duration (>7 days) among smokers from the United States (U.S.) attending a residential substance treatment program [22], and following discharge from a psychiatric inpatient facility [11].
Socio-ecological theories also highlight the potential influence of a range of broader physical and social environmental characteristics of smokers on quitting behaviour [23]. Among smokers generally, characteristics associated with both attempts to quit and successful cessation include: residing in a smoke-free home [10, 24, 25]; absence of persons who smoke in the immediate environment [10, 25]; a partner being a non-smoker [26, 27]; and perception of support to quit from significant others [28, 29] and health care providers [16, 30]. Consequently, intervention strategies to aid smoking cessation have included: the introduction of smoke-free workplace policies [31]; enhancement of partner support for spouse's smoking cessation [32]; smoking cessation care being delivered by health care providers [33]; and increasing the availability of smoking cessation peer support programs [34].
Very little research has explored the prevalence of such physical and social environmental characteristics among persons with a mental illness. In the U.S., a study reported that only 24 % of smokers diagnosed with psychotic or mood disorders occupied a residence where smoking was not permitted inside [35], nearly half that reported in a national representative sample of smokers without a mental illness (46 %) [36]. Among clients of U.S. community mental health services, the proportion of smokers with acquaintances that smoked was more than twice that of non-smokers (78 % vs 35 %) and smokers were reported to have higher rates of household second-hand smoke exposure (47 % vs 28 %) [37]. In one Australian study, the proportion of smokers with a mental illness living in a smoke-free home was found to be 42 %, almost 20 % less than those without a mental illness [38].
In addition, few studies have explored the association between the physical and social environmental characteristics of smokers with a mental illness and their quitting behaviour and motivation. In one such study, among U.S. smokers with co-occurring severe mental illness and substance use disorders, Ferron et al. [39] found that more social contact with non-substance using (including tobacco) friends was positively associated with a higher number of quit attempts. Survey data from the United Kingdom (UK) [40] and U.S. [41] similarly suggest that aspects of the physical and social environment have an impact on smoking and quitting behaviour of smokers with a mental illness. Among recent quitters with a current mental illness, 46–58 % identified social support to quit from friends, family and doctors as key enabling factors in their successful quitting [41]; and among forensic psychiatric inpatients, exposure to others smoking and lack of encouragement from psychiatric staff to quit were identified as barriers to successful smoking cessation [40]. Further, qualitative research undertaken in several countries, including g the U.S. [42, 43], UK [44], Scotland [45], Australia [46], and Canada [47], has suggested that a lack of support to quit from family and friends [44] and health care professionals [43–46], and socialising with other smokers [42, 45, 47] contribute to continued smoking by this group.
Given the limited evidence available, it is suggested that a greater understanding of the characteristics of smokers with a mental illness that are associated with their quitting behaviour and motivation [48] is required to facilitate the development of effective smoking cessation interventions. We conducted a study that aimed to 1) report the prevalence of smoking characteristics and a variety of physical and social environmental characteristics of smokers with a mental illness and 2) explore the association between such characteristics and recent quitting behaviour and motivation.
Design and setting
A cross-sectional descriptive study was undertaken in the context of a smoking cessation intervention trial [49] conducted in four adult psychiatric inpatient facilities in New South Wales (NSW), Australia.
Sample and recruitment procedure
Research staff approached all patients admitted to the four psychiatric inpatient facilities over a 19 month period (October 2012 and April 2014) to assess for study eligibility [49]. Research staff were independent of the hospitals, received standardised training in mental illness and its impacts, and had completed or were in the process of completing an undergraduate degree in a health related area. Patients eligible for the trial were: current smokers (smoked tobacco in the month prior to admission); at least 18 years of age; willing to provide contact details; and able to give informed consent to participate in the trial. No other exclusion criteria were applied.
Ethics, consent and permissions
Ethics approval was obtained from the Hunter New England Human Research Ethics Committee (reference no: 11/12/14/4.02) and the University of Newcastle Human Research Ethics Committee (reference no: H-2012-0061). Written consent was obtained from all participants.
Data collection procedures
Consenting participants completed a face-to-face structured interview, administered by research staff during their hospital stay. Interviews were administered in a quiet area of the inpatient unit and took approximately 40 min to complete. Participants could opt to have short breaks during the data collection process as required. Interviews were carried out prior to participant allocation to the intervention or usual care control condition of the overarching smoking trial [49]. Characteristics of smoking and of the participants' physical and social environment relevant to smoking, and recent quitting behaviour and motivation were collected by the interview. Participant clinical and demographic information was obtained via the facility electronic medical record system and the participant interview.
Clinical and demographic information
The following participant data were collected from the patient medical record system: age, gender, relationship status (single, married/de facto, separated/divorced, widowed, did not state/inadequately described), Aboriginal and/or Torres Strait Islander status (Aboriginal and/or Torres Strait Islander, neither, did not state), primary mental health diagnosis at discharge (schizophrenia and related psychoses, anxiety and stress related disorders, mood disorders, substance- related disorders, personality and other disorders), legal status at admission (voluntary, involuntary), and length of stay (total days between admission and discharge).
The following clinical and demographic information was obtained from the participant interview: level of alcohol use (AUDIT-C) [50], education (primary school, third year of high school, school certificate (fourth year high school), Higher School Certificate [HSC] (sixth year high school), TAFE certificate or diploma (tertiary qualification not obtained from a university), bachelor degree, post graduate degree), employment details (full time, part time, household duties, student, unemployed/other), receipt of a government payment (yes, no), and living circumstances (on own, with others).
Smoking characteristics
The smoking characteristics of participants prior to admission were: smoking status (daily smoker, weekly smoker, irregular smoker [smoked cigarettes less than weekly), cigarettes per day, level of nicotine dependence (Fagerstrom Test for Nicotine Dependence [FTND]) [51], age initiated smoking, and number of years smoked.
Physical and social environmental characteristics
Participants were asked if they: lived in a smoke-free house prior to admission (a place of residence where smoking is not permitted inside; yes, no), lived with smokers prior to admission (lived with at least one other smoker; yes, no), and had a partner who smoked (partner smokes, partner does not smoke/no partner).
Participants were also asked to rate on a seven point Likert- type scale ('very supportive' to 'actively discourage', 'unsure' and 'not applicable'), how supportive they perceived the following persons would be if they were to attempt to quit smoking: partner, family, friends, general practitioner (primary care physician; GP), psychiatrist, and 'other' mental health professional (psychologists, social workers, nurses, counsellors and case managers). Participants were asked if they had someone in their life they felt was their key support person (a person of whom they could rely and/or routinely provided assistance and general support; yes, no).
Recent quitting behaviour and motivation
Measures of recent quitting behaviour were: a quit attempt in past six months (yes, no); and, for those who had attempted to quit in the past six months, the number of times (once, two to three times, more than three times) and duration of longest quit attempt in that period (days). Quit attempts were defined as not smoking on purpose for a period of at least 24 h, with the intention of quitting smoking [52].
Measures of smoking related motivation were: readiness to quit and smoking identity. To assess current readiness to change, the Readiness to Quit Smoking Questionnaire [53] was used, eliciting responses to five items in a Likert scale format. Smoking identity was measured using a single question asking respondents to indicate how easy it was for them to see themselves as a non-smoker [14]. Participants responded on a five point Likert- type scale ranging from very easy to very difficult, with an 'unsure' option.
Data were analysed using SPSS Statistics version 22 [54]. The following numerical variables were transformed to categorical variables for the purpose of association analyses: cigarettes per day (1–10, 11–20, 21–30, >31) [55], age initiated smoking (<14 years, ≥ 14 years) [56], number of years smoked (≤10, 11–20, >20 years) [20], number of quit attempts in the past six months (1, ≥2) [9, 57], and duration of longest quit attempt in the last six months (<1 month, ≥ 1 month) [10, 57].
The following variables were categorised to two levels: smoking status (daily smoker, weekly/irregular smoker), nicotine dependence (low-moderate [FTND score ≤5], high [FTND score ≥ 6]) [58], readiness to quit (pre-contemplative, contemplative or a more progressed stage), and ease of seeing self as a non-smoker (easy, difficult/unsure). All measures pertaining to the degree of perceived social support to quit smoking from significant persons/clinicians were also categorised to two levels (supportive, unsupportive/unsure/not applicable).
Participant clinical and demographic information, smoking and physical and social environmental characteristics, and recent quitting behaviour and motivation were summarised using descriptive statistics.
Chi-square analysis was used to explore univariate associations between each separate smoking and physical and social environmental characteristic, and recent quitting behaviour and motivation. Variables with a p-value of ≤ 0.25 were subsequently entered into multivariable logistic regression models, using both backward elimination and stepwise variable selection to ensure model stability. Significance level was set at 0.05 for the inclusion of variables in the final models. Separate models were developed for five dependent variables: quit attempt in the past six months (yes, no), number of quit attempts in past six months (one, two or more), duration of quit attempt in the past six months (<1 month, ≥ 1 month), readiness to quit (pre-contemplative, contemplative or a more progressed stage), and ease of seeing self as a non-smoker (easy, difficult/unsure).
Of the 3626 patients admitted to the four inpatient facilities in the study period, 64 % (n =2315) were approached by research staff. For those not approached, the primary reasons for non-contact were a short length of stay (≤ one night; 38 %) and psychiatric instability for the duration of time spent as an inpatient (35 %). Of the 2315 patients approached, 2078 (90 %) agreed to be assessed for study eligibility, of which 841 (40 %) were ineligible, predominantly due to being non-smokers (n = 797, 95 %). Sixty one per cent (n = 754) of eligible smokers consented and completed the survey (Fig. 1).
Flow diagram illustrating the number of patients approached, assessed for eligibility and recruited into the study
Patient clinical and demographic information
Table 1 describes the clinical and demographic characteristics of patients approached and not approached, and participants and non-consenters. Approximately one third (30 %) of participants lived on their own, 66 % with a partner or with others, and 4 % reported being homeless (not in table).
Table 1 Clinical and demographic characteristics of not approached and approached patients, and participants and non-consenters
Prevalence of smoking characteristics
Participants smoking characteristics are described in Table 2. Almost all (93 %) were daily smokers; 51 % were assessed as highly nicotine dependent; nearly three quarters (74 %) smoked >10 cigarettes per day; 68 % had commenced smoking before 16 years of age; and more than half (55 %) had smoked for more than 20 years.
Table 2 Smoking characteristics
Prevalence of physical and social environmental characteristics
Forty four per cent of participants lived with at least one other smoker, and 32 % lived in a house where smoking was permitted inside (Table 3). Fifty one per cent of those with a partner reported that their partner smoked.
Table 3 Physical and social environmental characteristics
Almost all participants (92 %) could identify a key support person in their life on whom they could rely and/or routinely provided assistance and general support. Seventy one per cent of participants with a partner believed the partner would be supportive of them making a quit attempt. Eighty two per cent and 68 % of participants believed their family and friends would be supportive of them quitting, respectively. Eighty one, 91 and 80 % of participants believed that their psychiatrist, GP, or another mental health professional, respectively, would be supportive of them attempting to quit.
Quitting behaviour and motivations
Thirty one per cent of participants had attempted to quit in the past six months; with 57 % of those who had done so having made a single quit attempt, and 30 and 13 % having attempted to quit two to three times or more than three times, respectively. Of those who had made a quit attempt in the past six months, 21 % were abstinent for at least one month.
In terms of motivation and readiness to quit, 45 % of participants were assessed as being either contemplative or at a more progressed stage. Forty three percent reported it would be easy to see themselves as a non-smoker, whereas 43 and 14 % reported it would be difficult or that they were unsure.
Smoking, physical and social and environmental characteristics associated with quitting behaviour and motivation
Variables with a p-value of ≤0.25 in the chi-square analyses and hence entered in the multivariable logistic regression models are noted in Tables 2 and 3. The findings of the five regression models were as follows:
Quit attempt in the past six months: Weekly/irregular smokers were twice as likely as daily smokers to have attempted to quit in the past six months (OR = 2.07, 95 % confidence interval (CI): 1.17 to 3.64, p < 0.05) (Table 4). Those who had been smoking for less than 10 years were 1.65 (95 % CI: 1.11 to 2.47, p < 0.05) times more likely than those who had smoked for more than 20 years to have attempted to quit in the past six months.
Number of quit attempts in the past six months: Smokers who perceived their psychiatrist to be supportive of them quitting smoking were 2.83 (95 % CI: 1.64 to 4.88, p < 0.001) times more likely than those who perceived their psychiatrist to be unsupportive or who did not have a psychiatrist to have attempted to quit two or more times in the past six months.
Duration of quit attempt in the past six months: Smokers of 1–10 cigarettes per day were 16.23 (95 % CI: 2.05 to 128.24, p < 0.05) times more likely to have made a quit attempt of longer duration, compared to heavier smokers (31 cigarettes or more). Participants not residing with other smokers were 2.02 (95 % CI: 1.002 to 4.06, p < 0.05) times more likely to have quit for one month or longer in the past six months.
Readiness to quit: Participants who started smoking at the age of 14 or after were 1.40 (95 % CI: 1.04 to 1.87, p < 0.05) times more likely be in the contemplative or a more progressed stage of change, relative to those who initiated smoking prior to the age of 14.
Identity as a smoker: Weekly/irregular smokers were 2.79 (95 % CI: 1.47 to 5.29, p < 0.05) times more likely than daily smokers to easily see themselves as a non-smoker; low-moderate nicotine dependent smokers were 2.34 (95 % CI: 1.72 to 3.18, p < 0.001) times more likely to easily see themselves as a non-smoker than highly dependent smokers; and participants who had been smoking for less than 10 years were 2.34 (95 % CI: 1.55 to 3.52, p < 0.001) times more likely to easily see themselves this way than participants who had smoked for more than 20 years.
Table 4 Multivariable logistic regression results for smoking and physical and social environmental characteristics associated with quitting behaviour and motivation
This is the first study reporting both the prevalence of a range of smoking and physical and social environmental characteristics of smokers with a mental illness, and the association of such characteristics with quitting behaviour and motivation. In line with previous research, assessment of smoking characteristics indicated a high prevalence of daily smoking, high nicotine dependence and heavy smoking in terms of cigarettes per day; and further, that smoking appeared to be a long-established behaviour. With respect to physical environmental characteristics, smoking was 'present' in the home lives of many participants: nearly one half lived with others who were also smokers and for one third, the home was not smoke-free. Whilst with respect to social environmental characteristics, perceived support for quitting from significant others and health professionals was variable, with a lack of support most evident for friends; one third (32 %) not indicating that friends would be supportive.
The results suggest that despite many participants expressing interest in quitting and making recent quit attempts, reflecting the findings of previous research [2, 12], a number of smoking and physical and social environmental characteristics may serve to sustain their tobacco use. In line with the broader smoking literature [15, 16] as well as previous research among smokers with a mental illness [11, 22], 'lighter' smokers (less nicotine dependent, smoking fewer cigarettes or less than daily) were more likely to have attempted or to be at least contemplating quitting. Such findings suggest a potential benefit of interventions aimed at reducing cigarette consumption among persons with a mental illness in not only decreasing the degree of immediate harm caused by heavy smoking [59] but also increasing the likelihood of subsequent quit attempts and cessation [4, 60]. The findings that those who had been smoking for a fewer number of years were more likely to envisage life without smoking and to have recently attempted to quit, and that smokers who initiated smoking at a younger age were likely to be less 'ready' to quit, similarly reflects findings from general population smokers [10, 19] and perhaps highlights the importance of providing cessation intervention to young smokers and to all smokers as soon as possible after initiation.
In terms of the physical environment, previous research has reported the presence of smoking in the home environment to be less prevalent among the general Australian population, than for the participants in this study: 34 % [61] (as compared to 44 %) living with another smoker, and only 7 % [62] (as compared to 32 %) residing in a home that was not smoke free. Further, differences between Australian smokers without a mental illness are also evident in comparison to smokers in the present study: 21 % residing in a home that was not smoke free (as compared to 32 %), and 42 % of those with a current partner reporting their partner to be a smoker (as compared to 51 %) (International Tobacco Control Policy Evaluation Study: Survey Data, unpublished 2013 and 2014). In line with research undertaken with smokers generally [24, 26, 56], the potential influence of other smokers in the immediate environment was indicated by the finding in this study that participants who did not live with other smokers were more likely to have recently made a quit attempt of at least one month duration.
With respect to the social environment, almost all participants (92 %) identified a key support person whom they relied on and/or who routinely provided assistance and support for their well-being and functioning; suggesting the potential to involve support persons, and possibly family carers [63] in smoking cessation interventions. While evidence suggests that involvement of family carers in treatment delivery can be effective in improving mental health outcomes for persons with a mental illness [64], the potential of such carers to support someone with a mental illness to quit smoking appears not to have been explored by research. One U.S. survey of recent quitters with a mental illness does suggest however, that family and friendship networks generally could have a role in encouraging and supporting quitting behaviour [41]. In the present study, while a majority of participants perceived that family, a partner and friends would be supportive of their making a quit attempt, nevertheless quite significant proportions also reported either that such people would be unsupportive of a quit attempt or that they were uncertain of their support (family 18 %; partner 29 % and friends 32 %), indicating a need for further research to explore their potential to play a role in smoking cessation interventions for this group.
The large majority of participants perceived their GP (91 %), psychiatrist (81 %) and other mental health professional/s (80 %) to be supportive of a quit attempt. Physician advice has been identified to have a particularly positive impact on smoking and quitting behaviour [65] and this was reinforced by the study finding that those participants who perceived psychiatrists as supportive of quitting were more likely to have recently made a greater number of quit attempts. Although the differences in the perceived support across the health professional groups were minimal, 'other' mental health professionals were least likely to be seen as supportive; a finding somewhat reflective of previous research suggesting allied health professionals, including psychologists are less likely to routinely assess for or offer intervention for smoking [66], despite the likely efficacy of their doing so [33]. It is possible that higher rates of nicotine dependence reported among some mental health professions, compared to their general health counterparts contributes to a more benign perception of smoking [67] and hence a lower likelihood of intervening. Given the integral role of mental health professionals in caring for persons with a mental illness, and the professional status in particular of psychiatrists, the importance of their accepting provision of smoking cessation care as part of their professional role has been noted previously [68].
The strengths of this study include its conduct with a large and diverse sample of smokers with a mental illness and a relatively high consent rate. However, it is noted that smokers who stayed in the hospital for one night or less and those with psychotic type disorders may be underrepresented, while patients with anxiety/stress and substance-related disorders may be over-represented as compared to aggregate descriptive statistics for the facility's patient population during the recruiting period. The sample consisted of smokers who had consented to take part in an overarching smoking trial and it is unknown whether the prevalence and role of physical and social environmental factors may have differed somewhat for this sample as compared to the broader group of smokers with a mental illness. It is noted that findings need to be interpreted in the context of the cross sectional study design. Future research employing a longitudinal design would add strength to the conclusions that could be drawn. The utilisation of solely self-report data may also pose a limitation, in that accounts of recent quitting behaviour may have been under or over-estimated.
This paper provides evidence for the importance of considering characteristics of smoking and also of the physical and social environment in cessation interventions for persons with a mental illness. With respect to the latter, it expands previous knowledge in this field in identifying the importance of encouraging physical environments that promote smoking cessation and the potential benefit of engaging significant others and health care providers, particularly psychiatrists.
The datasets generated and analysed during the current study are not publicly available to preserve the privacy of participants, however are available from the corresponding author on reasonable request.
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Howard LM, Bekele D, Rowe M, Demilew J, Bewley S, Marteau TM. Smoking cessation in pregnant women with mental disorders: a cohort and nested qualitative study. BJOG. 2013;120(3):362–70.
Kerr S, Woods C, Knussen C, Watson H, Hunter R. Breaking the habit: a qualitative exploration of barriers and facilitators to smoking cessation in people with enduring mental health problems. BMC Public Health. 2013;13:221.
Lawn SJ, Pols RG, Barber JG. Smoking and quitting: a qualitative study with community-living psychiatric clients. Soc Sci Med. 2002;54(1):93–104.
Goldberg JO, Moll S, Washington A. Exploring the challenge of tobacco use and schizophrenia. Psychiatr Rehab Skills. 1996;1(2):55–67.
Rose JS, Chassin L, Presson CC, Sherman SJ. Prospective predictors of quit attempts and smoking cessation in young adults. Health Psychol. 1996;15(4):261–8.
Metse AP, Bowman JA, Wye P, Stockings EA, Adams M, Clancy R, Terry M, Wolfenden L, Freund M, Allan J et al. Evaluating the efficacy of an integrated smoking cessation intervention for mental health patients: study protocol for a randomised controlled trial. Trials. 2014;15(1):266.
Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res. 2007;31(7):1208–17.
Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom K-O. The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. Br J Addict. 1991;86(9):1119–27.
Stockings EA, Bowman J, Baker AL, Terry M, Clancy R, Wye P, Knight J, Moore L, Adams M, Colyvas K et al. Impact of a post-discharge smoking cessation intervention for smokers admitted to an inpatient psychiatric facility: a randomised controlled trial. Nicotine Tob Res. 2014;16(11):1417–28.
Crittenden KS, Manfredi C, Lacey L, Warnecke R, Parsons J. Measuring readiness and motivation to quit smoking among women in public health clinics. Addict Behav. 1994;19(5):497–507.
Corp IBM. IBM SPSS Statistics for Windows, Version 22.0. Armonk: IBM Corp.; 2013.
Hyland A, Laux FL, Higbee C, Hastings G, Ross H, Chaloupka FJ, Fong GT, Cummings KM. Cigarette purchase patterns in four countries and the relationship with cessation: findings from the International Tobacco Control (ITC) Four Country Survey. Tob Control. 2006;15 Suppl 3:iii59–64.
Siahpush M, Borland R, Scollo M. Factors associated with smoking cessation in a national sample of Australians. Nicotine Tob Res. 2003;5(4):597–602.
Nicholson AK, Borland R, Davey ME, Stevens M, Thomas DP. Predictors of wanting to quit in a national sample of Aboriginal and Torres Strait Islander smokers. Med J Aust. 2015;202(10):S26–32.
Fagerstrom KO, Heatherton TF, Kozlowski LT. Nicotine addiction and its assessment. Ear Nose Throat J. 1991;69:763–5.
Kelly DL, McMahon RP, Wehring HJ, Liu F, Mackowick KM, Boggs DL, Warren KR, Feldman S, Shim JC, Love RC et al. Cigarette smoking and mortality risk in people with schizophrenia. Schizophr Bull. 2011;37(4):832–8.
Evins AE, Cather C, Rigotti NA, Freudenreich O, Henderson DC, Olm-Shipman CM, Goff DC. Two-year follow-up of a smoking cessation trial in patients with schizophrenia: increased rates of smoking cessation and reduction. J Clin Psychiatry. 2004;65(3):307–11. quiz 452–303.
Australian Institute of Health and Welfare (AIHW). Australia's health 2008. AIHW Cat no. AUS 99. Canberra: AIHW; 2008.
Centre for Epidemiology and Research. Report on Adult Health from the New South Wales Population Health Survey. Sydney: NSW Department of Health; 2010. p. 2011.
New South Wales Department of Health. NSW Carers Action Plan 2007–2012. North Sydney: State Government of New South Wales; 2007.
Harvey C, O'Hanlon B. Family psycho-education for people with schizophrenia and other psychotic disorders and their families. Aust N Z J Psychiatry. 2013;47(6):516–20.
Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2008;2:CD000165.
Akpanudo SM, Price JH, Jordan T, Khuder S, Price JA. Clinical psychologists and smoking cessation: treatment practices and perceptions. J Commun Health. 2009;34(6):461–71.
Connolly M, Floyd S, Forrest R, Marshall B. Mental health nurses' beliefs about smoking by mental health facility inpatients. Int J Ment Health Nurs. 2013;22(4):288–93.
Williams JM, Stroup TS, Brunette MF, Raney LE. Tobacco use and mental illness: a wake-up call for psychiatrists. Psychiatr Serv. 2014;65(12):1406–8.
The authors would like to thank the participants, clinicians and the research team, in particular the recruiting staff, that enabled this study to be undertaken.
This research was funded by the National Health and Medical Research Council (grant number: G1100130).
University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
Alexandra P. Metse, John Wiggers, Paula Wye, Lyndell Moore, Richard Clancy, Luke Wolfenden, Megan Freund, Tara Van Zeist & Jenny A. Bowman
Hunter Medical Research Institute, Lot 1 Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
Hunter New England Population Health, Longworth Ave, Wallsend, NSW, 2287, Australia
John Wiggers, Paula Wye & Luke Wolfenden
Centre for Translational Neuroscience and Mental Health, Corner Edith and Platt Streets, Waratah, NSW, 2298, Australia
Richard Clancy
National Drug and Alcohol Research Centre, University of New South Wales, 22-32 King Street, Randwick, NSW, 2031, Australia
Emily Stockings
Alexandra P. Metse
John Wiggers
Paula Wye
Lyndell Moore
Luke Wolfenden
Megan Freund
Tara Van Zeist
Jenny A. Bowman
Correspondence to Alexandra P. Metse.
APM drafted the manuscript and participated in the conception, design and coordination of the study. JAB, JW and PW conceived the study, participated in its design and coordination, and assisted in drafting the manuscript. ES, LM and RC participated in the study design, implementation and interpretation of findings, and assisted with manuscript preparation. LW and MF contributed to the design of the study, interpretation of findings and drafting of the manuscript. TVZ contributed to the analyses, interpretation of findings and manuscript preparation. All authors critically revised and approved the final manuscript for publication.
Metse, A.P., Wiggers, J., Wye, P. et al. Smoking and environmental characteristics of smokers with a mental illness, and associations with quitting behaviour and motivation; a cross sectional study. BMC Public Health 16, 332 (2016). https://doi.org/10.1186/s12889-016-2969-1
Quitting motivation


text:
David B. Morris is a writer and scholar, emeritus professor of literature at the University of Virginia.  His main interest is pain and its various manifestations.

Interest in pain

Morris wrote an award-winning article about pain for Arthritis Today, and lectured to wide audiences like American Academy of Pain Medicine, American Pain Society, American Society for Pain Management Nurses and The International Association for the Study of Pain (IASP). Morris is a founding co-director of the Taos Writing Retreat for Health Professionals, co-sponsored by Kaiser-Permanente and the University of New Mexico School of Medicine.

Awards and honors
1992 PEN/Diamonstein-Spielvogel Award for the Art of the Essay, The Culture of Pain

Books
 The Religious Sublime (1972)
 Alexander Pope: The Genius of Sense (1984)
 The Culture of Pain (1991)
 Earth Warrior (1995), about anti-driftnet campaign in the North Pacific
 Illness and Culture in the Postmodern Age (1998)

References

University of Virginia faculty
Living people
PEN/Diamonstein-Spielvogel Award winners
Year of birth missing (living people)
American male writers

redpajama_set_name: RedPajamaWikipedia


text:
Under: Europe's First Underwater Restaurant Looks Like A Rock From Outside, But Only Until You Step Inside
Europe is home to the Greek Parthenon in Athens, the Roman Colosseum in Rome, the Eiffel Tower in Paris and many, many more architectural masterpieces. You know what it's lacking, though? An underwater restaurant. But a company called Snøhetta is on...
Europe is home to the Greek Parthenon in Athens, the Roman Colosseum in Rome, the Eiffel Tower in Paris and many, many more architectural masterpieces. You know what it's lacking, though?...
Share 9.9K
I Show Quirky Vegetable Personalities Through Alphabet Letters (25 Pics)
13 New Before & After Images That Show How I Retouch Pictures To Look Like Surreal Images
7 Eccentric Costumed Motorbike Taxi Drivers In Nairobi

redpajama_set_name: RedPajamaCommonCrawl


One field of home repair and maintenance that is often overlooked by people is regular cleaning and examination of their rain gutters and downspouts. It's very simple to recognize why gutter cleaning frequently winds up being forgotten. A number of individuals simply forget about their gutters and the vital role that they perform.
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Our Gutter Cleaning technicians are friendly and professional. We work carefully and meticulously and are fully insured. We never ever rest extension ladders on your gutters or leave scuff-marks on your outdoor deck from a gutter clean out. Our gutter cleaning service will never compromise your landscaping. After the completion of your clean out, we will make sure to examine the landscaping and leave it in a much better condition than when we showed up.
We Do The Job Right — The purpose of your gutters is to move the rainwater away from your property. We ensure that the gutters and the downspouts are cleared out to ensure that they can do what they were created to do.
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If you think that the cost of gutter cleaning is too costly, then you probably don't understand just exactly how vital it is to have a qualified professional company, clear, clean and maintain your rain gutters and downspouts. Depending on the type of building material utilized, rain gutters can last for several years or perhaps a lifetime. But the catch here is that they must be well preserved. You can't expect anything to last for any length of time if you don't take care of it. This is specifically true when it comes to your rain gutters and downspouts.
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Why should you care about all of this? In a word, money. If you are procrastinating working with a gutter cleaning company simply because you are trying to save a dollar, you are going to be in for a shock when the time comes to remove and replace your rain gutters.
It's a simple cause and effect, if you do not maintain your gutters and downspouts then you are going to end up needing to remove and replace your gutters sooner than typical. This can result in a bill that varies between anywhere from a thousand dollars ($1,000) all the way up to close to ten-thousand dollars. That's a lot more money than the expense of gutter cleaning.
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So, just what is the typical cost to clean gutters in different kinds of houses with different lengths of gutter systems ? The following examples need to give you an idea of what the market average prices are. Let's assume that you have a single-story house with 150 feet of rain gutters. In this case, you should be looking at a typical expense of $135 to $200. What about a single-story home with about 180 feet of gutters and downspouts? In this case, you should be looking at an expense of about $175 to $225. If you have a two-story house with around 200 feet of gutters you are going to be looking at an average expense of about $ 197 to 277 bucks.
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Now, if the skilled professional gutter cleaning company you hire quote you a higher price, you do not need to get out of sorts. What you ought to do is ask why the quote is greater. There are a number of factors why a gutter cleaning business might wind up charging you more. If you understand the reasons then you will have the ability to determine if you are being overcharged, or if your expense is in fact fair.
The primary reason triggering your gutters cleaning bill to be greater is if your rain gutters and downspouts have actually been ignored for a long period of time. Gutters that are excessively nasty are going to take a lot more work to clear, clean and maintain. So, it makes sense that your invoice would be greater. After all, you honestly would not expect a business to undertake additional work for free, now would you?
Another thing that can cause your gutter cleaning bill to be higher is if you have gutter guards in place. What are gutter guards? Gutter guards are various types of devices that American home owners have installed to attempt to keep debris from getting in their gutters. Whether having gutter guards is worth the trouble is undecided. What isn't undecided is the simple fact that having gutter guards is going to cause a greater gutter cleaning charge.
When you have rain gutter guards they need to be removed and then installed again after the cleaning procedure is finished. This essentially boils down to the same complication as having excessively grimy rain gutters. When there is more work required you can anticipate to pay a greater invoice.
When you are a House owner you have a lot of responsibilities that you have to look after, if you desire your house to increase in value. One of the most crucial preventative maintenance items that you need to take note of are, your gutters and downspouts. The important thing you really need to bear in mind is that the expense of gutters cleaning is quite cost effective, while the expense of having a brand-new gutter system replaced, and water damage repair is not.


text:
Q: Показ страниц пагинации Есть у меня код, который выводит пагинацию на странице:

Это выводятся все элементы как есть - от первого до MaxPage:
@if (Model.IsFirst())
{

<<

<

}
else
{

<<

<

}

@for (var i = 1; i <= Model.MaxPageCount; i++)
{
    if (Model.IsCurrent(i))
    {

            @i

    }
    else
    {

            @i

    }
}

Проблемы начинаются, когда число страниц становится больше 10 (а частенько в пагинации и по триста страниц бывает) - они улетают за правую границу экрана.
Сижу думаю, какое условие нужно взять чтобы пагинация показывалась красиво.
Попробуем формализовать условие. Есть некоторая IEnumerable<int> от 1 до Model.MaxPageCount и есть некоторое число PageNumber (текущий номер страницы) которое принадлежит этой последовательности.
Не уверен точно, но допустим мне надо получить не более пяти элементов ДО текущей страницы и не более пяти элементов ПОСЛЕ текущей страницы.
При этом я не знаю, как красиво обработать ситуацию, что если страниц ДО не хватает (допустим, мы смотрим страницу 3, тогда ДО будут страницы 1 и 2) то после наверное стоит взять чуть больше - не пять, а на на три больше. Но и не факт, что ПОСЛЕ хватит нужного числа страниц.
Вопрос скорее на красивый и простой алгоритм (как это принято делать в типичных пагинаторах?), возможно что конкретную формулу я и сам напишу. Если кто сталивался с подобной задачей и знает, как такое можно сделать - предложите вариант. Я смотрел разные варианты XPagedList на github, но какого-то удобного варианта не нашёл.

A: Что то типа такого?
List<int> GeneratePages(int currentPage, int totalPages)
{
    var pages = new List<int>();
    for(var i=currentPage; i>0 && i>=currentPage-5; i--) pages.Add(i);
    pages.Reverse();
    for(var i=currentPage+1; i<=totalPages && i<=currentPage+5; i++) pages.Add(i);
    return pages;
}

Проверка
Console.WriteLine( string.Join(",", GeneratePages(50, 100)));
Console.WriteLine( string.Join(",", GeneratePages(1, 100)));
Console.WriteLine( string.Join(",", GeneratePages(2, 100)));
Console.WriteLine( string.Join(",", GeneratePages(98, 100)));
Console.WriteLine( string.Join(",", GeneratePages(99, 100)));
Console.WriteLine( string.Join(",", GeneratePages(100, 100)));

Результаты
45,46,47,48,49,50,51,52,53,54,55
1,2,3,4,5,6
1,2,3,4,5,6,7
93,94,95,96,97,98,99,100
94,95,96,97,98,99,100
95,96,97,98,99,100

Если, например, хочется видеть в сумме 11 элементов (то есть в идеале 5 слева, 5 спава, 1 текущий) и адаптировать при сдвигах (2 слева, 1 текущий, 8 справа - для страницы номер 3), то ваот второй вариант
List<int> GeneratePages(int currentPage, int totalPages, int expectedpages)
{
    var beforeCurrent = new Stack<int>();
    var afterCurrent = new Queue<int>();
    var expected = expectedpages - 1;
    var i = currentPage-1;
    var j = currentPage+1;

    while(expected > 0)
    {
        var local = expected;

        if (i > 0) {
            beforeCurrent.Push(i);
            i--;
            expected--;
        }

        if (j<=totalPages && expected > 0)
        {
            afterCurrent.Enqueue(j);
            j++;
            expected--;
        }

        if (local == expected) break;
    }

    var res = new List<int>();
    while(beforeCurrent.Count>0) res.Add(beforeCurrent.Pop());
    res.Add(currentPage);
    while(afterCurrent.Count>0) res.Add(afterCurrent.Dequeue());
    return res;
}

Проверяем
Console.WriteLine( string.Join(",", GeneratePages(50, 100, 11)));
Console.WriteLine( string.Join(",", GeneratePages(1, 100, 11)));
Console.WriteLine( string.Join(",", GeneratePages(2, 100, 11)));
Console.WriteLine( string.Join(",", GeneratePages(98, 100, 11)));
Console.WriteLine( string.Join(",", GeneratePages(99, 100, 11)));
Console.WriteLine( string.Join(",", GeneratePages(100, 100, 11)));
Console.WriteLine( string.Join(",", GeneratePages(2, 5, 11)));

Вывод
45,46,47,48,49,50,51,52,53,54,55
1,2,3,4,5,6,7,8,9,10,11
1,2,3,4,5,6,7,8,9,10,11
90,91,92,93,94,95,96,97,98,99,100
90,91,92,93,94,95,96,97,98,99,100
90,91,92,93,94,95,96,97,98,99,100
1,2,3,4,5

A: Сделано по ответу @VladD:
void Main()
{
    var lastPage = 20;
    var currentPage = 3;

    var result = this.GetPaging(currentPage, lastPage);

    result.Dump();
}

IEnumerable<int> GetPaging(int currentPage, int lastPage)
{
    var maxBefore = 5;
    var maxAfter = 5;

    var first = currentPage - maxBefore;

    if(first < 1)
        first = 1;

    var last = currentPage + maxAfter;

    if(last > lastPage)
        last = lastPage;

    return Enumerable.Range(first, last - first);
}

redpajama_set_name: RedPajamaStackExchange


Australian surgeon Dr Ivan Thompson shares what drives him to work with Médecins Sans Frontières (MSF), reflecting on his recent assignment aiding Cameroonians affected by violence.
I'd always wanted to work overseas. I'd also long admired MSF and it had been on my mind to join. Once I retired, I thought it was time to do something.
You've recently returned from working as a surgeon with MSF in Bamenda, Cameroon. What are our teams doing in Bamenda?
MSF is responding to the medical and health needs of local populations affected by violence in the South-West and North-West regions of Cameroon. Tens of thousands of people have fled the country and hundreds of thousands more are displaced within the western regions. There are frequent clashes between armed groups, most schools are closed, and many health centres have been destroyed. Many people have been forced to seek shelter in the bush to avoid attacks, where they face a lack of food and difficulty reaching healthcare.
Even if patients can reach a health facility, many cannot afford treatment. In Bamenda, the capital of the North-West region, we are supporting a private hospital and working to strengthen the capacity of the health system to respond to emergencies.
What did you find most rewarding about this assignment?
Despite the challenges, it was hugely rewarding to feel that we were making a difference to the health of the people. There were regional ambulances in Bamenda, but these were highly inaccessible to the population as they were expensive and required pre-payment. Region-wide curfews also made it difficult for people to reach the hospital at night. There were many cases of women having to deliver their babies at home without any medical care, as they were unable to travel. MSF set up an ambulance service to improve the ability of these patients to reach our care.
We also began a decentralised medical care program involving an outreach team of health workers, who work with local health centres to deliver medication and health education. The aim is to catch conditions like malaria and diarrhoeal diseases, which are common causes of morbidity and mortality, early. This reduces the number of patients who arrive at the hospital at a very late stage, extremely sick. The MSF team is now developing surgical and anaesthetic services to bolster the level of care.
Was there a particularly memorable patient you treated?
One day we received a young boy who had been hiding in the bush with his family to avoid armed groups. When they came out to find food, they became caught in fighting. The patient's brother was killed, and he was hit by a bullet which damaged his spinal cord. He was brought to the hospital in a taxi, having been turned back from reaching another hospital due to roadblocks. In theatre, I excised his wounds and performed a debridement (removing the bullet and the damaged tissue). While it turned out that his spine was essentially intact, the injury to his spinal cord caused by the cavitation effect of the bullet was severe. It remained to be seen if he could make any significant recovery. We were eventually able to successfully transfer him to a hospital with higher resolution capacity for long-term management of his treatment.
There were many times when we couldn't transfer patients needing higher level care to this hospital due to the security context and roadblocks. Towards the end of my time in Bamenda, the hospital was forced to significantly reduce the provision of surgical care due to security concerns. It was very apparent that the violence is having a significant impact on Cameroonians needing urgent medical care.
How have you drawn on skills or experience from previous jobs for your role as a surgeon with MSF?
I was lucky in that I had broad, general exposure to lots of procedures during my training as a surgeon, which has proved very useful. Even if I haven't handled something for 30 years, I often find it is still there in my head somewhere! You won't always be at ease, but when you can bring things back to basic principles, generally you can cope. I have been confident in relying on my skills and doing the best I can in the circumstances. The futility can get to you – I have sometimes wondered in frustration, "why can't people stop killing each other?" But at the end of the day, if you focus on what you can do, you can make a world of difference.


The purpose of this study was primarily to find whether entrepreneurial orientation (EO) theory can be applied in Finnish immigrant-led enterprises' context. The positive relationship between entrepreneurial orientation and firm performance has been widely researched, thus we wanted to test the EO and firm performance relationship in this context too. Secondly, we also wanted to study in the same context whether EO is a unidimensional or a multidimensional construct in explaining the firm performance. And thirdly, we also wanted to study the impact of EO and firm performance in new immigrant-led Finnish ventures. However, the study doesn't cover the entire population of immigrant-led enterprises in Finland; it covers only the immigrant-led enterprises (N = 855) that had received the consultation services from Enterprise Helsinki between 2008 and 2011. The empirical part of this research was based on a quantitative study. We designed a survey based on the popularly used EO and firm performance scales as suggested by our literature framework. The questionnaire was sent to the founders or the top managements of immigrant-led enterprises that had received services of Enterprise Helsinki at some point during their entrepreneurial career in Finland. A total of 78 responses were received, corresponding to a response rate of over 9 %. The data collected for this research were analyzed according to our theoretical framework and the research objectives. First the reliability and validity tests were performed in order to move to the next step of statistical analyses. We used SPSS tool for doing the statistical analyses. The statistical methods used in this research included correlation matrix, regression analysis including both the multi-level regression and curvilinear regression. Our results suggested that there is a positive relationship between EO and firm performance in the immigrant-led enterprises' context; however the correlation is not a strong one. Our findings also showed that EO is a multidimensional construct in explaining the relationship of EO with firm performance. And finally, we determined that the impact of EO on firm performance in new ventures is not different than older firms.


text:
103 Eisenhower Parkway, Roseland, NJ 07068
Seton Hall University School of Law, Newark, New Jersey, 2011
Rutgers University, Criminal Justice and Sociology, 2008
U.S. District Court, District of New Jersey, 2011
Notable Representations
Michael J. Paragano is an associate at Nagel Rice. He concentrates his practice in the areas of personal injury, medical malpractice, class actions and civil litigation.
Prior to joining Nagel Rice in 2016, Michael was an associate at a New Jersey law firm where he exclusively focused his practice representing plaintiffs in civil litigation, including personal injury and medical malpractice matters.
Michael attended college at Rutgers University in New Brunswick, New Jersey where he obtained his Bachelor of Arts in Criminal Justice and Sociology, with honors. Thereafter, Mr. Paragano received his Juris Doctor from the Seton Hall University School of Law, cum laude.
While in law school, he was a member of the Mock Trial Team and received the Joseph P. Lordi Memorial Scholarship based on academics after his first year. Following law school, he served as law clerk for the Honorable Donald W. De Leo, Surrogate of Hudson County.
He was admitted to practice law in New Jersey and the District of New Jersey in 2011 and New York in 2012. He is a member of the Middlesex County Bar Association as well as the New Jersey Association for Justice (NJAJ). He currently serves as the Co-Chairman of the Young Lawyers Division for the Middlesex County Bar Association.
Michael was named to the Super Lawyer's Rising Stars list, 2017 – 2020.
Balducci v. Cige, 456 N.J. Super. 219 (App. Div. 2018)
$400,000 – settlement for customer injured when she slipped and fell on liquid in a restaurant
$100,000 – settlement in case involving pedestrian struck by motor vehicle while crossing the street in a crosswalk
$1,100,000 – settlement for an injured driver when another vehicle crossed over into his lane and struck him head on.
$500,000 – settlement for a dog bite resulting in permanent facial scarring and emotional distress
$460,000 – settlement for a family injured when a motor vehicle struck their vehicle from behind on the Garden State Parkway.
$312,500 – settlement for a passenger injured when a garbage truck made an improper left turn and struck the vehicle she was traveling in.
$250,000 – settlement for customer injured on ice/snow that accumulated on the floor in a mall.
$250,000 – settlement for passenger injured when a motor vehicle left the highway and struck the vehicle in the lane she was traveling in.
$200,000 – settlement for customer injured when she slipped on debris located on the floor of a deli.
$100,000 – settlement in case involving pedestrian struck by motor vehicle while crossing the street in a crosswalk.


text:
Affordable Care Act Insurance Obamacare Politics
What TrumpCare Says About America
May 8, 2017 ChrisByrnes.com Views 0 Comments aca, AHCA, American Health Care Act, obamacare, trumpcare
The GOP has passed its long-touted repeal of the Affordable Care Act (ACA) in the American Health Care Act of 2017 (AHCA). While it is hard to hear cautious voices of reason above the saber-rattling and keg stands, Friday's narrow 217-213 vote tally was only in the House of Representatives. The TrumpCare deal is far from complete.
Contortion of the purpose behind the Affordable Care Act
The ACA (or Obamacare, depending upon the speaker) provided a way for more Americans to have health insurance, which should hypothetically allow them to have access to health care.
Some in the business world hated it. They claimed it was a load of paperwork, regulations and compliance. Ads, put on the air within hours of the law's signing, misconstrued parts of its text. With enough repetition, people had opinions ranging from confused all the way to terrified of their impending death panel.
But hey, at least we gave the ACA the time it needed to settle in. Patients and providers were able to learn the ropes. The healthcare industry grew an effective and functional system. Oh, wait. No, we did not.
Talking heads on TV and bloggers on the Internet continued to scare. Republican governors put up roadblocks to metaphorical construction crews sent to repair the expected cracks and potholes. The crumbling bridges that resulted frustrated healthcare providers and began to leave a negative impression on patients' view of the law.
For-profit healthcare, even with increased protections under the ACA, does not work
Many healthcare organizations and private doctors have proven to be unwilling to step up to the plate and deal with the new system. Rather, they throw their hands in the air over too complicated paperwork and the plain difficulty of providing healthcare to poor people (Medicaid) and old people (Medicare).
Yes, such populations present different challenges than they're used to managing from carriers of private health insurance. The answer is adaptation. However, some choose to throw the baby out with the bathwater and refuse to provide care for patients with this type of coverage.
Despite the best efforts of the ACA, many reports show a good chunk of people in this country were not better able to get care, because they could not find anyone who would take their insurance.
We don't care, the honest reality TrumpCare could bring to our most vulnerable
With TrumpCare, we have replaced one new system, going through its growing pains, with another new system built from chaos and fear.
Perhaps the AHCA at least will give people the honest facts: their healthcare, and the problems it gives to families and communities, is not the concern of the government. It is not the concern of the medical-industrial complex, either. A for-profit system means they want to make money. Our failing hearts are our problem.
Look on the bright side, this toughlove healthcare may actually improve the health of Americans. With reduced access to pain management, less opiate prescribing can mean fewer addicts. Our frail elders will no longer suffer dangerous adverse reactions from medications they'll no longer be prescribed. Or, if they are, their expense will be unaffordable. No longer able to fork out for cholesterol testing and Lipitor, maybe people will decide it is time to cut back on burgers and pizza. Embrace the salad bar.
What the ACA said about America is that we care about each other, and it is important for all of us to have attainable access to healthcare. In practice, this meant some of us will pay more and some less. It expressed that a citizen's health impacts the country collectively, and responsibility for the provision of care is also a collective responsibility.
Whereas TrumpCare says that we are all in it for ourselves. Some of us can get 22 MRIs of our left knee, and some of us can barely afford immunizations for our children. But those shots aren't the responsibility of that knee. The knee can afford to buy those MRIs, and screw the kids.
← How Jimmy Kimmel's Story Did More For Obamacare Than Politicians Ever Could
Nurses Wish They Could Tell You These 10 Things →
The TRUTH: What GOP Health Bill Does to Medicaid
June 23, 2017 Chris Byrnes 0
Senator Ron Johnson Called Me to Discuss Healthcare
September 27, 2017 Chris Byrnes 0
Vast List of Groups Opposing American Health Care Act
March 23, 2017 Sander Moiller 0


CIFF KIDS FW 18-19 edition, dating from January 31 to February 2 takes place in its own venue at the Forum Copenhagen in the center of Copenhagen. CIFF KIDS, a separate fair from Copenhagen International Fashion Fair is an innovative platform to kid's fashion and lifestyle brands. The trade show is Northern Europe's most progressive kids fashion and lifestyle fair helping the growth of over 300 brands.
Pitti Immagine Filati 82, la manifestazione internazionale del settore dei filati per maglieria, si terrà a Firenze dal 24 al 26 gennaio.
Damir Doma returns to his homeland to present the autumn winter 2018-19 collection within the vaulted chambers of the Halle Am Berghain.
La terza edizione di TheOneMilano che si terrà a fieramilanocity dal 23 al 26 febbraio rivoluziona il format e lancia un nuovo progetto che coniuga fur, prêt-à-porter e lifestyle.
L'Assemblea Generale e Ordinaria dell'Istituto Italo Cinese ha nominato il Cavaliere del Lavoro Mario Boselli Presidente.
Designers unite in the fight against cancer.
The winners of the 2017 Fashion Awards in Partnership with Swarovski, were announced by the British Fashion Council. The prestigious event was held at the Royal Albert Hall in London on Monday 4th December to celebrate creative individual's that have changed the possibilities of fashion over the past year.
A new award that is introduced into the Fashion Awards.
MAN/ WOMAN shows introduces a new concept focusing on one of its top end markets: Japan, their newest concept MAN/ WOMAN Tokyo.
Camera Nazionale della Moda Italiana announces that Stefania Vismara joined the Association's management team as General Manager on 1 December.
On Tuesday 5th December, White's press conference will take place at Spiral Hall, Tokyo.


text:
"""
************
File Caching
************

Implements a cache on local disk for Synapse file entities and other objects
with a `FileHandle <https://docs.synapse.org/rest/org/sagebionetworks/repo/model/file/FileHandle.html>`_.
This is part of the internal implementation of the client and should not be
accessed directly by users of the client.
"""
from __future__ import absolute_import
from __future__ import division
from __future__ import print_function
from __future__ import unicode_literals
from builtins import str

import collections
import datetime
import json
import operator
import os
import re
import shutil
import six
from math import floor
import synapseclient.utils as utils
from synapseclient.lock import Lock
from synapseclient.exceptions import *

CACHE_ROOT_DIR = os.path.join('~', '.synapseCache')

def epoch_time_to_iso(epoch_time):
    """
    Convert seconds since unix epoch to a string in ISO format
    """
    return None if epoch_time is None else utils.datetime_to_iso(utils.from_unix_epoch_time_secs(epoch_time))

def iso_time_to_epoch(iso_time):
    """
    Convert an ISO formatted time into seconds since unix epoch
    """
    return None if iso_time is None else utils.to_unix_epoch_time_secs(utils.iso_to_datetime(iso_time))

def compare_timestamps(modified_time, cached_time):
    """
    Compare two ISO formatted timestamps, with a special case when cached_time
    ends in .000Z.

    For backward compatibility, we always write .000 for milliseconds into the cache.
    We then match a cached time ending in .000Z, meaning zero milliseconds
    with a modified time with any number of milliseconds.

    :param modified_time: float representing seconds since unix epoch
    :param cached_time: string holding a ISO formatted time
    """
    if cached_time is None or modified_time is None:
        return False
    if cached_time.endswith(".000Z"):
        return cached_time == epoch_time_to_iso(floor(modified_time))
    else:
        return cached_time == epoch_time_to_iso(modified_time)

def _get_modified_time(path):
    if os.path.exists(path):
        return os.path.getmtime(path)
    return None

class Cache():
    """
    Represent a cache in which files are accessed by file handle ID.
    """

    def __setattr__(self, key, value):
        # expand out home shortcut ('~') and environment variables when setting cache_root_dir
        if key == "cache_root_dir":
            value = os.path.expandvars(os.path.expanduser(value))
            #create the cache_root_dir if it does not already exist
            if not os.path.exists(value):
                os.makedirs(value)
        self.__dict__[key] = value

    def __init__(self, cache_root_dir=CACHE_ROOT_DIR, fanout=1000):

        ## set root dir of cache in which meta data will be stored and files
        ## will be stored here by default, but other locations can be specified
        self.cache_root_dir = cache_root_dir
        self.fanout = fanout
        self.cache_map_file_name = ".cacheMap"

    def get_cache_dir(self, file_handle_id):
        if isinstance(file_handle_id, collections.Mapping):
            if 'dataFileHandleId' in file_handle_id:
                file_handle_id = file_handle_id['dataFileHandleId']
            elif 'concreteType' in file_handle_id and 'id' in file_handle_id and file_handle_id['concreteType'].startswith('org.sagebionetworks.repo.model.file'):
                file_handle_id = file_handle_id['id']
        return os.path.join(self.cache_root_dir, str(int(file_handle_id) % self.fanout), str(file_handle_id))

    def _read_cache_map(self, cache_dir):
        cache_map_file = os.path.join(cache_dir, self.cache_map_file_name)

        if not os.path.exists(cache_map_file):
            return {}

        with open(cache_map_file, 'r') as f:
            cache_map = json.load(f)
        return cache_map

    def _write_cache_map(self, cache_dir, cache_map):
        if not os.path.exists(cache_dir):
            os.makedirs(cache_dir)

        cache_map_file = os.path.join(cache_dir, self.cache_map_file_name)

        with open(cache_map_file, 'w') as f:
            json.dump(cache_map, f)
            f.write('\n') # For compatibility with R's JSON parser

    def contains(self, file_handle_id, path):
        """
        Given a file and file_handle_id, return True if an unmodified cached
        copy of the file exists at the exact path given or False otherwise.
        :param file_handle_id:
        :param path: file path at which to look for a cached copy
        """
        cache_dir = self.get_cache_dir(file_handle_id)
        if not os.path.exists(cache_dir):
            return False

        with Lock(self.cache_map_file_name, dir=cache_dir):
            cache_map = self._read_cache_map(cache_dir)

            path = utils.normalize_path(path)

            cached_time = cache_map.get(path, None)
            if cached_time:
                return compare_timestamps(_get_modified_time(path), cached_time)
        return False

    def get(self, file_handle_id, path=None):
        """
        Retrieve a file with the given file handle from the cache.

        :param file_handle_id:
        :param path: If the given path is None, look for a cached copy of the
                     file in the cache directory. If the path is a directory,
                     look there for a cached copy. If a full file-path is
                     given, only check whether that exact file exists and is
                     unmodified since it was cached.

        :returns: Either a file path, if an unmodified cached copy of the file
                  exists in the specified location or None if it does not
        """
        cache_dir = self.get_cache_dir(file_handle_id)
        if not os.path.exists(cache_dir):
            return None

        with Lock(self.cache_map_file_name, dir=cache_dir):
            cache_map = self._read_cache_map(cache_dir)

            path = utils.normalize_path(path)

            ## If the caller specifies a path and that path exists in the cache
            ## but has been modified, we need to indicate no match by returning
            ## None. The logic for updating a synapse entity depends on this to
            ## determine the need to upload a new file.

            if path is not None:
                ## If we're given a path to a directory, look for a cached file in that directory
                if os.path.isdir(path):
                    matching_unmodified_directory = None
                    removed_entry_from_cache = False  # determines if cache_map needs to be rewritten to disk

                    # iterate a copy of cache_map to allow modifying original cache_map
                    for cached_file_path, cached_time in six.iteritems(dict(cache_map)):
                        if path == os.path.dirname(cached_file_path):
                            # compare_timestamps has an implicit check for whether the path exists
                            if compare_timestamps(_get_modified_time(cached_file_path), cached_time):
                                # "break" instead of "return" to write removed invalid entries to disk if necessary
                                matching_unmodified_directory = cached_file_path
                                break
                            else:
                                # remove invalid cache entries pointing to files that that no longer exist or have been modified
                                del cache_map[cached_file_path]
                                removed_entry_from_cache = True

                    if removed_entry_from_cache:
                        # write cache_map with non-existant entries removed
                        self._write_cache_map(cache_dir, cache_map)

                    if matching_unmodified_directory is not None:
                        return matching_unmodified_directory

                ## if we're given a full file path, look up a matching file in the cache
                else:
                    cached_time = cache_map.get(path, None)
                    if cached_time:
                        return path if compare_timestamps(_get_modified_time(path), cached_time) else None

            ## return most recently cached and unmodified file OR
            ## None if there are no unmodified files
            for cached_file_path, cached_time in sorted(cache_map.items(), key=operator.itemgetter(1), reverse=True):
                if compare_timestamps(_get_modified_time(cached_file_path), cached_time):
                    return cached_file_path
            return None

    def add(self, file_handle_id, path):
        """
        Add a file to the cache
        """
        if not path or not os.path.exists(path):
            raise ValueError("Can't find file \"%s\"" % path)

        cache_dir = self.get_cache_dir(file_handle_id)
        with Lock(self.cache_map_file_name, dir=cache_dir):
            cache_map = self._read_cache_map(cache_dir)

            path = utils.normalize_path(path)
            ## write .000 milliseconds for backward compatibility
            cache_map[path] = epoch_time_to_iso(floor(_get_modified_time(path)))
            self._write_cache_map(cache_dir, cache_map)

        return cache_map

    def remove(self, file_handle_id, path=None, delete=None):
        """
        Remove a file from the cache.

        :param file_handle_id: Will also extract file handle id from either a File or file handle
        :param path: If the given path is None, remove (and potentially delete)
                     all cached copies. If the path is that of a file in the
                     .cacheMap file, remove it.

        :returns: A list of files removed
        """
        removed = []
        cache_dir = self.get_cache_dir(file_handle_id)

        ## if we've passed an entity and not a path, get path from entity
        if path is None and isinstance(file_handle_id, collections.Mapping) and 'path' in file_handle_id:
            path = file_handle_id['path']

        with Lock(self.cache_map_file_name, dir=cache_dir):
            cache_map = self._read_cache_map(cache_dir)

            if path is None:
                for path in cache_map:
                    if delete is True and os.path.exists(path):
                        os.remove(path)
                    removed.append(path)
                cache_map = {}
            else:
                path = utils.normalize_path(path)
                if path in cache_map:
                    if delete is True and os.path.exists(path):
                        os.remove(path)
                    del cache_map[path]
                    removed.append(path)

            self._write_cache_map(cache_dir, cache_map)

        return removed

    def _cache_dirs(self):
        """
        Generate a list of all cache dirs, directories of the form:
        [cache.cache_root_dir]/949/59949
        """
        for item1 in os.listdir(self.cache_root_dir):
            path1 = os.path.join(self.cache_root_dir, item1)
            if os.path.isdir(path1) and re.match('\d+', item1):
                for item2 in os.listdir(path1):
                    path2 = os.path.join(path1, item2)
                    if os.path.isdir(path2) and re.match('\d+', item2):
                        yield path2

    def purge(self, before_date, dry_run=False):
        """
        Purge the cache. Use with caution. Delete files whose cache maps were last updated prior to the given date.

        Deletes .cacheMap files and files stored in the cache.cache_root_dir, but does not delete
        files stored outside the cache.
        """
        if isinstance(before_date, datetime.datetime):
            before_date = utils.to_unix_epoch_time_secs(before_date)
        count = 0
        for cache_dir in self._cache_dirs():
            ## _get_modified_time returns None if the cache map file doesn't
            ## exist and n > None evaluates to True in python 2.7(wtf?). I'm guessing it's
            ## OK to purge directories in the cache that have no .cacheMap file
            last_modified_time = _get_modified_time(os.path.join(cache_dir, self.cache_map_file_name))
            if last_modified_time == None or before_date > last_modified_time:
                if dry_run:
                    print(cache_dir)
                else:
                    shutil.rmtree(cache_dir)
                count += 1
        return count

redpajama_set_name: RedPajamaGithub


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