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Erectile dysfunction is a stumbling block for all couples in the world. It troubles partners unexpectedly and ruins their relations. Men become silent and try to avoid spending time in their women’s company. Women start thinking that something is wrong with their appearance and that men cannot erect because they are not attractive anymore. Cialis is a drug that can make men’s intimate relations not so complicated. Tadalafil brings back erection back to the norm and women start feeling pretty and desired again.

Cialis Can Be Different

It’s a well-known fact that there are two types of drugs according to their origin: brand and generic ones. Many people think that they differ much. They think that only brand-name medicines can produce the best effect and cope with the problem. The truth is that generics are mere analogs. They have the same composition and can treat the same health disorders.

So, what’s the difference? Why does this distinctive feature make people think that brand-name drugs are better than generics? The matter is in their price. Generics are cheaper but a cheap thing doesn’t always mean a bad thing. The research shows that contemporary pharmaceutical companies spend huge sums on research to have the right to sell solid drugs with an excellent reputation. Generics take the formula and rename the medicine. They economize on international fame but reserve the quality. So, there is no need to pay more to get the desired results.

Generic variants of Tadalafil are also of high-quality. They differ in strength, shape, and form. There are six main analogs of Cialis.

Cialis Soft Tabs

These tablets have a strong effect and improve men’s health. Erectile dysfunction is a delicate problem and it requires a soft solution. Cialis Soft Tabs produce such an effect and help to gain a natural erection.

Generic Cialis

The generic variant of the brand doesn’t differ from the original. Its price is lower and when buying a blister that contains more than 100 pills, a person can save a solid sum.

Female Cialis

This is the only drug variant that can be taken by females. Scientists have found out that women can also lack sexual desire after menopause, childbirth, and surgery. Female Cialis brings back sensitivity of the clitoris. It leads to better lubrication and a woman feels pleasure instead of irritation and burning provoked by the dryness.

Cialis Black 800

Cialis Black 800 is not to be taken by males who have first signs of impotence. Only patients who have serious problems with erection and even neglected impotence take Black Cialis. Doctors prescribe these pills to those who also lack libido and stamina. One pill contains 80mg of the active component. It means that they are strong but can cause severe adverse effects in case of improper intake.

Cialis Professional

Men with impotence need professional help. Cialis Professional has an improved formula. Their aim is to find the reason, delete it and let a person experience a stable erection that promises satisfaction in bed for both partners.

Cialis Super Active+

If a person needs to raise the level of testosterone, improve erection, get rid of premature ejaculation, and experience sexual arousal, then it’s high time to take Cialis Super Active+. Compared to other generic variants, this type starts working in 5-7 minutes. That’s their PLUS.

Where to Get Pills?

Online pharmacies can supply people with the generic every man needs. The online drugstore offers high-quality products, discounts, and bonuses for regular customers and quick service to let everyone get the drugs as soon as possible.

List of verified online pharmacies:

• canadapharmacy.com
• canadadrugsdirect.com
• northwestpharmacy.com
• costco.com
• cvs.pharmacy
• pillpack.com

Our everyday goal is to provide you with affordable medicines for fast and efficient ED treatment. And though there are numerous resources available for those, who need to know more about male impotence, some questions still remain.

We really want you to learn more about Generic Viagra and its effects. We need you to have enough information to feel safe while taking it. So, here are top FAQs and physician’s answers to them.

Brand vs. Generic Viagra. Is there any difference?
Actually, there is no. People believe that anything that has generic in its name is of bad quality. We still don’t understand where this idea came from. Today we are trying to convince our patients of the false of this opinion. Ingredients and elements in both drug types are identical. So are the effects.

People call it aphrodisiac. Can Viagra be regarded as such?
You may say it for fun. But don’t take it seriously, because these pills never increase the sexual need as aphrodisiacs do. Generic Viagra only helps those, who are sexually inspired. When relationship crisis is the reason for impotence, no blue pill can cure it.

Can Generic Viagra cure ED?
Unfortunately, it can’t. In fact, neither of existing drugs can. We call them dysfunction treatment medicines, yet they all are only permanent solutions. Recently there has appeared a theory that these pills can be taken regularly to help men be ready whenever needed.

Is it safe to take pills daily?
If a man consults his physician, this variant may be suggested. Though cases are rare. Besides, to escape side effects and ensure best results a proper dose should be chosen. That may be tough, so only a few doctors do that.

You’ve mentioned the dosage. Could you tell what the recommended dose is?
As I’ve mentioned, it’s the physician who can decide what doses are suitable in different cases. The prescription will depend on numerous factors. However, 50mg are regarded as the most frequent and suitable choice. The pill is taken 40-60 minutes before the intercourse. The time difference depends on toleration and efficacy. Sometimes the dose either decreases to 25mg or increases to 100mg.

And for how long does the pill work?
It depends. On average, it functions during 5 hours. The first two hours are characterized by a very high plasma concentration. Then the action subsides, but gradually. Some men state that the effect wasn’t as great as they expected (2-3 hours). I have an answer to that too. And it sounds like much alcohol and fattening foods. Don’t expect pills to work for more than six hours. If they do, don’t get too excited. It’s the first symptom of the problem that requires medical examination.

One may read much about Viagra interaction with other pills. So, should one refuse from other treatment courses and medicines, while he’s trying to manage his ED problems?
Refusing from serious treatment courses to give way to Viagra is surely not the way out. And you are right: Generic Viagra interacts with many various drugs. However, this isn’t necessary the interaction that leads to lethal outcomes. It should never be mixed with medicines that include nitroglycerin as the combination of this sort will surely lead to blood flow problems or even a heart attack.

What about other medicines?
Professional examination and consultation will help dot the i’s and cross the t’s.

Are there any foods that these pills should not be mixed with?
Yes, there are. Though their list is short. I’ve mentioned fattening foods and alcohol. You can drink some wine and eat fries or steak, of course. But in moderation. Too much alcohol will lead to vision changes and even dizziness. Too much fattening foods will increase the time amount required for pills’ effective work. What I want to add to the list is grapefruit juice.

Really? Never though it could cause any problems…
No one did. FYI, grapefruit juice prevents Viagra from absorbing into the system. Generic Viagra can increase in man’s blood and lead to side effects. Some of them are really dangerous.

What minor or serious side effects are the commonest? And what is more important: can males escape them all?
Any drug can cause side effects. Frankly speaking, it is even normal to experience side effects, because they always come with positive ones. Consumption of the generic product is not an exception. The severity or mildness depends on the dose being taken. Mild ones can include head- or stomach ache, dizziness or nausea. They are absolutely harmless, so there’s nothing to get worried about.

What about severe cases?
These are rarely reported. They develop after the combination of pills with the foods and beverages mentioned above. If there is an abnormal heart rate or chest pain, a man should rush to the hospital.

Is there any advice for those, who faced ED?
Well, the only tip I can give is not to hesitate over professional examination. The sooner you go to your physician, the faster your sexual life gets back to norm.

Thanks for tips and recommendations. We hope they will be handy for millions of ED sufferers.
It was a pleasure to share some important facts.

Study Limitations

Our study has limitations. We evaluated a commercially insured population; rates of dispense as written requests and prescription reversals may differ for uninsured patients. Our measure of reversal was linked to the specific prescription that was adjudicated by the pharmacy. Some of the unfilled prescriptions may not represent clinically significant medication non-adherence, because patients may have requested new prescriptions for different medications to treat the same condition. However, previous studies indicate that patients who are initially prescribed branded medications are less likely to subsequently adhere to any medication in the class when compared with patients prescribed generics. We recruited during a 1-month period in the winter. We did not account for seasonality; patient medication use and prescription requests may vary by season. We also are unsure of the extent of misclassification in this data set, because pharmacies may not accurately capture all patient dispense as written requests in administrative data sets, which may have led to conservative estimates of dispense as written rates.

Conclusions

Overall, we found that both patients and physicians commonly make dispense as written requests, totaling approximately 5% of all prescriptions. Advocates of dispense as written may argue that providing physicians and patients with greater discretion offers greater choice, opportunities for communication, and adherence to therapy. However, our results indicate that dispense as written requests are associated with excess costs, and that patients are less likely to fill prescriptions with dispense as written designations. Some private health plans have implemented financial penalties to reduce the rates of dispense as written designation. The cost savings and clinical effects of these policies should be studied to better understand what policies best encourage cost-effective medication use and adherence to chronic therapy.

Physicians and patients should be aware that dispense as written designations not only increase costs to the patient but also adversely affect rates that patients purchase those prescriptions. Educational efforts to encourage generic acceptability should target those most likely to express concern about generics. Our findings indicate that specialists, older physicians, and patients aged 55 to 74 years are more likely to request dispense as written and may represent targets for educational outreach. These efforts should focus on initiation of chronic medications, because patients disproportionately fail to purchase these prescriptions when either physicians or patients request dispense as written.

Prescriptions for certain classes of medications were far more likely to be accompanied by a dispense as written request. In particular, classes with narrow therapeutic indices, such as thyroid medications, anticoagulants, and anticonvulsants, were commonly delivered with a dispense as written request. There has been substantial debate in the scientific literature as to the equivalency of these products; although the literature may not corroborate these clinical concerns, it is likely that patients and physicians have a clinical rationale for these requests. The high rates of dispense as written requests for migraine products, ulcer agents, and hypnotics are more surprising, and may be related to effective marketing campaigns to patients and physicians.

It is interesting to observe that physicians request dispense as written frequently for single-source branded products, medications for which no generics could be automatically substituted. Physicians with a strong preference for branded medications may not be aware of whether a generic is available and may request the branded agent as a preventive measure. Alternatively, physicians may request the branded medication to ensure that pharmacists do not substitute a different medication in the class for the prescribed medication (eg, substitution of simvastatin for atorvastatin [Lipitor, Pfizer Inc, New York, NY]); this so-called therapeutic substitution is generally not permitted without first contacting the physician. It is unclear whether these requests ultimately exert any influence on the medication that is delivered to the patient.

Substantial geographic variation in dispense as written requests was seen. This variation may reflect patterns of marketing or the culture of medical education and prescribing that pervade different regions. These also may reflect habit, reflex, or consequences of automatically checked boxes in electronic prescribing systems or on standardized prescription pads. In addition, these variations may be related to geographic differences in pharmacy practice that influence communication with patients and physicians.

Among multi-source brands, physician dispense as written requests were associated with increased rates of prescription reversals (OR 1.16, P<;.001), indicating that patients did not fill these prescriptions. New prescriptions (ie, the first maintenance prescriptions filled in a chronic medication class) had greater odds of reversal than subsequent maintenance prescriptions (OR 2.07, P<;.001). Rates of reversal also were higher for acute medications compared with maintenance medications (OR 1.37 P<;.001). Strong relationships were seen when we tested the interactions of dispense as written requests and initial maintenance or acute prescriptions. Among initial maintenance prescriptions, physician dispense as written (OR 1.50, P<;.001) and patient dispense as written (OR 1.60, P<;.001) were associated with greater odds of reversal. Similar trends were seen for acute medications; physician dispense as written was associated with 1.42 greater odds and patient dispense as written was associated with 1.61 greater odds of reversal compared with those filling subsequent maintenance medications, indicating higher rates of patient failure to fill these prescriptions. Among single-source brand medications, the neutral control where dispense as written designations should have no effect on which medication is actually filled, we found little effect of dispense as written designation on reversal rates. Overall, physician dispense as written was associated with a small reduction in reversal rates (OR 0.89, P<;.001). Acute medications and new prescriptions for maintenance medications were more likely to be reversed (OR 2.2 and 2.9, respectively; P<;.001 for both), although the odds of reversal was not influenced by dispense as written status. Discussion

In this national sample of prescriptions written for patients receiving drug coverage administered by a large pharmacy benefits manager, approximately 5% of all prescriptions included a dispense as written designation requesting dispensing of a brand product. Dispense as written requests were made by prescribers (2.7% of prescriptions) and patients (2.0% of prescriptions). Prescriptions written with dispense as written designations were more likely to be reversed, indicating that they were less likely to be purchased by patients and went unfilled. In particular, when chronic therapy was initiated, physician and patient dispense as written requests led to more than 50% greater odds of non-filling.

By substituting the generic alternative for each multi-source brand that was filled after both physician and patient dispense as written designation, the patient population in this sample could have reduced their charges by more than $1.7 million and the health plans could have experienced more than a $10.6 million reduction in costs in the 1-month study period. By assuming a similar rate of dispense as written requests in uninsured patients, patients covered by state or federal governments, and other commercially insured beneficiaries, we can estimate the savings potential of a policy that eliminates the dispense as written option. With more than 3.6 billion prescriptions filled in the United States annually,14 patient charges could be reduced by as much as $1.2 billion annually and health system costs could be reduced by as much as $7.7 billion by eliminating dispense as written opportunities. We are unable to estimate the implications of specifying dispense as written for single-source brands because these designations likely have minimal effect on the actual prescriptions delivered.

We evaluated approximately 5.6 million prescriptions that were delivered to retail or mail-order pharmacies and adjudicated through Caremark during the 1-month period. These prescriptions were written for 2,047,124 patients by 315,379 specialist physicians, 126,430 generalists, and 39,128 non-physician prescribers (eg, nurse practitioners). Patients and their insurance plans, respectively, paid an average of $17.90 and $26.67 for generic medications, $49.50 and $158.25 for single-source brands, and $44.50 and $135.26 for multi-source brands.

Of the prescriptions we evaluated, 151,670 (2.7%) were designated as dispense as written by physicians and 112,243 (2.0%) were designated as dispense as written by patients. A majority of prescriptions designated as dispense as written by physicians were single-source brand products for which no generic alternatives were available. Most patient-assigned dispense as written prescriptions were for multi-source brands, which could have otherwise been substituted at the pharmacy without contacting the physician. Patient requests for dispense as written took place almost exclusively at retail pharmacies, whereas approximately one third of physician requests were filled at mail-order pharmacies.

Among multi-source brands used to treat chronic conditions (maintenance medications), patients failed to fill prescriptions more frequently when either patients or physicians requested dispense as written, compared with prescriptions with no dispense as written designation.

In multivariate analyses, older physicians were more likely to request dispense as written than younger ones, and patients age 55 to 74 years were most likely to receive physician dispense as written prescriptions. The odds of requesting dispense as written was 78.5% greater for specialists than generalists (P<;.001). Compared with rates of dispense as written request for oral antidiabetics (the referent class), a dispense as written was more likely to be written for anticonvulsants (odds ratio [OR] 2.2), estrogens (OR 2.2), migraine treatments (OR 2.4), thyroid medications (OR 9.8), and anticoagulants (OR 3.9). Physician dispense as written was more common in the northeast section of the country (OR 1.76 vs west, P<;.001) and when submitted to mail-order pharmacies.

The likelihood of patient dispense as written requests also varied by therapeutic class and region. Compared with oral antidiabetics, patient dispense as written requests were more common for ulcer agents (OR 6.1), hypnotics (OR 4.3), migraine medications (OR 14.4), contraceptives (OR 3.7), thyroid medications (OR 16.5), estrogens (OR 3.6), anticonvulsants (OR 4.8), anticoagulants (OR 4.5), and analgesics (OR 4.5). Patient dispense as written was requested most frequently in the west; there were 32.4% greater odds for having a patient-assigned dispense as written in the west than in the northeast (P<;.001). Dispense as written was most commonly requested by patients who were 55 to 74 years of age, for maintenance medications, and at retail pharmacies.

For each eligible prescription submitted, we constructed explanatory variables to assess the relationship between physician, patient, treatment, and pharmacy characteristics and dispense as written use and prescription filling. Physician variables included primary specialty, practice type (primary care, specialist, non-physician prescriber), and prescriber age. Patient characteristics included age (in years), gender, and US census region of residence. Treatment variables included the dispense as written assignment, GPI4/GPI2-designated therapeutic class, brand/generic status, and patient out-of-pocket cost (in dollars per 30-day equivalent prescription). Pharmacy characteristics included the type of dispensing pharmacy (retail or mail). Prescriptions were categorized as either acute or maintenance (chronic) using the First Data Bank designation. Maintenance medications were further categorized as either an “initiation” or “continuation” of therapy. Initiation prescriptions were defined on the basis of no paid pharmacy claims for a drug in the same therapeutic class in the 6 months before the index prescription claim. Maintenance continuation prescriptions were preceded by 1 or more paid claims in the previous 6 months, indicating recent use.
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Analysis Plan
We used descriptive statistics to evaluate patient, physician, pharmacy, and prescription characteristics. We described rates of dispense as written for both single-source brands and multi-source brands, despite the fact that dispense as written for single-source brands may not have any effect on prescription delivery. We also present rates of prescription reversals, prescription claims approved by a payer and then reversed by the pharmacy because they were not purchased by the patient and went unfilled, stratified by dispense as written designation and prescription type.

To assess the relationship between physician, patient, prescription, and pharmacy characteristics with physician and patient dispense as written requests, we used generalized estimating equations to adjust for clustering at the patient level. Our outcomes, at the submitted prescription level, were the presence or absence of physician dispense as written in one model and the presence or absence of patient dispense as written for the other. We studied whether physician, member, treatment, and pharmacy characteristics were associated with the submission of prescriptions with a dispense as written designation. When comparing rates of dispense as written requests by drug class, we selected oral diabetes medications as our referent category because they are essential medications, commonly prescribed, and include both generic and brand-name options.

Multivariate generalized estimating equation models were used to estimate the relationship between patient and physician dispense as written selection and whether the claim was reversed, indicating the medication was not purchased by the patient and went unfilled. In these models, we were interested in the relationship between dispense as written designation and rates of multi-source brand medication filling, because these are the medications for which dispense as written designations most clearly affect the medication received. Thus, in our primary model, we included only multi-source brand and generic medications. We ran a distinct model with single-source brands as a neutral control because we did not expect that dispense as written designation would have any effect on the medication that was delivered and, as a result, the likelihood of actual purchasing. In these models, we controlled for patient, physician, and pharmacy covariates and adjusted for clustering within patients. We included interactions between physician and patient dispense as written designations and prescription characteristics (initiation of a chronic medication, maintenance medication continuation, or acute medication), because we hypothesized that dispense as written designation may have the greatest effect on purchasing rates in new prescriptions or acute prescriptions, when patients first learn about the medication costs. Statistical evaluations were performed using SAS Version 9.1 with SAS/STAT(r) (SAS Institute Inc, Cary, NC) and Stata SE 9.1 for Windows (StataCorp LP, College Station, Tex).

Dispense as written requests may have important implications for patient adherence. Patients are more adherent when they are initiated on generic or lower-cost medications.9 Although dispense as written requests would seem to reflect a conscious decision by patients or their physicians to use a specific agent, the increased cost-sharing that results from a dispense as written designation may decrease the likelihood that patients actually fill their prescriptions.

Little is known about how frequently physicians or patients request dispense as written, the medications for which dispense as written is most commonly used, and the physician and patient characteristics associated with dispense as written requests. Previous descriptive analyses of this practice were conducted when generic use was far less common and have limited applicability to current practice.10, 11, 12 No prior studies have investigated the effect of dispense as written requests on patients’ likelihood to fill their prescriptions or on overall health system costs. By using transactional data from a large national pharmacy benefits manager, we assessed rates and correlates of dispense as written requests and the relationship between these requests and rates of filled prescriptions.

Materials and Methods

Sample
We identified all patients enrolled in employer-sponsored health plans who received pharmacy benefits from CVS Caremark in calendar years 2008 and 2009. From this sampling frame, we selected all members with a) continuous eligibility for pharmacy benefits between July 1, 2008, and January 31, 2009, and b) a valid entry for gender and date of birth in the administrative record. We limited our sample to patients who submitted a prescription claim from any retail or mail-order pharmacy for adjudication between January 1 and 31, 2009, the identification period. We excluded all clients who were enrolled in a plan that imposed penalties for dispense as written requests, because dispense as written requests in these settings may not reflect those in the general population.

For patients who submitted multiple eligible prescriptions within a class, we selected the prescription with the latest date during the identification period, which likely eliminates accidental or erroneous prescriptions that were delivered. If a member submitted prescriptions in multiple therapeutic classes, each was deemed eligible and included in the analysis. We included all therapeutic categories defined by MediSpan’s Generic Product Identifier (GPI-2).

We identified the dispense as written assignment and the brand status from the submitted claim record. We categorized claim records into 1 of 3 mutually exclusive categories: a physician-assigned dispense as written (Physician Dispense as Written); a member-assigned dispense as written (Patient Dispense as Written); or no Dispense as Written. Brands were listed as either single-source brand, indicating no generic equivalent was available at the time of the study, or multi-source brands, which are branded medications with a generic equivalent. For every eligible prescription, we also determined whether the prescription was purchased (“filled”) or reversed. Reversed prescriptions are those that the patient chose not to purchase, and therefore were not filled.

Background

All US states have adopted generic substitution laws to reduce medication costs. However, physicians may override these regulations by prescribing branded drugs and requesting that they are dispensed as written. Patients also can make these requests. Little is known about the frequency and correlates of dispense as written requests or their association with medication filling.

Methods
We identified beneficiaries of a large pharmacy benefits manager who submitted a prescription claim from any pharmacy in January 2009. We categorized claims as a physician-assigned dispense as written, patient-assigned dispense as written, or no dispense as written. We described rates of these requests and used generalized estimating equations to evaluate physician, patient, treatment, and pharmacy characteristics associated with dispense as written requests. We also used generalized estimating equations to assess the relationship between dispense as written designation and rates prescriptions are not filled by patients.

Results
Our sample included 5.6 million prescriptions for more than 2 million patients. More than 2.7% were designated as dispense as written by physicians, and 2.0% were designated as dispense as written by patients. Substantial variation in dispense as written requests were seen by medication class, patient and physician age, and geographic region. The odds of requesting dispense as written was 78.5% greater for specialists than generalists (P<;.001). When chronic prescriptions were initiated, physician dispense as written (odds ratio 1.50, P<;.001) and patient dispense as written (odds ratio 1.60, P<;.001) were associated with greater odds that patients did not fill the prescription. Conclusion
Dispense as written requests were common and associated with decreased rates of prescription filling. Options to reduce rates of dispense as written requests may reduce costs and improve medication adherence.

With the recent expansion of health insurance coverage to millions of Americans, there is increasing pressure to control health care costs. Greater use of generic medications has been identified as one approach to reduce medication costs without compromising quality. Studies do not suggest meaningful differences in clinical efficacy between brand-name and generic products. Yet generic medications remain underused when appropriate, and efforts to encourage their use can reduce both patient and health system costs.
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Every state has enacted generic substitution laws to promote generic drug use. However, both physicians and patients express concern about the safety and efficacy of generics. Physicians can ensure that a brand-name medication is delivered, even when a generic equivalent is available, by indicating “dispense as written” on their prescription. Similarly, patients can request that a brand be delivered rather than the generic equivalent at the point of purchase.

Our abstracted data include diagnosis; presence or absence of specific key diagnostic criteria in the case of sinusitis, otitis media, or pharyngitis; whether an antibiotic was prescribed or not; and if an antibiotic was prescribed, which one (to assess use of narrow- vs. broad- spectrum antibiotics).

Second, future Oregon BRFSS data will provide valuable information about changes in public knowledge about safe antibiotic use and expectations surrounding the receipt of antibiotics to treat upper respiratory infections.
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Third, annual analysis of prescribing trends in the Oregon Medicaid fee-for-service population will continue to shed light on clinician prescribing behaviors. This analysis will allow comparisons between prescribing rates in the general community as opposed to those in the residency clinics assessed as part of the curriculum project.

Finally, we hope to analyze trends in two new measures in the Health Plan Employer Data Information Set (HEDIS®) related to appropriate treatment of children with upper respiratory infections and appropriate testing for pediatric pharyngitis.

Conclusion
Effecting change in antibiotic use requires interventions at multiple levels to all types of health care professionals and to lay audiences. These interventions work best when performed in different settings (e.g., community health talks, education forums for health professionals, or media messages), and through the combined efforts of both public health and medical education organizations. Physicians and other clinicians play a key role in education their patients about the dangers of inappropriate antibiotic use, how and when to use antibiotics appropriately, and how best to care for symptoms caused by viral pathogens. To do this effectively, clinicians must possess good communication skills to use in eliciting the patients’ true concerns, in educating patients both directly and through printed or Web-based materials, and in negotiating with patients when antibiotics are not indicated. Given the time constraints common in today’s outpatient environment, they must also have easy access to high-quality patient education materials that can reinforce verbal messages and reduce the time needed for direct education.

The programs described in this article provide a wide range of educational opportunities for both clinicians and lay audiences. Many of them are intended to empower clinicians to educate their patients about this important public health issue. By pursuing these avenues, we expect clinicians to become much more active in this area of health promotion.