Shitty First Drafts

-- Anne Lamott (1995)

from Bird by Bird : Some Instructions on Writing and Life

Now, practically even better news than that of short assign­ments is the idea of shitty first drafts. All good writers write them. This is how they end up with good second drafts and terrific third drafts. People tend to look at successful writers, writers who are getting their books published and maybe even doing well financially, and think that they sit down at their desks every morning feeling like a million dollars, feeling great about who they are and how much talent they have and what a great story they have to tell; that they take in a few deep breaths, push back their sleeves, roll their necks a few times to get all the cricks out, and dive in, typing fully formed passages as fast as a court reporter. But this is just the fantasy of the uninitiated. I know some very great writers, writers you love who write beautifully and have made a great deal of money, and not one of them sits down routinely feeling wildly enthusiastic and confident. Not one of them writes elegant first drafts. All right, one of them does, but we do not like her very much. We do not think that she has a rich inner life or that God likes her or can even stand her. (Although when I mentioned this to my priest friend Tom, he said you can safely assume you've created God in your own image when it turns out that God hates all the same people you do.)

Very few writers really know what they are doing until they've done it. Nor do they go about their business feeling dewy and thrilled. They do not type a few stiff warm-up sentences and then find themselves bounding along like huskies across the snow. One writer I know tells me that he sits down every morning and says to himself nicely, "It's not like you don't have a choice, because you do--you can either type or kill yourself." We all often feel like we are pulling teeth, even those writers whose prose ends up being the most natural and fluid. The right words and sentences just do not come pouring out like ticker tape most of the time. Now, Muriel Spark is said to have felt that she was taking dictation from God every morning--sitting there, one supposes, plugged into a Dictaphone, typing away, humming. But this is a very hostile and aggressive position. One might hope for bad things to rain down on a person like this.

For me and most of the other writers I know, writing is not rapturous. In fact, the only way I can get anything written at all is to write really, really shitty first drafts.

The first draft is the child's draft, where you let it all pour out and then let it romp all over the place, knowing that no one is going to see it and that you can shape it later. You just let this childlike part of you channel whatever voices and visions come through and onto the page. If one of the char­acters wants to say, "Well, so what, Mr. Poopy Pants?," you let her. No one is going to see it. If the kid wants to get into really sentimental, weepy, emotional territory, you let him. Just get it all down on paper, because there may be something great in those six crazy pages that you would never have gotten to by more rational, grown-up means. There may be something in the very last line of the very last paragraph on page six that you just love, that is so beautiful or wild that you now know what you're supposed to be writing about, more or less, or in what direction you might go--but there was no way to get to this without first getting through the first five and a half pages.

I used to write food reviews for California Magazine before it folded. (My writing food reviews had nothing to do with the magazine folding, although every single review did cause a couple of canceled subscriptions. Some readers took umbrage at my comparing mounds of vegetable puree with various ex-presidents' brains.) These reviews always took two days to write. First I'd go to a restaurant several times with a few opinionated, articulate friends in tow. I'd sit there writing down everything anyone said that was at all interesting or funny. Then on the following Monday I'd sit down at my desk with my notes, and try to write the review. Even after I'd been doing this for years, panic would set in. I'd try to write a lead, but instead I'd write a couple of dreadful sentences, XX them out, try again, XX everything out, and then feel despair and worry settle on my chest like an x-ray apron. It's over, I'd think, calmly. I'm not going to be able to get the magic to work this time. I'm ruined. I'm through. I'm toast. Maybe, I'd think, I can get my old job back as a clerk-typist. But probably not. I'd get up and study my teeth in the mirror for a while. Then I'd stop, remember to breathe, make a few phone calls, hit the kitchen and chow down. Eventually I'd go back and sit down at my desk, and sigh for the next ten minutes. Finally I would pick up my one-inch picture frame, stare into it as if for the answer, and every time the answer would come: all I had to do was to write a really shitty first draft of, say, the opening paragraph. And no one was going to see it.

So I'd start writing without reining myself in. It was almost just typing, just making my fingers move. And the writing would be terrible. I'd write a lead paragraph that was a whole page, even though the entire review could only be three pages long, and then I'd start writing up descriptions of the food, one dish at a time, bird by bird, and the critics would be sitting on my shoulders, commenting like cartoon characters. They'd be pretending to snore, or rolling their eyes at my overwrought descriptions, no matter how hard I tried to tone those descriptions down, no matter how conscious I was of what a friend said to me gently in my early days of restaurant reviewing. "Annie," she said, "it is just a piece of chicken. It is just a bit of cake."

But because by then I had been writing for so long, I would eventually let myself trust the process--sort of, more or less. I'd write a first draft that was maybe twice as long as it should be, with a self-indulgent and boring beginning, stupefying descriptions of the meal, lots of quotes from my black-humored friends that made them sound more like the Manson girls than food lovers, and no ending to speak of. The whole thing would be so long and incoherent and hideous that for the rest of the day I'd obsess about getting creamed by a car before I could write a decent second draft. I'd worry that people would read what I'd written and believe that the accident had really been a suicide, that I had panicked because my talent was waning and my mind was shot.

The next day, though, I'd sit down, go through it all with a colored pen, take out everything I possibly could, find a new lead somewhere on the second page, figure out a kicky place to end it, and then write a second draft. It always turned out fine, sometimes even funny and weird and helpful. I'd go over it one more time and mail it in.

Then, a month later, when it was time for another review, the whole process would start again, complete with the fears that people would find my first draft before I could rewrite it.

Almost all good writing begins with terrible first efforts. You need to start somewhere. Start by getting something--anything down on paper. A friend of mine says that the first draft is the down draft--you just get it down. The second draft is the up draft--you fix it up. You try to say what you have to say more accurately. And the third draft is the dental draft, where you check every tooth, to see if it's loose or cramped or decayed, or even, God help us, healthy.

What I've learned to do when I sit down to work on a shitty first draft is to quiet the voices in my head. First there's the vinegar-lipped Reader Lady, who says primly, "Well, that's not very interesting, is it?" And there's the emaciated German male who writes these Orwellian memos detailing your thought crimes. And there are your parents, agonizing over your lack of loyalty and discretion; and there's William Bur­roughs, dozing off or shooting up because he finds you as bold and articulate as a houseplant; and so on. And there are also the dogs: let's not forget the dogs, the dogs in their pen who will surely hurtle and snarl their way out if you ever stop writing, because writing is, for some of us, the latch that keeps the door of the pen closed, keeps those crazy ravenous dogs contained.

Quieting these voices is at least half the battle I fight daily. But this is better than it used to be. It used to be 87 percent. Left to its own devices, my mind spends much of its time having conversations with people who aren't there. I walk along defending myself to people, or exchanging repartee with them, or rationalizing my behavior, or seducing them with gossip, or pretending I'm on their TV talk show or whatever. I speed or run an aging yellow light or don't come to a full stop, and one nanosecond later am explaining to imaginary cops exactly why I had to do what I did, or insisting that I did not in fact do it.

I happened to mention this to a hypnotist I saw many years ago, and he looked at me very nicely. At first I thought he was feeling around on the floor for the silent alarm button, but then he gave me the following exercise, which I still use to this day.

Close your eyes and get quiet for a minute, until the chatter starts up. Then isolate one of the voices and imagine the person speaking as a mouse. Pick it up by the tail and drop it into a mason jar. Then isolate another voice, pick it up by the tail, drop it in the jar. And so on. Drop in any high-maintenance parental units, drop in any contractors, lawyers, colleagues, children, anyone who is whining in your head. Then put the lid on, and watch all these mouse people clawing at the glass, jabbering away, trying to make you feel like shit because you won't do what they want--won't give them more money, won't be more successful, won't see them more often. Then imagine that there is a volume-control button on the bottle. Turn it all the way up for a minute, and listen to the stream of angry, neglected, guilt-mongering voices. Then turn it all the way down and watch the frantic mice lunge at the glass, trying to get to you. Leave it down, and get back to your shitty first draft.

A writer friend of mine suggests opening the jar and shoot­ing them all in the head. But I think he's a little angry, and I'm sure nothing like this would ever occur to you.

Reflection:

In Anne Lamotts article "shitty first drafts," she illustrates the struggles and over emphasis people put on themselves when writing an essay. Famous writers, despite what an average college student may think, are not superhuman. They do not pump out masterpieces in a matter of moments. Like the average college student, famous writers and writers in general struggle when creating a piece. They to encounter meaning distractions such as writers block, ADD, as so many of us think we are suffering from and those little voices in our heads that make us judge our writing so harshly even though it is just the first draft. Lamotts examines her own troubles and distractions. Through the use of much pathos, she conveys feelings of frustration and anger when writing. She explains that every writer often feels like they are trying to pull teeth when writing. Why doesn't is show flow out of our mind? This only applies to one unnamed writer which Lamotts hints as being somewhat satanic.
Writing, as she continues to explain in the same emotional direction is a matter of life or death. She explains about one writer sitting down every morning and saying to himself, "It's not like you don't have a choice because you do--you can either type or kill yourself." Lamotts points out her strong paranoia when writing her shitty first drafts. She accepts that they are horrible, but hopes no one will see them before she revises her work. Lamotts concludes stating that she has learned to cope with her self paranoid and distracted self by closing her eyes, thinking of all those voices that get to her head, isolate them and mentally toss them in a jar and close the lid. First drafts are never going to be a final product which is why, as she explains to the reader, should not stressed over. They are meant to be "shitty", they are a draft, and is just a stepping stone toward making the final product.

What Is The Most Effective Way To Help Pregnant Smokers Quit:
Telephone Counseling Or Midwife Delivered Home Based Counseling?

Lauren Kropa, Bachelor of Science in Medical Studies
Physician Assistant Student
Department of Physician Assistant Studies
King's College
Dickson City PA USA

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Citation:

Lauren Kropa: What Is The Most Effective Way To Help Pregnant Smokers Quit: Telephone Counseling Or Midwife Delivered Home Based Counseling?. The Internet Journal of Academic Physician Assistants. 2007. Volume 6 Number 1.

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Keywords: smoking cessation, pregnancy, pregnant smokers, counseling, prenatal care

Table of Contents

Abstract
Introduction
Methods
Background
Discussion
Conclusion
References

Abstract Currently 11% – 22% of pregnant women in the United States smoke throughout pregnancy. The effects that smoking has on the development of the fetus include low birth weight, preterm delivery and other serious problems. Peri-natal and neo-natal deaths increase by 33% in the offspring of smokers. Therefore, is its important as clinicians to determine which smoking cessation method will be most effective in the pregnant population. This article compares two methods of smoking cessation, telephone counseling and home based counseling. The purpose was to determine which method was most effective in the pregnant population. The results of this analysis clearly show that neither method significantly reduced the number of pregnant smokers as compared to their control group. This analysis proves that despite the importance of smoking cessation in pregnancy, there is no effective method to help pregnant smokers quit and more studies need to be completed.

Introduction

This article will address two methods of smoking cessation; motivational counseling by midwives and motivational counseling by other professionals via telephone. The purpose of this article is to attempt to find an effective smoking cessation method for pregnant women, in turn, reducing the number of adverse affects to the fetus.

Television ads, magazine advertisements, and billboards all expose the adverse effects of smoking on the human body. Since, a fetus is part of a woman's body for nine months, it makes sense that there are similar health affects on that fetus. 11% to 22% of pregnant women in the United States smoke throughout pregnancy. ¹ Tobacco use during pregnancy continues to be the leading preventable cause of low birth weight.

Overall, efforts to reduce smoking in the general population are growing. Despite these efforts, nearly 400,000 deaths still occur each year from the abuse of tobacco products. ² , ³ New drugs are coming to market and smoking cessation programs are available in nearly every community. Less can be said, however, about efforts to reduce smoking in pregnancy. All of the new smoking cessation drugs are Category C drugs. Therefore, there is not enough information known about the drug to use it safely during pregnancy. Nicotine replacement is also controversial. Regardless, the high number of pregnant smokers necessitates a more in depth look at these methods in pregnant women.

Current clinical practice guidelines to aid in smoking cessation suggest brief counseling of 3-5 minutes and supplemental written material; however, cessation rates generated by these recommendations are modest at best. ¹ Although reducing smoking during pregnancy is a United States Public Health Goal for 2010, current research is lacking an effective, safe, and economical way to promote smoking cessation during pregnancy. ¹ Brief counseling is ineffective and nicotine replacement and other pharmacologic methods are controversial. These issues provide pregnant smokers with very few options. In contrast, there is some current research on motivational counseling, a less controversial method of smoking cessation. ¹ Its effectiveness will be discussed later in this article. Clearly, a better method must be found if the Public Health Goal for 2010 is going to be met.

Methods

A literature search was completed via computer within the following databases: CDC, PubMed, Ebsco, CINAHL, Science Full Text (Wilson), and Lexis-Nexis academic universe. The databases were searched for various combinations of the following search terms: smoking cessation, methods, pregnancy, midwife counseling, telephone counseling, effective, quit smoking, and pregnant smokers.

The best type of study to decide the most effective smoking cessation method would be a randomized controlled study. This type of study is best for answering a question about prevention and therapy. The type of therapy we are testing (counseling) does not allow for double-blinded studies. This is because the persons doing the counseling needed to know which intervention they would be giving. In fact, if the counselors did not know which group they were in, they could inadvertently bias the study by providing too little or too much counseling. The study could not be blinded because the counselors needed to know their boundaries. However, persons interpreting the results could be blinded so they are not aware of which group they are analyzing in order to eliminate bias.

These topics were lacking abundant, appropriate studies. However, two recent, relevant and statistically sound studies were found on the PubMed site. One study was on Midwife counseling (Aug 05) and the other on telephone counseling (July 06). These studies were chosen because they were the most up to date articles on this topic.

Background

Peri-natal and neonatal deaths increase by 33% in the offspring of smokers. ⁴ Nicotine is a powerful vasoconstrictor that reduces uterine and placental blood flow. This can lead to problems such as spontaneous abortion and placental abruption. ⁴

It is a well-known fact that smoking causes low birth weight. The magnitude of the weight difference is directly proportional to the number of cigarettes the mother smoked. The mechanism for this decreased birth weight is unclear, but decreased nutritional intake, as a cause, has been ruled out. ⁴

A study done by Scott Montgomery, PhD and colleagues has also linked obesity and diabetes in the offspring as long-term complications of in utero nicotine exposure. “The authors suspect that both diabetes and obesity may stem from ‘lifelong metabolic dysregulation, possibly due to fetal malnutrition or toxicity caused by smoking during pregnancy.” ⁵

Other disorders that are shown to be increased in the offspring of pregnant smokers are childhood cancer, SIDS, and decreased intellectual functioning. ³ The specific pathophysiologies for these disorders has yet to be identified.

Given these well-documented detrimental effects of smoking, it is becoming more and more important as clinicians to decrease the number of pregnant women who smoke. We now know that smoking not only affects the fetus, but also affects the offspring for decades to come. The trouble is that smoking cessation methods continue to prove themselves inadequate in pregnant women.

One method that may increase smoking cessation in pregnancy is motivational counseling. Certified Nurse Midwives or other trained professionals can do this. It can take place in offices, patients' homes, or via telephone. Motivational counseling is a one to one counseling style that is used extensively in smoking cessation training courses. ¹ It is a well-studied method of smoking cessation and has been proven effective for the general population. However, it has been proven ineffective in several dated studies with pregnant women. ⁶ Motivational counseling uses a non-paternalistic, non-judgmental method to facilitate the patient's independent initiative to positive health behaviors. When implemented correctly, it can be used to treat various substance abuse disorders, and influence diet and exercise. ⁶

The use of nicotine replacement and bupropion or other pharmacological methods are relatively unstudied in the pregnant population and therefore cannot be recommended. Future studies need to explore this much needed area, since counseling methods of smoking cessation are challenging and time consuming. There are also homeopathic remedies to help persons quit smoking. Acupuncture and hypnosis have become more popular in the last few decades for smoking cessation. Evidence can be found both for and against the use of these two methods in pregnancy. These treatments are also unproven for smoking cessation in pregnancy and therefore, like the pharmacologic methods, need to be studied more thoroughly.

Discussion

Study #1

The first article is a study called “Efficacy of Telephone Counseling for Pregnant Smokers.” It was published in Obstetrics and Gynecology in July of 2006 by Rigotti NA, et.al. ¹ This study was a randomized controlled study performed from September 2001 to July 2004 in Massachusetts. It was one of only two up to date studies on this topic. This study was designed to compare proactive pregnancy tailored telephone counseling to “best practice” brief counseling (control). The outcome to be measured was cotinine-verified smoking cessation at the end of pregnancy. Cotinine is a metabolite of nicotine found in blood, urine and saliva and normally remains in the body for two to four days after exposure to nicotine. ⁷ , ⁸ Therefore, a way to assess study participants truthfulness about smoking cessation is to measure plasma or salivary cotinine levels.

Pregnant smokers were originally recruited from two separate sources: a managed care organization and a group of community based prenatal providers. However, since this did not yield a sufficient number of participants 140 other obstetric care providers were invited to refer patients and 35 of the providers referred one or more participants.

The study included 442 pregnant smokers. The pregnant women had a mean gestational age between 12 and 13 weeks. Participants were selected at their prenatal visits if they were older than 18, had smoked at least one cigarette in the past seven days, were English speaking and planned to live locally for the next year. The patients also had to be reachable by phone and willing to consider altering their smoking habits during pregnancy.

Women who had miscarried, had been smoke free for the past week and women who were referred after 26 weeks of gestation were not included. Of the 1,444 women referred, 657 were not eligible, 122 were unable to be contacted and 223 refused to participate.

Participants were not required to sign a commitment to quit. This was done in an attempt to include all smokers and broaden the study. It was thought that this would reduce the number of people who refused to participate because of the fear of not being able to quit.

The women were randomized by computer-generated randomization into two groups. They were matched for a multitude of factors including age, cigarettes per day, race, depressive symptoms and confidence in ability to quit as well as many others.

Intervention subjects received a series of telephone calls scheduled according to their needs. After each call, participants received a summary letter of the call and targeted written material. The intervention group received a mean of five calls throughout the study. Participants were allowed up to a total of 90 minutes of counseling during pregnancy and a total of 15 minutes post partum. The participants in the intervention group received an average of 68 minutes of counseling.

The control group received a pregnancy tailored smoking cessation booklet. The control group was also offered the number to the local quit line. In addition, to ensure participants in the control group received at least the “recommended counseling” each enrollment call concluded with the American College of Obstetricians and Gynecologists (ACOG) recommended smoking cessation counseling. The ACOG recommended counseling lasted about 5 minutes for each control participant.

The control and intervention groups were similar in almost every category. There were over 20 categories, everything from age to depressive symptoms, cigarettes per day, and health insurance. This limited the significant differences that could have altered the study.

Every counselor in the study had a master's or bachelor's degree. These counselors were required to tape record one week of interviews each month. Impartial parties assessed these interviews to be sure the groups were receiving the required level of counseling.

The results of this study showed that 21% of the intervention group quit and 16% of the control group quit. The difference was not significant enough for the study to conclude that telephone counseling is superior to the control. One significant conclusion to this study was that telephone counseling proved to be effective for nearly two thirds of light smokers in the sample group. Light smokers were categorized as smoking less than 10 cigarettes per day.

The telephone study had some drawbacks. Smoking cessation was verified by salivary cotinine levels at the end of pregnancy. The study's participants had to mail in their saliva; however, only 67% of participants did so. The persons who did not mail their saliva were counted as smokers. This could have led to a higher reported number of smokers. Also, the study included 442 smokers, however, the actual number of smokers in the clinics was higher because about 34% refused to participate in the study and 50% were ineligible. Although these persons were not included in the study, it still limits the study since the results cannot be generalized to all pregnant smokers.

Another drawback was that the control group members who wanted extra help could have called the number for a local quit line. The number of participants who called the quit line and how long they were counseled for, was not tracked in this study. This may have affected results in that the patients who called may have actually received more counseling than was recorded. One other thing that could have altered the results was that instead of using routine practice, which most pregnant women receive, they used “best practice” as control. Best practice is exactly what is recommended by the ACOG and likely exceeds the usual clinical care. If routine practices were used, telephone counseling would have probably proved to be more effective.

Study #2

The second study was called “Randomized Controlled Trial of Home Based Motivational Interviews by Midwives to Help Pregnant Smokers Quit or Cut Down.” This trial was completed by Tappin DM, et al., and was published in August of 2005 by the British Medical Journal. ⁹ The study was a non-blinded trial analyzed by intent to treat.

This study included pregnant women who were regular smokers and presented to one of two hospitals in Glasgow, Scotland for routine prenatal care. The women were randomized into two groups according to how many cigarettes they smoked per day. Smokers were divided into three groups based on the amount they smoked: less than ten cigarettes per day, ten to twenty, and greater than twenty. The control and experimental groups were matched for the three different amounts of cigarettes per day.

Compliance data was collected by way of midwives taping counseling sessions. An unbiased group at the Center for Alcoholism, Substance Abuse and Addictions at the University of New Mexico assessed the interviews for proficiency. This group found that nearly all interviews were proficient and two-thirds were expert level according to the Motivational Interviewing Skills Code (MISC), which is used to assess the effectiveness of motivational counseling.

The study included 762 out of 1684 pregnant smokers in the Glasgow area. In order to be included in the study women had to be smokers at their initial visit and be less than twenty-four weeks gestation. The median age of gestation was 13 weeks.

The outcome measured was self-reported smoking cessation verified by plasma or salivary cotinine concentrations. These plasma or saliva samples were collected and tested throughout pregnancy at prenatal visits.

In this study, data was also collected on adverse events, including antenatal admissions, miscarriage, termination of pregnancy, preterm delivery (<>

All women received standard health promotion information and the intervention group was offered motivational interviewing at home. The intervention group received home visits by four dedicated nurse midwives who received 5 days of training before providing counseling. These midwives were required to record all interviews to be reviewed and assessed for adequacy. Each intervention group member received an average total of 56 minutes of counseling. The control received the standard health promotion information only.

The results were 4.8% of women in the intervention group had self-reported and cotinine verified cessation compared to the control group, which had 4.6%. The difference between the control and the intervention was not statistically significant. This proves that home based motivational counseling is just as effective as standard health promotion information.

The size of the study population was adequate; however, only 45% of pregnant smokers in the two hospitals studied actually joined the study. Therefore, this study cannot be generalized to all pregnant smokers in this area. Another drawback to the study is that the midwives and the participants knew which group they were in and this could have affected the results. A person blinded to both groups, however, analyzed the primary outcome data (quit, cut down, same, more). Also, the control and experimental groups were not matched for anything other than amount of cigarettes they smoked. The authors suggest that lack of similarities created a wide confidence interval and in turn suggests that because of this, other significant differences may be present.

Pregnant women who quit before the booking interview were not included in the study. The authors state this as a drawback to their study, citing that this meant their study included heavier, more dependant smokers, who could not quit via their own motivation.

Conclusion

These studies failed to show a statistically effective method of smoking cessation in pregnancy. These studies found that telephone counseling and motivational counseling were not more effective for smoking cessation in pregnancy than brief, in office counseling. Therefore, it can be concluded that the interventional methods used did not significantly increase smoking cessation.

One interesting conclusion from the telephone counseling study is that telephone counseling is an effective method for light smokers and those who had tried to quit in the past. A repeat study including only this population should be done to verify that telephone counseling is an effective method to help light smokers quit.

Both studies verified smoking cessation with a cotinine level. One study used only salivary and the other used plasma or salivary. There is no proven difference in specificity or sensitivity that makes one method better than the other. The cotinine level in plasma and saliva can be affected by exposure to second-hand smoke and the use of a nicotine patch or other source of nicotine replacement ¹ , ⁴ This means that elevated cotinine levels in the participants is not necessarily accurate in verifying smoking cessation. Using this test could lead to smoking cessation being under-recorded. These variables were not accounted for in either of the above studies and may have slightly lowered the number of women counted as successful quitters.

These studies are the most up-to-date and their findings coincide with previous studies on the same topics. This proves that these methods are not effective for the pregnant population. The continual lack of an effective method shows that we need studies to assess nicotine replacement and pharmacological methods in the pregnant population.

References

1. Rigotti NA, Park ER, Regan S, Chang Y, Perry K, Loudin B, Quinn V. Efficacy of telephone counseling for pregnant smokers: a randomized controlled trial. Obstet Gynecol. 2006; 108: 83-92.

2. Connelly MT, Inui TS. Principals of Disease Prevention. In: Braunwald E, Hauser SL, Fauci AS, et al, eds. Harrison's Principals of Internal Medicine. 15th Edition. New York, NY: McGraw Hill; 2001: 46-49.

3. Burns DM. Nicotine Addiction. In: Braunwald E, Hauser SL, Fauci AS, et al, eds. Harrison's Principals of Internal Medicine. 15th Edition. New York, NY: McGraw Hill; 2001: 2574-2577.

4. Van Meurs K. Stanford University School of Medicine. Cigarette Smoking, Pregnancy and the Developing Fetus. Available at: [med.stanford.edu/medicalreview/s ... ] . Accessed December 8, 2006.

5. PulmonaryReviews.com. Smoking During Pregnancy Even Worse Than You Think. Available at: [www.pulmonaryreviews.com/march02 ... ] . Accessed December 8, 2006.

6. Rollnick S, Miller WR. Motivational Interviewing. What is MI? Available at: [www.motivationalinterviewing.org ... ] . Accessed December 10, 2006.

7. Craig Medical Distribution Inc. Nicotine/Cotinine (COT). Available at: [www.craigmedical.com/nicotine.ht ... ] . Accessed December 8, 2006.

8. Foundation for Blood Research. Cotinine Testing. Available at: [www.fbr.org/publications/pamphle ... ] . Accessed December 8, 2006.

9. Tappin DM, Lumsden MA, Gilmour WH, et al. Randomised controlled trial of home based motivational interviewing by midwives to help pregnant women quit or cut down. BMJ. 2005; 331: 373-377.

What is the most effective way to help pregnant smokers quit: telephone counseling or midwife delivered home based counseling?

In this article the author explores and researches which form of counseling is more beneficial for pregnant smokers; telephone counseling or midwife delivered home based counseling. 11-22% of pregnant women in the United States smoke during pregnancy. Through logos explanation, it is found that smoking is directly connected to low birth weight. "The magnitude of the weight difference is directly proportional to the number of cigarettes the mother smoked. This whole article exhibits strong pathos because of the subject at hand. This subject is very emotional in itself as the subject, the baby, is such a innocent and extraordinary gift to the world, and it is saddening when they are harmed during birth due to lack of care during its incubation period. This article is an example of a scientific writing because it presents an experiment to be examined and tested, gives statistics and general information about the topic at hand, and concludes with an answer. Through research from credible sources (ethos) the experiment found that neither telephone nor midwife delivered home based counseling made a significant difference in reducing smoking cessation during pregnancy compared to normal brief, in office counseling. Ethos is shown in this article because the author, Lauren Kropa, a physician assistant student, credits her sources such as "Motivational Interviewing" by Rollnick S. Miller and Foundation for Blood Research, Cotinine Testing. Other questions that could be brought up from this research article could be, "What are differing tactics to reduce smoking cessation during pregnancy in other countries?" or "To what degree does second-hand smoke effect women during pregnancy?"

Spectator Risks at Sporting Events: blog numero uno

Spectator Risks at Sporting Events

James E. Winslow, M.D., MPH
Department of Emergency Medicine
Wake Forest University

Adam O. Goldstein, M.D., MPH
Department of Family Medicine
University of North Carolina

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Citation:

James E. Winslow, Adam O. Goldstein: Spectator Risks at Sporting Events. The Internet Journal of Law, Healthcare and Ethics. 2007. Volume 4 Number 1.

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Keywords: Spectator, risk, injury, hockey, baseball, recreation

Abstract Introduction: Spectator injuries take place at sporting events as a result of incidents in the playing arena. Venues assume little responsibility to ensure spectator safety based on the legal doctrine of “assumption of risk”. This paper reviews the literature to define the risk to spectators at baseball and hockey venues. Methods: A search of MEDLINE, LexisNexis, and Google was carried out for relevant articles including reports in the medical, legal, and lay press. Results: Only 5 studies were found in the literature. 51 media articles were found addressing this topic. Most research originates from the legal community. At least 5 spectator deaths have been reported at baseball games since 1970. There are only 2 known spectator deaths at hockey games. Conclusion: There is a need for injury surveillance at sporting events. Such research will help define the risk and help venue operators increase spectator safety.

Work done at Department of Emergency Medicine, Wake Forest University Health Sciences

No outside support or funding received

Introduction

Over 15 million Americans attend sporting events yearly.[ ¹ , ² ] Spectator death and injury have occurred in hockey and baseball. [ ³ , ⁴ ] Despite these deaths, little information quantifies the risk to spectators or discusses ways to reduce these risks. Many spectators may falsely assume that they are safe at such events, or that the owner/operators of sporting venues are ensuring their safety and will take responsibility if they are injured. The different responses of these sports to spectator injuries have important implications for injury prevention and future research. This article will specifically review spectator injury at baseball and hockey events. In each of these categories specific examples will be provided of injuries. A description will also be given of the principles of liability and the idea of “assumption of risk”.

Methods

A search of MEDLINE, LexisNexis, and Google was done. Keywords used included “spectator injury”, “injury”, “hockey injuries”, “baseball injuries”, “assumption of risk”, “recreation”, and “spectator death”. Review articles, research studies, media articles, and legal cases were reviewed. Bibliographies of all sources were also reviewed.

Results

In the media 51 articles were found which addressed spectator injury secondary to events in the playing area. In the medical and epidemiological literature 5 articles were found which dealt with this subject. The date range of the articles is from 1978 to 2004. In baseball, 5 spectators appear to have been killed as a result of objects leaving the field. With the available data it is not possible to estimate the number of baseball spectators injured. Only 2 examples of hockey spectator deaths were found in the media. As with baseball there is not enough data to estimate the number of injuries to hockey spectators. With the current state of research it is not possible to estimate the actual risk to spectators who attend baseball and hockey games.

Results for Baseball

No comprehensive listing exists, by stadium or division type, of the number or severity of spectator injuries occurring at baseball games. One recently published study by Milsten gives the incidence of injuries to Major League Baseball (MLB) fans from foul balls as 35.1 injuries per every million spectator visits. The paper gives limited detail regarding the actual injuries.[ ⁵ ] The only other discussion of spectator injuries at baseball games occurs in the legal literature. The majority of baseball injuries to spectators occur from baseballs leaving the field at high velocity and entering spectator-viewing areas, with the most vulnerable areas down the 1st or 3rd base lines, or directly behind home plate. More rarely, injuries occur from other flying projectiles such as broken bats.[MSOffice1]

Types of baseball injuries

The majority of injuries involve facial or head trauma from direct contact with a hit baseball. Injuries from objects other than baseballs, such as fractured baseball bats that go into the stands, are less frequently described but equally serious. At a professional baseball game in Canada, a 39-year-old woman was struck by a bat while sitting in the third row. The woman required 11 days of hospitalization for unknown injuries.[ ⁶ ] Most injuries suffered by fans involve the head and maxillofacial region which makes sense given that the head and face are the most exposed areas. [MSOffice2]

Principles regarding liability for injury at baseball games

The legal literature surrounding baseball injuries discusses primarily the liability surrounding injuries, not the injuries themselves. Courts operate under the premise that the spectator “assumes the risk” of attending a baseball game. The courts feel that it should be obvious to the spectator that a baseball can hit them. This is why the back of many sporting tickets carry a warning declaring that there are inherent dangers in attending the game. It is unclear if spectators truly appreciate what is written on that warning, or what the legal ramifications are to them if injured. Spectators at most professional sporting events fall under this same “assumption of risk” concept. The legal principles which apply to baseball liability are similar to those which apply to hockey. Nationally, plaintiffs who take non-sporting venue related owner negligence cases to trial win a verdict 37% of the time.[ ⁷ ] In contrast, except in “extraordinary” circumstances, spectators injured by objects from the field almost never win damages.[MSOffice3] [ ³ ]

Courts analyze several factors when deciding if a fan has assumed the risk. The closer the spectator is to the playing surface the higher the likelihood that they have assumed the risk. Courts look at whether the injury occurred during the game and if the spectator had been to previous games. In the event that a spectator has been to a previous game, it is assumed that the spectator should be more familiar with the inherent dangers. Legal criteria regarding whether the game is in progress exist because if the game is not in progress then the spectator has less reason to expect that projectiles might leave the playing area. Normally if these criteria are even partially met, the spectator or the spectator's family will not win an award.[ ⁸ ] None of the legal criteria actually define the risks faced by spectators. [MSOffice4]

Some states have laws regarding who is responsible for spectator safety at baseball games. These laws specifically address protective shielding for spectators. The Illinois Baseball act is typical of the laws that exist in many states. It says,

“The owner or operator of a baseball facility shall not be liable for any injury to the person or property of any person as a result of the person being hit by a ball or bat unless: (1) the person is situated behind a screen, backstop, or similar device is defective (in a manner other than width or height) because of the negligence of the owner or operator of the baseball facility: or (2) the injury is caused by willful and wanton conduct, in connection with the game of baseball, of the owner or operator or any baseball player, coach or manager employed by the coach or operator.”

Other state laws are similar to the Illinois law.[ ⁹ ]

In 1986, a woman suffered a broken jaw from a foul ball. She was about 3 feet away from the edge of a protective screen. The appeals court found that the stadium was not under the obligation to fence in the entire spectator area. The court stated that

“spectators accept the inherent dangers in a sporting event and assume the risk of injury insofar as such risks are obvious and necessary”.[ ⁸ ]

Some courts feel that a bat leaving the playing field constitutes an extraordinary circumstance that may make the venue operator liable. A California Court found in favor of one plaintiff who was struck by a bat because it felt that it was not common knowledge that bats might fly into the stands. In this case, a 6-year-old child had her jaw broken by a baseball bat at a MLB game. The child was sitting close to the field on the 3rd base line when a bat fragment curved around a net meant to protect spectators and struck her causing a deficit in the use of her arms. A lower court awarded the family a million dollars.[ ¹⁰ ] The Court of Appeals, however, overruled this judgment, saying that the operator had no obligation to warn spectators because the risk, even from bat injuries, is “well known”.[ ⁹ ] The court went further by stating that most fans want to be involved in the game in “an intimate way”, and are “hoping that they might come into contact with some projectile from the field”, and “welcome that risk”.[MSOffice5] [ ¹⁰ ]

Shielding at baseball games to prevent injuries

For 3 decades, the accepted practice to protect spectators from baseball injuries has been to place protective netting behind home plate. Presumably, protective baseball nets must have reduced the number of serious injuries. There are no regulations governing fan screening at minor league games, and the netting practices vary greatly.

According to James C. Kozlowski, a law professor at James Madison University, the guidelines for protective screening were set down in Akins v Glen Falls City School District. [ ¹¹ ]

“Owners and operators of ball fields must only provide screening for the area of the field behind the plate where the danger of being struck by a ball is greatest… such screening must be of sufficient extent to provide adequate protection for as many spectators as may reasonably be expected to desire such seating in the course of an ordinary game. “[ ⁸ ]

This opinion was made despite the lack of epidemiologic data delineating the extent of risks or data determining what percentage of spectators would desire protected seating.

Determining the real injury risks to baseball spectators

The legal criteria cited above make major assumptions about risks that are not substantiated by data. No published studies exist to determine if spectators are aware of, understand, or agree with the assumption of risk concept which is printed on the back of their tickets. A spectator attending 1 or more prior games may or may not be aware of the different types of possible injuries. Since there is minimal research that looks at the frequency, location, or types of possible injuries, it appears difficult to believe spectators could be adequately informed of the risk. The risks would not even appear to be the same, since the velocity of baseballs pitched and hit at major league levels is higher than that at minor league or collegiate levels.

Thus, from a public health viewpoint, it is difficult to see how the majority of spectators at professional baseball events can have a clear grasp of injury risks or legal ramifications assumed at such events. It appears even less tenable that a minor could appreciate these risks given the competing elements of speed and excitement, elements known to increase youth experimentation with risky behaviors.[ ¹² ] To say that fans “welcome a risk” is to deny the competing reality that fans “appreciate being safe”. While all fans desire a “souvenir” baseball, it requires a leap of faith unsubstantiated by data to suggest that they would sacrifice their own personal safety or that of their family for such an opportunity. [ ⁶ , ⁸ , ⁹ , ¹² , ¹³ , ¹⁴ ]

Results for Hockey

Hockey is a sport similar to baseball in that spectators are in close proximity to rapidly moving projectiles. Hockey pucks can reach speeds of 150 km/hr, roughly the same speed reached by baseballs, and weigh approximately 0.16 kg (5.75 ounces).[ ⁴ , ⁶ ] As with baseball, this can lead to an inherent danger for spectators, and minimal research could be found which addresses that risk.

Types of hockey injuries

As with baseball most reported injuries involve the head and face. In March 2002, a 13-year-old girl, who was sitting 100 ft (30.5 M) from the playing area, died of injuries after being injured by a hockey puck.[ ⁴ ] This was the 1st spectator death in the National Hockey League (NHL) in 85 years. A study by Milzman found that during 127 hockey games, there were 122 people injured by pucks, 90 of which required stitches. Of the total injured 45% required transport to a hospital emergency room. The study also found that females and children were injured 2.6 times more frequently than adult males. As with baseball most reported injuries involve the head and face.[MSOffice6] [ ¹⁵ ]

There were multiple examples of hockey puck injuries to spectators found in the media. These injuries include a 13-year-old Canadian who sustained a severe head injury; a mother of a teenage player lost sight in 1 eye; a 9-year-old sustained a skull fracture; a 53-year-old sustained partial loss of vision; and a 21-year old died secondary to a head injury.[ ⁴ ]

Legal Standards for Spectator Safety in Hockey

The legal standards for assessing “assumption of risk” and liability in hockey injuries are similar to those used in baseball. Courts often ask the following questions when addressing whether a hockey spectator has “assumed the risk”.

• Was the danger obvious so that the patron must have assumed the risk by attending?
• Was the danger so obvious that the owner or operator were under no duty to warn or protect the spectators?
• Is the spectator familiar enough with the game to understand the dangers?
• Are the facilities constructed in accordance with normal standards?
• Would it have been possible to have constructed additional safety features at a reasonable cost without impeding visibility?

As with baseball, few of these questions address the actual risk to spectators.

Court decisions resulting from suits brought by hockey and baseball spectators are quite similar. In Sawyer v State, a 13-year-old was injured by a hockey puck. The court stated that:

“she admits to having seen pucks striking the [protective]net on her previous visits to the arena and, … it cannot be said that a reasonably prudent person of [the plaintiff's] years, intelligence, and degree of development, would not have fully appreciated the danger and, hence… assumed the risk”.[ ⁹ ]

The above case illustrates the same acceptance of inherent risk. Even though the spectator was a minor the court found that in this case she was able to appreciate the dangers involved and “assume the risk”.[MSOffice7]

Protective shielding to prevent injuries to hockey spectators

Despite similar legal liability, professional hockey has responded to spectator injuries differently than professional baseball. For instance, the NHL and other venue operators responded to the recent spectator death by increasing safety devices at hockey venues. The NHL mandated that protective screens around the rink must be at least 5 ft (1.52 M) high and mandated protective netting to stretch from the top of the protective screen to the ceiling.[ ¹⁶ ] The City of Winnipeg spent $44,000 to place netting around the entire circumference of all its 30 public rinks. Many people in Canada have argued that the Plexiglas screens around the rink should be increased from 8 to 16 feet.[ ³ ] The Canada Safety Council has listed spectator injury from hockey pucks as a serious concern.[MSOffice8] [ ⁴ , ¹⁷ ]

Discussion

There are significant medical and legal concerns regarding spectator injuries at baseball and hockey venues. From a public health viewpoint, the central question is can more be done to reduce and prevent spectator injuries at sporting events? Looking at the examples of baseball and hockey, it is instructive to realize that different approaches to injuries have resulted in different potential risk profiles. At hockey events, the risk of serious injury to spectators may have declined with the changes made widely across venues. Neither professional nor minor league baseball have made similar uniform safety changes.

Defining what spectators consider acceptable levels of risk at sporting events is an important question. A potential way to do this is by looking at levels of risk that people accept in daily life. For instance, the Journal of Compensation and Working Conditions gives the average risk of dying for workers in the United States as 49 /1 million workers each year.[ ¹⁸ ] In the year 2000, airlines experienced 8.4 fatalities/1 million passenger enplanements.[ ¹⁹ ] Comparing the risks of automobile travel (more commonly thought of as safe) to motorcycles (more commonly thought of as dangerous) shows that in 2000 there were 1.5 deaths/1 million miles traveled in automobiles compared to 27 deaths/1 million miles traveled on motorcycles.[ ²⁰ , ²¹ ] The examples used above have known levels of risks associated with them allowing people to choose whether to accept the risk or not. With spectator injuries at sporting events, the risk is not known. Currently, spectators' only notice of risk is the liability assumption warning printed in small print on the back of tickets. Whether this warning is read, understood or impacts on spectator behavior at sporting events is unknown.

The U.S. legal system has ruled that people who willingly assume risk cannot hold the owners of baseball or hockey venues liable for damages if they are injured as a result of actions on the playing surface. From the review of the literature it is obvious that there is a risk to attending these events. This literature also demonstrates a significant lack of data about epidemiology of spectator injuries. Given the fact that a large number of people each year attend large spectator events, some type of injury surveillance system is needed.

An injury surveillance system could answer many important questions. For instance, how many spectators are injured or killed each year? The answer to this question would help quantitate the actual risk faced by spectators. It would allow spectators and the parents of small children to make intelligent decisions regarding how safe it is to attend different events. Other research questions might include the relationship between the use of alcohol and injury frequency and severity. Do repeated visits to sporting events raise or lower the likelihood of spectator injury? Do most of the injuries consist of minor orthopedic injuries or more serious head injuries? The answers to the questions would allow sporting venues and clubs to better protect spectators. It could also lead to a change in how the games are played. Perhaps if certain injuries are common then changes could be made to the balls, pucks, or safety equipment. Racetrack operators have already noted that wheels were sometimes flying into stands so wheel tethers were placed on cars.

The only way to answer these questions would be by first conducting prospective studies of spectator injuries at sporting events. Collaborative efforts between sports industry and researchers would facilitate data collection. For instance, most venues have EMS personnel already present. This may represent an opportunity to collect and record injury information on site, making national data collection much easier. Such a project would give epidemiologists access to larger data sets for analysis and the sports industry valuable information on how to better protect spectators.[MSOffice9]

Acknowledgments:

Thank you to Don Pathman, MD, MPH, for review of this manuscript.

References

1. Baseball attendance down 3.5 percent. August 18, 2003, The Associated Press. [reds.enquirer.com/2002/04/18/red ... ]

2. Grange, J.T. and G.W. Baumann, The California 500: medical care at a NASCAR Winston Cup race. Prehosp Emerg Care, 2002.6(3): p. 315-8.

3. Horrow, R., Violence in Sports: Agressive or Excessive. May 29, 2002, sportsline.com.

4. Tragedy Should Spur Action., Canada Safety Council. Vol. XLVI, No. 2, April 2002 [www.safety-council.org/news/sc/2 ... ]

5. Milsten, A.M., et al., Variables influencing medical usage rates, injury patterns, and levels of care for mass gatherings. Prehospital Disaster Med, 2003. 18(4): p. 334-46.

6. Chu, G. and K.M. Johnston, Baseball: Spectator or Contact Sport? Clinical Journal of Sport Medicine, July 2000. 10(3): p. 204-205.

7. Tort and Contract. July 23, 2002, National Center for State Courts. [/www.ncsconline.org]

8. James C. Kozlowski, J.D., Ph.D, Adequacy of Spectator Protection in Danger Zone A Jury Issue. May 1993, NRPA Law Review, Parks & Recreation. [classweb.gmu.edu/jkozlows/corone ... ]

9. County, C.C.o.C., James Jasper v. Chicago National League Ball Club, inc. August 25,1999. [www.state.il.us/court/Opinions/A ... ]

10. Michigan, S.C.o., Bandstra CJ. Benejam v. Detroit Tigers Inc. July 10, 2001,Michigan Lawyers Weekly [www.milawyersweekly.com]

11. James C. Kozlowski, J.D. Letter to the Author. June 22, 2003: Fairfax, VA.

12. Recreational Safety. May 2001, Children's Safety Network. [www.childrenssafetynetwork.org/R ... ]

13. Orinick, S., Baseball Field Layout, "Steve the Ump". [www.stevetheump.com/field_layout ... ] .

14. Appeals, C.C.o., Gary N Teneyck v. Roller Hockey Colorado. August 3, 2000. [caselaw.lp.findlaw.com/scripts/g ... ]

15. Milzman, D. The Puck Stops Here: Spectator Injuries, A real Risk Watching Hockey Games. Annals of Emergency Medicine. October 2000.36(4): S24.

16. NHL Approves Safety nets, hurry-up face-offs. October 3, 2002, CBC Sports Online. [cbc.ca/cgi-bin/templates/sportsV ... ]

17. Protecting Hockey Spectators. September 2000, Canada Safety Council. [/www.safety-council.org/news/sc/ ... ]

18. Toscano, G., Dangerous Jobs. Compensation and Working Conditions, Summer 1997. [www.bls.gov/iif/oshwc/cfar0020.p ... ]

19. Table 3. Passenger Injuries and Injury Rates, 1982 through 2001, for U.S. Air Carriers Operating Under 14 CFR 121, National Transportation Safety Board. [www.ntsb.gov/aviation/Table3.htm ... ] .

20. Table 2-17: Motor Vehicle Safety Data, Bureau of Transportation Statistics. US Department of Transportation. [www.bts.gov/publications/nationa ... ]

21. Table 2-22: Motorcycle Rider Safety Data, Bureau of Transportation Statistics. [www.bts.gov/publications/nationa ... ]

Spectator risks at sporting events

This article explains the topic of injuries received by spectators in sporting events, hockey and baseball in particular. It illustrates who is at fault when a spectator is injured at a sporting event and the arguments against or for a plaintiff. Through logos explanation, the article covers that only 37% of the time the plaintiff wins their case in accordance to a spectator injury at a sporting event. In such sports as baseball and hockey, it is explained that the closer the spectator is to the playing area, he or she has recognized the assumption of risk they might encounter. Because of amount of risk, sports such as hockey and baseball have taken certain precautions to avoid spectator injury. Extra protective netting has been placed to lessen the chance of spectator injury. This article is an example of scientific writing because it investigates a topic and gives arguments for and against the subject by giving numerical data and presents court cases that are congruent to the topic. Such cases as Sawyer v. State and Akins v. Glen Falls City School District presents facts that in a sporting event, hockey in the first case, the spectator, though a minor, has still “assumed the risk” of being present at a sporting event. In the case of Akins v. G.F.C.S.D, owners and operators of ball fields (baseball) were to place protective netting in only the most dangerous spots of the playing field, i.e. where a spectator is most likely to get struck by a baseball. Ethos is presented in this article as it is written by two college professors and presents a number of references to sources about the subject. In a pathos point, there is little evidence that connects the reader to the article in an emotional aspect. This article is mainly logos, giving factual evidence about the topic at hand.

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[MSOffice1]Logos, factual information.

[MSOffice2]Logos, presenting fact about a specific injury in baseball.

[MSOffice3]Spectators are aware of the assumption of risk concept.

[MSOffice4]If a person or persons have been to a sporting event more then once then they are well aware of the ramifications of sitting closer to the playing field, making their chances of winning a case less likely.

[MSOffice5]Again, presents logos, giving a specific case of an injury from a broken bat, but lost the case because the person “welcomed the risk of injury.”

[MSOffice6]Logos

[MSOffice7]These court cases show that the plaintiff has little chance of winning a spectator injury case because the opposing argument is always that they have “assumed the risk” by attending a sporting event.

[MSOffice8]Logos. Protective netting has been placed to lower spectator injuries in sporting events.

[MSOffice9]Spectators, when at sporting events, ultimately have assumed the risk at hand and are liable for any injuries received during a sporting event, not the organization.