Public policy for the control of tobacco-related disease

A School-Based Intervention Program to Prevent Adolescent Smoking

Research has shown that tobacco use usually begins in early adolescence, results in an increase in future health problems, and ultimately affects national health care costs. Despite the messages about the dangers of smoking, young people continue to smoke. A school-based tobacco education program designed to produce a more favorable attitude about the positive effects of not smoking and increase knowledge of the hazards of smoking was implemented for 6th graders in a parochial middle school. After the intervention, there was a significant increase in knowledge about tobacco but no change in attitudes regarding the use of tobacco. The results have implications for school nurses who design and teach programs to prevent tobacco use.

Smoking behaviors and attitudes during adolescence prospectively predict support for tobacco control policies in adulthood

INTRODUCTION

Several cross-sectional studies have examined factors associated with support for tobacco control policies. The current study utilized a longitudinal design to test smoking status and attitude toward smoking measured in adolescence as prospective predictors of support for tobacco control policies measured in adulthood.

METHODS

Participants (N = 4,834) were from a longitudinal study of a Midwestern community-based sample. Hierarchical multiple regression analyses tested adolescent smoking status and attitude toward smoking as prospective predictors (after controlling for sociodemographic factors, adult smoking status, and adult attitude toward smoking) of support for regulation of smoking in public places, discussion of the dangers of smoking in public schools, prohibiting smoking in bars, eliminating smoking on television and in movies, prohibiting smoking in restaurants, and increasing taxes on cigarettes.

RESULTS

Participants who smoked during adolescence demonstrated more support for discussion of the dangers of smoking in public schools and less support for increasing taxes on cigarettes but only among those who smoked as adults. Those with more positive attitudes toward smoking during adolescence demonstrated less support as adults for prohibiting smoking in bars and eliminating smoking on television and in movies. Moreover, a significant interaction indicated that those with more positive attitudes toward smoking as adolescents demonstrated less support as adults for prohibiting smoking in restaurants, but only if they became parents as adults.

CONCLUSIONS

This study's findings suggest that interventions designed to deter adolescent smoking may have future benefits in increasing support for tobacco control policies.

A comprehensive model for mental health tobacco recovery in new jersey

Despite the high prevalence of tobacco use, disproportionate tobacco consumption, and excess morbidity and mortality, smokers with mental illness have reduced access to tobacco dependence treatment across the health care spectrum. We have developed a comprehensive model for Mental Health Tobacco Recovery in New Jersey (MHTR-NJ) that has the overarching goal of improving tobacco cessation for smokers with serious mental illness. Important steps involve engaging patients, professionals and the community to increase understanding that addressing tobacco use is important. In addition to increasing demand for tobacco treatment services, we must educate mental health professionals in evidence-based treatments so that patients can seek help in their usual behavioral health care setting. Peer services that offer hope and support to smokers are essential. Each of the policy or cessation initiatives described address the two core goals of this model: to increase demand for tobacco cessation services for mentally ill smokers and to help more smokers with mental illness to quit. Each has been pilot tested for feasibility and/or effectiveness and revised with feedback from stakeholders. In this way this implementation model has brought together academics, clinicians, administrators and mental health consumers to develop tobacco programming and policy that has been tested in a real world environment and serves as a model for other states.

Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic

CONTEXT

The global tobacco epidemic may kill 10 million people annually in the next 20-30 years, with 70% of these deaths occurring in developing countries. Current research, treatment, and policy efforts focus on cigarettes, while many people in developing regions (Asia, Indian subcontinent, Eastern Mediterranean) smoke tobacco using waterpipes. Waterpipes are increasing in popularity, and more must be learned about them so that we can understand their effects on public health, curtail their spread, and help their users quit.

OBJECTIVE

To conduct a comprehensive review regarding global waterpipe use, in order to identify current knowledge, guide scientific research, and promote public policy.

DATA SOURCES

A Medline search using as keywords "waterpipe", "narghile", "arghile", "shisha", "hookah", "goza", "hubble bubble" and variant spellings (for example, "hooka"; "hukka") was conducted. Resources compiled recently by members of GLOBALink were used.

STUDY SELECTION

Every identified published study related to waterpipe use was included.

DATA SYNTHESIS

Research regarding waterpipe epidemiology and health effects is limited; no published studies address treatment efforts. Waterpipe use is increasing globally, particularly in the Eastern Mediterranean Region, where perceptions regarding health effects and traditional values may facilitate use among women and children. Waterpipe smoke contains harmful constituents and there is preliminary evidence linking waterpipe smoking to a variety of life threatening conditions, including pulmonary disease, coronary heart disease, and pregnancy related complications.

CONCLUSIONS

More scientific documentation and careful analysis is required before the spread of waterpipe use and its health effects can be understood, and empirically guided treatment and public policy strategies can be implemented.

Tobacco smoking: current concepts in etiology and treatment

Tobacco smoking is the most important preventable cause of death and disease. Despite an increased awareness of the addictive nature of smoking and availability of effective treatments, smoking continues to be widespread among individuals with psychiatric disorders. Moreover, mental health professionals remain reluctant to address smoking among their patients for a variety of reasons. Recent research has provided a wealth of data that have shaped the concept of tobacco smoking as a chronic addictive disorder and also demonstrated the efficacy of smoking cessation interventions. This paper reviews the important factors that contribute to smoking and the various pharmacological and psychosocial interventions for smoking cessation from a biopsychosocial perspective. It also makes recommendations for the rational use of these interventions to treat nicotine dependence in individuals with psychiatric disorders.

Tobacco smoking as a chronic disease: notes on prevention and treatment

Tobacco use represents a rare confluence of interesting circumstances. Elements of inheritable risk combine with powerful neuropharmacology and a ubiquitous environmental exposure and result in an epidemic that claims over 430,000 lives and costs us over $100 billion annually. It is the single most important remediable public health problem in the United States. Most smokers want to quit smoking and a simple advice from a physician can increase the likelihood of doing so. Moreover, there are a number of pharmacologic and behavioral therapies that are proven to be effective in smoking cessation. Yet, there is an apparent reluctance among physicians to address smoking cessation, perhaps due to a sense of frustration or low self-efficacy. Physicians play an important role in smoking cessation, and intensive interventions are necessary to improve their participation and efficacy. Teaching practical smoking cessation techniques within medical school curricula, with an opportunity for standardized practice and self-evaluation, may be an effective strategy to improve physician practice in this area. Since most smokers try their first cigarette before the age of 18, and youth smoking is on the rise, targeted interventions aimed at preventing initiation and encouraging cessation of smoking among youth are needed. For all tobacco users, a better understanding of the pharmacology and physiology of nicotine addiction may translate into targeted and individualized treatment and prevention strategies, which may improve success rates dramatically. To better control this epidemic, and to meet the nation's public health goals for the year 2010 [145], local tobacco control interventions need to be multifaceted and well integrated into regional and national efforts [146]. Because of the physician's unique societal role with respect to tobacco, doctors may indeed find it possible to impact public opinion and significantly reduce the toll of tobacco by acting at the public health and public policy levels [147]. Those interested in engaging in the public health debate can do more than relay facts about tobacco and health. Involvement in tobacco-control issues provides the opportunity to impact the environmental influences promoting smoking among patients, and is likely to be synergistic with efforts to help smokers quit within the office. Physicians who take steps to engage in local public health initiatives are likely to magnify the effects of their efforts at the bedside [148, 149].

Public health implications of voters' attitudes regarding statewide tobacco policy

BACKGROUND

Tobacco use remains the most preventable cause of death and disability in the United States. Public opinion regarding tobacco use is not only an important barometer of the likelihood of effective tobacco-control legislation, but also identifies ongoing public health educational needs. Because > 63,000 children become new smokers annually in Pennsylvania, we chose to evaluate the statewide public health tobacco perspective in order to help tailor future public policy interventions.

STUDY DESIGN AND SETTING

Registered voters were randomly contacted in a statewide telephone survey. To reduce response bias, an independent polling firm conducted the 643 structured interviews.

RESULTS

Most respondents were >or= 45 years old (55%), female (54%), and had at least some college education (62%). Twenty-eight percent (95% confidence interval [CI], 25 to 32%) were current tobacco users, and 38% (95% CI, 34 to 42%) had lost family members or friends to smoking-related disease. Ninety-two percent (95% CI, 90 to 94%) expressed "concern" about adolescent tobacco use, but only 46% (95% CI, 42 to 50%) believed that government needed to do more. Of respondents opposed to government involvement, 65% (95% CI, 61 to 68%) believed it was an improper role for government, or that there are more important non-health government priorities. When framed more personally, 80% (95% CI, 77 to 83%) indicated that elected officials have a responsibility to "dedicate a significant portion of tobacco settlement" to prevention. Still, 28% (95% CI, 25 to 32%) would oppose laws restricting smoking in establishments frequented by youth.

CONCLUSIONS

Prior public health education initiatives have been effective in shaping the tobacco-related health concerns of Pennsylvania voters. As expected, the overwhelming majority of respondents are concerned about youth tobacco use and agree that money should be spent on tobacco-control initiatives. In contrast, many are reluctant to support "government" involvement in what is still seen as a personal issue. Future public health initiatives should focus on this dichotomy and should highlight the utility of an integrated policy approach to tobacco control.

Is 'stage of change' related to knowledge of health effects and support for tobacco control?

We examine the heterogeneity among current and former smokers categorized by 'stage of change' with respect to their perceptions about tobacco and tobacco control. Current and former smokers (n = 846) from a general population sample of adults in Ontario, Canada, were subdivided according to the stages of change categories (precontemplation, contemplation, preparation, action, maintenance, and termination) and compared on measures of knowledge, attitudes, and support. Multivariate analyses were conducted adjusting for sociodemographic covariates. Adjusted overall increases across the six stages were observed for seven of eight knowledge items and for all attitude and support items. Among current smokers, adjusted increases across the three stages were detected for a majority of items. However, statistically significant differences from one stage to the next, across all three current smoker stages, were detected only for one item. Among former smokers, adjusted increases across the three stages were observed for a minority of items. The stages of change classification was useful for differentiating subgroups of current smokers with regard to knowledge, attitudes, and support for tobacco control measures.

The pediatrician's role in reducing tobacco exposure in children

OBJECTIVE

Pediatricians have a unique and important role to play in the prevention and treatment of childhood and adolescent tobacco use, the protection of patients from the harmful effects of environmental tobacco smoke, and the encouragement of smoking cessation among parents. However, because recent research indicates that physician training in tobacco dependence is woefully weak and lacks a model for training, this article constructs a useful approach to this problem.

METHODOLOGY

A comprehensive review of the literature served as the basis for the development of a new model for pediatrician training in tobacco dependence.

RESULTS

A comprehensive model is presented for training pediatricians in the areas of reducing infant and child exposure to environmental tobacco smoke, preventing youth smoking initiation, and providing smoking cessation assistance for adolescents and parents.

CONCLUSIONS

Pediatricians have been called on to play an active role in the antitobacco arena. Because of their unique opportunity to interact with children, adolescents, and parents, pediatricians can and should be antitobacco interventionists. For this to occur, however, additional guidance should be provided to pediatricians during their training to better prepare them to carry out effective assessment and intervention practices. smoking initiation, smoking prevention, smoking cessation, environmental tobacco smoke, pediatricians.

An instrument for assessing the quality of tobacco-control policies: the ACT-L scale

BACKGROUND

Efforts to prevent and decrease tobacco use and tobacco-related disease include improving the quality of tobacco-control laws to make them more stringent in controlling tobacco advertising, youth access, and exposure to environmental tobacco smoke (ETS). However, because there are no instruments to empirically evaluate the quality of such laws, it has been difficult to demonstrate that their quality is associated with decreased youth access or tobacco-related morbidity. We present the first instrument for empirically assessing the quality of tobacco-control policies.

METHODS

Recommendations for the content of an ideal, comprehensive tobacco-control policy were used as the 55 items in the Assessment of the Comprehensiveness of Tobacco Laws Scale (ACT-L Scale). Raters evaluated 71 tobacco-control laws with the scale; 70 of these were actual California laws and 1 was a model law from Americans for Non-smokers' Rights (ANR).

RESULTS

Interrater (r = 0.64-0.89) and internal-consistency (r = 0.63-0.88) reliability of the scale and subscales were high, and validity was established by demonstrating that the ANR model law received a significantly higher total score (mean = 18.75) than all actual laws (mean = 2.04). California tobacco-control laws were poor in all areas (youth access, ETS, tobacco advertising).

CONCLUSIONS

The ACT-L scale can be used to compare and evaluate the quality of tobacco-control laws, highlight areas in which further policy efforts are needed, quantify improvement in such policies, and empirically demonstrate the positive health impact of high-quality tobacco-control laws.

Tobacco and lung cancer

Cigarette smoking is responsible for enormous health consequences. Lung cancer is fatal in over 80% of cases, and effective treatment is limited. The medical impact of cigarette smoking will diminish with effective measures to prevent smoking and nicotine addiction and to promote smoking cessation. Efforts should focus on the teenage population, with a combination of social, economic, and legislative interventions.

Mobilizing a low-income African-American community around tobacco control: a force field analysis

A statewide tobacco control campaign in California has been highly successful in reducing public exposure to the health hazards of secondhand smoke. Over 250 cities and counties in California have enacted local ordinances to regulate smoking in public places and workplaces. Although low-income people of color are disproportionately affected by the use of tobacco, the issue of regulating secondhand smoke tends to be a lower priority in communities that are confronted by other, more immediately pressing social justice issues, such as high rates of violence and lack of economic opportunity. This article describes the process undertaken by a county health department to mobilize a low-income African American community in a San Francisco Bay Area city to support a local ordinance mandating 100% smoke-free workplaces and restaurants. These efforts are more likely to succeed if health advocates (1) reframe issues in a context that acknowledges the political, economic, and social justice realities and strengths of the community; (2) organize within existing local networks and foster the integration of tobacco issues into the group's existing work; and (3) can defer their own agendas during times of community grieving and healing.

Health education intervention strategies: recommendations for future research

While the ultimate goal of health education interventions is to positively influence health status, more proximal indicators of success are changes in intermediate outcomes, or impact. Because health education interventions work through intermediate outcomes, the linkage to health status is often assumed to be at a conceptual or theoretical level. The term health education intervention strategy is a heuristic device used to conceptualize and organize a large variety of activities. There is a wide range of studies and reports in the literature that either test specific intervention strategies or report on larger health education efforts combining several strategies. This article organizes the discussion to focus on individual-, community-, and policy-level interventions. Mass communications are also considered, and the authors comment on program planning issues that cut across specific interventions at the individual, community, and policy levels. Eleven recommendations are offered for future health education intervention research.

Creating capacity through health education: what we know and what we don't

Researchers in health education have rarely convened to outline research priorities in the field. This article discusses the results of a meeting to develop a research agenda aimed at creating capacity to promote and maintain health. Salient research findings related to individual and community health are summarized and priority issues for future research are presented.

Health Care Crisis: The Head and Neck Cancer Patient and Affordable Health Insurance

In an evaluation of 30 patients with head and neck cancer, we found that 14 (46%) were uninsured at the time of diagnosis and 15 (50%) had yearly incomes below the poverty level. Tobacco and alcohol were identified as risk factors in 25 (83%) of the patients. These patients spent an average of $2,781 on carcinogenic agents yearly, increasing the risk of cancer 55 times that of the unexposed population, whereas the cost of a health insurance policy was $2,321 per year. To remedy the disparities and incongruities of this situation, we advocate patient education to influence behavioral change in these high-risk groups, a lowering of insurance rates, legal reform, and continued physician activism toward managing the current health care crisis.