Improving clinic- and neighborhood-based smoking cessation services within federally qualified health centers serving low-income, minority neighborhoods

A scoping review of the use of quality improvement methods by community organizations in the United States, Australia, New Zealand, and Canada to improve health and well-being in community settings

Background

Health-care facilities have used quality improvement (QI) methods extensively to improve quality of care. However, addressing complex public health issues such as coronavirus disease 2019 and their underlying structural determinants requires community-level innovations beyond health care. Building community organizations’ capacity to use QI methods is a promising approach to improving community health and well-being.

Objectives

We explore how community health improvement has been defined in the literature, the extent to which community organizations have knowledge and skill in QI and how communities have used QI to drive community-level improvements.

Methods

Per a published study protocol, we searched Scopus, Web of Science, and Proquest Health management for articles between 2000 and 2019 from USA, Australia, New Zealand, and Canada. We included articles describing any QI intervention in a community setting to improve community well-being. We screened, extracted, and synthesized data. We performed a quantitative tabulation and a thematic analysis to summarize results.

Results

Thirty-two articles met inclusion criteria, with 31 set in the USA. QI approaches at the community level were the same as those used in clinical settings, and many involved multifaceted interventions targeting chronic disease management or health promotion, especially among minority and low-income communities. There was little discussion on how well these methods worked in community settings or whether they required adaptations for use by community organizations. Moreover, decision-making authority over project design and implementation was typically vested in organizations outside the community and did not contribute to strengthening the capability of community organizations to undertake QI independently.

Conclusion

Most QI initiatives undertaken in communities are extensions of projects in health-care settings and are not led by community residents. There is urgent need for additional research on whether community organizations can use these methods independently to tackle complex public health problems that extend beyond health-care quality.

Physical and Sociocultural Community-Level Influences on Cigar Smoking among Black Young Adults: An In-Depth Interview Investigation

Black young adults experience disparately high rates of cigar use and its health consequences. Little research has explored community-level influences on cigar smoking in this population, especially concerning product-specific influences and cigar smokers' perceptions. We conducted in-depth interviews with 40 Black young adult (ages 21-29) cigar smokers in the Washington, D.C. area and analyzed themes regarding physical and sociocultural community-level factors perceived to influence cigar use. Themes were further analyzed based on participants' predominant cigar products (cigarillos, large cigars, blunts). Participants reported easy access to affordable cigarillos, widespread cigarillo sales and targeted marketing, norms of cigar and blunt smoking for stress relief, socialization, and cultural participation, and ubiquitous cigar and blunt smoking cues, all of which promoted cigar use in their communities. Future research should further explore how community-level influences contribute to disproportionate cigar use among Black young adults. Our findings suggest that programs and policies addressing physical and sociocultural community-level pro-smoking influences may help mitigate cigar smoking disparities.

Characteristics and Service Use of Medicare Beneficiaries Using Federally Qualified Health Centers

BACKGROUND

Federally Qualified Health Centers (FQHCs) provide primary care for millions of Americans, but little is known about Medicare beneficiaries who use FQHCs.

OBJECTIVE

To compare patient characteristics and health care service use among Medicare beneficiaries stratified by FQHC use.

RESEARCH DESIGN

Cross-sectional analysis of 2011 Medicare fee-for-service beneficiaries aged 65 years and older.

SUBJECTS

Subjects included beneficiaries with at least 1 evaluation and management (E&M) visit in 2011, categorized as FQHC users (≥1 E&M visit to FQHCs) or nonusers living in the same primary care service areas as FQHC users. Users were subclassified as predominant if the majority of their E&M visits were to FQHCs.

MEASURES

Demographic characteristics, physician visits, and inpatient care use.

RESULTS

Most FQHC users (56.6%) were predominant users. Predominant and nonpredominant users, compared with nonusers, markedly differed by prevalence of multiple chronic conditions (18.2%, 31.7% vs. 22.7%) and annual mortality (2.8%, 3.8% vs. 4.0%; all P<0.05). In adjusted analyses (reference: nonusers), predominant users had fewer physician visits (RR=0.81; 95% CI, 0.81-0.81) and fewer hospitalizations (RR=0.84; 95% CI, 0.84-0.85), whereas nonpredominant users had higher use of both types of service (RR=1.18, 95% CI, 1.18-1.18; RR=1.09, 95% CI, 1.08-1.10, respectively).

CONCLUSIONS

Even controlling for primary care delivery markets, nonpredominant FQHC users had a higher burden of chronic illness and service use than predominant FQHC users. It will be important to monitor Medicare beneficiaries using FQHCs to understand whether primary care only payment incentives for FQHCs could induce fragmented care.

System change interventions for smoking cessation

BACKGROUND

System change interventions for smoking cessation are policies and practices designed by organizations to integrate the identification of smokers and the subsequent offering of evidence-based nicotine dependence treatments into usual care. Such strategies have the potential to improve the provision of smoking cessation support in healthcare settings, and cessation outcomes among those who use them.

OBJECTIVES

To assess the effectiveness of system change interventions within healthcare settings, for increasing smoking cessation or the provision of smoking cessation care, or both.

SEARCH METHODS

We searched databases including the Cochrane Tobacco Addiction Group Specialized Register, CENTRAL, MEDLINE, Embase, CINAHL, and PsycINFO in February 2016. We also searched clinical trial registries: WHO clinical trial registry, US National Institute of Health (NIH) clinical trial registry. We checked 'grey' literature, and handsearched bibliographies of relevant papers and publications.

SELECTION CRITERIA

Randomized controlled trials (RCTs), cluster-RCTs, quasi-RCTs and interrupted time series studies that evaluated a system change intervention, which included identification of all smokers and subsequent offering of evidence-based nicotine dependence treatment.

DATA COLLECTION AND ANALYSIS

Using a standardized form, we extracted data from eligible studies on study settings, participants, interventions and outcomes of interest (both cessation and system-level outcomes). For cessation outcomes, we used the strictest available criteria to define abstinence. System-level outcomes included assessment and documentation of smoking status, provision of advice to quit or cessation counselling, referral and enrolment in quitline services, and prescribing of cessation medications. We assessed risks of bias according to the Cochrane Handbook and categorized each study as being at high, low or unclear risk of bias. We used a narrative synthesis to describe the effectiveness of the interventions on various outcomes, because of significant heterogeneity among studies.

MAIN RESULTS

We included seven cluster-randomized controlled studies in this review. We rated the quality of evidence as very low or low, depending on the outcome, according to the GRADE standard. Evidence of efficacy was equivocal for abstinence from smoking at the longest follow-up (four studies), and for the secondary outcome 'prescribing of smoking cessation medications' (two studies). Four studies evaluated changes in provision of smoking cessation counselling and three favoured the intervention. There were significant improvements in documentation of smoking status (one study), quitline referral (two studies) and quitline enrolment (two studies). Other secondary endpoints, such as asking about tobacco use (three studies) and advising to quit (three studies), also indicated some positive effects.

AUTHORS' CONCLUSIONS

The available evidence suggests that system change interventions for smoking cessation may not be effective in achieving increased cessation rates, but have been shown to improve process outcomes, such as documentation of smoking status, provision of cessation counselling and referral to smoking cessation services. However, as the available research is limited we are not able to draw strong conclusions. There is a need for additional high-quality research to explore the impact of system change interventions on both cessation and system-level outcomes.

Cigarette Smoking, Desire to Quit, and Tobacco-Related Counseling Among Patients at Adult Health Centers

Objectives. We determined cigarette smoking prevalence, desire to quit, and tobacco-related counseling among a national sample of patients at health centers. Methods. Data came from the 2009 Health Center Patient Survey and the 2009 National Health Interview Survey. The analytic sample included 3949 adult patients at health centers and 27 731 US adults. Results. Thirty-one percent of health center patients were current smokers, compared with 21% of US adults in general. Among currently smoking health center patients, 83% desired to quit and 68% received tobacco counseling. In multivariable models, patients had higher adjusted odds of wanting to quit if they had indications of severe mental illness (adjusted odds ratio [AOR] = 3.26; 95% confidence interval [CI] = 1.19, 8.97) and lower odds if they had health insurance (AOR = 0.43; 95% CI = 0.22, 0.86). Patients had higher odds of receiving counseling if they had 2 or more chronic conditions (AOR = 2.05; 95% CI = 1.11, 3.78) and lower odds if they were Hispanic (AOR = 0.57; 95% CI = 0.34, 0.96). Conclusions. Cigarette smoking prevalence is substantially higher among patients at health centers than US adults in general. However, most smokers at health centers desire to quit. Continued efforts are warranted to reduce tobacco use in this vulnerable group.

Black versus white differences in rates of addressing parental tobacco use in the pediatric setting

OBJECTIVE

To examine racial differences in rates of screening parents for cigarette smoking during pediatric outpatient visits and to determine if a parental tobacco control intervention mitigates racial variation in whether cigarette smoking is addressed.

METHODS

As part of the Clinical Effort Against Secondhand Smoke Exposure (CEASE) randomized controlled trial, exit interviews were conducted with parents at 10 control and 10 intervention pediatric practices nationally. Parents were asked to report if during the visit did anyone ask if they smoke cigarettes. A generalized linear mixed model was used to estimate the effect of black vs white race on asking parents about cigarette smoking.

RESULTS

Among 17,692 parents screened at the exit interview, the proportion of black parents who were current smokers (16%) was lower than the proportion of white parents who smoked (20%) (P < .001). In control group practices, black parents were more likely to be asked (adjusted risk ratio 1.23; 95% confidence interval 1.08, 1.40) about cigarette smoking by pediatricians than whites. In intervention group practices both black and white parents were more likely to be asked about smoking than those in control practices and there was no significant difference between black and white parents in the likelihood of being asked (adjusted risk ratio 1.01; 95% confidence interval 0.93, 1.09).

CONCLUSIONS

Although a smaller proportion of black parents in control practices smoked than white, black parents were more likely to be asked by pediatricians about smoking. The CEASE intervention was associated with higher levels of screening for smoking for both black and white parents.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

Tobacco smoking and its association with illicit drug use among young men aged 15-24 years living in urban slums of Bangladesh

Background

Tobacco smoking (TS) and illicit drug use (IDU) are of public health concerns especially in developing countries, including Bangladesh. This paper aims to (i) identify the determinants of TS and IDU, and (ii) examine the association of TS with IDU among young slum dwellers in Bangladesh.

Methodology/Principal Findings

Data on a total of 1,576 young slum dwellers aged 15–24 years were extracted for analysis from the 2006 Urban Health Survey (UHS), which covered a nationally representative sample of 13,819 adult men aged 15–59 years from slums, non-slums and district municipalities of six administrative regions in Bangladesh. Methods used include frequency run, Chi-square test of association and multivariable logistic regression. The overall prevalence of TS in the target group was 42.3%, of which 41.4% smoked cigarettes and 3.1% smoked bidis. The regression model for TS showed that age, marital status, education, duration of living in slums, and those with sexually transmitted infections were significantly (p<0.001 to p<0.05) associated with TS. The overall prevalence of IDU was 9.1%, dominated by those who had drug injections (3.2%), and smoked ganja (2.8%) and tari (1.6%). In the regression model for IDU, the significant (p<0.01 to p<0.10) predictors were education, duration of living in slums, and whether infected by sexually transmitted diseases. The multivariable logistic regression (controlling for other variables) revealed significantly (p<0.001) higher likelihood of IDU (OR = 9.59, 95% CI = 5.81–15.82) among users of any form of TS. The likelihood of IDU increased significantly (p<0.001) with increased use of cigarettes.

Conclusions/Significance

Certain groups of youth are more vulnerable to TS and IDU. Therefore, tobacco and drug control efforts should target these groups to reduce the consequences of risky lifestyles through information, education and communication (IEC) programs.

Dissemination strategies to improve implementation of the PHS smoking cessation guideline in MCH public health clinics: experimental evaluation results and contextual factors

We report results from an experimental study that tested the effectiveness of dissemination interventions to improve implementation of smoking cessation guidelines in maternal and child public health clinics. We additionally examine individual clinic results for contextual explanations not apparent from the experimental findings alone. Twelve clinics in Illinois were randomized to three dissemination strategies: (i) core dissemination (provision of the 2000 Public Health System Clinical Practice Guideline and a tested smoking cessation program, including program supplies and training), (ii) core dissemination and access to telephone counseling and (iii) core dissemination, telephone counseling access and outreach visits to clinics. Implementation outcomes were post-dissemination improvements over baseline in the percent of smokers reporting receipt/exposure to (i) provider advice, (ii) self-help booklet, (iii) videos, (iv) posters and (v) an adjunct intervention. Results showed significant increases in the percent of smokers receiving a booklet (overall) and an adjunct intervention (Groups 2 and 3). There were no increases in smoker-reported provider advice or videos and poster exposure. Examination of individual clinic findings showed that seven clinics accounted for all the experimental effectiveness. Smoker-reported provider advice to quit also increased in these clinics. Type of clinic and the absence of disruptive events distinguished clinics with and without effective dissemination outcomes.

Smoking frequency, prevalence and trends, and their socio-demographic associations in Alberta, Canada

OBJECTIVES

To determine the numbers of smokers, smoking prevalence and trends, and to examine their socio-demographic associations in Alberta using data from three Canadian national health surveys undertaken between 2000 and 2005.

METHODS

The three surveys collected self-reported health data from Canadians aged 12 years and older. The weighted number of smokers and the smoking prevalence by health region and by urban/rural status were determined. The socio-demographic associations of smoking in Alberta were examined using logistic regression analysis.

RESULTS

The numbers of smokers and the smoking prevalence were both higher among men than women, in middle-aged groups (20-39 and 40-59 years) than in younger (12-19 years) and older (> or = 60 years) groups, and among Canadian-born people than immigrants to Canada. The smoking prevalence tended to 1) increase with the increasing rurality of residence, 2) decrease over the timeframe examined, 3) be inversely proportional to educational level and 4) be inversely proportional to household income. The number of smokers was largest in urban areas and among those who reported the highest education and household income.

DISCUSSION

The new tobacco legislation being introduced in Alberta in 2009 may decrease the smoking prevalence in the province, but additional interventions in the regions with the largest numbers of smokers may help further reduce the smoking population and overall smoking prevalence in Alberta.

Multilevel analysis of the chronic care model and 5A services for treating tobacco use in urban primary care clinics

OBJECTIVE

To examine the chronic care model (CCM) as a framework for improving provider delivery of 5A tobacco cessation services.

METHODS

Cross-sectional surveys were used to obtain data from 497 health care providers in 60 primary care clinics serving low-income patients in New York City. A hierarchical generalized linear modeling approach to ordinal regression was used to estimate the probability of full 5A service delivery, adjusting for provider covariates and clustering effects. We examined associations between provider delivery of 5A services, clinic implementation of CCM elements tailored for treating tobacco use, and the degree of CCM integration in clinics.

PRINCIPAL FINDINGS

Providers practicing in clinics with enhanced delivery system design, clinical information systems, and self-management support for cessation were 2.04-5.62 times more likely to perform all 5A services ( p<.05). CCM integration in clinics was also positively associated with 5As delivery. Compared with none, implementation of one to six CCM elements corresponded with a 3.69-30.9 increased odds of providers delivering the full spectrum of 5As ( p<.01).

CONCLUSIONS

Findings suggest that the CCM facilitates provider adherence to the Public Health Service 5A clinical guideline. Achieving the full benefits of systems change may require synergistic adoption of all model components.

Using the Chronic Care Model to Address Tobacco in Health Care Delivery Organizations: A Pilot Experience in Washington State

This article describes a Washington State—based Systems Change Pilot Project in which the chronic care model and the model for improvement were used as tools to promote tobacco cessation—related changes within a health care system. Three diverse sites participated in the pilot. Site teams tailored plan-do-study-act tests to site circumstances, addressing current resources and barriers to implementing change. Teams tested system changes that incorporated tobacco use documentation into the routine health services provided. Findings from this pilot suggest that (a) even simple changes with minimal disruption of services can make a difference in improving documentation of tobacco use status; (b) changes to routine practices of health organizations may not be sustainable if ongoing quality assurance mechanisms are not developed; and (c) systems implemented for other disease states within the same organization or patient population are not instinctively applied to tobacco, because of a multitude of factors.

Readiness to quit smoking in rural communities

The purpose of this study was to determine psychosocial and demographic factors associated with readiness to quit smoking among rural current and recent former smokers. This cross-sectional study of 333 rural adults was part of a larger quasi-experimental study testing the effect of a population-based Quit and Win Contest on quitting. Readiness to quit, partner support to quit smoking, stressful life events, depressive symptoms, and demographic characteristics were measured via a phone interview three months after the Contest. Participants with greater positive partner support to quit smoking were more ready to quit. Minority participants were more ready to quit, compared with Caucasian respondents.

Racial and ethnic disparities in smoking-cessation interventions: analysis of the 2005 National Health Interview Survey

BACKGROUND

Recent national surveys document racial and ethnic disparities in receipt of smoking-cessation advice. This study updates and expands prior analyses using survey data for 2005, and evaluates the association between smokers' race and ethnicity and three separate measures of healthcare-encounter-based tobacco interventions: screening, smoking-cessation advice, and use of smoking-cessation aids.

METHODS

Analyses are based on 4756 smokers (aged 18 and older) reporting a healthcare encounter within the past year who participated in the 2005 National Health Interview Survey (NHIS). Multivariate-adjusted OR and 95% CI for receipt of tobacco interventions in non-Hispanic black and Hispanic smokers were compared to those of non-Hispanic white smokers, adjusted for smokers' characteristics (sociodemographics, health status, and healthcare-utilization factors, and smoking-related characteristics). Analyses were done in 2006.

RESULTS

Results show that compared to white smokers, black and Hispanic smokers had significantly lower odds of (1) being asked about tobacco use (AOR=0.70 and AOR=0.69, respectively); (2) being advised to quit (AOR=0.72 and AOR=0.64, respectively); or (3) having used tobacco-cessation aids during the past year in a quit attempt (AOR=0.60 and AOR=0.59, respectively). Compared to 2000 NHIS published data, the prevalence of receipt of advice to quit from a healthcare provider increased from 52.9% in 2000 to 61.2% in 2005, with increases across racial and ethnic groups.

CONCLUSIONS

Despite progress in smokers' being advised to quit during healthcare encounters in the past 5 years, black and Hispanic smokers continue to be less likely than whites to receive and use tobacco-cessation interventions, even after control for socioeconomic and healthcare factors. Further actions are needed to understand and eliminate this disparity.

Health system changes to facilitate the delivery of tobacco-dependence treatment

In 1996, the Agency for Health Care Policy and Research (AHCPR, now AHRQ, the Agency for Healthcare Research and Quality) released the first federal clinical practice guideline for smoking cessation that was updated in 2000 by the United States Public Health Service (USPHS). The innovative guideline identified six evidence-based strategies for healthcare systems to facilitate the institutionalization of tobacco dependence treatment so that smokers received evidence-based treatments as a routine part of health care. A growing body of evidence demonstrates the importance of systems approaches. This paper discusses the evidence for the systems-level strategies outlined in the guidelines, as well as future directions and needed systems-level research. Promising strategies include: (1) clinical systems organized to cue assessment of smoking status and assistance to smokers, (2) leveraging clinical information systems to provide performance feedback, (3) providing full insurance coverage for evidence-based cessation treatment, and (4) including tobacco-cessation treatment as a measured standard of care by national accreditation organizations. These systems-level approaches increase the likelihood that tobacco use is addressed systematically in the healthcare delivery system. Further research to optimize the effectiveness and adoption of these strategies will help ensure that patients receive evidence-based interventions that foster tobacco-use cessation.

Cardiovascular health disparities: a systematic review of health care interventions

Racial and ethnic disparities in cardiovascular health care are well documented. Promising approaches to disparity reduction are increasingly described in literature published since 1995, but reports are fragmented by risk, condition, population, and setting. The authors conducted a systematic review of clinically oriented studies in communities of color that addressed hypertension, hyperlipidemia, physical inactivity, tobacco, and two major cardiovascular conditions, coronary artery disease and heart failure. Virtually no literature specifically addressed disparity reduction. The greatest focus has been African American populations, with relatively little work in Hispanic, Asian, and Native American populations. The authors found 62 interventions, 27 addressing hypertension, 9 lipids, 18 tobacco use, 8 physical inactivity, and 7 heart failure. Only 1 study specifically addressed postmyocardial infarction care. Data supporting the value of registries, multidisciplinary teams, and community outreach were found across several conditions. Interventions addressing care transitions, using telephonic outreach, and promoting medication access and adherence merit further exploration.

Inferring strategies for disseminating physical activity policies, programs, and practices from the successes of tobacco control

Efforts at reducing tobacco use in the United States and Canada over the last half century have been amazingly successful. This article examines those efforts in order to identify policies, programs, and practices found useful in tobacco control that might be usefully disseminated to world populations to improve rates of physical activity. Tobacco-control activities began with efforts to influence the individual smoker through public education and counter-advertising. Increasing awareness of the addictive properties of tobacco, industry efforts to manipulate those properties, and to target youth with aggressive advertising, fueled public outrage that supported additional policy changes to include community interventions, legal actions, and restraints against the tobacco industry. The article first examines ways to view the process of transferring knowledge from one enterprise (reducing tobacco consumption) to another (increasing physical activity). Several theories of knowledge generalization and dissemination are explored: transfer, knowledge utilization, application, diffusion, and implementation. The second section identifies the dissemination of tobacco control by means of brief health behavior-change interventions for smoking cessation that have been successfully integrated into primary clinical care. The question of whether similar strategies can be successfully disseminated to increase physical activity is examined in detail. The article then moves on to look at the success of arguably the most successful program in the world at achieving a reduction in tobacco control-the State of California. Finally, we compare and contrast some of the lessons as they have played out in another national context-Canada. In the concluding section, some lessons are identified that we believe may be successfully utilized in societal attempts to increase physical activity in world populations.

Urban-rural disparities in smoking behaviour in Germany

Background

It is currently not clear whether individuals living in metropolitan areas differ from individuals living in rural and urban areas with respect to smoking behaviours. Therefore, we sought to explore the relation between residential area and smoking behaviours in Germany.

Methods

We used a nationwide German census representative for the general population of Germany. A number of 181,324 subjects aged 10 years or older were included. Information on the average daily usage of cigarettes that have or had been smoked formerly or currently was available in subjects who have ever smoked. A daily consumption of more than 20 cigarettes was considered heavy smoking. Logistic regression analyses were performed sex-stratified and adjusted for relevant confounders.

Results

Analyses revealed inhabitants of metropolitan areas to be more likely current smokers than inhabitants of rural areas (odds ratio 1.56, 95%-confidence interval 1.51; 1.62). Among current and former smokers those who lived in urban communities had also increased odds for being heavy smokers than those who lived in rural communities.

Conclusion

We conclude that living in an urban and particularly living in a metropolitan area is a determinant of both smoking and severity of current smoking. Tobacco control programs should recognize the difference in living conditions between rural and urban areas.