The first decade of the Massachusetts Tobacco Control Program

American Cancer Society's report on the status of cancer disparities in the United States, 2021

In this report, the authors provide comprehensive and up-to-date US data on disparities in cancer occurrence, major risk factors, and access to and utilization of preventive measures and screening by sociodemographic characteristics. They also review programs and resources that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. The overall cancer death rate is 19% higher among Black males than among White males. Black females also have a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. There are also substantial variations in death rates for specific cancer types and in stage at diagnosis, survival, exposure to risk factors, and receipt of preventive measures and screening by race/ethnicity, socioeconomic status, and geographic location. For example, kidney cancer death rates by sex among American Indian/Alaska Native people are ≥64% higher than the corresponding rates in each of the other racial/ethnic groups, and the 5-year relative survival for all cancers combined is 14% lower among residents of poorer counties than among residents of more affluent counties. Broad and equitable implementation of evidence-based interventions, such as increasing health insurance coverage through Medicaid expansion or other initiatives, could substantially reduce cancer disparities. However, progress will require not only equitable local, state, and federal policies but also broad interdisciplinary engagement to elevate and address fundamental social inequities and longstanding systemic racism.

Gender-sexuality alliance membership and activities: associations with students' comfort, confidence and awareness regarding substance use resources

Belonging to a school Gender and Sexuality Alliance (GSA) is associated with lower substance use among LGBTQ+ youth. However, it is unknown whether GSA participation facilitates access to resources for substance use concerns. Using longitudinal data from 38 Massachusetts high schools, we compared sources of support for substance use concerns listed by GSA members (n = 361) and nonmembers (n = 1539). Subsequently, we tested whether GSA membership was associated with comfort, confidence and awareness regarding substance use resources in school and the community. Finally, we assessed whether specific GSA activities and discussions (e.g. social support) were associated with these outcomes. Among students with recent substance use, GSA membership was associated with greater comfort, confidence and awareness regarding school-based substance use resources in the spring semester, adjusted for fall semester levels and non-GSA club involvement. Furthermore, students in GSAs where members reported more advocacy and social support activities reported higher levels of comfort, confidence and awareness regarding community-based substance use resources. These results indicate that among students using alcohol or nicotine products, GSA members may be more receptive to school-based substance use prevention efforts. Furthermore, GSA-based social support and activism experiences may promote access to community-based substance use resources.

Getting the Word Out: New Approaches for Disseminating Public Health Science

The gap between discovery of public health knowledge and application in practice settings and policy development is due in part to ineffective dissemination. This article describes (1) lessons related to dissemination from related disciplines (eg, communication, agriculture, social marketing, political science), (2) current practices among researchers, (3) key audience characteristics, (4) available tools for dissemination, and (5) measures of impact. Dissemination efforts need to take into account the message, source, audience, and channel. Practitioners and policy makers can be more effectively reached via news media, social media, issue or policy briefs, one-on-one meetings, and workshops and seminars. Numerous “upstream” and “midstream” indicators of impact include changes in public perception or awareness, greater use of evidence-based interventions, and changes in policy. By employing ideas outlined in this article, scientific discoveries are more likely to be applied in public health agencies and policy-making bodies.

Scaling up Evidence-Based Interventions in US Public Systems to Prevent Behavioral Health Problems: Challenges and Opportunities

A number of programs, policies, and practices have been tested using rigorous scientific methods and shown to prevent behavioral health problems (Catalano et al., Lancet 379:1653-1664, 2012; National Research Council and Institute of Medicine, 2009). Yet these evidence-based interventions (EBIs) are not widely used in public systems, and they have limited reach (Glasgow et al., American Journal of Public Health 102:1274-1281, 2012; National Research Council and Institute of Medicine 2009; Prinz and Sanders, Clinical Psychology Review 27:739-749, 2007). To address this challenge and improve public health and well-being at a population level, the Society for Prevention Research (SPR) formed the Mapping Advances in Prevention Science (MAPS) IV Translation Research Task Force, which considered ways to scale up EBIs in five public systems: behavioral health, child welfare, education, juvenile justice, and public health. After reviewing other efforts to scale up EBIs in public systems, a common set of factors were identified as affecting scale-up in all five systems. The most important factor was the degree to which these systems enacted public policies (i.e., statutes, regulations, and guidance) requiring or recommending EBIs and provided public funds for EBIs. Across systems, other facilitators of scale-up were creating EBIs that are ready for scale-up, public awareness of and support for EBIs, community engagement and capacity to implement EBIs, leadership support for EBIs, a skilled workforce capable of delivering EBIs, and data monitoring and evaluation capacity. It was concluded that the following actions are needed to significantly increase EBI scale-up in public systems: (1) provide more public policies and funding to support the creation, testing, and scaling up of EBIs; (2) develop and evaluate specific frameworks that address systems level barriers impeding EBI scale-up; and (3) promote public support for EBIs, community capacity to implement EBIs at scale, and partnerships between community stakeholders, policy makers, practitioners, and scientists within and across systems.

Reduction in emergency department visits for children's asthma, ear infections, and respiratory infections after the introduction of state smoke-free legislation

Despite the benefits of smoke-free legislation on adult health, little is known about its impact on children's health. We examined the effects of tobacco control policies on the rate of emergency department (ED) visits for childhood asthma (N=128,807), ear infections (N=288,697), and respiratory infections (N=410,686) using outpatient ED visit data in Massachusetts (2001-2010), New Hampshire (2001-2009), and Vermont (2002-2010). We used negative binomial regression models to analyze the effect of state and local smoke-free legislation on ED visits for each health condition, controlling for cigarette taxes and health care reform legislation. We found no changes in the overall rate of ED visits for asthma, ear infections, and upper respiratory infections after the implementation of state or local smoke-free legislation or cigarette tax increases. However, an interaction with children's age revealed that among 10-17-year-olds state smoke-free legislation was associated with a 12% reduction in ED visits for asthma (adjusted incidence rate ratios (aIRR) 0.88; 95% CI 0.83, 0.95), an 8% reduction for ear infections (0.92; 0.88, 0.97), and a 9% reduction for upper respiratory infections (0.91; 0.87, 0.95). We found an overall 8% reduction in ED visits for lower respiratory infections after the implementation of state smoke-free legislation (0.92; 0.87, 0.96). The implementation of health care reform in Massachusetts was also associated with a 6-9% reduction in all children's ED visits for ear and upper respiratory infections. Our results suggest that state smoke-free legislation and health care reform may be effective interventions to improve children's health by reducing ED visits for asthma, ear infections, and respiratory infections.

Navigating Government Service as a Physician

Working in government can be a remarkable life experience for anyone but particularly for those who have trained in the worlds of medicine and public health. This article describes some lessons learned from a physician initially based in academic medicine and public health who has since spent more than a decade serving in leadership positions at the state and federal levels. Many of the described themes about policy making can guide health professionals who wish to understand and ultimately contribute to the public sector. Certainly, the challenges and risks are noteworthy. However, for those willing and able to take the leap, government service can offer extraordinary opportunities not only for tremendous personal growth but also for making broader contributions to public health.

Methods of Melanoma Detection

Detection and removal of melanoma, before it has metastasized, dramatically improves prognosis and survival. The purpose of this chapter is to (1) summarize current methods of melanoma detection and (2) review state-of-the-art detection methods and technologies that have the potential to reduce melanoma mortality. Current strategies for the detection of melanoma range from population-based educational campaigns and screening to the use of algorithm-driven imaging technologies and performance of assays that identify markers of transformation. This chapter will begin by describing state-of-the-art methods for educating and increasing awareness of at-risk individuals and for performing comprehensive screening examinations. Standard and advanced photographic methods designed to improve reliability and reproducibility of the clinical examination will also be reviewed. Devices that magnify and/or enhance malignant features of individual melanocytic lesions (and algorithms that are available to interpret the results obtained from these devices) will be compared and contrasted. In vivo confocal microscopy and other cellular-level in vivo technologies will be compared to traditional tissue biopsy, and the role of a noninvasive "optical biopsy" in the clinical setting will be discussed. Finally, cellular and molecular methods that have been applied to the diagnosis of melanoma, such as comparative genomic hybridization (CGH), fluorescent in situ hybridization (FISH), and quantitative reverse transcriptase polymerase chain reaction (qRT-PCR), will be discussed.

Tobacco policy in Israel: 1948-2014 and beyond

BACKGROUND

Tobacco is the only consumer product known to kill half of its users, and is a significant cause of death and disability to exposed nonsmokers. This presents a unique conundrum for modern democracies, which emphasize personal liberty, yet are obligated to protect citizens. In Israel, the death toll in 2014 from smoking is expected to reach 8000 deaths; nearly a fifth of the population smokes, and over two-thirds of the population are exposed to tobacco smoke.

AIM

This paper provides an overview of tobacco policy in Israel since the inception of the State, presents the development of the National Tobacco Control Plan, and recommends future actions.

METHODS

Sources for this article included the Knesset (Israeli Parliament) and Ministry of Health websites, Health Minister Reports to the Knesset on Smoking, and the scientific literature.

RESULTS

Israel has an impressive record on tobacco control policy, beginning with taxation in 1952, landmark smoke-free air and marketing legislation in the early 1980's, tax increases and expansions of smoke-free air and marketing legislation in the ensuing years, and the addition of subsidized smoking cessation technologies in 2010. Until 2011, actions were taken by various organizations without formal coordination; since the passage of the National Tobacco Control Plan in 2011, the Ministry of Health has held responsibility for coordinating tobacco control, with an action plan. The plan has been partially implemented. Smoke-free air laws were expanded, but enforcement is poor. Passage of critical marketing and advertising restrictions is stalled. Requested funds for tobacco control did not materialize.

RECOMMENDATIONS

In order to prevent hundreds of thousands of preventable premature deaths in the coming decades, Israel should considerably strengthen tobacco control policies to include: guaranteed funding for tobacco control; strong curbs on advertising, promotion and sponsorship of tobacco and smoking products; public education; law enforcement; protection of children from exposure to tobacco; regulation of electronic cigarettes and other alternative harm-reducing products; tobacco control research; and systematic monitoring of, and periodic updates to, the National Tobacco Control Plan. Israel should also begin discussions of Endgame scenarios, and consider abolition of tobacco, as it continues its progress towards making smoking history.

Old myths, new myths: challenging myths in public health

Myths are widely held beliefs and are frequently perpetuated through telling and retelling. We examined 10 myths in public health research and practice. Where possible, we traced their origins, interrogated their current framing in relation to the evidence, and offered possible alternative ways of thinking about them. These myths focus on the nature of public health and public health interventions, and the nature of evidence in public health. Although myths may have some value, they should not be privileged in an evidence-informed public health context.

Youth indoor tanning and skin cancer prevention: lessons from tobacco control

Youth use of ultraviolet-emitting indoor tanning beds represents a present and emerging public health crisis. Nearly 30% of white female high school students report tanning indoors, and a quarter of high school tanners have used a tanning bed more than 20 times in the past year. Despite the significant health risks of tanning beds, including potentially deadly melanoma and eye problems, limited actions have been taken in the U.S. to protect youth. Tobacco control policies and campaigns, which have sharply reduced youth smoking, may provide a useful framework to control indoor tanning among young people. This article describes several evidence-based tobacco control strategies with potential applicability to indoor tanning within the context of the U.S. Further, current tobacco control policies and current indoor tanning policies in the U.S. are compared, and recommendations on how to curtail youth indoor tanning are discussed.

Availability and range of tobacco products for sale in Massachusetts pharmacies

OBJECTIVE

New tobacco control policies have been introduced in Massachusetts which restrict tobacco product sales in pharmacies. The purpose of this investigation was to outline the scope of pharmacy involvement in the tobacco market by assessing the availability and range of tobacco products sold in Massachusetts pharmacies.

METHODS

Public listings of licenced pharmacies and tobacco retailers in Massachusetts were examined to determine the proportion of pharmacies licenced to sell tobacco, and the proportion of tobacco retailers possessing a pharmacy licence. Telephone interviews were conducted with a random sample (n=70) of pharmacies possessing a tobacco licence to assess the availability and range of tobacco products for sale. The availability of nicotine replacement therapy (NRT) products was assessed as a comparison.

RESULTS

The majority of pharmacies in Massachusetts possessed a tobacco licence (69%), and pharmacies made up 9% of licenced tobacco retailers. Among pharmacies surveyed that reported selling tobacco (90%), cigarettes were the most available tobacco product for sale (100%), followed by cigars (69%), little cigars/cigarillos (66%), moist snuff (53%), pipe tobacco (49%), roll-your-own tobacco (34%), snus (14%), dissolvable tobacco (11%) and electronic cigarettes (2%). Nearly all pharmacies selling tobacco offered the nicotine patch (100%), gum (100%) and lozenge (98%).

CONCLUSIONS

Tobacco-free pharmacy policies would affect a majority of Massachusetts pharmacies and remove a variety of tobacco products from their store shelves. Further, nearly one in ten tobacco retailers would be eliminated by prohibiting tobacco sales in Massachusetts pharmacies statewide.

Behavioral medicine and the health of our nation: accelerating our impact

PURPOSE

A key goal of this paper is to illustrate the impact of behavioral medicine on the factors that influence population health. A second goal is to consider the delicate balance between relevance and excellence as we bring our science to bear on important social and public health problems. If we are to increase the translation of our evidence and accelerate our impact, we must increase our relevance while maintaining excellence in our scientific methods.

METHODS

What are the pressing questions facing those that we would like to use our work, and how we can increase our relevance to theirs? We must work on the marriage of relevance and excellence-use rigorous methodologies, but be flexible in our approach, using study designs and methods that will get rapid yet rigorous answers to the questions that are facing practice and policy settings.

CONCLUSION

We have the tools and the knowledge to impact the health of our nation.

Knowledge of the New Tobacco Hazards Prevention Act Is Associated With Smokers’ Behavior of Seeking Help in Smoking Cessation in Taiwan

Evidence that smoking area restrictions and raising cigarette taxes affect smokers’ behavior of seeking help in cessation is limited. The authors conducted a case-control study of 200 participants in Taipei City, Taiwan, from December 2008 to June 2009 to evaluate the association between knowledge on legislation and the behavior of seeking help in smoking cessation. They compared smokers who sought assistance in clinics/classes and smokers who did not, matching for age, gender, and recruitment time. In a univariate model, both banning smoking and increasing prices had positive effects on smokers’ behavior, but the effect size of the latter was larger ( P = .021). A better knowledge of the regulations was associated with cessation effort (odds ratio [OR] = 2.74; 95% confidence interval [CI] = 1.44-5.23), as were being more influenced by increased prices (OR = 2.44; 95% CI = 1.38-4.34) and by smoking bans (OR = 2.32; 95% CI = 1.29-4.16). Increased knowledge of the regulations is associated with seeking help for smoking.

Implementing state tobacco treatment services: lessons from the Massachusetts experience

This case study was conducted between 2000 and 2003 to examine the implementation of community based tobacco treatment programs funded by the Massachusetts Department of Public Health Tobacco Control Program (MTCP). Four dimensions of implementation, drawn from several models of program evaluation are explored: (a) quantity of services, (b) quality of services, (c) implementation/use of systems, and (d) sustainability. The quantity of services delivered was high, reflecting MTCP's focus on increasing availability of services, particularly in underserved populations. The quality of physician-delivered tobacco intervention did not meet national benchmarks for delivery of all 5As (Ask, Advise, Assess, Assist, Arrange follow-up) and only about half of organizations reported routine systems for auditing tobacco use documentation. Implementation of systems to identify tobacco users and deliver tobacco treatment varied widely by community health settings, with low rates of tobacco use documentation found. Finally, in an era of greater competition for scarce prevention dollars, sustainability of services over time must be planned for from the outset, as indicated by the success of programs that sustained services by proactively and creatively incorporating tobacco treatment into their organizations. This case study can inform states' policies in their design of tobacco treatment services in community health settings.

Does the introduction of comprehensive smoke-free legislation lead to a decrease in population smoking prevalence?

AIMS

To investigate changes in population smoking prevalence in jurisdictions which have implemented comprehensive smoke-free legislation, taking into account long-term trends in smoking behaviour.

DESIGN

Interrupted time series analysis of population-level survey data using segmented regression.

SETTING

Twenty-one countries, American states or Canadian provinces which have implemented comprehensive smoke-free legislation.

PARTICIPANTS

Respondents sampled in large representative surveys of smoking prevalence.

MEASUREMENTS

For each jurisdiction, segmented regression models quantify any upwards or downwards trend in smoking prevalence prior to the introduction of smoke-free legislation, any immediate change in the level of smoking prevalence at the time smoke-free legislation was introduced, and any change in the trend in smoking prevalence post-legislation compared to the pre-legislation period.

FINDINGS

In all but three locations there was a statistically significant decline in smoking prevalence prior to the introduction of smoke-free legislation. In two locations, Washington and the Republic of Ireland, there was an immediate decline in the level of smoking prevalence at the introduction of legislation. In six American states there was a significant change in the rate of decline in smoking prevalence, with smoking prevalence declining more steeply in the post-legislation period compared to the pre-legislation period. No change in the level or trend of population smoking prevalence was seen in 13 of the 21 locations studied.

CONCLUSIONS

The introduction of comprehensive smoke-free legislation has increased the rate at which smoking prevalence was declining in some locations, but in the majority of jurisdictions had no measureable impact on existing trends in smoking prevalence.

The impact of Massachusetts' smoke-free workplace laws on acute myocardial infarction deaths

OBJECTIVES

We examined the rate of acute myocardial infarction (AMI) deaths in Massachusetts before and after the implementation of a comprehensive smoke-free workplace law in July 2004.

METHODS

We used Poisson regression models to examine the impact of the state law in cities and towns with and without previous local smoking bans and the effect of the local laws for the period of 1999 through 2006.

RESULTS

The AMI mortality rate decreased by 7.4% (95% confidence interval [CI] = 3.3%, 11.4%) after implementation of the state law. The state ban had an impact in cities and towns with no prior local smoking ban (9.2% decrease; P < .001) but not cities and towns with a prior local smoking ban. However, there was a nonsignificant 4.9% (95% CI = -5.0%, 13.9%) decrease associated with the local smoking ban that preceded the effect of the state ban. The effect of the state ban was modest (-1.6%) in the first 12 months after implementation but much larger after the first 12 months (-18.6%; P < .001).

CONCLUSIONS

Comprehensive statewide smoke-free workplace laws in Massachusetts were associated with an estimated 270 fewer AMI deaths per year. These results add to the evidence suggesting that smoke-free air laws are associated with lower rates of AMI.

Progress in tobacco control

AIM

To present the Tobacco Control interventions which are currently accepted as effective.

METHODS

Review the available regulatory strategy laid down in the Framework Convention for Tobacco Control and explore the basis for the Treaty and the appropriateness of the response with particular reference to Europe.

RESULTS

An evidence-based approach was built up over some sixty years. At first a slow revelation of the catastrophic health effects of smoking is revealed. Then a reluctance to see tobacco addiction as a disease or even as an addiction delays attempts to develop active treatments. A powerful, corrupt industry demanding to be treated as normal delays effective interventions to control demand or supply.

DISCUSSION

The pace of Tobacco Control is too slow. An effective FCTC would still see millions of unnecessary premature deaths in this century. Most deaths will not be in the west where the true effects of this industry are accepted and where mechanisms to combat the worst abuses of industrial power exist. They will occur in the developing world. The FCTC provisions must be achieved and then some. It would be foolish to rely on it alone especially on its approach to control of supply. The role of the treatment of tobacco dependence may be underrated in Tobacco Control. In many other diseases, whether infections such as tuberculosis or lifestyle related such as hypertension, the role and availability of effective treatments often provides the catalyst to drive the social changes necessary to lead to commitment to effective change.

Using a cessation-related outcome index to assess California's cessation progress at the population level

Background

The California Tobacco Control Program (CTCP) has employed strategies to change social norms around smoking in order to decrease the prevalence of smoking and tobacco-related diseases. Research is scarce on CTCP's impact on overall smoking cessation in California.

Methods

Tobacco Use Supplement to the Current Population Survey (TUS-CPS) data from 1992–1993 to 2006–2007 was used to create a cessation-related outcome index (CROI), which was a summarised z score of the following determinants: plan to quit, quit attempt and recent quit rate for each of the 50 US states. CROI trends over the period of six separate TUS-CPSs were plotted for California and other comparison states, for 18–34 year olds and for those 35 years or older separately in the context of historical cigarette price z score trend.

Results

California had a consistently high CROI for both age groups. The CROI trend line increased moderately in California for both age groups despite a declining cigarette price z score trend. In contrast, other selected states with a declining cigarette price z score trend had a declining CROI trend for both age groups.

Conclusions

The increase of CROI in California while cigarette price z score trend declined suggests that the implementation of CTCP, even without a significant direct cessation component, has had a profound impact on cessation outcomes.

The Master Settlement Agreement and its impact on tobacco use 10 years later: lessons for physicians about health policy making

The issue of tobacco industry responsibility for population health problems and compensation for their treatment has been growing since the 1960s. In 1999, the state attorneys general collectively launched the largest class action lawsuit in US history and sued the tobacco industry to recover the costs of caring for smokers. In what became known as the Master Settlement Agreement (MSA), states were rewarded billions of dollars and won concessions regarding how cigarettes could be advertised and targeted to minors. Ten years after this settlement, much is known about how MSA monies were distributed and how states have used the money. There is some understanding about how much of the money went toward offsetting the health-care costs attributable to smoking and whether resources were allocated to efforts to reduce smoking in a particular state. However, there are few data on what effect, if any, the MSA had on tobacco control locally and nationally. This commentary explores these issues, as well as how the tobacco industry has evolved to offset the losses incurred by the settlement. Finally, an analysis of the complexities of current tobacco policy making is provided so that physicians and other health-care advocacy groups can more completely understand the present-day political dynamics and be more effective in shaping tobacco control policy in the future.

Translating research evidence into practice to reduce health disparities: a social determinants approach

Translating research evidence to reduce health disparities has emerged as a global priority. The 2008 World Health Organization Commission on Social Determinants of Health recently urged that gaps in health attributable to political, social, and economic factors should be closed in a generation. Achieving this goal requires a social determinants approach to create public health systems that translate efficacy documented by research into effectiveness in the community. We review the scope, definitions, and framing of health disparities and explore local, national, and global programs that address specific health disparities. Such efforts translate research evidence into real-world settings and harness collaborative social action for broad-scale, sustainable change.

The quarter that changed the world

BACKGROUND

The California Department of Public Health (CDPH), California Tobacco Control Program (CTCP) is one of the longest-running comprehensive tobacco control programmes in the USA, resulting from a 1988 ballot initiative that added a 25-cent tax on each pack of cigarettes and a proportional tax increase on other tobacco products. This programme used a social norm change approach to reduce tobacco use.

METHODS

The operation, structure, evolution, programme dissemination and results are reviewed.

RESULTS

The sustained programme implementation has reduced adult per capita cigarette consumption by over 60% and adult smoking prevalence by 35%, from 22.7% in 1988 to 13.8% in 2007. From 1988 to 2004, lung and bronchus cancer rates in California declined at nearly four times the rate of decline seen in the rest of the USA and the programme is associated with an $86 billion savings in healthcare costs. Youth smoking rates among 12-17 years olds are the second lowest in the nation.

CONCLUSIONS

The social norm change approach is effective at reducing tobacco consumption, adult smoking and youth uptake. This approach resulted in declines in tobacco-related diseases and is associated with savings in healthcare expenditures. In considering CTCP's effectiveness, the takeaway message is that it should be viewed as a unified programme rather than a collection of independent interventions. The programme was designed and implemented as one where the parts complement and reinforce each other. Its effectiveness is dependent on its comprehensive strategy rather than any one part of the intervention.

Chronic Obstructive Pulmonary Disease hospitalization rates in Massachusetts: a trend analysis

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) causes a huge economic burden and >80% of COPD cases are attributable to smoking. Massachusetts introduced a comprehensive Tobacco Control Program (MTCP) in January 1993. A trend analysis of COPD hospitalization rates might indirectly reflect the potential impact of such comprehensive tobacco control programs.

METHODS

Age-adjusted COPD hospitalization rates/100,000 was abstracted from the Massachusetts Community Health Information Profile Database between 1989 and 2005. Joinpoint Regression Analyses program was employed to estimate annual percent changes (APC) in COPD rates by age, sex and race.

RESULTS

In 1989, 265/100,000 age-adjusted COPD hospitalization rates were reported that increased to 423/100,000 in 1993, and then declined to 329/100,000 in 2005. A significant annual decline of 5.6 percentage points was observed in overall COPD rates from 1993 onwards. A similar temporal pattern, with an age-gradient and a slower annual decline in female COPD rates relative to male COPD rates, was observed. COPD rates in both Blacks and Whites were similar to the general overall pattern. Such consistent annual declines in COPD hospitalization rates from 1993 onwards in Massachusetts also closely correspond to the introduction of the MTCP in January 1993.

CONCLUSION

The findings indirectly suggest that smoking cessation should remain the cornerstone strategy for the prevention and control of COPD burden. However, additional studies across different population settings are essential for a definitive conclusion with regard to the immediate impact of a comprehensive tobacco control program on COPD hospitalization rates showing possible gender susceptibility.

Individual, social-normative, and policy predictors of smoking cessation: a multilevel longitudinal analysis

OBJECTIVES

We assessed the prospective impact of individual, social-normative, and policy predictors of quit attempts and smoking cessation among Massachusetts adults.

METHODS

We interviewed a representative sample of current and recent smokers in Massachusetts by telephone in 2001 through 2002 and then again twice at 2-year intervals. The unit of analysis was the 2-year transition from wave 1 to wave 2 and from wave 2 to wave 3. Predictors of quit attempts and abstinence of longer than 3 months were analyzed using multilevel analysis. Predictors included individual, social-normative, and policy factors.

RESULTS

Multivariate analyses of 2-year transitions showed that perceptions of strong antismoking town norms were predictive of abstinence (odds ratio = 2.06; P < .01). Household smoking bans were the only policy associated with abstinence, but smoking bans at one's worksite were significant predictors of quit attempts.

CONCLUSIONS

Although previous research showed a strong relation between local policy and norms, we found no observable, prospective impact of local policy on smoking cessation over 2 years. Our findings provide clear support for the importance of strong antismoking social norms as a facilitator of smoking cessation.

Sustainability for behaviour change in the fight against antibiotic resistance: a social marketing framework

Antibiotic resistance is one of today's most urgent public health problems, threatening to undermine the effectiveness of infectious disease treatment in every country of the world. Specific individual behaviours such as not taking the entire antibiotic regimen and skipping doses contribute to resistance development as does the taking of antibiotics for colds and other illnesses that antibiotics cannot treat. Antibiotic resistance is as much a societal problem as it is an individual one; if mass behaviour change across the population does not occur, the problem of resistance cannot be mitigated at community levels. The problem is one that potentially can be solved if both providers and patients become sufficiently aware of the issue and if they engage in appropriate behaviours. Although a number of initiatives have been implemented in various parts of the world to elicit behaviour change, results have been mixed, and there is little evidence that trial programmes with positive outcomes serve as models of sustainability. In recent years, several scholars have suggested social marketing as the framework for behaviour change that has the greatest chance of sustained success, but the antibiotic resistance literature provides no specifics for how the principles of social marketing should be applied. This paper provides an overview of previous communication-based initiatives and offers a detailed approach to social marketing to guide future efforts.

Coronary heart disease deaths and decreased smoking prevalence in Massachusetts, 1993-2003

We used the previously validated IMPACT coronary heart disease (CHD) mortality model to estimate the CHD deaths attributable to reductions in smoking prevalence following the introduction of the Massachusetts Tobacco Control Program (MTCP) in 1993. A 29% and 31% decline in smoking prevalence and CHD mortality rates occurred, respectively (from 1993 to 2003). A total of 425 fewer CHD deaths, which generated approximately 3365 extra life-years, were attributable to decreased smoking prevalence. With these results in mind, a comprehensive tobacco control program should be sustained and supported.

Regionalization of local public health systems in the era of preparedness

Post-9/11, preparedness planning has catalyzed intrastate regionalization of local public health resources throughout the United States. Investigating this trend unveils several regionalization themes, relevant in other sectors of government, which are applicable to local public health. In this review article, we begin by briefly examining the lessons learned from regionalization for police and fire services, drawing comparisons to public health. Then we provide a brief history of the accelerating regionalization of local public health services sparked by the current attention to emergency preparedness. In particular, we offer case studies from Massachusetts and the National Capital Region to highlight examples of regionalization outcomes related to networking, coordination, standardization, and centralization of public health services. The impact of social capital on preparedness is also explored. Finally, we summarize research needs for the future.

The costs, effects and cost-effectiveness of counteracting overweight on a population level. A scientific base for policy targets for the Dutch national plan for action

OBJECTIVES

To gain insight in realistic policy targets for overweight at a population level and the accompanying costs. Therefore, the effect on overweight prevalence was estimated of large scale implementation of a community intervention (applied to 90% of general population) and an intensive lifestyle program (applied to 10% of overweight adults), and costs and cost-effectiveness were assessed.

METHODS

Costs and effects were based on two Dutch projects and verified by similar international projects. A markov-type simulation model estimated long-term health benefits, health care costs and cost-effectiveness.

RESULTS

Combined implementation of the interventions--at the above mentioned scale--reduces prevalence rates of overweight by approximately 3 percentage points and of physical inactivity by 2 percentage points after 5 years, at a cost of 7 euros per adult capita per year. The cost-effectiveness ratio of combined implementation amounts to euro 6000 per life-year gained and euro 5700 per QALY gained (including costs of unrelated diseases in life years gained). Sensitivity analyses showed that these ratios are quite robust.

CONCLUSIONS

A realistic policy target is a decrease in overweight prevalence of three percentage points, compared to a situation with no interventions. In reality, large scale implementation of the interventions may not counteract the expected upward trends in The Netherlands completely. Nonetheless, implementation of the interventions is cost-effective.

Lessons from cost-effectiveness research for United States public health policy

The application of cost-effectiveness analysis to health care has been the subject of previous reviews. We address the use of economic evaluation methods in public health, including case studies of population-level policies, e.g., environmental regulations, injury prevention, tobacco control, folic acid fortification, and blood product safety, and the public health promotion of clinical preventive services, e.g., newborn screening, cancer screening, and childhood immunizations. We review the methods used in cost-effectiveness analysis, the implications for cost-effectiveness findings, and the extent to which economic studies have influenced policy and program decisions. We discuss reasons for the relatively limited impact to date of economic evaluation in public health. Finally, we address the vexing question of how to decide which interventions are cost effective and worthy of funding. Policy makers have funded certain interventions with rather high cost-effectiveness ratios, notably nucleic acid testing for blood product safety. Cost-effectiveness estimates are a decision aid, not a decision rule.

Tobacco industry marketing, population-based tobacco control, and smoking behavior

Two of the major influences of cigarette smoking behavior are tobacco industry marketing and public health tobacco-control activities. These vie with each other to influence the proportion of each generation who initiate smoking, the intensity level reached by smokers, and the time before smokers are able to quit successfully. This article provides a brief summary of the evidence associating tobacco marketing practices (organized under the four "Ps" of marketing), with smoking behavior. The evidence for causality in this association is considered convincing. Publicly funded, comprehensive, statewide tobacco-control programs were introduced into the United States in the late 1980s, with money either from tobacco taxes or from legal settlements of states with the tobacco industry. These programs use organized statewide approaches to implement current recommendations on "best practices" to discourage tobacco use, recommendations that have changed over time. During the 1990s, "best practices" evolved to include protection against secondhand smoke, sale of cigarettes to minors, and restrictions on tobacco advertising. Evaluations have been published on four statewide tobacco-control programs (Sydney/Melbourne, California, Massachusetts, and Florida) and a national program aimed at youth (American Legacy Program). For each program, there was a positive association with reduced smoking. The evidence supporting the conclusion that tobacco-control programs reduce smoking behavior is evaluated as strong.

Trends in head and neck cancer incidence in relation to smoking prevalence: an emerging epidemic of human papillomavirus-associated cancers?

The trends in head and neck cancer incidence and smoking prevalence are reviewed, discussing where such trends parallel but also how and why they may not. In the U.S., public health efforts at tobacco control and education have successfully reduced the prevalence of cigarette smoking, resulting in a lower incidence of head and neck cancer. Vigilance at preventing tobacco use and encouraging cessation should continue, and expanded efforts should target particular ethnic and socioeconomic groups. However, an unfortunate stagnation has been observed in oropharyngeal cancer incidence and likely reflects a rising attribution of this disease to oncogenic human papillomavirus, in particular type 16 (HPV-16). For the foreseeable future, this trend in oropharyngeal cancer incidence may continue, but with time the effects of vaccination of the adolescent and young adult female population should result in a lower viral prevalence and hopefully a reduced incidence of oropharyngeal cancer. To hasten the reduction of HPV-16 prevalence in the population, widespread vaccination of adolescent and young adult males should also be considered.

Trends in nicotine yield in smoke and its relationship with design characteristics among popular US cigarette brands, 1997-2005

OBJECTIVES

To determine whether nicotine yields in the smoke of cigarettes would show an overall increase over time or an increasing trend limited to any particular market category (eg, full flavour vs light, medium (mild) or ultralight; mentholated vs non-mentholated), manufacturer, or brand family or brand style, and whether nicotine yields in smoke would be associated with measurable trends in cigarette design.

METHODS

Machine-based measures of nicotine yield in smoke and measures of cigarette design features related to nicotine delivery (ventilation, nicotine content in the tobacco rod and number of puffs), as well as market category descriptors, were obtained from annual reports filed with the Massachusetts Department of Public by tobacco manufacturers for 1997-2005. Trends in nicotine yield and its relationship with design features and market parameters were analysed with multilevel mixed-effects regression modelling procedures.

RESULTS

A statistically significant trend was confirmed in increased nicotine yield, of 0.019 (1.1%) mg/cig/year over the period 1997-2005 and 0.029 (1.6%) mg/cig/year over the period 1998-2005. The increasing trend was observed in all major market categories (mentholated vs non-mentholated, and full flavour vs light, medium (mild) or ultralight). Nicotine yield in smoke was positively associated with nicotine concentration in the tobacco and number of puffs per cigarette, both of which showed increasing trends during the study period.

CONCLUSIONS

This study confirms increased machine-measured levels of nicotine, the addictive agent in cigarettes, in smoke, to be a result of increased nicotine in the tobacco rod and other design modifications.

Reduced lung cancer deaths attributable to decreased tobacco use in Massachusetts

BACKGROUND

Approximately 88% of the lung cancer deaths in men and 71% in women occurring in the US are attributable to cigarette smoking, with almost 3,700 annual lung cancer deaths in Massachusetts. In the state, male lung cancer death rates are showing a per year annual decline following a peak in the early 1990s. Such recent declines could be mostly attributed to tobacco control efforts over the past 40 years.

METHOD

This study predicts how many fewer lung cancer deaths have occurred in Massachusetts possibly attributable to tobacco control activities. The study employs the US National Cancer Institute's "Joinpoint" Regression Analysis Program (version 3.0) using statewide age-standardized (2000 US Standard Population) lung cancer death rates from 1931 to 2003 for each of the sexes. 95% confidence intervals (CI) were also calculated.

RESULTS

Modeled male lung cancer death rates stabilized from the calendar year 1977 onwards but showed significant decline from 1992 onwards, while females showed a deceleration in rising lung cancer rates from 1993 onwards. Therefore, based on their corresponding beta-coefficients (slope) and standard error for each of the two calendar years 19,665 (95% CI: 18,655; 20,765) fewer lung cancer deaths in males and 3,855 (95% CI: 3,630; 4,055) fewer lung cancer deaths in females were estimated to have occurred from 1977 to 1993 onwards, respectively, largely because of the anti-smoking interventions in the past.

CONCLUSIONS

Reductions in tobacco smoking are a major factor in the decrease in lung cancer mortality rates. Sustained progress in tobacco control is essential.

Effective tobacco control in Washington State: a smart investment for healthy futures

BACKGROUND

Tobacco use remains the leading cause of preventable death in the United States. Following the 1998 Master Settlement Agreement with the tobacco industry, Washington State dedicated substantial funding to the creation of a statewide, comprehensive tobacco control program. This report documents the history and observed effectiveness of that program.

CONTEXT

In 2000, the Washington legislature allocated $100 million out of the first Master Settlement payment of $320 million to tobacco control. The comprehensive tobacco control program was launched late that same year with an annual budget of $15 million.

METHODS

We used existing data from state and national health behavior surveillance systems to describe smoking prevalence among adults and youth. For adult measures, we used data from the Washington State Behavioral Risk Factor Surveillance System and the National Health Interview Survey. For youth measures, we used data from the Washington State Healthy Youth Survey and the national Monitoring the Future survey. We used the National Cancer Institute's "Joinpoint" software to compare trends.

CONSEQUENCES

Between 1990 and 2001, adult smoking prevalence in Washington was nearly unchanged, as it was in the United States as a whole. However, from 2001, one year after Washington instituted its comprehensive tobacco control program, to 2005, the prevalence of smoking among adults in Washington declined significantly from 22.5% to 17.6%, and by a significantly larger amount than it did nationally during the same period (22.7% to 20.9%). In addition, the prevalence of youth smoking also declined faster in Washington than it did nationally; for example, from 2000 to 2004, smoking prevalence among 8th graders declined from 12.5% in 2000 to 7.8% in 2004 in Washington but only from 12.2% in to 9.3% nationally.

INTERPRETATION

Significant reductions in smoking prevalence among Washington residents following the implementation of a comprehensive tobacco control program funded at a level near that recommended by the Centers for Disease Control and Prevention indicate that tobacco control programs are an effective investment for states committed to improving public health.

The relative effect of household and workplace smoking restriction on health status among Chinese Americans living in New York City

Households and workplaces are the predominant location for exposure to secondhand smoke. The purpose of this study is to examine the association between health status and smoking restrictions at home and work and to compare the relative effect of household and workplace smoking restrictions on health status. This study uses data from a cross sectional representative probability sample of 2,537 Chinese American adults aged 18-74 living in New York City. The analysis was limited to 1,472 respondents who work indoors for wages. Forty-three percent of respondents reported a total smoking ban at home and the workplace, 20% at work only, 22% home only, and 15% reported no smoking restriction at home or work. Nonsmokers [corrected] who live under a total household smoking ban only or both a total household and total workplace ban were respectively 1.90 and 2.61 times more likely to report better health status compared with those who reported no smoking ban at work or home. Before the NYC Clean Indoor Air Act second-hand smoke (SHS) exposure among this immigrant Chinese population at home and work was high. This study finds that household smoking restrictions are more strongly associated with better health status than workplace smoking restrictions. However, better health status was most strongly associated with both a ban at work and home. Public health efforts should include a focus on promoting total household smoking bans to reduce the well-documented health risks of SHS exposure.

Recent lung cancer patterns in younger age-cohorts in Ireland

BACKGROUND

Smoking causes 85% of all lung cancers in males and 70% in females. Therefore, birth cohort analysis and annual-percent-changes (APC) in age-specific lung cancer mortality rates, particularly in the youngest age cohorts, can explain the beneficial impacts of both past and recent anti-smoking interventions.

METHODS

A long-term time-trend analysis (1958-2002) in lung cancer mortality rates focusing on the youngest age-cohorts (30-49 years of age) in particular was investigated in Ireland. The rates were standardised to the World Standard Population. Lung cancer mortality data were downloaded from the WHO Cancer Mortality Database to estimate APCs in death rates, using the Joinpoint regression (version 3.0) program. A simple age-cohort modelling (log-linear Poisson model) was also done, using SAS software.

RESULTS

The youngest birth cohorts (born after 1965) have almost one-fourth lower lung cancer risk relative to those born around the First World War. A more than 50% relative decline in death rates among those between 35 and 39 years of age was observed in both sexes in recent years. The youngest age-cohorts (30-39 years of age) in males also showed a significant decrease in death rates in 1998-2002 by more than 3% every five years from 1958-1962 onwards. However, death rate declines in females are slower.

CONCLUSIONS

The youngest birth cohorts had the lowest lung cancer risk and also showed a significant decreasing lung cancer death rate in the most recent years. Such temporal patterns indicate the beneficial impacts of both recent and past tobacco control efforts in Ireland. However, the decline in younger female cohorts is slower. A comprehensive national tobacco control program enforced on evidence-based policies elsewhere can further accelerate a decline in death rates, especially among the younger generations.