Population-based tobacco control: progress and prospects

Smoking Cessation Attempts in Relation to Prior Health Care Charges: The Effect of Antecedent Smoking-Related Symptoms?

Purpose.

We hypothesize that elevated charges among former smokers reflect differential cessation of sicker individuals. We ascertained the relationship between prior health care charges and time to smoking cessation.

Design.

Prospective, observational study using panel survey data and administrative health plan records.

Setting.

A large managed care organization in Minnesota.

Subjects.

A stratified random sample of 8000 health plan members 40 years and older, yielding 611 current smokers at baseline.

Measures.

Smoking cessation measured via self-report survey. Health care charges, mortality, and disenrollment data derived from automated health plan databases.

Results.

Among smoking adults without chronic disease diagnoses at baseline, a first attempt at quitting smoking was positively associated with the presence of any inpatient charges (relative risk [RR], 1.9; p < .05) or any emergency department or urgent care charges (RR, 1.4; p < .10). We also observed positive associations between total charges and ambulatory charges in the top tertile (RR, 1.5 and 1.6, respectively; p < .05) with a first attempt at quitting smoking, further suggesting graded relationships. Among smoking adults with one or more of four chronic disease diagnoses at baseline, being in the top two tertiles of total charges or ambulatory care charges was predictive of a subsequent attempt at quitting smoking.

Conclusions.

Higher health care charges, particularly from ambulatory (primary care clinic) settings, predicted smoking cessation among both individuals with and without chronic diseases. These charges may be proxies for other factors, such as smoking-related symptoms or physician advice or messaging regarding smoking cessation.

Stay away from tobacco: a pilot trial of a school-based adolescent smoking prevention program in Beijing, China

A quasiexperimental study was conducted to explore the efficacy of the program Stay Away from Tobacco (SAFT). Participants-from 11 classes with 381 students total in grades 7, 8, 10, and 11-were assigned by class to three groups (intervention group T with school teachers delivering the program, intervention group R with researchers delivering the program, and comparison group C). Data were collected at baseline, immediately after the intervention, and 6 months after the intervention. Self-reported smoking was the outcome measure. The 30-day smoking prevalence in group C increased from 4% at baseline to 10% at the 6-month follow-up, whereas this rate declined from 11% to 6% in group T, and from 9% to 1% in group R. For group T, the odds ratio (for 30-day smoking) and the regression coefficient (for indexed number of cigarettes smoked) assessing interactions between intervention and time were 0.20 (p < .001) and -.1605 (p < .05), respectively. The same statistics for group R were 0.09 (p < .001) and -.2406 (p < .01), respectively. The predicted smoking rate declined by 19% from baseline to 6-month follow-up in group T (11.5% vs. 9.3%), and the same rate declined by 26% in group R (11.1% vs. 8.2%). The results from this pilot trial suggest that SAFT can reduce cigarette smoking among middle and high school students through its effect on improving these students' refusal skills and changing their perceived mental and physical values from smoking. A full-scale evaluation is recommended.

Does methodology affect the ability to monitor tobacco control activities? implications for HEDIS and other performance measures

BACKGROUND

It is unclear whether methodological differences in sample size, survey methods, and analysis approach significantly affect the ability to accurately monitor tobacco control activities and to make rate comparisons.

METHODS

Questionnaires were sent to 64,764 members of nine health plans in diverse settings soon after their visit to a primary care clinician. Of these 41,677 completed responses were received. We compared responses received by mail and by telephone follow-up for the percentage of smokers, characteristics of smokers, and their rates of reporting physician cessation counseling.

RESULTS

Overall, 10.2% were current cigarette smokers, but the proportion was 8.6% for mail responders and 17.2% for phone follow-up responders. Smokers identified by phone follow-up were different from mail responders in most demographic and smoking characteristics and their reports of clinical smoking cessation activities differed for six of nine clinician smoking cessation actions. Calculating advice rates as a proportion of visits produced lower rates with more dispersion among plan rates than doing so without accounting for visit variation.

CONCLUSIONS

Smoking surveys using only mailed questionnaires dramatically undersample smokers, especially in some demographic groups. Comparisons of tobacco counseling among health plans can be improved by ensuring an adequate sample size and response rate and by analyzing by frequency of quit advice.

The state of office-based interventions for youth tobacco use

Tobacco use is a serious pediatric health issue as dependence begins during childhood or adolescence in the majority of tobacco users. Primary care settings provide tremendous opportunities for delivering tobacco treatment to young tobacco users. Although evidence-based practice guidelines for treating nicotine dependence in youths are not yet available, professional organizations and the current clinical practice guideline for adults provide recommendations based on expert opinion. This article reports on the current tobacco treatment practices of pediatric and family practice clinicians, discusses similarities and differences between adolescent and adult tobacco use, summarizes research efforts to date and current cutting-edge research that may ultimately help to inform and guide clinicians, and presents existing recommendations regarding treating tobacco use in youths. Finally, recommendations are made for the primary care clinician, professional organizations, and health care systems and policies. Pediatricians and other clinicians can and should play an important role in treating tobacco dependence in youths.

Prices, policies and youth smoking, May 2001

Youth smoking continues to be an important public health problem. Many policy tools designed to reduce youth smoking are based on economic principles. This paper describes the economic and policy context of tobacco use aiming at reducing youth smoking and explains the economic rationale for tobacco control tools such as excise tax and price, clean indoor air laws, youth access laws and the broad provision of health information to the public. An overview of economic models of addiction provides the framework for empirical analysis of the impact of these policies. This is followed by a summary of the empirical evidence of the effectiveness of various tobacco control tools that are primarily economic in nature. The most consistent finding in this literature is that higher cigarette prices discourage youth smoking. Compared to the effects of cigarette taxation and price on youth smoking, the evidence on the effectiveness of the youth access laws and clean indoor air laws are still mixed and inconclusive. More research is needed to address issues such as: (1) the effects of gender, age, race and socio-economic status on the relationship between tobacco control policies and youth smoking; (2) better measurement of the outcome variables to account for the multi-dimensional nature of dependence; and (3) the effects of excise taxes and other tobacco control policies with regard to a host of dimensions of smoking such as initiation, cessation, and more generally the trajectories of tobacco use that would include patterns of progression, maintenance, regression, cessation, and relapse. More frequently collected longitudinal data than those currently available are needed to address the above issues. Understanding smoking behavior cannot be achieved without incorporating familial and other social contexts.

Tobacco industry youth tobacco prevention programming: a review

This review provides a description of the youth tobacco prevention activities of the Tobacco Institute and the 6 largest U.S. tobacco companies. A computer search of PsycINFO and MedINFO from 1984 to the present, and a concurrent web metasearch of DogPile.com under the terms "tobacco industry" and "youth smoking prevention" was completed. All journal articles and web pages that discussed tobacco industry youth tobacco prevention program methods were examined. Programming was examined by whether it addressed 13 types of components that constitute effective tobacco use prevention. It is concluded that self-generated tobacco industry programming is lacking several of the types of components that are contained in effective programming. Providing financial support of nonindustry programming greatly improves this effort; however, the concept of tobacco industry involvement in youth tobacco prevention needs continued examination.

Susceptibility of youth to tobacco: a social ecological framework for prevention

For most smokers, tobacco dependence begins in childhood or adolescence. This review summarizes the state of social science with respect to the prevention of tobacco use. Social ecology is introduced as a theoretical framework useful for organizing prevention approaches. In recent years, the field has shifted from approaches directed at individuals, towards appreciation of additional, more comprehensive social and environmental influences on initiation. These range from intra-individual factors (including physiological responses to nicotine and the psychology of use) to individual, interpersonal, organizational, community, and population factors affecting access and demand. This review highlights prevention approaches that address social and societal influences, from school programs that attempt to change susceptibility of individual youth to tobacco, to community projects, media campaigns, restrictive policies, and tobacco pricing. The most promising approaches are those designed with input based on extensive formative research including studies with youth, directed at multiple levels of the social ecology, and sustained over time with significant resources and ongoing, multi-sector inputs.

Addressing social and cultural disparities in tobacco use

Disparities in smoking as a function of ethnicity exist, but part of that disparity appears to be mediated by education level. Smoking prevalence differences by ethnicity disappear or decrease substantially when controlling for education level. Nonetheless, ethnicity remains an important consideration when striving to understand the mechanisms associated with smoking, as well as in the development of smoking prevention and treatment programs. In this paper, the complex interrelationships among ethnicity, social class, and smoking are discussed in brief, and a framework for developing a systematic means of addressing social disparities in tobacco use is described.