No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Evidence Reviews and Recommendations on Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke: A Summary of Selected Guidelines
Abstract
Comparison of the evidence summaries presented here reveals considerable general
agreement on the effectiveness or ineffectiveness of the interventions reviewed,
with only a few instances in which different reviews reached different conclusions.There is uniform agreement on the effectiveness of the clinical interventions,
although the magnitude of the effects differed slightly. Screening patients for
tobacco use, delivering brief advice or more intense or frequent counseling to quit,
and the use of pharmacologic treatments (nicotine replacement or bupropion as
first-line therapies) were identified as effective in increasing patient tobacco use
cessation. Self-help education materials were assessed as less effective or
inconsistent.The health care system interventions evaluated in these reviews primarily focused on
increasing the delivery or use of effective clinical strategies. For most
interventions, the assessment of effectiveness was consistent across the evidence
reviews. Provider reminder systems (alone or in combination with other
interventions), patient cessation support provided by telephone (when implemented
with other interventions), and interventions to reduce patient out-of-pocket costs
for effective cessation treatments were all identified as effective. The reviews
differed slightly in the assessment of provider education programs. Two of the
reviews, the Community Guide and the SGR, identified limitations in
the evidence of effectiveness of provider education when implemented alone. The
reviews were consistent, however, in identifying stronger evidence of effectiveness
when provider education efforts were combined with other interventions, such as a
provider reminder system. The assessments of community interventions to reduce exposure to ETS, reduce tobacco
use initiation, and increase tobacco use cessation were also consistent. Both the
Community Guide and the SGR identified smoking bans and
restrictions as effective in reducing exposure to ETS, and potentially effective in
reducing tobacco use prevalence. Regarding community education efforts to reduce
exposure to ETS in the home, the Community Guide found insufficient
evidence to make a recommendation, whereas the SGR identified mass media messages
included in the state campaigns in California and Massachusetts as effective in
protecting children from exposure to ETS.The evidence reviews of interventions to reduce tobacco use initiation in children
and adolescents uniformly agreed on the effectiveness of increasing the unit price
of tobacco products. The reviews differed slightly in the assessment of the evidence
of effectiveness of mass media campaigns in reducing tobacco use among youth. All of
the guidelines, however, identified effective campaigns characterized by a solid
theoretical basis, use of formative research in designing the messages, and a
broadcast campaign of reasonable intensity over an extended period of time. One
reason for the stronger recommendation in the Community Guide is
the addition of recent evaluations of effectiveness of state campaigns in Florida
26,
27 and Massachusetts,
28 which were not available for earlier reviews.Evidence reviews of interventions to increase tobacco use cessation uniformly
documented the effectiveness both of increasing the unit price of tobacco products
and of mass media campaigns (when implemented with other interventions). Telephone
cessation support, when implemented with other interventions, was also identified as
effective in increasing tobacco use cessation. Regarding telephone support, these
reviews all found greater evidence of effectiveness for proactive support (contact
or follow-up initiated by a clinician or counselor) than for reactive (patient
initiates all contact).
... 5 Although Medicaid may cover cessation resources, patients and providers may not be aware of available resources without promotion. 6,7 Mass media promotions are effective, 8,9 with the Australian National Tobacco Campaign as an example of a successful countrywide multimedia outreach using primarily TV advertisements. 10 However, mass media campaigns may be difficult to tailor to a targeted population, and expensive to sustain with reported costs of $293 to $1,796 per quitter in studies of two campaigns promoting multimodal tobacco cessation in the U.S. 8,9,11,12 Studies report increases in quitline calls from mailings promoting cessation resources. ...
... 6,7 Mass media promotions are effective, 8,9 with the Australian National Tobacco Campaign as an example of a successful countrywide multimedia outreach using primarily TV advertisements. 10 However, mass media campaigns may be difficult to tailor to a targeted population, and expensive to sustain with reported costs of $293 to $1,796 per quitter in studies of two campaigns promoting multimodal tobacco cessation in the U.S. 8,9,11,12 Studies report increases in quitline calls from mailings promoting cessation resources. 13−19 Funded through state programs, quitlines offer free counseling that can double the chances of long-term quitting. ...
... Moving forward, cost effectiveness of direct-to-member mailings should be assessed, particularly given high costs of alternatives, such as mass media campaigns. 8,9 The printing costs discussed include only those incurred by the MIQS project or California Tobacco Control Program, and do not include costs of staff time, such as flyer development, or providing incentives. The healthcare costs per smoker in California in 2009 were $4,603 per smoker, with $2,505 being direct healthcare costs. ...
Introduction:
Innovative methods are needed to promote tobacco cessation services. The Medi-Cal Incentives to Quit Smoking project (2012-2015) promoted modest financial and medication incentives to encourage Medi-Cal smokers to utilize the California Smokers' Helpline (Helpline). This article describes the implementation and impact of two different direct-to-member mailing approaches.
Methods:
Medi-Cal Incentives to Quit Smoking promotional materials were mailed directly to members using two approaches: (1) household mailings: households identified through centralized membership divisions and (2) individually targeted mailings: smokers identified by medical codes from Medi-Cal managed care plans. Mailings included messaging on incentives, such as gift cards or nicotine patches. Number of calls per month, calls per unit mailed, and associated printing costs per call were compared during and 1 month after mailings. Activated caller response was based on reporting a household mailing promotional code or based on requesting financial incentives for individually targeted mailings. Analyses were conducted in 2018.
Results:
Direct-to-member mailings, particularly with incentive messaging, demonstrated an increase in call volumes during and 1 month after mailing, and increased Medi-Cal calls to the Helpline per unit mailed. Mailings with only counseling messages had the lowest percentage of activated calls per unit mailed, whereas the incentive messaging mailings were consistently higher. Although household mailings demonstrated lower printing costs per call, individually targeted mailings had a higher percentage of activated calls per unit mailed.
Conclusions:
Household and individually targeted mailings are feasible approaches to increase Medi-Cal calls to the Helpline, particularly with incentive messaging. Choosing an approach and messaging depends on available resources, timing, and purpose.
Supplement information:
This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.
... Tobacco dependence treatment includes brief advice and counseling for smoking prevention and cessation and recommending or prescribing approved cessation medications [27,29,30]. Health professionals who receive training in smoking cessation counseling are one-and-a-half-to two-times more likely to offer clients smoking cessation interventions and client quit rates increase when counseling is delivered by a variety of healthcare providers [30][31][32][33][34][35][36]. Health professionals continue to report a lack of training and doubt their effectiveness in treating client tobacco use and dependence despite having direct access to clients who smoke [25,31,[37][38][39][40][41][42][43][44] and available evidence-based guidelines [30,45,46]. ...
... Educational institutions can contribute positively to tobacco control measures by implementing entry-level student education programs on treating tobacco use and dependence detailed in Article 12 and 14 of the WHO FCTC [29,108,109]. Brief cessation counseling is politically feasible [110] and cost-effective clinically compared to other medical and disease prevention interventions, and is also a recognized avenue to strengthen health systems globally [30,34,45,46,109]. The majority of entry-level students represented in this systematic review are similar to clinical disciplines offering tobacco dependence counseling: medicine [51][52][53][54]60,61,[111][112][113][114][115][116][117][118][119][120][121]; nursing [47,59,62,[122][123][124][125][126][127]; pharmacy [10,48,55,128,129]; dentistry [67,[130][131][132][133][134]; dental hygiene [9,135,136]; chiropractic therapy [137][138][139]; physical therapy [140]; and midwifery [39,40,141]. ...
The objective of this study was to perform a systematic review to examine the effectiveness of tobacco dependence education versus usual or no tobacco dependence education on entry-level health professional student practice and client smoking cessation. Sixteen published databases, seven grey literature databases/websites, publishers’ websites, books, and pertinent reference lists were searched. Studies from 16 health professional programs yielded 28 RCTs with data on 4343 healthcare students and 3122 patients. Two researchers independently assessed articles and abstracted data about student knowledge, self-efficacy, performance of tobacco cessation interventions, and patient smoking cessation. All forms of tobacco were included. We did not find separate interventions for different kinds of tobacco such as pipes or flavoured tobacco. We computed effect sizes using a random-effects model and applied meta-analytic procedures to 13 RCTs that provided data for meta-analysis. Students’ counseling skills increased significantly following the 5As model (SMD = 1.03; 95% CI 0.07, 1.98; p < 0.00001, I2 94%; p = 0.04) or motivational interviewing approach (SMD = 0.90, 95% CI 0.59, 1.21; p = 0.68, I2 0%; p < 0.00001). With tobacco dependence counseling, 78 more patients per 1000 (than control) reported quitting at 6 months (OR 2.02; 95% CI 1.49, 2.74, I² = 0%, p = 0.76; p < 0.00001), although the strength of evidence was moderate or low. Student tobacco cessation counseling improved guided by the above models, active learning strategies, and practice with standardized patients.
... Increases in unit price of cigarettes are inversely related to smoking [3][4][5]. Excise tax is one of the primary public health strategies used to increase price [1,6,7]. However, instead of quitting or reducing consumption, smokers may seek lower-priced cigarettes, thereby potentially undermining the public health benefit of tax increases [8][9][10][11][12][13][14][15][16][17][18][19]. ...
... Therefore, the constant, β1, presented the adjusted average per pack price before using any other price-minimizing strategies (e.g. the adjusted average price for carton purchasers was obtained by controlling for coupon use, purchase from Indian reservations and brand choice). For each of the 18 groups described above, we also used separate multivariate regressions with the following specification to estimate pass-through rates of excise tax: o on state + β 6 . ...
Aims:
To evaluate state cigarette excise tax pass-through rates for selected price-minimizing strategies.
Design:
Multivariate regression analysis of current smokers from a stratified, national, dual-frame telephone survey.
Setting:
United States.
Participants:
A total of 16 542 adult current smokers aged 18 years or older.
Measurements:
Cigarette per pack prices paid with and without coupons were obtained for pack versus carton purchase, use of generic brands versus premium brands, and purchase from Indian reservations versus outside Indian reservations.
Findings:
The average per pack prices paid differed substantially by price-minimizing strategy. Smokers who used any type of price-minimizing strategies paid substantially less than those who did not use these strategies (P < 0.05). Premium brand users who purchased by pack in places outside Indian reservations paid the entire amount of the excise tax, together with an additional premium of 7-10 cents per pack for every $1 increase in excise tax (pass-through rate of 1.07-1.10, P < 0.05). In contrast, carton purchasers, generic brand users or those who were likely to make their purchases on Indian reservations paid only 30-83 cents per pack for every $1 tax increase (pass-through rate of 0.30-0.83, P < 0.05).
Conclusions:
Many smokers in the United States are able to avoid the full impact of state excise tax on cost of smoking by buying cartons, using generic brands and buying from Indian reservations.
... We examined all reviews published by Cochrane (Cochrane 2008 4 th quarter, online) [4] the Guide,567 pertaining to tobacco control. Each review was categorized by the level of design of the included studies, setting , and method of data synthesis. ...
... The Guide conducted 21 SRs which formed the basis for their recommendations567. ...
The systematic review (SR) lies at the core of evidence-based medicine. While it may appear that the SR provides a reliable summary of existing evidence, standards of SR conduct differ. The objective of this research was to examine systematic review (SR) methods used by the Cochrane Collaboration ("Cochrane") and the Task Force on Community Preventive Services ("the Guide") for evaluation of effectiveness of tobacco control interventions.
We searched for all reviews of tobacco control interventions published by Cochrane (4th quarter 2008) and the Guide. We recorded design rigor of included studies, data synthesis method, and setting.
About a third of the Cochrane reviews and two thirds of the Guide reviews of interventions in the community setting included uncontrolled trials. Most (74%) Cochrane reviews in the clinical setting, but few (15%) in the community setting, provided pooled estimates from RCTs. Cochrane often presented the community results narratively. The Guide did not use inferential statistical approaches to assessment of effectiveness.
Policy makers should be aware that SR methods differ, even among leading producers of SRs and among settings studied. The traditional SR approach of using pooled estimates from RCTs is employed frequently for clinical but infrequently for community-based interventions. The common lack of effect size estimates and formal tests of significance limit the contribution of some reviews to evidence-based decision making. Careful exploration of data by subgroup, and appropriate use of random effects models, may assist researchers in overcoming obstacles to pooling data.
... increased cigarettes taxes) is the most effective strategy to promote cessation. (Hopkins et al 2001;Hyland et al., 2006) In addition, while the impact of large community-based health promotion interventions is inconsistent, there is preliminary evidence that tailoring community-level interventions to reach high-risk segments of the population may enhance outcomes. (Fisher et al., 1995;Robinson, 2005;Sorensen et al., 1998;Merzel and D'Afflitti, 2003) However, the effectiveness of these tobacco control interventions for immigrant populations is not known. ...
... The study design is a pre-post-test quasi-experiment with representative cohorts from two large Chinese immigrant communities: Flushing, Queens, the intervention community; and Sunset Park, Brooklyn, the comparison community. A multi component community-based intervention, based in behavioral theory and evidence-based smoking cessation programs, was conducted with the NYCDOH and community-based partners, including the American Cancer Society, Chinese Branch (ACS), and Asian Americans for Equality (AAFE) (Hopkins et al., 2001;Azjen, 1991). The hypothesis tested was that tobacco-related policies (i.e. ...
To estimate the effectiveness of a tailored multicomponent community-based smoking cessation intervention among Chinese immigrants living in New York City, implemented within the context of state and city-wide tobacco control policy initiatives for the general population.
A pre-post-test quasi-experimental design with representative samples from Chinese populations living in two communities in New York City: Flushing, Queens, the intervention community and Sunset Park, Brooklyn, the comparison community. From November 2002 to August 2003 baseline interviews were conducted with 2537 adults aged 18-74. In early 2006, 1384 participants from the original cohort completed the follow-up interview. During the intervention period (October 2003 to September 2005), both communities were exposed to tobacco control public policy changes. However, only Flushing received additional linguistically and culturally-specific community-level tobacco control interventions.
From 2002 to 2006 overall smoking prevalence among Chinese immigrants declined from 17.7% to 13.6%, a relative 23% decrease. After controlling for socio-demographic characteristics, there was an absolute 3.3% decrease in smoking prevalence attributed to policy changes with an additional absolute decline in prevalence of 2.8% in the intervention community relative to the control community.
City-wide tobacco control policies are effective among high-risk urban communities, such as Chinese immigrants. In addition, community-based tailored tobacco control interventions may increase the reduction in smoking prevalence rates beyond that achieved from public policies.
... emphasizes the need for more effective strategies that facilitate smoking cessation (Hopkins et al., 2001). Several studies suggest that difficulty in controlling nicotine use behaviors results from nicotine's ability to enhance the motivating function of cues associated with obtaining rewards. ...
Despite an abundance of evidence illustrating the harmful effects of nicotine use, only a small percentage of users successfully quit (Messer et al., 2008). Moreover, current treatments for nicotine cessation produce only a slight increase in the likelihood of successfully quitting, which emphasizes the need for more effective strategies that facilitate smoking cessation (Hopkins et al., 2001). Several studies suggest that difficulty in controlling nicotine use behaviors results from nicotine’s ability to enhance the motivating function of cues associated with obtaining rewards. These studies indicate that it is of value to understand the behavioral and neuropharmacological mechanisms by which nicotine enhances responding for conditioned rewards. Unfortunately, despite ample non-human studies, there is a paucity of literature examining nicotine’s ability to enhance reward responding in humans. Thus, in order to better understand the reward mechanisms that underlie the risk for becoming dependent, the aim of the current study was to examine nicotine’s effects on conditioning, extinction, and reinstatement in humans. Using a novel virtual reality translation of the hallmark conditioned place preference paradigm to investigate the aforementioned objectives, our main findings suggest that nicotine (1) increases the sensitivity of reward properties by enhancing the strength of food-reward conditioning, (2) delays the rate of extinction of conditioned preferences, and (3) increases the reinstatement of previous conditioning. These findings demonstrate the efficacy of utilizing the virtual conditioned place preference paradigm in understanding the behavioral mechanisms by which nicotine enhances responding for conditioned rewards, and provide insight into how nicotine can be particularly resistant to treatment. Importantly, these data provide key information for future work aimed at increasing the understanding of how conditioning paradigms can help treat and prevent substance dependences.
... Clinical interventions have been shown to increase motivationtoquitandimproveabstinence rates. 9 Furthermore, smoking cessation decreasestherateinlungfunctiondecline among COPD patients. 10 ...
... Existe evidência de que as campanhas multimédia podem ajudar na prevenção dos jovens em começar a fumar e aumentar a taxa de cessação tabágica entre jovens e adultos quando combinadas com outras intervenções. 48 Por exemplo, uma avaliação das campanhas multimédias anti-tabágicas na Noruega composta de mensagens sobre os efeitos negativos de fumar, descobriu que não fumadores dos municípios que tinham as campanhas tinham menor probabilidade de começar a fumar do que os não fumadores nos municípios sem essas campanhas. 43 Actualmente, o tabaco causa perdas de centenas de biliões de dólares por ano. ...
... Increasing cigarette unit price is one of the most effective population-based strategies to reduce cigarette consumption, prevent smoking initiation, and increase rates of successful quitting. [1][2][3][4][5] However, cigarette manufacturers have developed a wide range of pricing strategies, including lower priced generic brands and price-related discounts, to counteract the effect of tobacco control strategies to increase price. [6][7][8][9] In 2011, the major manufacturers spent $8.37 billion on cigarette advertising and promotion, among which $7.75 billion (or 92.7%) went to price-related discounts or promotional allowances to reduce retail prices. ...
Context: Raising unit price is one of the most effective ways of reducing cigarette consumption. A large proportion of US adult smokers use generic brands or price discounts in response to higher prices, which may mitigate the public health impacts of raising unit price.
Objective: The main purpose of this study was to evaluate the retail price impact and the determinants of price-related discount use among US adult smokers by their most commonly used cigarette brand types.
Methods: Data from the 2009-2010 National Adult Tobacco Survey, a telephone survey of US adults 18 years or older, was used to assess price-related discount use by cigarette brands. Price-related discounts included coupons, rebates, buy 1 get 1 free, 2 for 1, or any other special promotions. Multivariate logistic regression was used to assess sociodemographic and tobacco use determinants of discount use by cigarette brands.
Results: Discount use was most common among premium brand users (22.1%), followed by generic (13.3%) and other brand (10.8%) users. Among premium brand users, those who smoked 10 to 20 cigarettes per day were more likely to use discounts, whereas elderly smokers, non-Hispanic blacks, those with greater annual household income, dual users of cigarettes and other combustible tobacco products, and those who had no quit intentions were less likely to do so. Among generic brand users, those who had no quit intentions and those who smoked first cigarette within 60 minutes after waking were more likely to use discounts.
Conclusions: Frequent use of discounts varies between smokers of premium and generic cigarette brands. Setting a high minimum price, together with limiting the use of coupons and promotions, may uphold the effect of cigarette excise taxes to reduce smoking prevalence.
... Despite declines in cigarette smoking prevalence during the past 50 years, tobacco use remains the single most preventable cause of death and disease in the U.S. 1,2 Mass media campaigns can effectively reduce cigarette use by reducing smoking initiation among youth and promoting cessation among adults, particularly when combined with other evidence-based tobacco prevention and control interventions. [3][4][5][6][7][8] However, with recent declines in public funding for state and local tobacco control programs, 9 a critical question is whether the economic investments required for these mass media campaigns can be justified by the public health benefits. ...
Background: In 2012, CDC launched the first federally funded national mass media antismoking campaign. The Tips From Former Smokers (Tips) campaign resulted in a 12% relative increase in population-level quit attempts.
Purpose: Cost-effectiveness analysis was conducted in 2013 to evaluate Tips from a funding agency’s perspective.
Methods: Estimates of sustained cessations; premature deaths averted; undiscounted life years (LYs) saved; and quality-adjusted life years (QALYs) gained by Tips were estimated.
Results: Tips saved about 179,099 QALYs and prevented 17,109 premature deaths in the U.S. With the campaign cost of roughly $48 million, Tips spent approximately $480 per quitter, $2,819 per premature death averted, $393 per LY saved, and $268 per QALY gained.
Conclusions: Tips was not only successful at reducing smoking-attributable morbidity and mortality but also was a highly cost-effective mass media intervention.
... However, in most countries, most young people in this age attend regular, private, or technical schools. [19] Second, these data apply only to children who participated in the survey on the day the surveys were administered in schools. School response rates have been high throughout the GYTS and other surveys, and only 21 survey sites have recorded student response rates less than 80%. ...
Tobacco use among the adolescents in india is believed to be on an increase. Therefore, a systematic review was carried out to summarize these studies. Several electronic databases were searched, supplemented by screening reference lists, smoking-related websites, and contacting experts. Selection, extraction, and quality assessments were carried out by one or two independent reviewers. The focus was on studies conducted on the school-going children in india and discussed in a global perspective. A narrative review was carried out. Many of the studies lacked sufficient power to estimate precise risks associated with the study subjects, as it mainly involved questionnaire studies. Studies were often designed to investigate tobacco use, but many had major methodological limitations including poor control and imprecise measurements of exposure. Studies in india showed a high risk of major health-related illness and several forms of cancers such as oro-pharyngeal cancers associated with the chewing form of tobacco. Studies from other regions and of other cancer types were not consistent. Tobacco use is increasing among the adolescents and has become an persistent issue that is usually carried over to their adulthood. In india, there is a stringent need for awareness creating oral health education programs in the school and college premises.
... Esta estrategia puede tener resultados en algunas personas. Sin embargo, la evidencia para el consejo médico en cambios del estilo de vida es débil, con rangos de éxito de alrededor del 2,5-10% [1][2][3][4] . Sabemos que el cumplimiento de los tratamientos médicos tiene un promedio cercano al 50%, con una gran variabilidad en los diferentes estudios [5][6][7] . ...
... In 2001 the CDC Community Preventive Services Task Force based its strong recommendation for cessation media campaigns mainly on the effectiveness of extended high-intensity campaigns implemented in California, Massachusetts, and Oregon, campaigns which included excise tax increases, clean indoor air laws, and community-based anti-tobacco education (Hopkins et al. 2001). None of the studies reviewed evaluated the impact of campaigns alone. ...
... 39 • When public places and private workplaces restrict smoking, fewer cigarettes are smoked [46][47][48][49][50][51][52][53][54][55] and more smokers try to quit. 56,57 Does the Public Change What They Think About Secondhand Smoke After Smoke-free Laws Go Into Effect? ...
... The evidence related to specific interventions is summarized in Additional File 1, Table S1, and draws on systematic reviews from the Cochrane Collaboration (4 th quarter 2008) [42], the US Preventive Services Task Force [14], and the Task Force on Community Preventive Services [13]. A similar review of the evidence was published in 2001, nearly a decade ago [43]. Interventions reviewed took place in clinical and community settings, and spanned legislation, enforcement, taxation, medical financing, communication, education, and clinical prevention. ...
Tobacco control is an area where the translation of evidence into policy would seem to be straightforward, given the wealth of epidemiological, behavioural and other types of research available. Yet, even here challenges exist. These include information overload, concealment of key (industry-funded) evidence, contextualization, assessment of population impact, and the changing nature of the threat.
In the context of Israel's health targeting initiative, Healthy Israel 2020, we describe the steps taken to develop a comprehensive tobacco control strategy. We elaborate on the following: a) scientific issues influencing the choice of tobacco control strategies; b) organization of existing evidence of effectiveness of interventions into a manageable form, and c) consideration of relevant philosophical and political issues. We propose a framework for developing a plan and illustrate this process with a case study in Israel.
Broad consensus exists regarding the effectiveness of most interventions, but current recommendations differ in the emphasis they place on different strategies. Scientific challenges include integration of complex and sometimes conflicting information from authoritative sources, and lack of estimates of population impact of interventions. Philosophical and political challenges include the use of evidence-based versus innovative policymaking, the importance of individual versus governmental responsibility, and whether and how interventions should be prioritized.The proposed framework includes: 1) compilation of a list of potential interventions 2) modification of that list based on local needs and political constraints; 3) streamlining the list by categorizing interventions into broad groupings of related interventions; together these groupings form the basis of a comprehensive plan; and 4) refinement of the plan by comparing it to existing comprehensive plans.
Development of a comprehensive tobacco control plan is a complex endeavour, involving crucial decisions regarding intervention components. "Off the shelf" plans, which need to be adapted to local settings, are available from a variety of sources, and a multitude of individual recommendations are available. The proposed framework for adapting existing approaches to the local social and political climate may assist others planning for smoke-free societies. Additionally, this experience has implications for development of evidence-based health plans addressing other risk factors.
... Raising prices of tobacco products through raising taxes is one of the most effective ways to reduce tobacco use [1], and has been recommended as a major component of a comprehensive tobacco control strategy [2]. One way in which tobacco taxation measures can be undermined is through the widespread availability of contraband cigarettes . ...
Non-First Nations people purchasing cigarettes on First Nations reserves do not pay applicable taxes. We estimated prevalence and identified correlates of purchasing contraband cigarettes on reserves; we also quantified the share of contraband purchased on reserves relative to reported total cigarette consumption and the associated financial impact on taxation revenue.
Data from the Ontario Tobacco Survey, a regionally stratified representative population telephone survey that over-samples smokers.
Ontario, Canada.
A total of 1382 adult current smokers.
Reported status of purchasing cigarettes on reserves and the quantity of cigarettes bought on reserves. The prevalence of purchasing cigarettes on reserves was assessed with descriptive statistics. A two-part model was used to analyse correlates of having recently purchased contraband.
A total of 25.8% reported recent purchasing and 11.5% reported usual purchasing. Heavy smoking, having no plans to quit and lower education were correlated with recent purchasing. Heavy smoking and not having plans to quit were also correlated with buying more packs of cigarettes on reserves. Contraband purchases on reserves accounted for 14.0% of the reported total cigarette consumption and resulted in an estimated tax loss of $122.2 million.
There was substantial purchasing of contraband cigarettes on reserves in Ontario, resulting in significant losses in tax revenues. The availability of these cheap cigarettes undermines the effectiveness of tobacco taxation to reduce smoking. Wherever indicated, governments should strengthen their contraband prevention and control measures, as recommended by the Framework Convention on Tobacco Control, to ensure that tobacco taxation achieves its intended health benefits and that tax revenues are protected.
The early years of childhood represent a crucial window of opportunity for investments in skills or capabilities that can place children on the path to well-being in adulthood. Many recent studies in the last decade have focused on the importance of early human capital investments in academic and social skills for promoting long-term educational and economic success. The chapters in this volume explicitly examine the role of health - another type of human capital - in promoting children's early and later educational success and well-being. The impacts of health and education outcomes of salient programs, policies, and practices are summarized with an emphasis on policy implications. The chapters present conceptual issues, research findings, and program and policy implications of promoting good health and school readiness in the first five years of life. These chapters were written by leading researchers in the multidisciplinary study of early learning and human capital formation and represent revised and updated versions of presentations made at a national invitational conference that was held at the Federal Reserve Bank of Minneapolis in late 2010. The book addresses three important themes. The first is the integration of both early health and education as important building blocks of current and later child well-being. Health practices and behaviors interact with educational and social experiences to affect outcomes for children and families. A variety of determinants of child and adult well-being such as prenatal care, family poverty, and access to high-quality early learning programs express their influence early in life yet are often investigated in isolation from each other. This is due in part to the fragmentation of fields of inquiry and the allocation of resources and funding.
In 2010, US health care spending reached approximately $2.59 trillion, or $8,402 per person (Centers for Medicare and Medicaid Services, 2012). Despite greater per capita spending relative to other industrialized nations, the United States has lower performance on several health outcome measures for both the child and the adult populations (OECD, 2011). In 2009-10, in an effort to reform the US health care system, the Obama Administration made health care top domestic policy priority. After a long and contentious debate in Congress the Patient Protection and Affordable Care Act (ACA) was passed on March 23, 2010. As implementation proceeds, provisions within the ACA have begun to alter the financing and delivery of health care for millions of Americans, the most noteworthy being a large-scale expansion of affordable coverage options for lower-income children and adults beginning in 2014. The ACA is a comprehensive piece of legislation and is expected to affect access to health insurance by children and adults, their health care related spending and financial burden, and their consumption of medical care - in other words, their ABCs. This chapter focuses on identifying the potential effects of the Affordable Care Act for children. For each of the ABCs - access, burden, and consumption - we summarize current knowledge from the research literature and then identify and briefly describe important provisions from the ACA that are expected to influence these outcomes.
Health and Education in Early Childhood presents conceptual issues, research findings, and program and policy implications in promoting well-being in health and education in the first five years of life. Leading researchers in the multidisciplinary fields of early learning and human capital formation explore the themes of the integration of health and education in promoting young children's well-being; the timing of influences on child development; and the focus on multiple levels of strategies to promote healthy early development. Through this, a unique framework is provided to better understand how early childhood health and education predictors and interventions contribute to well-being at individual, family community, and societal levels and to policy development. Key topics addressed in the chapters include nutritional status, parenting, cognitive development and school readiness, conduct problems and antisocial behavior, obesity, and well-being in later childhood and adulthood.
Historically, early childhood education programs were developed to promote children's cognitive, literacy, and social-emotional development for school entry and beyond and to counteract the negative effects of poverty that are transmitted fromgeneration to generation. In response to President Lyndon B. Johnson's War on Poverty, preschool programs, such as the federally funded Head Start, emerged in the 1960s with the belief that environmental context can have an impact on children's cognitive and social-emotional development (Condry, 1983). After several decades of research, there is now strong evidence documenting that investments aimed at improving school readiness for economically disadvantaged children are an effective strategy to prevent problems before they arise (Duncan and Murnane, 2011). Since the emphasis on early childhood education interventions proposed in the 1960s, American society has come to rely on its schools to reduce the achievement gap particularly among children born into poverty (Duncan and Murnane, 2011). Currently, a large variety of curricula under the broad framework of several instructional approaches have been developed and implemented in response to the multiple perspectives of best practices for promoting early childhood learning. However, with so many curricula and instructional approaches in existence, early education researchers, teachers, and policymakers have questioned which preschool instructional approach is most effective and whether or not gains due to preschool programs are sustained over time.
Health and Education in Early Childhood presents conceptual issues, research findings, and program and policy implications in promoting well-being in health and education in the first five years of life. Leading researchers in the multidisciplinary fields of early learning and human capital formation explore the themes of the integration of health and education in promoting young children's well-being; the timing of influences on child development; and the focus on multiple levels of strategies to promote healthy early development. Through this, a unique framework is provided to better understand how early childhood health and education predictors and interventions contribute to well-being at individual, family community, and societal levels and to policy development. Key topics addressed in the chapters include nutritional status, parenting, cognitive development and school readiness, conduct problems and antisocial behavior, obesity, and well-being in later childhood and adulthood.
Review question/objective:
The objective of this review is to examine the effectiveness of entry-level education on smoking cessation or prevention and tobacco-dependence interventions on health professional student practice in promoting client health and on client smoking cessation behaviors.The specific review question to be addressed: what is the effect of entry-level tobacco dependence education on: (1) health professional students' knowledge and skills and self-efficacy, (2) performance of tobacco prevention and cessation interventions, and (3) client smoking cessation behaviors?
Using a poverty line of about $23,000 for a family of four, the Census Bureau counted more than 16 million US children living in poor families in 2011. Poor children begin school well behind their more affluent age mates and, if anything, lose ground during the school years. On average, poor US kindergarten children have lower levels of reading and math skills and are rated by their teachers as less well behaved than their more affluent peers. As we document below, children from poor families also go on to complete less schooling, work and earn less, and are less healthy. Understanding the origins and persistence of these differences in fortune is a vital step toward ensuring the prosperity of future generations. Our focus is on what low income in childhood, particularly early childhood, means for health and a successful labor market career later in life. Identifying causal impacts is tricky, since poverty is associated with a cluster of disadvantages that may be detrimental to children, such as low levels of parental education and living with a single parent. To determine how children would be affected by a policy that increased family incomes but did nothing else, we focus on distinguishing the effects of family income from those of other sources of disadvantage. In policy terms, this approach will enable us to address the following question: to what extent are successes in adulthood affected by a policy such as the US Earned Income Tax Credit that boosts the family incomes of low-income parents with children, but does not directly change any other characteristic of their family environments?
This book is a primary resource on how to improve health and prevent disease in states and communities. The book uses systemic review methods to evaluate population-oriented health interventions. The recommendations of the Task Force on Community Preventive Services are explicitly linked to the scientific evidence developed during systematic reviews. This book examines the effectiveness and efficiency of interventions to combat such risky behaviors as tobacco use, physical inactivity, and violence; to reduce the impact and suffering of specific conditions such as cancer, diabetes, vaccine-preventable diseases, and motor vehicle injuries; and to address social determinants on health such as education, housing, and access to care. The chapters are grouped into three broad categories: changing risk behaviors; reducing specific diseases, injuries, and impairments; and methodological background for the book itself.
Health and Education in Early Childhood presents conceptual issues, research findings, and program and policy implications in promoting well-being in health and education in the first five years of life. Leading researchers in the multidisciplinary fields of early learning and human capital formation explore the themes of the integration of health and education in promoting young children's well-being; the timing of influences on child development; and the focus on multiple levels of strategies to promote healthy early development. Through this, a unique framework is provided to better understand how early childhood health and education predictors and interventions contribute to well-being at individual, family community, and societal levels and to policy development. Key topics addressed in the chapters include nutritional status, parenting, cognitive development and school readiness, conduct problems and antisocial behavior, obesity, and well-being in later childhood and adulthood.
Previous publications and research conferences from the Human Capital Research Collaborative have built support for the argument that early childhood programs strengthen health outcomes and school readiness (University of Minnesota and the Federal Reserve Bank of Minneapolis, 2010). The case for promoting investments in early childhood health, however, must be based on strong evidence that such investments will result in specific health benefits to young children, health improvements across the lifespan, and economic returns to society. Recent research shows that the earliest period of life forms the foundation for a healthier life course, and interventions are now available to address the important health problems of early life. Background Children are recognized as the most vulnerable and dependent members of society (Jameson and Wehr, 1993), and measures of infant and child well-being are often used to measure the overall health of a society. Disparities in health and social gradients in health indicators are shaped early in life and sustained across the lifespan (Conley, Strully, and Bennett, 2003). Health is important for many reasons, including the fact that it is a critical determinant of economic productivity across the lifespan; the ability of adults to be productive workers is influenced by their health status.
O presente artigo realiza um estudo sobre os principais desafios jurídicos do processo de implementação da regulação sobre etiquetagem e embalagem de produtos de tabaco na Colômbia. Para isso é preciso conhecer os processos de elaboração da legislação para o controle do tabaco, os avanços conquistados pela jurisprudência da Corte Constitucional colombiana e as medidas administrativas levadas a cabo pelo Ministério da Saúde, ponto central para o controle da droga no país. Também é indispensável estudar o conjunto dessas ações, considerando o plano de medidas Mpower, especialmente com relação à proibição de toda forma de publicidade, promoção e patrocínio de produtos de tabaco, plano que permitiu, a partir da harmonização dos conteúdos da normativa internacional com o ordenamento interno colombiano, estruturar as bases da política governamental e implementar com eficácia a legislação atual.
Despite the internet's broad reach and potential to influence consumer behaviour, there has been little examination of the volume, characteristics, and target audience of online tobacco and e-cigarette advertisements.
A full-service advertising firm was used to collect all online banner/video advertisements occurring in the USA and Canada between 1 April 2012 and 1 April 2013. The advertisement and associated meta-data on brand, date range observed, first market, and spend were downloaded and summarised. Characteristics and themes of advertisements, as well as topic area and target demographics of websites on which advertisements appeared, were also examined.
Over a 1-year period, almost $2 million were spent by the e-cigarette and tobacco industries on the placement of their online product advertisements in the USA and Canada. Most was spent promoting two brands: NJOY e-cigarettes and Swedish Snus. There was almost no advertising of cigarettes. About 30% of all advertisements mentioned a price promotion, discount coupon or price break. e-Cigarette advertisements were most likely to feature messages of harm reduction (38%) or use for cessation (21%). Certain brands advertised on websites that contained up to 35% of youth (<18 years) as their audience.
Online banner/video advertising is a tactic used mainly to advertise e-cigarettes and cigars rather than cigarettes, some with unproven claims about benefits to health. Given the reach and accessibility of online advertising to vulnerable populations such as youth and the potential for health claims to be misinterpreted, online advertisements need to be closely monitored.
This study assessed differences in the indoor air quality and occupancy levels in seventeen bars due to a city-wide smoking ban that took effect on September 1, 2005 in Austin, Texas, USA. We measured the following in each venue before and after the smoking ban: mean number of occupants, mean number of lit cigarettes, temperature, relative humidity, room volume, and PM 2.5 , CO, and CO 2 concentrations. Additionally, VOC measurements were conducted at three of the venues. There was not a statistically significant change in occupancy, but the best estimate PM 2.5 concentrations in the venues decreased 71–99%, a significant reduction in all venues, relative to the pre-ban levels; CO concentrations decreased significantly in all but one venue; and concentrations of VOCs known to be emitted from cigarettes decreased to below the detection limit for all but two common compounds. These results suggest that the smoking ban has effectively improved indoor air quality in Austin bars without an associated decrease in occupancy.
Aims: The goal of the study was the exploration of the influence of tobacco control policies in German in-patient substance abuse treatment centres on the smoking status of alcohol-addicted patients at discharge.
Method: A multi-centre field study with pre–post design was carried out in 40 in-patient treatment centres in Germany. The tobacco control policy questionnaire was answered by the director of each treatment centre (N = 40). Data from 774 alcohol addicted patients could be assessed at admission and discharge. A multi-level-analysis (HLM) was carried out to identify the predictive value of institutional tobacco control policy on smoking status post-rehabilitation.
Findings: Findings uncovered that the strength of tobacco control policy lie in the areas of assessment of smokers, enforcement of smoking restrictions and restrictiveness of smoking policy. Comprehensiveness of smoking restrictions and intensity of smoking-related training of the employees are significant predictors for the variance in quit rates between the institutions. Significant individual predictors for quitting include gender, tobacco dependency and educational status.
Conclusions: Results support findings from other areas like schools and public areas stating the effectiveness of restrictive smoking policies. However, this patient group is especially resistant to change, quit rates are low and effects of tobacco control policy small; the latter partly due to the distal character of policy variables for the individual.
IntroductionIn view of the serious health risks and high costs to the health care system of tobacco consumption, getting young people
to avoid smoking is an important element of preventive health care. The aim of this study was to give an overview of the scientific
literature on cost-effectiveness in smoking preventive interventions within this age group.
MethodsA literature search was conducted in publicly available databases.
ResultsEight studies confirming the cost-effectiveness of those programmes were identified. These publications evaluate behaviour-based
as well as environment-related interventions. Depending on the specific measures used, the results varied enormously. Nevertheless,
in most scenarios the cost-effectiveness was favourable with less than 20,000 euros per life year gained (LYG) or quality-adjusted
life year (QALY). In the long-term perspective some studies estimate significant cost savings from a societal perspective.
ConclusionAccording to the available evidence, the authors assume that smoking prevention in adolescents is cost-effective. Due to the
small number of comparable studies, there is a lack of reliable evidence regarding the economic aspects of primary tobacco
prevention.
Because public health funds are limited, programs need to be prioritized.
We used data on 15 risk factors from Italy's public health surveillance to inform prioritization of programs. We ranked risk factors using a score based on the product of six criteria: deaths attributable to risk factors; prevalence of risk factors; risk factor prevalence trend; disparity based on the ratio of risk factor prevalence between low and high education attainment; level of intervention effectiveness; and cost of the intervention.
We identified seven priorities: physical inactivity; cigarette smoking (current smoking); ever told had hypertension; not having blood pressure screening; ever told had high cholesterol; alcohol (heavy drinking); not eating five fruits and vegetables a day; and not having a fecal occult blood test.
This prioritization method should be used as a tool for planning and decision making.
Childhood obesity is a well-documented public health crisis. Even many children who are not overweight have inadequate physical activity, poor nutrition, excessive television and other screen time, or some combination thereof. The solution lies in the community. Environmental interventions are among the most effective for improving public health. In addition to addressing lifestyle issues in the office, physicians should advocate for environmental approaches. We can advocate at institutional, local, state, and federal levels through speaking, writing, and collaborating with others. In the United States, the timing is right to synergize with efforts such as the White House Task Force on Childhood Obesity and the Surgeon General's emphasis on changing the national conversation "from a negative one about obesity and illness" to a positive one about health and fitness.
The results of a sun protection audit of outdoor recreational environments in three NSW coastal towns.
Thirty public swimming pools, beaches, sports grounds and skate parks were visited at two time points before and after summer (October 2009 and April 2010) and audited for the availability of sun protection, supportive polices and signage.
There was insufficient shade in more than half (58%) of the observed sites at sports grounds, 49% of areas at beaches and 40% of areas at skate parks with most of these sites relying on natural shade (47-58%). Although pools were more likely to have shade available over most of the observed areas (36%) and permanent shade structures (75%), no shade was observed over any main outdoor pools. Similarly, there was only shade available over one of the main sporting grounds, one main beach and none of the main skate ramps. For other types of sun protection, sunscreen was the most popular product available either for free (nine sites) or for sale (eight sites). All pools had at least one supportive sun protection policy but only two of the total 30 sites had any related signage.
This study demonstrates recent findings in relation to the accessibility of sun protection in these settings and the need for health promoting organisations to support and engage councils to invest in more sun protection strategies. The areas of focus should be shade provision particularly at beaches, skate parks and sports grounds; extending the availability of other types of sun protection; and introducing related policies and signage in more sites.
The multiphase optimization strategy (MOST) is a new methodological approach for building, optimizing, and evaluating multicomponent interventions. Conceptually rooted in engineering, MOST emphasizes efficiency and careful management of resources to move intervention science forward steadily and incrementally. MOST can be used to guide the evaluation of research evidence, develop an optimal intervention (the best set of intervention components), and enhance the translation of research findings, particularly type II translation. This article uses an ongoing study to illustrate the application of MOST in the evaluation of diverse intervention components derived from the phase-based framework reviewed in the companion article by Baker et al. (Ann Behav Med, in press, 2011). The article also discusses considerations, challenges, and potential benefits associated with using MOST and similar principled approaches to improving intervention efficacy, effectiveness, and cost-effectiveness. The applicability of this methodology may extend beyond smoking cessation to the development of behavioral interventions for other chronic health challenges.
The U.S. Surgeon General reports that there is no safe level of exposure to secondhand smoke (SHS). The purpose of this study was to measure levels of fine particulate matter in nonsmoking casino restaurants after enactment of Nevada's Clean Indoor Air Act (NCIAA).
Fine particulate matter<2.5 microm in diameter (PM2.5) concentrations were measured in 16 casino hotel restaurants and gaming areas for a total of 32 venues. A battery-operated SidePak aerosol monitor was discreetly used for at least 30 min in each venue.
Nonsmoking restaurant PM2.5 levels ranged from 5 to 101 microg/m3 (M=31; SD=22.9) while gaming areas ranged from 20 to 73 microg/m3 (M=48; SD=15.9). There was a significant difference in PM2.5 between restaurants and gaming areas, t30=-2.54, p=.017. There was also a strong correlation between the levels of restaurant PM2.5 and gaming area PM2.5 (r=.71; p=.005).
Fine PM2.5 in all casino areas was above what the Environmental Protection Agency recommends as healthy. This information can be used to educate policy decision makers when discussing potential strengthening of the law.
Sodium consumption raises blood pressure, increasing the risk for heart attack and stroke. Several countries, including the United States, are considering strategies to decrease population sodium intake.
To assess the cost-effectiveness of 2 population strategies to reduce sodium intake: government collaboration with food manufacturers to voluntarily cut sodium in processed foods, modeled on the United Kingdom experience, and a sodium tax.
A Markov model was constructed with 4 health states: well, acute myocardial infarction (MI), acute stroke, and history of MI or stroke.
Medical Panel Expenditure Survey (2006), Framingham Heart Study (1980 to 2003), Dietary Approaches to Stop Hypertension trial, and other published data.
U.S. adults aged 40 to 85 years.
Lifetime.
Societal.
Incremental costs (2008 U.S. dollars), quality-adjusted life-years (QALYs), and MIs and strokes averted.
Collaboration with industry that decreases mean population sodium intake by 9.5% averts 513 885 strokes and 480 358 MIs over the lifetime of adults aged 40 to 85 years who are alive today compared with the status quo, increasing QALYs by 2.1 million and saving $32.1 billion in medical costs. A tax on sodium that decreases population sodium intake by 6% increases QALYs by 1.3 million and saves $22.4 billion over the same period.
Results are sensitive to the assumption that consumers have no disutility with modest reductions in sodium intake.
Efforts to reduce population sodium intake could result in other dietary changes that are difficult to predict.
Strategies to reduce sodium intake on a population level in the United States are likely to substantially reduce stroke and MI incidence, which would save billions of dollars in medical expenses.
Department of Veterans Affairs, Stanford University, and National Science Foundation.
To compare the methods and findings of systematic reviews (SRs) on common tobacco control interventions from two organizations: the Cochrane Collaboration ("Cochrane") and the US Task Force for Community Preventive Services ("the Guide").
Literature review. We retrieved all reviews pertaining to tobacco control produced by the Cochrane and the Guide. We identified seven common topics and compared methods and findings of the retrieved reviews.
There was considerable variability in the designs of included studies and methods of data synthesis. On average, Cochrane identified more studies than did the Guide (Mean 43.7 vs. 19.0), with only limited overlap between sets of included studies. Most Cochrane reviews (71.4%) were synthesized narratively, whereas most Guide reviews (85.7%) were synthesized using a median of effect size. Despite these differences, findings of the reviews yielded substantial agreement.
Cochrane and the Guide conduct SRs on similar tobacco control-related topics differently. The SRs of the two organizations include overlapping, but nonidentical sets, of studies. Still, they usually reach similar conclusions. Identification of all pertinent original studies seems to be a weak point in the SR process. Policy makers should use reviews from both organizations in formulating tobacco control policy.
Tobacco use is the leading preventable cause of death in the USA and will soon be the leading cause of preventable death worldwide. The only way to decrease tobacco-related morbidity and mortality in the short term is to help current smokers quit. Fortunately, effective clinical- and population-based interventions that increase tobacco cessation exist. However, these interventions are not being implemented, leaving most smokers to use the least effective approach to cessation (an unassisted quit attempt). This review summarizes the evidence for the effectiveness of clinical- and population-based interventions and recommendations from various organizations regarding tobacco use treatment. It also outlines proposed strategies for improving clinical and public health practice to increase tobacco cessation.
The co-use of alcohol and tobacco by adolescents is a public health problem that continues well into adulthood and results in negative behavioral, social, and health consequences. The purpose of this study was to examine the co-use of alcohol and tobacco among ninth-graders in south-central Louisiana.
We created a health habits survey to collect data from 4,750 ninth-grade students, mean age 15.4 years. Cross-sectional analysis used chi2, 1-way analysis of variance, and logistic regression methods.
Almost 20% of students were co-users. Students who were white, performed poorly in school, did not expect to graduate high school, and had more discretionary money to spend were more likely to be co-users. Co-users had friends who got drunk weekly and were more likely to approve of alcohol use among friends than among adults. Significant differences in attitudes toward drinking and smoking were observed between co-users and nonusers. For adolescent drinkers, including girls, hard liquor was the preferred beverage.
These data for high school students are applicable for prevention strategies at a critical age when harmful health behaviors can mark the start of lifelong habits. Intervention efforts will be successful only if they account for multiple levels of influence.
Medicaid recipients are disproportionately affected by tobacco-related disease because their smoking prevalence is approximately 53% greater than that of the overall US adult population. This study estimates state-level smoking-attributable Medicaid expenditures.
We used state-level and national data and a 4-part econometric model to estimate the fraction of each state's Medicaid expenditures attributable to smoking. These fractions were multiplied by state-level Medicaid expenditure estimates obtained from the Centers for Medicare and Medicaid Services to estimate smoking-attributable expenditures.
The smoking-attributable fraction for all states was 11.0% (95% confidence interval, 0.4%-17.0%). Medicaid smoking-attributable expenditures ranged from $40 million (Wyoming) to $3.3 billion (New York) in 2004 and totaled $22 billion nationwide.
Cigarette smoking accounts for a sizeable share of annual state Medicaid expenditures. To reduce smoking prevalence among recipients and the growth rate in smoking-attributable Medicaid expenditures, state health departments and state health plans such as Medicaid are encouraged to provide free or low-cost access to smoking cessation counseling and medication.
The purpose of this study was to use the Community Readiness Model to examine local smoke-free policy development.
A descriptive, cross-sectional design was used to assess 64 Kentucky communities. Dimensions of readiness included a community's knowledge of the problem and existing voluntary smoke-free policies; leadership for policy development; resources for policy development; climate surrounding policy development; existing voluntary policy efforts; and political climate for policy development. Dimension scores were summed to identify one of six overall readiness stages: (1) unawareness; (2) vague awareness; (3) preplanning; (4) preparation; (5) initiation; and (6) endorsement.
Correlations between dimensions and overall readiness scores were evaluated. One-way analysis of variance was used to evaluate regional trends, and multiple regression was used to assess the influence of sociodemographic/political variables on policy readiness.
The knowledge dimension rated highest, and community climate rated lowest. Most communities were in the lower stages of readiness. No relationship was found between overall readiness and region (F [4,59] = 1.17; p > .05); nor were there regional differences among dimension scores. Smaller communities were less ready for local policy development than larger ones (adjusted R2 = .25; p = .003).
The Community Readiness Model is appropriate for understanding local policy development, and it provides advocates with information that may prove helpful in advancing smoke-free policy.
The issue of environmental tobacco smoke (ETS) and the harms it causes to nonsmoking bystanders has occupied a central place in the rhetoric and strategy of antismoking forces in the United States over the past 3 decades. Beginning in the 1970s, anti-tobacco activists drew on suggestive and incomplete evidence to push for far-reaching prohibitions on smoking in a variety of public settings. Public health professionals and other antismoking activists, although concerned about the potential illness and death that ETS might cause in nonsmokers, also used restrictions on public smoking as a way to erode the social acceptability of cigarettes and thereby reduce smoking prevalence. This strategy was necessitated by the context of American political culture, especially the hostility toward public health interventions that are overtly paternalistic.
PURPOSE This systematic review evaluates the effectiveness of population-based interventions to improve vaccination coverage. The paper 1) presents a framework for evaluating interventions to improve vaccination coverage , 2) describes selected strategies for improving coverage , and 3) systematically reviews available information on the effectiveness of these strategies in improving vaccination coverage and other outcomes to assess their effectiveness.
We compared the relative effectiveness of four different conditions of self-help and social support provided to people attempting to quit smoking in conjunction with a televised cessation program: Smokers ready to quit were able to request written manuals from hardware stores to accompany a televised program. At worksites we provided the written manual to all workers. At a random half of the worksites, we also provided training to discussion leaders who subsequently led discussions among smokers attempting to quit with the program. At health maintenance organization sites we invited smokers who had requested program materials to participate in similar group discussions at health centers. In this paper we report one year follow-up results for the above four groups and compare them with previously reported results of a self-help manual alone. Results for the television plus manual condition were better than those of past studies (25 percent nonsmoking prevalence and 10 percent continuous cessation one year after the program) and considerably better than the manual alone. None of the other conditions designed to supplement the manual plus television produced better long-term outcomes; we explore the reasons for this. The program did encourage and help over 50,000 Chicago smokers to attempt quitting with the American Lung Association manual, 100 times as many as would have done so without the televised program. At least 15 other similar programs implemented since 1984 multiply this effect.
Evaluations of 40 mass media programs/campaigns designed to influence cigarette smoking were reviewed. Information/motivation programs/campaigns generally produced changes in awareness, knowledge, and attitudes. Extensive national campaigns also produced meaningful behavioral change. Programs/campaigns designed to promote some specific smoking-related action produced mixed results, depending in large part on the type of promotion involved. Mass media cessation clinics were found to be effective, with media plus social support being more effective than viewing plus printed material, and either combination being more effective than viewing alone. It was concluded that mass media health promotion programs can be more effective than many academics may have thought, but that the knowledge necessary to ensure such success is seriously lacking. Research studies, rather than simple evaluations, are needed to improve our knowledge base and build a science of mass media health promotion.
We examined the impact of a statewide antismoking media campaign on progression to established smoking among Massachusetts adolescents.
We conducted a 4-year longitudinal survey of 592 Massachusetts youths, aged 12 to 15 years at baseline in 1993. We examined the effect of baseline exposure to television, radio, and outdoor antismoking advertisements on progression to established smoking (defined as having smoked 100 or more cigarettes), using multiple logistic regression and controlling for age; sex; race; baseline smoking status; smoking by parents, friends, and siblings; television viewing; and exposure to antismoking messages not related to the media campaign.
Among younger adolescents (aged 12 to 13 years at baseline), those reporting baseline exposure to television antismoking advertisements were significantly less likely to progress to established smoking (odds ratio = 0.49, 95% confidence interval = 0.26, 0.93). Exposure to television antismoking advertisements had no effect on progression to established smoking among older adolescents (aged 14 to 15 years at baseline), and there were no effects of exposure to radio or outdoor advertisements.
These results suggest that the television component of the Massachusetts antismoking media campaign may have reduced the rate of progression to established smoking among young adolescents.
SMOKING is the leading preventable cause of death in our country. Smoking kills 434 000 people a year, more than 1000 every day1; it accounts for about 85% of all lung cancer deaths, about 80% of all chronic obstructive pulmonary disease deaths, and 30% of all heart disease deaths. In addition, smoking costs this country $52 billion annually in health care and other costs.2
In spite of the magnitude of this health hazard, most physicians have never received training in techniques to help patients stop smoking. Many physicians believe they are unprepared and unsuccessful in treating patients addicted to nicotine.3,4 However, recent scientific evidence suggests that physicians can help smokers stop and thus reduce the incidence of smoking-related diseases.
In 1989, the National Cancer Institute (NCI) used clinical trial results and consensus development to produce recommendations for physicians who treat patients
MAXON H. EDDY, MD: All right. I've read your articles about what's going on in Oregon.1-3I agree with you that their first attempt to use cost-effectiveness analysis to set priorities failed but that that failure did not necessarily doom the entire method. I also understand that even now Oregon's commission is not totally satisfied with the priority-setting process it eventually used and that it is seeking ways to improve the process. Based on what you've already written, I'll bet you're going to try to convince me that Oregon should use cost-effectiveness analysis to rank its services. I've got to warn you that you're going to have a hard time. In 40 years of practice I never withheld a test or treatment that I thought would help my patients, even when I had to absorb the cost myself. I believe that what we do in medicine should be determined
• This article describes the results of a three-hour training program that teaches residents a patient-centered counseling approach to smoking cessation, emphasizing questioning and exploring feelings, rather than providing information. Fifty internal medicine and family practice residents affiliated with a university medical center were assessed before and after training using questionnaires and videotape documenting changes in their knowledge about smoking, attitudes concerning intervention, and intervention skills. The residents showed a significant increase in knowledge and perceived themselves as having significantly more influence on their patients who smoke after completion of the training program. Counseling skills improved significantly in the use of questions and exploring feelings as judged by blind evaluation of videotapes. The results of this three-hour training program suggest that physicians in training are responsive to the teaching of specialized skills deemed important for promoting health behavior changes in their patients.
(Arch Intern Med 1988;148:1039-1045)
Cigarette smoking remains the greatest single cause of preventable death in contemporary society. The health consequences of tobacco use have been documented in thousands of studies. We are at a critical juncture in U.S. tobacco control history. The nation is poised on the brink of momentous changes in the health care system and in public policy regulating the use and marketing of tobacco products. This article will make four recommendations to help us capitalize on these changes.
Systematic reviews and evidence-based recommendations are increasingly important for decision making in health and medicine. Over the past 20 years, information on the science of synthesizing research results has exploded. However, some approaches to systematic reviews of the effectiveness of clinical preventive services and medical care may be less appropriate for evaluating population-based interventions. Furthermore, methods for linking evidence to recommendations are less well developed than methods for synthesizing evidence.The Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide) will evaluate and make recommendations on population-based and public health interventions. This paper provides an overview of the Guide’s process to systematically review evidence and translate that evidence into recommendations.The Guide reviews evidence on effectiveness, the applicability of effectiveness data, (i.e., the extent to which available effectiveness data is thought to apply to additional populations and settings), the intervention’s other effects (i.e., important side effects), economic impact, and barriers to implementation of interventions.The steps for obtaining and evaluating evidence into recommendations involve: (1) forming multidisciplinary chapter development teams, (2) developing a conceptual approach to organizing, grouping, selecting and evaluating the interventions in each chapter; (3) selecting interventions to be evaluated; (4) searching for and retrieving evidence; (5) assessing the quality of and summarizing the body of evidence of effectiveness; (6) translating the body of evidence of effectiveness into recommendations; (7) considering information on evidence other than effectiveness; and (8) identifying and summarizing research gaps.Systematic reviews of and evidence-based recommendations for population-health interventions are challenging and methods will continue to evolve. However, using an evidence-based approach to identify and recommend effective interventions directed at specific public health goals may reduce errors in how information is collected and interpreted, identify important gaps in current knowledge thus guiding further research, and enhance the Guide users’ ability to assess whether recommendations are valid and prudent from their own perspectives. Over time, all of these advantages could help to increase agreement regarding appropriate community health strategies and help to increase their implementation.
Background: This paper presents the results of systematic reviews of the effectiveness, applicability, other effects, economic impact, and barriers to use of selected population-based interventions intended to improve vaccination coverage. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis for recommendations by the Task Force on Community Preventive Services (the Task Force) regarding the use of these selected interventions. The Task Force recommendations are presented on pp. 92–96 of this issue.
AT THE turn of the last century, the American medical community developed a standardized assessment to help clinicians confront the leading cause of death at that time, infectious disease. This assessment, known as vital signs, included temperature, pulse rate, respiratory rate, and, later, blood pressure.1-3 Over time, the measurement of vital signs became an expected part of every clinic visit and an essential component of the database physicians use to evaluate, diagnose, and treat patients.As we approach the next century, American medicine is challenged by a different cause of illness and death—tobacco use. Cigarettes are now responsible for more than 430000 deaths each year in the United States.4 As with past epidemics of this magnitude, institutional changes in the practice of medicine must be adopted to overcome the enormous disease burden resulting from tobacco use.Making smoking status the "new vital
Study objective:To evaluate the effectiveness of two teaching interventions to increase residents’ performance of smoking cessation counseling.
Design:Randomized controlled factorial trial.
Setting:Eleven residency programs, in internal medicine (six), family medicine (three), and pediatrics (two). Programs were located in three university medical centers and four university-affiliated community hospitals.
Participants:261 residents who saw ambulatory care patients at least one half-day per week, and 937 returning patients aged 17 to 75 years who reported having smoked five or more cigarettes in the preceding seven days. Of the 937, 843 were eligible for follow-up, and 659 (78%) were interviewed by phone at six months.
Interventions:Two interventions (tutorial and prompt) and four groups. The tutorial was a two-hour educational program in minimal-contact smoking cessation counseling for residents. The prompt was a chart-based reminder to assist physician counseling. One group of residents received the tutorial; one, the prompt; and one, both. A fourth group received no intervention.
Measurement and results:Six months after the intervention, physician self-reports showed that residents in the tutorial + prompt and tutorial-only groups had used more counseling techniques (1.5–1.9) than had prompt-only or control residents (0.9). Residents in all three intervention groups advised more patients to quit smoking (76–79%) than did control group residents (69%). The tutorial had more effect on counseling practices than did the prompt. Physician confidence, perceived preparedness, and perceived success followed similar patterns. Exit interviews with 937 patients corroborated physician self-reports of counseling practices. Six months later, self-reported and biochemically verified patient quitting rates for residents in the three intervention groups (self-reported: 5.3–8.2%; biochemically verified: 3.4–5.7%) were higher than those for residents in the control group (self-reported: 5.2%; biochemically verified: 1.7%), though the differences were not statistically significant.
Conclusion:A simple and feasible educational intervention can increase residents’ smoking cessation counseling.
To test the impact of physician education and facilitator assisted office system interventions on cancer early detection and preventive services.
A randomised trial of two interventions alone and in combination.
Physicians in 98 ambulatory care practices in the United States.
The education intervention consisted of a day long physician meeting directed at improving knowledge, attitudes, and skills relevant to cancer prevention and early detection. The office system intervention consisted of assistance from a project facilitator in establishing routines for providing needed services. These routines included division of responsibilities for providing services among physicians and their staff and the use of medical record flow sheets.
The proportions of patients provided the cancer prevention and early detection services indicated annually according to the US National Cancer Institute.
Based on cross sectional patient surveys, the office system intervention was associated with an increase in mammography, the recommendation to do breast self examination, clinical breast examination, faecal occult blood testing, advice to quit smoking, and the recommendation to decrease dietary fat. Education was associated only with an increase in mammography. Record review for a patient cohort confirmed cross sectional survey findings regarding the office system for mammography and faecal occult blood testing.
Community practices assisted by a facilitator in the development and implementation of an office system can substantially improve provision of cancer early detection and preventive services.
KIE
In an imaginary dialogue on cost-effectiveness analysis in health care with his late father, a surgeon, Eddy discusses clinical, psychological, and philosophical problems that could block its successful implementation.
To evaluate the effectiveness of two teaching interventions to increase residents' performance of smoking cessation counseling.
Randomized controlled factorial trial.
Eleven residency programs, in internal medicine (six), family medicine (three), and pediatrics (two). Programs were located in three university medical centers and four university-affiliated community hospitals.
261 residents who saw ambulatory care patients at least one half-day per week, and 937 returning patients aged 17 to 75 years who reported having smoked five or more cigarettes in the preceding seven days. Of the 937, 843 were eligible for follow-up, and 659 (78%) were interviewed by phone at six months.
Two interventions (tutorial and prompt) and four groups. The tutorial was a two-hour educational program in minimal-contact smoking cessation counseling for residents. The prompt was a chart-based reminder to assist physician counseling. One group of residents received the tutorial; one, the prompt; and one, both. A fourth group received no intervention.
Six months after the intervention, physician self-reports showed that residents in the tutorial + prompt and tutorial-only groups had used more counseling techniques (1.5-1.9) than had prompt-only or control residents (0.9). Residents in all three intervention groups advised more patients to quit smoking (76-79%) than did control group residents (69%). The tutorial had more effect on counseling practices than did the prompt. Physician confidence, perceived preparedness, and perceived success followed similar patterns. Exit interviews with 937 patients corroborated physician self-reports of counseling practices. Six months later, self-reported and biochemically verified patient quitting rates for residents in the three intervention groups (self-reported: 5.3-8.2%; biochemically verified: 3.4-5.7%) were higher than those for residents in the control group (self-reported: 5.2%; biochemically verified: 1.7%), though the differences were not statistically significant.
A simple and feasible educational intervention can increase residents' smoking cessation counseling.
To assess the relative impacts of three physician-delivered smoking interventions in combination with follow-up contact from behavioral counselors.
Randomized controlled trial with pre- post measures of smoking rates. This paper reports six-month outcome data.
Participants were recruited from among patients seen by 196 medical and family practice residents in five primary care clinics.
Participants were 1,286 patients out of 1,946 eligible smokers approached. The patient group was 57% female and 91% white, had an average age of 35 years, and smoked, on average, slightly over one pack per day.
Physicians were trained to provide each of three interventions: advice only, brief patient-centered counseling, and counseling plus prescription of nicotine-containing gum (Nicorette). Half the patients received follow-up in the form of telephone counseling at three-monthly intervals from behavioral counselors.
Changes in smoking behaviors were assessed by telephone interview six months after physician intervention. The differences in one-week point prevalence cessation rates among the physician interventions were significant (p less than 0.01): advice only, 9.1%; counseling, 11.9%; counseling plus gum, 17.4%; with no effect for telephone counseling. The time elapsed from physician encounter to initial quitting and the length of that period of abstinence also showed significant benefit of the counseling interventions. Patients receiving physician counseling were much more likely than those not receiving counseling to rate their physician as very helpful (p less than 0.001). Multiple regression analyses are also reported.
Smoking intervention counseling provided by physicians is well received by patients and significantly increases the likelihood of cessation at six months, an effect that is augmented by the prescription of nicotine-containing gum, when compared with physician-delivered advice. Follow-up telephone counseling does not contribute significantly to smoking behavior changes.
We compared the counseling behaviors of two groups of health maintenance organization physicians: one group received training about smoking cessation counseling; the other group received the same training plus staff support and appointment time specially designated for follow-up of smokers. We interviewed patients after their office visits to measure smoking counseling. The group receiving staff support and designated follow-up time counseled more and made more follow-up appointments about smoking.
To increase the effect that primary care physicians have on their patients who smoke.
Randomized, controlled trial with 112 general internists and their patients who smoke.
Sample of 1420 patients from a general medicine clinic of a city-county teaching hospital, who smoke at least one cigarette a day and were recruited regardless of their interest in quitting smoking.
Physicians were randomly assigned to one of four groups: participants who received a protocol for smoking management and a lecture on the consequences and management of smoking (control); in addition, had nicotine gum freely available to patients (gum); had stickers attached to their smokers' charts (reminder); or had both gum and reminders (both).
The percentage of patients with a return visit at 6 months who quit smoking (alveolar carbon monoxide of less than nine parts per million) was 1.3% (control), 7.7% (gum), 7.0% (reminders), and 6.3% (both). At 1 year the percentages were 2.7%, 8.8%, 15.0%, and 9.6%, respectively. Subsequent pairwise comparisons showed that the three intervention groups were not significantly different, but that each was significantly different from the control group (P less than 0.05). Physicians in all three intervention groups spent significantly more time than did the physicians in the control group counseling their patients about smoking.
The availability of nicotine gum or labeling the charts of smokers can help primary care physicians increase their success rates two- to six-fold in helping patients quit smoking. If all primary care physicians used these procedures, they could help an additional 2 million smokers quit.
To test whether physicians who receive a continuing education program ("Quit for Life") about how to counsel smokers to quit would counsel smokers more effectively and have higher rates of long-term smoking cessation among their patients who smoke.
Randomized trial with blinded assessment of principal outcomes.
Four health maintenance organization medical centers in northern California.
Eighty-one internists assigned by blinded randomization to receive training (40) or serve as controls (41). Consecutive samples of smokers visiting each physician (mean, 25.6 patients per experimental and 25.2 per control physician).
Internists received 3 hours of training about how to help smokers quit. Physicians and their office staff also were given self-help booklets to distribute free to smokers and were urged to use a system of stickers on charts to remind physicians to counsel smokers about quitting.
On the basis of telephone interviews with patients after visiting the physician, we determined that internists who attended the Quit for Life program discussed smoking with more patients who smoked, spent more time counseling them about smoking, helped more patients set dates to quit smoking, gave out more self-help booklets, and made more follow-up appointments to discuss smoking than did internists in the control group. One year later, the rate of biochemically confirmed, long-term (greater than or equal to 9 months) abstinence from smoking was 1% higher among all patients of trained internists than among patients of controls (95% CI, -0.1% to +2.3%), and 2.2% (+0.2% to +4.3%) higher among the patients who most wanted to quit smoking.
This continuing education program substantially changed the way physicians counseled smokers. As a result, a few more patients who wanted to quit smoking achieved long-term abstinence.
Attitudes toward smoking intervention, and the intervention practices of 65 residents, 51 attending physicians, and 292 community physicians in central and western Massachusetts were assessed through a mailed questionnaire. Nearly all physicians reported that they obtained information on the smoking status of new patients and told smokers to quit. Proportionately fewer physicians, however, reported that they counseled their patients on how to stop smoking; those who did, did so for relatively brief periods of time. After differences in physician age and smoking status were controlled for, residents were significantly more likely than attending physicians to counsel their patients on how to stop smoking, but were also more likely (than attending and community physicians) to recommend or refer their patients to formal smoking cessation programs. A small percentage of the physicians responding (3%-16%) reported that they were prepared to counsel smokers, but most reported that information on where to refer patients, smoking cessation techniques, and skills training would be of great value. The results of this survey suggest practical differences between residents and attending and community physicians in approaching patients who smoke and in attitudes toward the need for additional skills and financial and organizational assistance.
Attitudes of physicians toward counseling patients about their smoking habits may influence whether and how counseling occurs. In this paper, the authors develop and test a conceptual model of these attitudes. The model includes four attitude dimensions: physicians' motivations to counsel, perceived health risk of smoking, perceived skills in counseling, and perceived costs and benefits to the physician of counseling. A self-report questionnaire including a 40-item measure of these attitudes was delivered to a random sample of male general practitioners, internists, surgeons, and obstetrician-gynecologists who were members of a western county medical society in 1978. The response rate was 76%. Based on factor analyses, 10 subscales and 3 global scales were formed by summing items. The item contents of scales are consistent with the authors' model, and reliability and item-discriminant validity are excellent. The authors' model may be useful in understanding the factors that affect the process and outcomes of physician counseling about smoking.
To assess the effectiveness and acceptability of incorporating the National Cancer Institute (NCI) Guide to Preventing Tobacco Use During Childhood and Adolescence into pediatric training.
Preintervention and postintervention self-reported surveys for residents receiving training and postintervention baseline surveys for those residents not receiving training. Measures include: (1) a self-reported knowledge, attitude, and behavior survey of residents; and (2) physician behavior reports from parent exit interviews.
A hospital-based pediatric residency program and continuity clinic.
Pediatric residents and parents of pediatric patients seen for well child examinations.
Structured NCI smoking cessation curriculum modified for delivery during scheduled teaching activities.
The NCI training was acceptable and perceived as important by residents. Many did not recall receiving the materials or training. Trained residents who remembered the intervention improved their smoking cessation counseling effectiveness. Most patients' parents think it appropriate for physicians to ask; however, most reported not having been asked about smoking or environmental smoke exposure.
For residents to learn effective prevention counseling strategies, systematic, reinforced preventive educational curricula must become an institutionalized part of residency training.
Although continuing medical education (CME) has long been used to inform physicians and teach specific skills, its efficacy in many areas is not well established. This randomized controlled trial assessed the effects of differing educational techniques on the cancer-control skills of 57 physicians.
The CME program was part of the Cancer Prevention in Community Practice Project in Hanover, New Hampshire, and was implemented in 1988. The program used several methods in its presentation, including interactive small-group discussion, role playing, videotaped clinical encounters, lecture presentations, and trigger tapes. Measurements included cross-sectional observations made by unannounced standardized patients (SPs) who, one year after the CME program, assessed 25 physicians who had participated in the program and 32 physicians who had not. To measure consistency in the SPs' performances and accuracy in assessing the physicians' performances, most interactions were audiotaped using a hidden microphone. Pearson chi-square, Fisher exact two-tailed test, and kappa coefficients were used for analysis.
Significantly higher ratings were found for the CME physicians in two areas: breast cancer risk-factor determination (determined maternal history: 80% versus 52%, p = .03; determined age at first period: 16% versus 0%, p = .02), and smoking cessation counseling (providing written material: 32% versus 9%, p = .03). The CME physicians were rated higher on all 19 study variables in the target areas of early detection of breast cancer and smoking cessation. The results show that the physicians' performance were better in those areas where the CME program had used performance-based learning, such as role playing or viewing and discussing a videotaped role-play encounter.
The educational techniques that rehearsed or portrayed clinical applications seem to have increased the physicians' performances of cancer-control clinical activities. The standardized-patient instrument seems to be particularly useful in evaluating interventions that address specific skills training.
The health benefits from quitting smoking have been well documented; however, most health insurance plans in the United States, both public and private, have excluded coverage of smoking cessation services. Since 1988, numerous public health policy documents have called for health insurance coverage of smoking cessation services, although there is little agreement over what kinds of services or interventions are most appropriate for health insurance coverage. The purposes of this paper are to (1) describe current public policy for health insurance coverage of smoking cessation services; (2) review the current status of policy adoption by private health insurance carriers, health maintenance organizations, self-funded employers, as well as public insurance programs including Medicare and Medicaid; (3) analyze the major barriers faced by health insurers, health care providers and policy makers in offering coverage for smoking cessation services; and (4) outline the specific policy options that the federal government, state governments, employers and anti-smoking coalitions can take to increase insurance coverage for smoking cessation services. The paper concludes with recommendations for practitioners, researchers and policy makers.
The mass media have been used as a way of delivering preventive health messages. They have the potential to reach and to modify the knowledge, attitudes and behaviour of a large proportion of the community.
To determine the effectiveness of mass media campaigns in preventing the uptake of smoking in young people.
We searched Medline, and 28 other electronic databases. Handsearching of key journals was also carried out, the bibliographies of identified studies were checked for additional references and contact with content area specialists was made. Date of last search June 1998.
Randomised trials, controlled trials without randomisation and time series studies that assessed the effectiveness of mass media campaigns (defined as channels of communication such as television, radio, newspapers, bill boards, posters, leaflets or booklets intended to reach large numbers of people and which are not dependent on person to person contact) in influencing the smoking behaviour (either objective or self-reported) of young people under the age of 25 years.
Information relating to the characteristics and the content of media interventions, participants, outcomes and methods of the study was abstracted by one reviewer and checked by a second. Studies were combined using qualitative narrative synthesis.
Six out of a total of 63 studies reporting information about mass media smoking campaigns met all of the inclusion criteria. All six studies used a controlled trial design. Two studies concluded that the mass media were effective in influencing the smoking behaviour of young people. Both of the effective campaigns had a solid theoretical basis, used formative research in designing the campaign messages and message broadcast was of reasonable intensity over extensive periods of time.
There is some evidence that the mass media can be effective in preventing the uptake of smoking in young people, but overall the evidence is not strong.
Audit and feedback has been identified as having the potential to change the practice of health care professionals.
To assess the effects of audit and feedback on the practice of health professionals and patient outcomes.
We searched MEDLINE up to June 1997, the Research and Development Resource Base in Continuing Medical Education, and reference lists of related systematic reviews and articles.
Randomised trials of audit and feedback (defined as any summary of clinical performance of health care over a specified period of time). The participants were health care professionals responsible for patient care.
Two reviewers independently extracted data and assessed study quality.
Thirty-seven studies were included, involving more than 4977 physicians. The reporting of study methods was inadequate for almost all studies. In 31 out of 37 studies the randomisation process could not be determined. Information regarding data analysis was also lacking. For example, power calculations were not mentioned in 27 out of 37 studies. A variety of behaviours were targeted including the reduction of diagnostic test ordering, prescribing practices, preventive care, and the general management of a problem, for example hypertension. Twenty-eight studies measured physician performance, one study targeted patient outcomes in diabetes and the remaining eight studies measured both physician performance and patient outcomes. The relative percentage differences ranged from -16% to 152%. The clinical importance of the changes was not always clear.
Audit and feedback can sometimes be effective in improving the practice of health care professionals, in particular prescribing and diagnostic test ordering. When it is effective, the effects appear to be small to moderate but potentially worthwhile. Those attempting to enhance professional behaviour should not rely solely on this approach.
This paper presents the results of systematic reviews of the effectiveness, applicability, other effects, economic impact, and barriers to use of selected population-based interventions intended to improve vaccination coverage. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis for recommendations by the Task Force on Community Preventive Services (the Task Force) regarding the use of these selected interventions. The Task Force recommendations are presented on pp. 92-96 of this issue.
Systematic reviews and evidence-based recommendations are increasingly important for decision making in health and medicine. Over the past 20 years, information on the science of synthesizing research results has exploded. However, some approaches to systematic reviews of the effectiveness of clinical preventive services and medical care may be less appropriate for evaluating population-based interventions. Furthermore, methods for linking evidence to recommendations are less well developed than methods for synthesizing evidence. The Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide) will evaluate and make recommendations on population-based and public health interventions. This paper provides an overview of the Guide's process to systematically review evidence and translate that evidence into recommendations. The Guide reviews evidence on effectiveness, the applicability of effectiveness data, (i.e., the extent to which available effectiveness data is thought to apply to additional populations and settings), the intervention's other effects (i.e., important side effects), economic impact, and barriers to implementation of interventions. The steps for obtaining and evaluating evidence into recommendations involve: (1) forming multidisciplinary chapter development teams, (2) developing a conceptual approach to organizing, grouping, selecting and evaluating the interventions in each chapter; (3) selecting interventions to be evaluated; (4) searching for and retrieving evidence; (5) assessing the quality of and summarizing the body of evidence of effectiveness; (6) translating the body of evidence of effectiveness into recommendations; (7) considering information on evidence other than effectiveness; and (8) identifying and summarizing research gaps. Systematic reviews of and evidence-based recommendations for population-health interventions are challenging and methods will continue to evolve. However, using an evidence-based approach to identify and recommend effective interventions directed at specific public health goals may reduce errors in how information is collected and interpreted, identify important gaps in current knowledge thus guiding further research, and enhance the Guide users' ability to assess whether recommendations are valid and prudent from their own perspectives. Over time, all of these advantages could help to increase agreement regarding appropriate community health strategies and help to increase their implementation.
There is good evidence that brief interventions from health professionals can increase rates of smoking cessation. A number of trials have examined whether specific skills training for health professionals leads them to have greater success in helping their patients who smoke.
The aim of this review was to assess the effectiveness of training health care professionals to deliver smoking cessation interventions to their patients, and to assess the additional effects of prompts and reminders to the health professional to intervene.
We searched the Cochrane Tobacco Addiction Group trials register for studies relating to training.
Randomised trials in which the intervention was training of health care professionals in smoking cessation. Trials were considered if they reported outcomes for patient smoking rates at least six months after the intervention. We reported on process outcomes, but we excluded trials that reported effects only on process outcomes and not smoking behaviour.
We extracted data in duplicate on the type of health professionals, the nature of and duration of the training, the outcome measures, method of randomisation, and completeness of follow-up. The main outcome measures were 1. Rates of abstinence from smoking after at least six months follow-up in patients smoking at baseline. 2. Rates of performance of tasks of smoking cessation by health care professionals including offering counselling, setting quit dates, giving follow-up appointments, distributing self-help materials and recommending nicotine gum.
Healthcare professionals who had received training were more likely to perform tasks of smoking cessation than untrained controls. Of eight studies that compared patient smoking behaviour between trained professionals and controls, six found no effect of intervention. The effects of training on process outcomes increased if prompts and reminders were used.
Training health professionals to provide smoking cessation interventions had a measurable effect on professional performance. There was no strong evidence that it changed smoking behaviour.
Background:
The aim of nicotine replacement therapy (NRT) is to replace nicotine from cigarettes. This reduces withdrawal symptoms associated with smoking cessation thus helping resist the urge to smoke cigarettes.
Objectives:
The aims of this review were to determine the effectiveness of the different forms of nicotine replacement therapy (chewing gum, transdermal patches, nasal spray, inhalers and tablets) in achieving abstinence from cigarettes, or a sustained reduction in amount smoked; to determine whether the effect is influenced by the clinical setting in which the smoker is recruited and treated, the dosage and form of the NRT used, or the intensity of additional advice and support offered to the smoker; to determine whether combinations of NRT are more effective than one type alone; and to determine its effectiveness compared to other pharmacotherapies.
Search strategy:
We searched the Cochrane Tobacco Addiction Group trials register in July 2002.
Selection criteria:
Randomized trials in which NRT was compared to placebo or no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow-up of less than six months.
Data collection and analysis:
We extracted data in duplicate on the type of subjects, the dose and duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed effects model (Peto).
Main results:
We identified 110 trials; 96 with a non NRT control group. The odds ratio for abstinence with NRT compared to control was 1.74 (95% confidence interval 1.64 - 1.86), The odds ratios for the different forms of NRT were 1.66 for gum, 1.74 for patches, 2.27 for nasal spray, 2.08 for inhaled nicotine and 2.08 for nicotine sublingual tablet/lozenge. These odds were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2mg gum (odds ratio 2.67, 95% confidence interval 1.69 - 4.22). There was weak evidence that combinations of forms of NRT are more effective. Higher doses of nicotine patch may produce small increases in quit rates. Only one study directly compared NRT to another pharmacotherapy, in which bupropion was significantly more effective than nicotine patch or placebo.
Reviewer's conclusions:
All of the commercially available forms of NRT (nicotine gum, transdermal patch, the nicotine nasal spray, nicotine inhaler and nicotine sublingual tablets/lozenges) are effective as part of a strategy to promote smoking cessation. They increase quit rates approximately 1.5 to 2 fold regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the smoker. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. There is promising evidence that bupropion may be more effective than NRT (either alone or in combination). However, its most appropriate place in the therapeutic armamentarium requires further study and consideration.
Bans on smoking and intensive educational campaigns can reduce smoking in public places Different methods are used to try and stop people smoking in public places such as hospitals and workplaces. The review looked at trials of different strategies, and found that simply putting up signs of a "no smoking" policy does not seem to help prevent people smoking in public places. However, complete bans that have strong support from management do work. Intensive educational campaigns and multi-component strategies also help reduce smoking in public places. Such strategies have been shown to work for hospitals in the United States, but research is needed on the best strategies for other places and other countries.
This report presents the results of systematic reviews of effectiveness, applicability, other effects, economic evaluations, and barriers to use of selected population-based interventions intended to reduce tobacco use and exposure to environmental tobacco smoke. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis of recommendations by the Task Force on Community Preventive Services (TFCPS) regarding the use of these selected interventions. The TFCPS recommendations are presented on page 67 of this supplement.
Laws restricting sales of tobacco products to minors exist in many countries, but young people may still purchase cigarettes easily.
The review assesses the effects of interventions to reduce underage access to tobacco by deterring shopkeepers from making illegal sales.
We searched the Cochrane Tobacco Addiction group trials register, MEDLINE and EMBASE. Date of the most recent searches: September 2004.
We included controlled trials and uncontrolled studies with pre- and post intervention assessment of interventions to change retailers' behaviour. The outcomes were changes in retailer compliance with legislation (assessed by test purchasing), changes in young people's smoking behaviour, and perceived ease of access to tobacco products.
One reviewer prescreened studies for relevance, and both reviewers independently assessed the studies for inclusion. One reviewer extracted data from included studies and the second checked them. Study designs and types of intervention were heterogeneous so results were synthesized narratively, with greater weight given to controlled studies.
We identified 34 studies of which 14 had data from a control group for at least one outcome. Giving retailers information was less effective in reducing illegal sales than active enforcement or multicomponent educational strategies, or both. No strategy achieved complete, sustained compliance. In three controlled trials, there was little effect of intervention on youth perceptions of access or prevalence of smoking.
Interventions with retailers can lead to large decreases in the number of outlets selling tobacco to youths. However, few of the communities studied in this review achieved sustained levels of high compliance. This may explain why there is limited evidence for an effect of intervention on youth perception of ease of access to tobacco, and on smoking behaviour.
Individual behavioural counselling for smoking cessation (Cochrane Review) The Cochrane Library, Issue 3
- T Lancaster
- Stead
- Lf
Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation (Cochrane Review). The Cochrane Library, Issue 3. Oxford, UK: Update Software, 2000.
Clonidine for smoking cessation (Cochrane Review) The Cochrane Library, Issue 3
- Gourlay
- Sg
- Stead Lf
- Benowitz
- Nl
Gourlay SG, Stead LF, Benowitz NL. Clonidine for smoking cessation (Cochrane Review). The Cochrane Library, Issue 3. Oxford, UK: Update Software, 2000.
Smoking cessation: clinical practice guideline, number 18. (Pub. No. [AHCPR] 96-0692)
- Health Agency
- Care Policy
- Research
Agency for Health Care Policy and Research. Smoking cessation: clinical practice guideline, number 18. (Pub. No. [AHCPR] 96-0692).Washington, DC: U.S. Department of Health and Human Services, 1996.
Growing up tobacco free: preventing nicotine addiction in children and youths
- Institute
- Medicine
Institute of Medicine. Growing up tobacco free: preventing nicotine addiction in children and youths. Washington, DC: National Academy Press, 1994.
Treating tobacco use and depen-dence: Clinical practice guideline Available at: www.surgeongeneral.gov/tobacco
- Fiore
- Bailey Wc Mc
- Cohen
- Sj
Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and depen-dence: Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, 2000. Available at: www.surgeongeneral.gov/tobacco. Accessed 13 July 2000.
Mass media and smoking cessation
- Flay
Clinical decision making
- Eddy