The impact of tobacco control programs on adult smoking

Objectives. We examined whether state tobacco control programs are effective in reducing the prevalence of adult smoking.Methods. We used state survey data on smoking from 1985 to 2003 in a quasi-experimental design to examine the association between cumulative state antitobacco program expenditures and changes in adult smoking prevalence, after we controlled for confounding.Results. From 1985 to 2003, national adult smoking prevalence declined from 29.5% to 18.6% (P<.001). Increases in state per capita tobacco control program expenditures were independently associated with declines in prevalence. Program expenditures were more effective in reducing smoking prevalence among adults aged 25 or older than for adults aged 18 to 24 years, whereas cigarette prices had a stronger effect on adults aged 18 to 24 years. If, starting in 1995, all states had funded their tobacco control programs at the minimum or optimal levels recommended by the Centers for Disease Control and Prevention, there would have been 2.2 million to 7.1 million fewer smokers by 2003.Conclusions. State tobacco control program expenditures are independently associated with overall reductions in adult smoking prevalence.Recent data from the Centers for Disease Control and Prevention (CDC) showed that adult smoking remained constant at 20.8% from 2004 to 2005 after years of steady decline.1 The CDC study cited a 27% decline in funding for tobacco control programs from 2002 through 2006 and smaller annual increases in cigarette prices in recent years as 2 possible explanations for stalled smoking rates. Our study is a systematic assessment of the association between adult smoking, funding for state tobacco control programs, and state cigarette excise taxes.In 1989, California began the first comprehensive statewide tobacco control program in the United States after passage of a state ballot measure that raised cigarette excise taxes by $0.25.2 Comprehensive programs include interventions such as mass media campaigns, increased cigarette excise taxes, telephone quit lines, reduced out-of-pocket costs for smoking cessation treatment, health care provider assistance for cessation, and restrictions on secondhand smoke in public places.3^–6 Subsequently, other states, including Massachusetts in 1992, Arizona in 1995, and Florida in 1998, began similar large-scale state tobacco control programs.3 Multistate tobacco control interventions with substantial financial support began in the 1990s, with assistance from US government programs (e.g., the CDC’s Initiatives to Mobilize for the Prevention and Control of Tobacco Use [IMPACT] and the National Cancer Institute’s Americans Stop Smoking Intervention Study [ASSIST]) and other national programs.3Some states also committed resources from other sources, such as revenue from the 1998 Master Settlement Agreement (MSA) between the 4 largest tobacco companies in the United States and 46 US states.7 The MSA imposes restrictions on the advertising, promotion, and marketing or packaging of cigarettes, including a ban on tobacco advertising that targets people younger than 18, and requires the tobacco companies to pay $246 billion over 25 years to the states. The MSA also established a foundation that became the American Legacy Foundation.Extensive research has shown that state tobacco control programs, combined with other efforts, such as the American Legacy Foundation’s national truth campaign, have been effective in reducing adolescent tobacco use.3^,8^,9 Following a large increase in adolescent smoking during the mid-1990s, there has been an unprecedented decline, with the national prevalence among high school students dropping from 36.4% in 1997 to 21.9% in 2003.10In marked contrast, there has been little research into the effects of state programs on the prevalence of adult smoking, which is unfortunate given that smoking cessation confers substantial health benefits to adults.3^,11^,12 To date, findings from California, Massachusetts, and Arizona suggest that state tobacco control programs have had some effect on adults.13^–16 From 1988 through 1999, the prevalence of adult smoking in California declined from 22.8% to 17.1%, compared with an overall national decline from 28.1% to 23.5% (a relative percentage decline of 25% in California and 16% elsewhere).13^,14 From 1992 through 1999, the relative percentage decline in adult smoking was 8% in Massachusetts compared with 6% nationwide.14^,15 Findings from Arizona from 1996 to 1999 suggest a greater effect: the relative percentage decline was 21% compared with 8% nationwide.16 In addition, per capita cigarette sales—a proxy for cigarette consumption—have declined faster in Arizona, California, Massachusetts, and Oregon (where another large-scale program began in 1997) than in the rest of the United States since the programs’ implementation.17 The ASSIST evaluation showed that smoking prevalence decreased more in ASSIST states than in non-ASSIST states by the end of an 8-year intervention; by contrast, the evaluation found no difference in per capita cigarette consumption.6^,18These few state-specific studies on the prevalence of adult smoking had important limitations. First, state-specific findings may not be generalizable. Second, none of the studies considered the key role of cigarette price increases on prevalence (i.e., through higher cigarette excise taxes, which have consistently been shown to reduce cigarette consumption and prevalence)3 or controlled for other state characteristics, such as demographic changes or secular trends. Third, the studies did not assess the potential effects of programs on adults of different ages. Although the ASSIST evaluation provides a more comprehensive view of state tobacco control programs, it failed to control for baseline differences in state-level demographics and policy variables between ASSIST and non-ASSIST states. Finally, none of the studies considered the possible long-term effects of tobacco control programs on adult smoking.In 1999, the CDC published Best Practices for Comprehensive Tobacco Control Programs,19 which provided states with guidelines and recommendations for 9 tobacco control program activities (e.g., community programs, counter-marketing, cessation), along with minimum and optimum funding levels for each specific activity. On the basis of this document, in fiscal year 2006, states should have allocated $6.47 per capita minimum and $17.14 optimally to tobacco control programs (i.e., the $5.98 and $15.85, respectively, recommended in the 1999 CDC document, adjusted for inflation).We used data on state tobacco control program expenditures and periodic surveys of adult smoking prevalence conducted by the US Census Bureau from 1985 to 2003 to answer the following questions: (1) After control for potentially confounding factors (e.g., cigarette excise taxes), were increases in state tobacco control program expenditures independently associated with declines in adult smoking prevalence, and did effects differ by age group? (2) What would have been the predicted effect of state tobacco control program expenditures on adult smoking prevalence if all states had met CDC-recommended minimum or optimum per capita funding levels from 1995 to 2003?     

Smoking cessation rates in the United States: a comparison of young adult and older smokers

Objectives. We compared smoking quit rates by age in a nationally representative sample to determine differences in cessation rates among younger and older adults.Methods. We used data on recent dependent smokers aged 18 to 64 years from the 2003 Tobacco Use Supplement to the Current Population Survey (n=31625).Results. Young adults (aged 18–24 years) were more likely than were older adults (aged 35–64 years) to report having seriously tried to quit (84% vs 66%, P<.01) and to have quit for 6 months or longer (8.5% vs 5.0%, P<.01). Among those who seriously tried to quit, a smoke-free home was associated with quitting for 6 months or longer (odds ratio [OR]=4.13; 95% confidence interval [CI]=3.25, 5.26). Compared with older smokers, young adults were more likely to have smoke-free homes (43% vs 30%, P<.01), were less likely to use pharmaceutical aids (9.8% vs 23.7%, P<.01), and smoked fewer cigarettes per day (13.2% vs 17.4%, P<.01).Conclusions. Young adults were more likely than were older adults to quit smoking successfully. This could be explained partly by young adults, more widespread interest in quitting, higher prevalence of smoke-free homes, and lower levels of dependence. High cessation rates among young adults may also reflect changing social norms.A key goal of tobacco control is to increase smoking cessation among young adults, because quitting at an early age increases the chances that a smoker will avoid the more serious health consequences of smoking.1 During the 1980s and 1990s, older smokers (50 years and older) were the most successful quitters,2^,3 and annual rates of successful quitting increased for all age groups.2 However, increases in cessation rates in the 1990s were greatest among young adults aged 20 to 34 years.2 Furthermore, among young adult smokers, but not older smokers, the increase in cessation rates was higher in states with higher cigarette prices and highest of all in California, which had a comprehensive statewide tobacco control program,2 suggesting that environmental factors may especially influence cessation rates among young adults. Projecting these national trends, we hypothesized that by 2003, young adults may have been the most successful quitters of any age group. Understanding recent changing influences on successful quitting could help increase the effectiveness of public health programs that aim to encourage cessation.Rates of successful quitting can differ between age groups because of differences in the proportion of smokers who try to quit, or because of differences in success rates among those who try. There is evidence that changes in the social norms surrounding smoking can lead to changes in the proportion of smokers who try to quit and that these norms can be influenced by tobacco-related news coverage4 and mass media advertising campaigns,5 both of which increased in the United States in the late 1990s with the Master Settlement Agreement and with the start of the American Legacy Foundation campaign.6 Young people (aged 0–29 years) may be particularly responsive to such influences,7 and throughout the 1990s, California’s tobacco control program used targeted media campaigns to specifically influence social norms about smoking.8Changes in social norms can also influence behavior associated with success in quitting. In particular, a decrease in levels of nicotine dependence among recent cohorts of smokers could partly explain higher rates of successful quitting among younger adults. Less-dependent smokers are more likely to successfully quit, presumably because of less-intense withdrawal symptoms.9^–11 Following the 1992 Environmental Protection Agency report classifying environmental tobacco smoke as a carcinogen,12 there was a rapid increase in social norms supporting restrictions on smoking,13 and increased restrictions on smoking at work and in public places have been associated with reduced levels of daily cigarette consumption.14^,15During the 1990s, an increasing proportion of smokers, particularly parents, banned smoking in the home.16 There is a strong association between smoke-free homes and successful quitting,17^,18 perhaps in part because a lapse, for example after a meal, is less likely. It is possible that recent birth cohorts who took up smoking under these restrictions at home and work may develop lower levels of dependence than previous cohorts,19 and they may themselves be more likely to live in a smoke-free home.During the 1990s, pharmaceutical aids became available to help overcome withdrawal symptoms, and these aids were associated with quitting success.20^,21 However, once these aids became easily available over the counter in 1996, their apparent effectiveness in population studies disappeared.22^,23 More in-depth analysis has suggested that effective use of pharmaceutical aids may be limited to smokers who are motivated to quit, such as those with a smoke-free home.24 Thus, differences in patterns of use of pharmaceutical aids between age groups may also contribute to recent differences in quitting success rates.We used a large nationally representative survey to compare US smoking cessation rates and associated tobacco-related behaviors between age groups. We compared attempted quitting rates across age groups each year as well as success rates among those who tried to quit smoking and explored whether there were important differences between age groups in prevalence of known correlates of cessation. We used multivariate logistic regression to establish whether differences in such correlates could account for differences in cessation rates, or whether younger smokers were quitting at higher rates than might be predicted by, for example, lower levels of addiction and a higher prevalence of smoke-free homes.     

Current smoking and type 2 diabetes among patients in selected Indian Health Service clinics, 1998-2003

Objectives. In non-American Indian/Alaska Native groups, current smoking prevalence is similar for those with or without diabetes (26%) We analyzed current smoking prevalence in American Indian/Alaska Natives by diabetes status.Methods. Data were extracted from Indian Health Service clinic visit information from 1998 to 2003. After consolidation into unique patient records, the sample comprised 71221 patients aged 14 years or older with both diabetes and current smoking information.Results. Cross-sectional results indicated that diabetic American Indian/Alaska Natives were significantly more likely than those without diabetes to be current smokers (29.8% vs 18.8%; P<.01). Smoking rates were 2 to 3 times higher among diabetic American Indians and Alaska Natives for each age category (P<.001), and current smokers with diabetes were more likely than nonsmokers to have glycosylated hemoglobin A_1c levels at 8.0% or higher (P <.05).Conclusions. American Indian/Alaska Natives with diabetes at all sites and age categories were found to smoke at significantly higher rates than those without diabetes. Smoking cessation programs should target diabetic patients to more effectively prevent complications and promote successful management of diabetes in American Indians/Alaska Natives.Several clinical and large prospective studies have reported significant links between smoking and the development of diabetes,1^,2 micro- and macrovascular complications,3 and impairment of metabolic control.4^,5 Foy6 reported a linear dose relationship of incident diabetes with increasing number of pack years of smoking, and an odds ratio of 5.7 (P>.001) for current smokers with 20 or more pack years of smoking. Smoking is an independent risk factor for cardiovascular disease, and acute and chronic tobacco exposure significantly impairs glucose tolerance and increases insulin resistance. Conversely, improvement in insulin sensitivity and elevated levels of high-density lipoprotein cholesterol both occur after smoking cessation.5 However, most studies in the general population have shown the prevalence of tobacco use to be similar among those with or without diabetes (26%), but many of these studies have used self-report of diabetes and tobacco use.7Diabetes is the fourth leading cause of death for American Indian and Alaska Native (AIAN) populations and is the major independent risk factor for cardiovascular disease, the leading cause of death among American Indians and Alaska Natives.8 AIAN populations have the highest reported tobacco use of any US ethnic group—40.4% reported from 1999–2001 Centers for Disease Control and Prevention (CDC) data,9 and 32% reported from 2005 CDC data.10 However, data that show smoking prevalence stratified by type 2 diabetes status are scarce. Although Indian Health Service (IHS) data are the most comprehensive nationally based AIAN health data available, the data report age, gender, socioeconomic status, and mortality rates but not disease or lifestyle behavior prevalence rates.8 In other national databases, only small samples of American Indians and Alaska Natives are included and therefore prevalence estimates are not representative or reliable. Many American Indians and Alaska Natives included in these data sets are misclassified as another race/ethnicity and vice versa (i.e., many people who do not have legitimate AIAN heritage self-identify as American Indian and Alaska Native).11^,12The Strong Heart Study, a longitudinal cohort study of cardiovascular disease among American Indians and Alaska Natives, has not reported current smoking by diabetes status but has reported similar rates of current smoking for those with incident cardiovascular disease (44.8%) compared with those with no incident cardiovascular disease (40.2%).13 Only 1 study of cardiovascular disease risk factors among American Indians and Alaska Natives reported smoking prevalence rates by diabetes status that were similar to the Strong Heart Study (34% vs 41%).14 However, that study used a telephone interview survey to assess self-reported diabetes and smoking prevalence rates.Gilmer et al.15 showed that for every 1% rise in glycosylated hemoglobin A_1c levels (HbA_1c; a more stable glucose measure over a 2- to 3-month period than single glucose measures), there was a 15% increase in the cost of medical care. Their report identified the clinical threshold of HbA_1c level at 8.0%, above which complication rates and costs significantly intensified. One way to maintain better glucose control and prevent complications is to eliminate smoking. However, the prevalence of smoking in diabetic American Indians and Alaska Natives who have HbA_1c levels at 8.0% or higher has not been adequately reported.We sought to describe current smoking prevalence by diabetes status among a large group of American Indian/Alaska Natives, as well as in diabetic American Indians and Alaska Natives whose glucose was not well controlled. Data were collected in the clinic setting and extracted from existing IHS and tribally owned health facility patient visit data from 1998 to 2003.     

Predictors of sustained smoking cessation: a prospective analysis of chronic smokers from the alpha-tocopherol Beta-carotene cancer prevention study

Objectives. Because US smoking rates have not declined during the past decade, there is a renewed need to identify factors associated with smoking cessation. Using a nested case–control design, we explored the association between ability to sustain cessation over an extended period and demographic, smoking, medical, and behavioral variables.Methods. We selected a sample of 1379 sustained quitters (abstinent from smoking for at least 40 months) and 1388 relapsers (abstinent for more than 8 months before relapse) from participants in the Alpha-Tocopherol Beta-Carotene Cancer Prevention Study, a nutritional intervention study involving Finnish men aged 50 to 69 years at baseline. Contingency table and multiple regression analyses were used to evaluate potential differences between the 2 groups on baseline variables.Results. Compared with sustained quitters, relapsers were more likely to report symptoms of emotional distress and higher levels of nicotine dependence, to drink more alcohol, and to report more medical conditions.Conclusions. Factors associated with both tobacco use and comorbid conditions impact an individual’s ability to maintain long-term smoking cessation. Understanding the underlying mechanisms of action and potential common pathways among these factors may help to improve smoking cessation therapies.Despite significant progress in smoking prevalence reduction within the United States since the mid-1990s, in the past 15 years, rates of smoking have remained virtually unchanged.1^–3 Smoking continues to be a significant public health issue with asubstantial associated cancer4 and health care burden.5 In the United States, current smoking rates are reported to be 21.6% of the adult population, with 440 000 deaths per year attributable to smoking.3 These unchanged smoking rates have occurred within a context of widely marketed cessation medications and consistent reports of strong motivation by smokers to quit smoking, which speaks to the difficulty of successfully achieving cessation for many smokers. Approximately 40% of current smokers attempt to quit in any given year, but only 5% sustain abstinence for more than a few weeks, and most relapse within a week.6 To effectively reduce the burden of tobacco use, there needs to be a better understanding of the factors associated with successful cessation.Smoking is a complex behavior that encompasses social, economic, environmental, behavioral, and physiological factors.7 A comprehensive model of smoking should account for as many of these dimensions or factors as possible. Like other substance abuse and dependence behaviors, smoking occurs along a trajectory from experimentation and initiation to cessation attempts (and relapse). Therefore, to understand factors associated with smoking behavior along that trajectory, researchers must compare 2 groups who have similar histories—that is, groups in which both have reached a prerequisite “stage” before diverging on the behavior of interest. This allows any differences in the 2 groups to be more precisely attributed to the differences in the behavior of interest.To illustrate this point, consider that to compare participants’ responses to a stimulus first requires participant exposure to the stimulus. Likewise, to compare smokers’ progression from 1 stage of the smoking trajectory to the next, the smokers must be “exposed” to the previous stage on the continuum. For example, to assess liability to dependence, researchers are now effectively arguing that comparison groups must be exposed to nicotine,8 or, in other words, individuals must progress through the cigarette-experimentation stage of the trajectory before liability to dependence can be assessed.In the case of smoking cessation, there are 2 relevant behaviors. The first is initiating a quit attempt and the second is sustaining that quit attempt. If the behavior of interest is sustained cessation, then a proper study design requires that all participants have made a quit attempt. In other words, smokers must progress to making a quit attempt before factors associated with quit length can be assessed. Individuals who have not made a quit attempt are not informative regarding their liability to relapse, and their inclusion in a study of sustained cessation presents a potential problem of misclassification bias. As an example, it has been suggested that a history of major depression may influence initiation of cessation but not maintenance of cessation.9^–10 To directly assess the impact of depression on the ability to sustain cessation (behavior of interest), individuals with and without a history of major depression who have all made a quit attempt (necessary exposure) should be compared.Previous literature has identified a number of factors that are likely to impact smoking cessation. Few studies, however, have clearly differentiated initiating versus sustaining cessation,11 so the impact of those factors on quit attempts versus sustained cessation is unknown. Demographic variables that have been reported to positively influence cessation include male gender, older age, higher education, and indicators of higher socioeconomic status.11^–17 A number of smoking-related factors, including those associated with nicotine dependence, are related to increased difficulty with cessation. These include higher numbers of cigarettes per day, earlier age of smoking onset, few to no previous quit attempts, and indicators of nicotine dependence, such as shorter time to first cigarette in the morning.18^–21 Comorbid conditions have also been demonstrated to impact cessation, including behavioral symptoms and psychiatric disorders22^–24 and medical conditions.25^–29 Despite this seemingly comprehensive list, a limited body of research has considered the impact of these types of factors longitudinally or has addressed the contribution of more than 1 domain of factors within a single study. This is because, at least in part, of the lack of available longitudinal data that encompass a wide range of potential factors.To address this gap, we performed a nested case–control study on a sample drawn from a large, randomized longitudinal clinical trial of male smokers that contained a number of relevant variables including smoking use and history, demographics, comorbid medical conditions, and comorbid behavioral symptoms. In a selected sample of individuals who had made at least 1 quit attempt, we evaluated differences between those individuals who were able to sustain abstinence from smoking for at least 40 months (sustained quitters) to individuals who relapsed within 8 months (relapsers). These intervals were chosen a priori in an effort to maximize differences between our groups on the behavior of interest—sustained cessation.     

Educational disparities in rates of smoking among diabetic adults: the translating research into action for diabetes study

Objectives. We assessed educational disparities in smoking rates among adults with diabetes in managed care settings.Methods. We used a cross-sectional, survey-based (2002–2003) observational study among 6538 diabetic patients older than 25 years across multiple managed care health plans and states. For smoking at each level of self-reported educational attainment, predicted probabilities were estimated by means of hierarchical logistic regression models with random intercepts for health plan, adjusted for potential confounders.Results. Overall, 15% the participants reported current smoking. An educational gradient in smoking was observed that varied significantly (P<.003) across age groups, with the educational gradient being strong in those aged 25 to 44 years, modest in those aged 45 to 64 years, and nonexistent in those aged 65 years or older. Of particular note, the prevalence of smoking observed in adults aged 25–44 years with less than a high school education was 50% (95% confidence interval: 36% to 63%).Conclusions. Approximately half of poorly educated young adults with diabetes smoke, magnifying the health risk associated with early-onset diabetes. Targeted public health interventions for smoking prevention and cessation among young, poorly educated people with diabetes are needed.Smoking is recognized as the leading preventable cause of death and one of the most potent risk factors for cardiovascular disease and cancer. The total annual direct and indirect costs of smoking in the United States for 1995–1999 were estimated to be $158 billion.1 In the United States during 1997–2001, cigarette smoking and tobacco exposure resulted in approximately 438000 premature deaths, 5.5 million years of potential life lost, and $92 billion in productivity losses annually.2 Diabetes confers a similar burden in annual health care expenditures ($132 billion).3Smoking may be a particularly important risk multiplier for adults with diabetes, because it is associated with hyperglycemia, microvascular complications, insulin resistance, and microalbuminuria4^–6 and greatly increases an already elevated risk of cardiovascular disease,7^,8 end-stage renal disease,9^,10 and death.11^,12 Moreover, although quitting smoking reduces the mortality risk, the detrimental effects can persist for years after quitting, especially for smokers with diabetes.13In the general patient population, poverty and lower educational attainment are linked to a higher prevalence of smoking.14 Nonetheless, relatively little is known about smoking patterns among adults with diabetes and, in particular, about the influence of social disparities, such as educational differences, on the prevalence of smoking in this group. Understanding which subpopulations are most at risk for smoking would help health plans and policymakers target their smoking cessation and prevention interventions among enrollees with diabetes.Translating Research Into Action for Diabetes (TRIAD) is an ongoing study of quality of care and self-care for people with diabetes in managed care settings in 7 US states that began in 2000.15 As part of TRIAD, we examined the relation between socioeconomic status and various health behaviors among people with diabetes. TRIAD surveyed a large cohort of adults with diabetes enrolled in managed care, enabling a detailed examination of smoking and social factors in addition to other factors that contribute to risk for future complications. Here we focus on the relation between educational attainment and smoking.     

A Comparison of Cessation Counseling Received by Current Smokers at US Dentist and Physician Offices During 2010–2011

Objectives. We compared patient-reported receipt of smoking cessation counseling from US dentists and physicians.Methods. We analyzed the 2010 to 2011 Tobacco Use Supplement of the Current Population Survey to assess receipt of smoking cessation advice and assistance by a current smoker from a dentist or physician in the past 12 months.Results. Current adult smokers were significantly less likely to be advised to quit smoking during a visit to a dentist (31.2%) than to a physician (64.8%). Among physician patients who were advised to quit, 52.7% received at least 1 form of assistance beyond the simple advice to quit; 24.5% of dental patients received such assistance (P < .05). Approximately 9.4 million smokers who visited a dentist in 2010 to 2011 did not receive any cessation counseling.Conclusions. Our results indicate a need for intensified efforts to increase dentist involvement in cessation counseling. System-level changes, coupled with regular training, may enhance self-efficacy of dentists in engaging patients in tobacco cessation counseling.Tobacco use is associated with several oral and perioral diseases because most tobacco use is administered orally.1–4 The National Call to Action to Promote Oral Health emphasized the need for tobacco cessation and other community programs to promote health.5 Hence, dental professionals have a critical role in helping their patients quit tobacco use.6 The impact of intensified involvement of dental professionals in tobacco prevention and cessation may be significant, considering that in 2010, 37% of US adults aged 19 to 64 years and 46.3% of persons aged 2 to 18 years visited a dentist.7The American Dental Association’s goal of reducing oral health disparities among underserved populations further highlights the importance of increased involvement of dentists in tobacco cessation.8 Oral health disparities may mirror disparities in tobacco use (e.g., individuals of low socioeconomic status have disproportionately high prevalence of tobacco use and also poor oral health care access).9,10 Hence, in recent years, tobacco cessation counseling by dentists has been prioritized in the United States, as evidenced by some of the Healthy People 2020 targets.11The US Public Health Service outlined a 5-step approach known as the 5 A’s to provide a structural framework for health professionals to help their patients quit tobacco use:

1. ask all patients whether they use tobacco,
2. advise all tobacco users to quit,
3. assess tobacco users’ willingness to quit,
4. assist tobacco users by offering medications and providing or referring for counseling or additional treatment, and
5. arrange follow-up contact to prevent relapse.12

Despite these developments, few nationally representative data exist on the implementation of tobacco cessation counseling among US dentists. To fill this gap in knowledge, we assessed patient-reported receipt of 2 of the 5 A’s (advice and assistance) from a dentist among current smokers who participated in the 2010 to 2011 Tobacco Use Supplement of the Current Population Survey (TUS-CPS), a nationally representative sample of US households with persons aged 18 years or older. To better provide context for the performance of dentists in delivering smoking cessation interventions, we compared patient recall of physician-delivered cessation interventions in the same sample.     

SimSmoke Model Evaluation of the Effect of Tobacco Control Policies in Korea: The Unknown Success Story

Objectives. We evaluated the effect of strict tobacco control policies, implemented beginning in 1995 in the Republic of Korea, on smoking prevalence and deaths.Methods. SimSmoke is a simulation model of the effect of tobacco control policies over time on smoking initiation and cessation. It uses standard attribution methods to estimate lives saved as a result of new policies. After validating the model against smoking prevalence, we used it to determine the Korean policies'' effect on smoking prevalence.Results. The model predicted smoking prevalence accurately between 1995 and 2006. We estimated that 70% of the 24% relative reduction in smoking rates over that period was attributable to tobacco control policies, mainly tax increases and a strong media campaign, and that the policies will prolong 104 812 male lives by the year 2027.Conclusions. Our results document Korea''s success in reducing smoking prevalence and prolonging lives, which may serve as an example for other Asian nations. Further improvements may be possible with higher taxes and more comprehensive smoke-free laws, cessation policies, advertising restrictions, and health warnings.Many Asian nations have smoking prevalence rates among males of at least 50%, leading to a large share of the world''s 5 million deaths attributable to smoking each year.¹ Worldwide, annual tobacco-related mortality is expected to increase to 10 million by 2030,¹ with an increasing share of those deaths in Asia, unless effective tobacco control measures are implemented.Most Asian nations have signed the Framework Convention for Tobacco Control, developed through the World Health Organization. This pact advocates high cigarette taxes, smoke-free indoor air laws, cessation treatment coverage, advertising bans, health warnings, and a well-organized media campaign. Thailand has implemented many of the suggested policies and has shown remarkable success in reducing male and female smoking rates.² Success in other Asian nations has not been documented.As recently as 1995, 67% of males smoked in the Republic of Korea.³ Taxes were increased gradually in the late 1990s, and some of the funds were allocated to tobacco control. The framework was ratified by Korea in May 2005. By the end of 2006, Korea had substantially increased the tax rate on cigarettes, implemented a strong antismoking campaign, strengthened clean air laws and health warnings, and made cessation treatments more accessible.³ No previous study evaluated the effect of these policies.When more than 1 policy is implemented, it is difficult for empirical studies to distinguish each policy''s effects.⁴ Simulation models combine information from diverse sources to examine the effects of different policies over time.^4,5 To determine these effects in Korea, we adopted the SimSmoke tobacco control policy model,^4,6–8 which simultaneously considers a broader array of public policies than do other smoking models.^9–14 The model has accurately explained trends in smoking rates for the United States as a whole and for several states,^7,15–17 as well as for other nations.²We used Korean data to develop a SimSmoke model for that country. We used the model to estimate the effect of individual and combined tobacco control policies implemented between 1995 and 2006 on male smoking prevalence and deaths.     

Tobacco use harm reduction, elimination, and escalation in a large military cohort

Objectives. We evaluated changing patterns of tobacco use following a period of forced tobacco abstinence in a US military cohort to determine rates of harm elimination (e.g., tobacco cessation), harm reduction (e.g., from smoking to smokeless tobacco use), and harm escalation (e.g., from smoking to dual use or from smokeless tobacco use to smoking or dual use).Methods. Participants were 5225 Air Force airmen assigned to the health education control condition in a smoking cessation and prevention trial. Tobacco use was assessed by self-report at baseline and 12 months.Results. Among 114 baseline smokers initiating smokeless tobacco use after basic military training, most demonstrated harm escalation (87%), which was 5.4 times more likely to occur than was harm reduction (e.g., smoking to smokeless tobacco use). Harm reduction was predicted, in part, by higher family income and belief that switching from cigarettes to smokeless tobacco is beneficial to health. Harm escalation predictors included younger age, alcohol use, longer smoking history, and risk-taking.Conclusions. When considering a harm reduction strategy with smokeless tobacco, the tobacco control community should balance anticipated benefits of harm reduction with the risk of harm escalation and the potential for adversely affecting public health.Cigarette smoking is the number 1 preventable cause of death and disability in the United States.^1,2 Although a vast array of smoking cessation strategies exist,³ nearly 20% of the US population are current smokers.⁴ Impeding efforts for a tobacco-free society are the facts that nicotine is highly addictive⁵ and, at any given time, only about 20% of smokers are ready, willing, or able to make a serious attempt to stop smoking.⁶ Although research efforts are under way to evaluate the efficacy of approaches for smokers not ready or able to quit (e.g., motivational interviewing),⁷ no method has demonstrated success.An alternative approach to providing treatment to smokers unable to quit is to “reduce the harm” associated with cigarette smoking.⁸ Proposed harm reduction strategies have included risk factor modification (e.g., dietary intake and physical activity) and chemoprevention strategies (e.g., antioxidants).⁹ However, the most controversial method of harm reduction is encouraging smokers to switch from cigarette smoking to other forms of tobacco, such as smokeless tobacco,^10,11 a known human carcinogen.^12,13Although switching from cigarettes to smokeless tobacco reduces risk related to heart disease and lung cancer,^14,15 critics of this strategy suggest that harm reduction may be associated with unintended consequences. A recent review by Tomar et al. concluded that the effectiveness of smokeless tobacco as a smoking-cessation strategy remains unknown and that available evidence suggests that smokeless tobacco use may be a gateway to smoking initiation in the United States.¹⁶ Furthermore, promoting smokeless tobacco for harm reduction has the potential to increase harm by opening the door to dual use of cigarettes and ST, with the latter used in venues where smoking is prohibited; this could undermine cessation attempts.^16,17 In the INTERHEART study, an international case–control study, dual use (i.e., concomitant use of cigarettes and smokeless tobacco) was associated with higher odds for acute myocardial infarction than was cigarette smoking alone.¹⁸ Finally, it is important to point out that, although switching from cigarette smoking to smokeless tobacco is safer than smoking cigarettes, smokeless tobacco is still far from safe.^12,13Proponents of harm reduction claim that for cigarette smokers who find complete smoking cessation an unobtainable goal, reducing harm through use of alternative nicotine sources with fewer health risks is better than continuing to smoke. These advocates often cite Sweden''s promotion of the smokeless product “snus” as an example of effective harm reduction.¹⁹ Swedish snus use has been linked to a decrease in smoking prevalence and a net population health benefit.^20,21 However, available data suggest that the Swedish and US populations behave differently.²² Specifically, both US male and female smokers have higher quit rates than in Sweden despite the higher rate of snus use in Sweden. Analysis of data in populations with high rates of tobacco use (both cigarettes and smokeless tobacco), such as the US military,²³ may provide additional information regarding the behavior of US tobacco users.We explored tobacco use patterns in a large military cohort from basic military training to 12-month follow-up. During basic military training, all tobacco use is forbidden (a well-enforced prohibition) for a 6-week period; therefore, smokers and smokeless tobacco users undergo forced tobacco abstinence. We assessed the extent to which cigarette smokers in this population switched to smokeless tobacco (e.g., harm reduction) following the smoking ban during basic military training.^12,13,24 We also explored the extent to which smokers increased their potential risk by switching to dual tobacco use (e.g., harm escalation).     

Long-term trends in adolescent and young adult smoking in the United States: metapatterns and implications

Objectives. We sought to describe long-term adolescent and young adult smoking trends and patterns.Methods. We analyzed adolescent data from Monitoring the Future, 1976 to 2005, and young adult (aged 18–24 years) data from the National Health Interview Survey, 1974 to 2005, overall and in subpopulations to identify trends in current cigarette smoking prevalence.Results. Five metapatterns emerged: we found (1) a large increase and subsequent decrease in overall smoking over the past 15 years, (2) a steep decline in smoking among Blacks through the early 1990s, (3) a gender gap reversal among older adolescents and young adults who smoked over the past 15 years, (4) similar trends in smoking for most subgroups since the early 1990s, and (5) a large decline in smoking among young adults with less than a high school education.Conclusions. Long-term patterns for adolescent and young adult cigarette smoking were decidedly nonlinear, and we found evidence of a cohort effect among young adults. Continued strong efforts and a long-term societal commitment to tobacco use prevention are needed, given the unprecedented declines in smoking among most subpopulations since the mid- to late 1990s.Cigarette smoking has long been recognized as having high mortality, morbidity, and economic costs.1^–6 Because of the addictive nature of nicotine,3^,7 preventing cigarette smoking is an especially important societal goal.4^,8 Most regular smokers smoke their first cigarette by age 18 years,9^–11 although there is some evidence that the age of initiation may be increasing.9^,11 Because smoking initiation rarely occurs at later ages, the critical time for prevention occurs in adolescence and early adulthood.4^,9^–13After a sharp increase in adolescent and young adult smoking that began during the late 1980s, there was a rapid and unprecedented decline in prevalence, especially among adolescents, beginning in the mid-to late 1990s.9^,14^,15 Most surveys suggest that adolescent prevalence has slowed or leveled off over the past few years.11^,14^,15Examining long-term trend data among adolescents and young adults can serve several purposes. Long-term trend data can help assess the effectiveness of past and existing prevention activities, assess the need for future prevention efforts, and predict the future burden of tobacco-related health effects.16 Building on previous national trend studies,3^,12^–26 we used smoothing techniques and regression analyses to comprehensively describe overall and subgroup-specific long-term cigarette smoking trends and to identify meta-patterns among adolescents and young adults in the United States.     

Snus Use and Smoking Behaviors: Preliminary Findings From a Prospective Cohort Study Among US Midwest Young Adults

The effect of snus use on smoking behaviors among US young adults is largely unknown. Data from the Minnesota Adolescent Community Cohort Study collected in 2010 to 2011 and 2011 to 2012 (participants aged 20–28 years) showed that young adult nonsmokers who had tried snus were subsequently more likely than those who had not tried snus to become current smokers (n = 1696; adjusted odds ratio = 1.79; 95% confidence interval = 1.01, 3.14). Snus use was not associated with subsequent smoking cessation or reduction among young adult current smokers (n = 488; P > .46).Tobacco use is the leading preventable cause of death in the United States.1 Snus, made of finely cut smokeless tobacco leaves packaged in small bags, was recently introduced in the United States and sales reached more than 1 million pounds in 2011.2 Swedish studies found that snus use was not associated with smoking initiation but was positively associated with smoking cessation.3,4 However, a US study showed that the effect of snus use in Sweden is unlikely to be replicated in the United States, at least on smoking cessation.5To date, no longitudinal studies have examined whether snus use promotes smoking among nonsmokers, or cessation among smokers, in young adults in the United States, who are still developing their tobacco use behaviors and have the highest prevalence of smoking in all ages.6,7 We used data collected from the Minnesota Adolescent Community Cohort Study to examine if snus use was associated with progression of smoking among young adult nonsmokers and smoking cessation and reduction among young adult current smokers.     

Longitudinal Investigation of Smoking Initiation and Relapse Among Younger and Older US Military Personnel

Objectives. We examined whether military service, including deployment and combat experience, were related to smoking initiation and relapse.Methods. We included older (panel 1) and younger (panel 2) participants in the Millennium Cohort Study. Never smokers were followed for 3 to 6 years for smoking initiation, and former smokers were followed for relapse. Complementary log-log regression models estimated the relative risk (RR) of initiation and relapse by military exposure while adjusting for demographic, health, and lifestyle factors.Results. Deployment with combat experience predicted higher initiation rate (panel 1: RR = 1.44; 95% confidence interval [CI] = 1.28, 1.62; panel 2: RR = 1.26; 95% CI = 1.04, 1.54) and relapse rate (panel 1 only: RR = 1.48; 95% CI = 1.36, 1.62). Depending on the panel, previous mental health disorders, life stressors, and other military and nonmilitary characteristics independently predicted initiation and relapse.Conclusions. Deployment with combat experience and previous mental disorder may identify military service members in need of intervention to prevent smoking initiation and relapse.Reducing tobacco use disparities is a high public health priority.1 The available evidence has shown that US military service members use tobacco more than the general population. The prevalence of smoking within the past 30 days among members of the US military in 2011 was estimated at 24.5%, exceeding the US adult population prevalence of 19.0%, as estimated from the National Health Interview Survey.2,3 These disparities result in serious consequences for US military personnel. Tobacco use accounts for at least 16% of all deaths among current and former US military personnel and 10% of hospital bed days in US Department of Defense health care facilities.4 In addition, tobacco use is associated with poorer job productivity. Specifically, 14.1% of lost workdays among military men and 3.0% among women can be attributed to smoking.5 Tobacco use by servicemembers may also set the stage for a lifetime of use that results in substantial morbidity and lost productivity and millions of years of potential life lost.6One approach to reducing tobacco use disparities among military personnel is to identify higher risk groups for more intensive smoking prevention programs. Although the higher prevalence might be explained by selection factors leading to more smokers entering the military, one investigation found that the prevalence of smoking and use of smokeless tobacco among military personnel on active duty was twice that of new male military recruits, leading the authors to conclude that the military environment in some way promotes tobacco use.7 Reasons for a higher smoking prevalence in the military may include boredom, a desire to maintain weight within standards, a military culture that promotes tobacco use, peer influences, coping strategy for mental health symptoms, deployment experiences, and stress reduction.8–14Longitudinal research on predictors of smoking initiation and relapse in military populations is sparse. Using data from the Millennium Cohort Study, we previously reported a higher risk of smoking initiation associated with deployment with combat exposure and relapse associated with any deployment.15 The initial participants who had never smoked were generally older than the usual age at smoking initiation and had considerable military experience, with 36% having been deployed to conflicts before the initiation of operations in Afghanistan and Iraq. Although most smokers have initiated smoking by age 18 years, an increasing proportion are initiating smoking between ages 18 and 29 years.16,17 The Millennium Cohort Study has subsequently recruited younger participants with little military experience (≤ 2 years) and can better address both smoking initiation in the age ranges in which adoption of this habit is more common and military exposures assessed longitudinally after enrollment into the study. We assessed risk factors associated with smoking initiation and relapse in both younger and older participants in the Millennium Cohort Study by examining military, mental health, and other characteristics associated with these outcomes.     

Patterns of Cigarette Smoking Initiation in Two Culturally Distinct American Indian Tribes

Objectives. To better understand patterns of initiation among American Indians we examined age-related patterns of smoking initiation during adolescence and young adulthood in 2 American Indian tribes. Methods. We used log-rank comparison and a Cox proportional hazard regression model to analyze data from a population-based study of Southwest and Northern Plains American Indians aged 18 to 95 years who initiated smoking by age 18 years or younger.Results. The cumulative incidence of smoking initiation was much higher among the Northern Plains Indians (47%) than among the Southwest Indians (28%; P < .01). In the Southwest, men were more likely than women to initiate smoking at a younger age (P < .01); there was no such difference in the Northern Plains sample. Northern Plains men and women in more recent birth cohorts initiated smoking at an earlier age than did those born in older birth cohorts. Southwest men and women differed in the pattern of smoking initiation across birth cohorts as evidenced by the significant test for interaction (P = .01).Conclusion. Our findings underscore the need to implement tobacco prevention and control measures within American Indian communities.Smoking rates in the US population have declined overall in the past several decades, from a high of 42% in 1960 to an estimate of 21% in 2007.¹ However, this decline has not been observed among all racial/ethnic groups nor among all age groups. The prevalence of smoking among American Indians and Alaska Natives, for example, is greater than 50% in many communities, roughly 2.5 times the prevalence in the US general population.^2–7 Furthermore, over the past 3 decades, rates of smoking have been rising in some tribal communities that have historically low rates,^2,8 roughly paralleling the increases in smoking-related diseases, including lung cancer and respiratory and cardiovascular diseases, in American Indians and Alaska Natives.^9,10 Smoking also contributes to the observation that American Indians and Alaska Natives trail only African Americans in years of potential life lost,¹¹ a key indicator of population health. Finally, adverse health outcomes associated with smoking are adding inordinately high health care costs to a dramatically underfunded Indian Health Service.¹²One of the key factors linked to nicotine dependence is age of smoking initiation. Studies have shown that an earlier age of smoking initiation is related to current and daily smoking^13,14 and that the transition from smoking initiation to established smoking generally takes 2 to 3 years.^15,16 However, a more recent study among a cohort of sixth graders reported that youth were susceptible to a rapid loss of autonomy over tobacco. This occurred within 1 or 2 days of first inhalation, and dependency was likely to appear before reaching a consumption rate of 2 cigarettes per day.¹⁷ In addition, smokers who begin smoking at younger ages are more likely than those starting later to develop nicotine dependence, thus making quitting more difficult.^13,14,18Studies among African Americans have revealed major declines in smoking prevalence among adolescents during the 1980s, which were offset by increased initiation among young adults during this period.¹⁹ Such data helped to enhance public health efforts to promote cessation and discourage initiation among African Americans. However, little is known about patterns of smoking initiation among American Indians and Alaska Natives. In a recent survey of South Dakota high school students, more than 45% of American Indian adolescents who were smoking reported starting to smoke before the age of 13 years.²⁰ To better understand the patterns of smoking initiation among American Indians, we conducted a study that examined the age of smoking initiation in 2 culturally distinct American Indian tribal groups across birth cohorts.     

Changes in Age Trajectories of Smoking Experimentation During the California Tobacco Control Program

Objectives. We aimed to investigate population-level changes in smoking initiation during California''s Tobacco Control (CTC) Program from 1990 to 2005, a period during which tobacco industry marketing practices also changed.Methods. We used a discrete time survival analysis of data from the California Tobacco Survey to model changes in age of first smoking experimentation across birth cohorts.Results. Smoking initiation patterns were stable across cohorts aged 9 years or older at the start of the CTC program. For children entering preadolescence since 1990, initiation declined with each more recent cohort. By 2005, the observed decline in experimentation was 80% for male participants and 92% for female participants at age 12 to 14 years; by age 15 to 17 years, 10% of Californian adolescents had experimented in 2005 compared with 45% in preprogram cohorts. However, rates of new experimentation after age 17 years did not change, except for a recent increase in late experimentation (after age 20 years) among young adult men.Conclusion. Our models suggest that the CTC program greatly reduced adolescent smoking initiation among younger adolescents. Late experimentation may have recently increased among young adult men in California, coincident with an increase in tobacco industry marketing aimed at young adults.Since the 1960s, adolescent smoking rates have changed in response to the competing influences of tobacco industry marketing campaigns^1–3 and public health tobacco control programs.^4,5 Reducing adolescent smoking has been a primary goal of the California Tobacco Control (CTC) Program,⁶ the longest-running large tobacco control program in the world. As an evaluation component, this program sponsors a population survey of tobacco use every 3 years. Previous survey estimates indicated that the CTC Program was associated with a lower age-specific prevalence of smoking from age 12 years, which was probably a consequence of reduced experimentation.⁵ However, it is not clear whether these age-specific changes led to an overall reduction in lifetime smoking initiation within a birth cohort, especially given the apparent effectiveness of recent tobacco advertising targeting young adults. We investigated changes in the trajectories of smoking experimentation across the age window of 10 to 24 years, in which almost all first experimentation has been documented to occur.⁷Previously, an age-period-cohort model⁸ identified that smoking experimentation for California was stable for cohorts born before 1979. Subsequent cohorts, those aged 12 years or younger when the California program started in 1990, had lower experimentation levels on average over the adolescent years. However, the model in that analysis used additive effects for age, period, and cohort, with the consequence that, for example, changes in experimentation rates at a given time were averaged across cohorts and ages. Period and cohort effects, which can identify time changes, applied equally across all ages. Thus, that analysis was unable to identify changes in smoking uptake at specific ages within the age window of 10 to 24 years. This may be of concern, because other interventions that reduced smoking in early adolescence were shown to not be associated with reduced smoking in later years.^9,10 In addition, there is specific concern that tobacco industry marketing campaigns have changed to target young adults, and this may have increased rates of smoking initiation in young adulthood.¹¹Recent contributions to the methodologic literature^12–17 have addressed shortcomings of age-period-cohort models in identifying age- and period-specific effects.^18,19 Incorporating suggestions from this literature, we modeled age-specific changes in the trajectory of smoking initiation among young Californians from 1990 to 2005. We hypothesized that age-specific changes have occurred in the pattern of smoking uptake among recent birth cohorts.     

Financial Strain and Smoking Cessation Among Racially/Ethnically Diverse Smokers

Objectives. We evaluated the influence of financial strain on smoking cessation among Latino, African American, and Caucasian smokers of predominantly low socioeconomic status.Methods. Smokers enrolled in a smoking cessation study (N = 424) were followed from 1 week prequit through 26 weeks postquit. We conducted a logistic regression analysis to evaluate the association between baseline financial strain and smoking abstinence at 26 weeks postquit after control for age, gender, race/ethnicity, educational level, annual household income, marital status, number of cigarettes smoked per day, and time to first cigarette of the day.Results. Greater financial strain at baseline was significantly associated with reduced odds of abstinence at 26 weeks postquit among those who completed the study (odds ratio [OR] = 0.77; 95% confidence interval [CI] = 0.62, 0.94; P = .01). There was a significant association as well in analyses that included those who completed the study in addition to those lost to follow-up who were categorized as smokers (OR = 0.78; 95% CI = 0.64, 0.96; P = .02).Conclusions. Greater financial strain predicted lower cessation rates among racially/ethnically diverse smokers. Our findings highlight the impact of economic concerns on smoking cessation and the need to address financial strain in smoking cessation interventions.An estimated 30.6% of US adults living in poverty smoke cigarettes, as compared with 20.4% of those living above the poverty level.¹ Current economic conditions in the United States will likely lead to increased financial strain for many smokers, particularly those of low socioeconomic status (SES). The ongoing global financial crisis and economic recession are expected to force millions of Americans into poverty as a result of increased unemployment rates and reduced availability of government assistance.²Furthermore, the increases in the US federal excise tax on tobacco implemented in April 2009, in combination with existing state tobacco excise taxes, have resulted in a significant rise in the cost of cigarettes. Although increases in cigarette pack prices have historically contributed to reductions in smoking prevalence rates, research suggests that increased taxation has had a declining influence on smoking in recent years.³ Moreover, there is evidence that increases in cigarette prices are associated with the purchase of cigarettes with higher tar and nicotine yields.⁴There is emerging evidence that financial strain may have an undesirable impact on tobacco use. Specifically, financial strain is associated with current smoking as well as greater daily cigarette consumption and smoking relapse.^5,6 Furthermore, smokers and individuals living in smoking households report greater financial strain than nonsmokers and those living in nonsmoking households.^7,8 The expense of smoking has been shown to “crowd out” other expenditures, including those associated with basic necessities.^9,10 Plausibly, this situation may lead to further increases in both financial strain and cigarette smoking. Thus, the current economic climate has made it increasingly important to characterize the association between financial strain and smoking, particularly within low-SES populations.Although a link between financial strain and smoking prevalence has been established, little is known about the impact of financial strain on smoking cessation. Low-SES smokers are as likely as smokers of higher SES to attempt smoking cessation, but they are less likely to quit successfully.¹¹ The economic recession and increased taxation on cigarettes may place a disproportionate financial burden on low-SES smokers, who may have difficulty quitting as a result of high levels of nicotine dependence,¹² reduced access to smoking cessation resources,¹³ and a variety of other factors.Recent findings from a large-scale national study in Australia indicated that smokers facing greater financial strain were less likely to quit smoking over a 1-year period, and financially strained ex-smokers were more likely to relapse over 1 year.¹⁴ In another study, ex-smokers were more likely to relapse after an involuntary job loss (possibly indicating greater financial strain).⁵ However, little is known about the impact of financial strain on a specific quit attempt among smokers receiving smoking cessation treatment. Studies have indicated that financial strain decreases after smoking cessation and that quitters experience less financial strain than those who have not quit.^15,16 Thus, quitting may attenuate smoking-related financial strain among low-SES smokers.In this study, we sought to characterize the influence of financial strain on smoking cessation among smokers of primarily low SES and diverse racial/ethnic backgrounds. We hypothesized that smokers who reported greater financial strain prior to the initiation of smoking cessation treatment would have lower cessation rates. To the best of our knowledge, this is the first study to examine the impact of financial strain on smoking cessation during a specific quit attempt in a racially/ethnically diverse sample of smokers.     

Quit attempts and quit rates among menthol and nonmenthol smokers in the United States

Objectives. We compared quit attempts and quit rates among menthol and nonmenthol cigarette smokers in the United States.Methods. We used data from the 2003 and 2006–2007 waves of the large, nationally representative Tobacco Use Supplement to the Current Population Survey with control for state-level tobacco control spending, prices, and smoke-free air laws. We estimated mean prevalence, quit rates, and multivariate logistic regression equations by using self-respondent weights for menthol and nonmenthol smokers.Results. In 2003 and 2007, 70% of smokers smoked nonmenthol cigarettes, 26% smoked menthol cigarettes, and 4% had no preference. Quit attempts were 4.3% higher in 2003 and 8.8% higher in 2007 among menthol than nonmenthol smokers. The likelihood of quitting was 3.5% lower for quitting in the past year and 6% lower for quitting in the past 5 years in menthol compared with nonmenthol smokers. Quit success in the past 5 years was further eroded among menthol-smoking Blacks and young adults.Conclusions. Menthol smokers are more likely to make quit attempts, but are less successful at staying quit. The creation of menthol preference through marketing may reduce quit success.On June 22, 2009, the Family Smoking Prevention and Tobacco Control Act was signed into law, granting the US Food and Drug Administration (FDA) the authority to regulate tobacco products by establishing the Center for Tobacco Products (CTP). As one of the first activities of the CTP, the FDA will review evidence on the impact of menthol in cigarettes on the public health to determine whether to recommend removal of mentholated cigarettes from the US market. Regarding the process of making decisions for a proposed ban on menthol in cigarettes, the act specifies that scientific evidence be considered with a broad population-based standard rather than a narrow individual standard. Specifically, the CTP must consider (1) the risks and benefits to the population as a whole, including users and nonusers of tobacco products, (2) the increased or decreased likelihood that existing users of tobacco products will stop using such products, and (3) the increased or decreased likelihood that those who do not use tobacco products will start using such products.¹In 2008, more than one third (33.9%) of past-month smokers aged 12 years and older reported smoking menthol cigarettes²; this rate equates to more than 10 million menthol smokers in the United States.³ The prevalence of menthol cigarette use is highest among Black smokers (82.6%) and young smokers (44.8%)²—2 groups that have been the target of menthol cigarette marketing by the tobacco industry.^4–6 Studies of youths indicate that menthol flavoring affects smoking initiation, with higher proportions of recent initiates smoking mentholated cigarettes compared with those who have been smoking more than 1 year,^2,7 and that middle-school smokers are more likely to smoke menthol cigarettes than are high-school smokers.⁷Recent research also suggests that smoking menthol cigarettes negatively influences smoking cessation among adults. One randomized controlled study showed no difference in 7-day point prevalence abstinence between menthol and nonmenthol smokers at 6 months,⁸ but 2 other studies^9,10 reported reduced cessation among menthol smokers, though results were not consistent across all follow-up time points. Of 5 population studies examining differences in smoking cessation by menthol cigarette use,^11–15 the 2 more recent studies reported significantly lower quit rates among menthol smokers compared with nonmenthol smokers at follow-up.^13,15 Gandhi et al.¹⁵ and Gundersen et al.¹³ also highlighted reduced cessation among Black and Latino menthol smokers. Few studies have explored the impact of menthol cigarette use on smoking cessation in large population-based studies. We used a large, recent national- and state-representative data set to examine quit rates among menthol and nonmenthol cigarette smokers. Unlike previous population studies, we explicitly considered the role of quit attempts and also controlled for the state tobacco control policies.     

Association of smoking cessation with financial stress and material well-being: results from a prospective study of a population-based national survey

Objectives. We used 4 waves of prospective data to examine the association of smoking cessation with financial stress and material well-being.Methods. Data (n = 5699 at baseline) came from 4 consecutive waves (2001–2005) of the Household Income and Labour Dynamics in Australia survey. We used mixed models to examine the participant-specific association of smoking cessation with financial stress and material well-being.Results. On average, a smoker who quits is expected to have a 25% reduction (P<.001; odds ratio [OR]=0.75; 95% confidence interaval [CI]=0.69, 0.81) in the odds of financial stress. Similarly, the data provided strong evidence (P<.001) that a smoker who quits is likely to experience an enhanced level of material well-being.Conclusions. Our findings indicate that interventions to encourage smoking cessation are likely to improve standards of living and reduce deprivation. The findings provide grounds for encouraging the social services sector to incorporate smoking cessation efforts into their programs to enhance the material or financial conditions of disadvantaged groups. The findings also provide additional incentives for smokers to stop smoking and as such can be used in antismoking campaigns and by smoking cessation services.Tobacco smoking in Australia is estimated to kill over 19000 people each year and is responsible for about 10% of the entire national burden of disease and injury.1 The social costs of smoking (e.g., loss of national productive capacity and health care cost) were estimated to be over Aus $21 billion (about US $18.6 billion) during 1998 to 1999.2 Smoking has also been linked to deteriorated standards of living and financial stress in Australia and elsewhere.3^–6 Although many studies have shown the health benefits of smoking cessation, even for people 65 years or older,7^–9 there are no published prospective reports of the financial consequences of cessation.Several studies, however, have focused on the consequences of financial stress and hardship in terms of smoking behavior. Graham used cross-sectional and qualitative data from a sample of working class mothers in the United Kingdom and reported that the major reason for relapse after cessation was difficulty coping with everyday problems and stress, including financial stress.10 She concluded that restricted access to material resources (income, employment, adequate housing, and the items needed to maintain a reasonable standard of living) hinders smoking cessation. Dorsett and Marsh used longitudinal data from a sample of single mothers in the United Kingdom and reported that smoking provides an affordable palliative for stress and that financial hardship was the main barrier to cessation. Hardship was referred to as the experience of financial anxiety, being in debt that cannot be paid off easily, and not being able to afford essential consumer items such as food and clothing.11 Similarly, Siah-push and Carlin used national data from 2 waves of a longitudinal study in Australia and reported that smokers who had more financial stress (e.g., difficulty paying electricity, gas, or telephone bills; going without meals because of a shortage of money) were less likely to quit and that ex-smokers who had more financial stress were more likely to relapse than those without stress.5 We used 4 waves of prospective data from a national sample in Australia to examine the longitudinal effect of smoking cessation on the likelihood of financial stress and levels of material well-being.     

Characteristics of physically active smokers and implications for harm reduction

Objectives. We sought to establish the prevalence of physical activity among smokers, whether or not physically active smokers were more likely to attempt cessation, and who these physically active smokers were.Methods. We used logistic regression to contrast physically active and inactive smokers in a secondary data analysis of the Canadian Community Health Survey Cycle 1.1.Results. Physically active smokers represented almost one quarter of the smoking population. Compared with physically inactive smokers, physically active smokers were more likely to have attempted cessation in the past year. Physically active smokers were more likely to be young, single, and men compared with their inactive counterparts. Income had no influence in distinguishing physically active and inactive smokers.Conclusions. Skepticism persists regarding the practicality and potential risks of promoting physical activity as a harm-reduction strategy for tobacco use. We found that a modest proportion of the daily smoking population was physically active and that engagement in this behavior was related to greater cessation attempts. Interventions could be developed that target smokers who are likely to adopt physical activity.Recent evidence has suggested that physical activity could act as a potential tobacco harm-reduction strategy for smokers.1 Although we have shown in previous work that physical activity fulfills several criteria that guide the development of potential tobacco harm-reduction strategies, skepticism remains regarding its practicality.1 The majority of the North American population does not fulfill the current public health recommendations for physical activity.2^,3 Because smokers have a tendency to participate in less physical activity compared with nonsmokers,4^–6 it is unclear how practical it would be to promote physical activity as a harm-reduction strategy.An additional concern associated with the adoption of physical activity as a potential harm-reduction strategy is the possibility that physical activity may unintentionally result in a delay in cessation. If smokers perceive physical activity as an effective strategy for reducing smoking-related morbidity and mortality, cessation attempts could be deferred or neglected.7 This would undermine the long-term goal of harm reduction: complete smoking cessation.8To maximize the effectiveness of physical activity as a tobacco harm-reduction strategy, physical activity must be promoted and advocated to those smokers most likely to adopt and maintain it. If smokers have no interest in becoming physically active, any effort to promote physical activity would be ineffective. The success of public health interventions that promote physical activity among smokers will be dependent upon the ability of health professionals to identify and target those smokers likely to participate in physical activity on a regular basis.If physical activity is to be regarded as an effective tobacco harm-reduction strategy, these concerns need to be addressed. Therefore, we sought to answer 3 specific questions: (1) What is the prevalence of physically active smokers within the smoking and general population? (2) Are physically active smokers more likely to attempt smoking cessation? (3) Which demographic characteristics differentiate physically active smokers from physically inactive smokers? Some answers to these questions were provided by Ward et al.,9 who examined characteristics of highly physically active and less physically active smokers in a sample of military recruits. They concluded that highly physically active smokers were more likely to be young men who earned higher family incomes, consumed more fruits and vegetables, were less dependent on nicotine, and were more likely to achieve cessation for a minimum of 24 hours compared with less physically active smokers.However, several limitations were identified in the study conducted by Ward et al. that may have influenced the results. Reliance on a sample of military recruits may have limited the generalizability of the results.9 Also, the assessment of physical activity levels by a single question may not have been as accurate as measuring frequency, duration, and intensity of specific physical activities. Thus, misclassification of physical activity levels may have occurred.9 We addressed these limitations by comparing physically active and inactive smokers with a more detailed measure of physical activity and a nationally representative sample of Canadians to provide further insight into the role of physical activity as a tobacco harm-reduction strategy.     

Efficacy of Initiating Tobacco Dependence Treatment in Inpatient Psychiatry: A Randomized Controlled Trial

Objectives. We evaluated the efficacy of a motivational tobacco cessation treatment combined with nicotine replacement relative to usual care initiated in inpatient psychiatry.Methods. We randomized participants (n = 224; 79% recruitment rate) recruited from a locked acute psychiatry unit with a 100% smoking ban to intervention or usual care. Prior to hospitalization, participants averaged 19 (SD = 12) cigarettes per day; only 16% intended to quit smoking in the next 30 days.Results. Verified smoking 7-day point prevalence abstinence was significantly higher for intervention than usual care at month 3 (13.9% vs 3.2%), 6 (14.4% vs 6.5%), 12 (19.4% vs 10.9%), and 18 (20.0% vs 7.7%; odds ratio [OR] = 3.15; 95% confidence interval [CI] = 1.22, 8.14; P = .018; retention > 80%). Psychiatric measures did not predict abstinence; measures of motivation and tobacco dependence did. The usual care group had a significantly greater likelihood than the intervention group of psychiatric rehospitalization (adjusted OR = 1.92; 95% CI = 1.06, 3.49).Conclusions. The findings support initiation of motivationally tailored tobacco cessation treatment during acute psychiatric hospitalization. Psychiatric severity did not moderate treatment efficacy, and cessation treatment appeared to decrease rehospitalization risk, perhaps by providing broader therapeutic benefit.Tobacco use among persons with mental illness is 2 to 4 times as great as among the general US population, with costly and deadly consequences.1–3 Persons with serious mental illness have an average life expectancy 25 years shorter than in the general population; the chief causes of death are chronic tobacco-related diseases such as cardiovascular disease, lung disease, and cancer.4 Annually, 200 000 of the 435 000 deaths in the United States attributed to smoking are believed to be among individuals with mental illness or addictive disorders.5Despite the significant health effects, smoking remains ignored or—even worse—encouraged in mental health settings.6,7 A minority of patients with mental illness report that a mental health provider has advised them to quit smoking, and some report active discouragement of quitting.8,9 Staff at some psychiatric hospitals still smoke with patients, rationalized as effective for building clinician–client rapport.10Since 1993, US hospitals have banned tobacco use under mandate of the Joint Commission on the Accreditation of Healthcare Organizations.11 In response to outcries from patient advocacy groups, however, the commission permitted an exception for inpatient psychiatry; similar policy exemptions have been granted to psychiatric facilities in Europe and Australia.12–14 Nearly 20 years later, more than half of state inpatient psychiatry units in the United States permit smoking, and half sell cigarettes to patients.15 Even among hospitals that ban tobacco use, cessation advice and treatment are rare.15,16 Without intervention, almost all patients return to smoking after a smoke-free psychiatric hospitalization, most within minutes of hospital discharge.8 Integrated treatments are needed.Nearly 8800 studies inform tobacco treatment clinical practice guidelines,17 and an extensive literature documents the efficacy of initiating treatment of tobacco dependence in hospital settings with general medical patients.18 Yet fewer than 2 dozen randomized clinical trials have treated smoking in persons with current mental illness,19 and the only published randomized trial examining inpatient psychiatry for initiating tobacco treatment was conducted with adolescents. The intervention group increased in motivation to quit, but the treatment effect on abstinence was not significant.20 The American Psychiatric Association identifies psychiatric hospitalizations as an ideal opportunity to treat tobacco dependence.21 Hospital-based tobacco treatment trials with the seriously mentally ill are needed to inform clinical practice guidelines.An obstacle to tobacco treatment in mental health settings has been concern that termination of cigarette smoking will increase psychiatric symptoms. Many in the clinical, research, and public arenas believe that tobacco use serves as a form of self-medication for persons with psychiatric disorders.22,23 If this were true, psychiatric symptoms would be expected to worsen and mental health service use to increase following treatment of tobacco use. Tobacco treatment trials with smokers with clinical depression, posttraumatic stress disorder, and schizophrenia, however, have demonstrated no adverse effect of treating tobacco dependence or of quitting smoking on mental health recovery.24–29Research has not examined the impact of treating tobacco dependence during an acute psychiatric hospitalization on mental health recovery. Patients for whom inpatient psychiatric care is deemed necessary typically present as suicidal, homicidal, or gravely disabled. The average length of inpatient psychiatric stay in the United States is about a week, and readmissions are common.8,16 Among patients hospitalized for mental illness in California in 2005 and 2006, 44% were rehospitalized within 12 months, reflecting the remitting and recurring natural course of many mental illnesses.30 In the literature, predictors of psychiatric hospitalization include psychosis, race/ethnicity (higher for African Americans), low socioeconomic status, and previous hospitalizations.24,31We evaluated the efficacy of a tobacco cessation intervention initiated with adult smokers during an acute inpatient psychiatric hospitalization. The setting was a locked unit with a complete smoking ban that managed patients’ nicotine withdrawal with nicotine replacement therapy (NRT) during hospitalization but did not provide cessation services, discharge NRT, or treatment referrals. Hospitalization in the acute psychiatric setting tends to be brief and unrelated to smoking. Furthermore, few patients hospitalized for psychiatric illness intend to quit smoking in the next 30 days.8,32,33 For this reason, we focused on increasing motivation and engagement during a brief period of institutionalized abstinence and offered cessation treatment and access to 10 weeks of NRT up to 6 months following hospital discharge.Our primary hypothesis was that participants randomized to the smoking cessation intervention would achieve greater 7-day point prevalence tobacco abstinence over 18 months after hospitalization than participants randomized to the usual care control condition. We examined psychiatric variables predictive of cessation success or failure. Our secondary aim was to assess the impact of the tobacco cessation intervention on mental health recovery and prediction of rehospitalization over the 18-month study follow-up, with adjustment for relevant clinical covariates.     

Use of consumer survey data to target cessation messages to smokers through mass media

Objectives. We identified the mass media channels that reach the most cigarette smokers in an attempt to more effectively target smoking cessation messages.Methods. Reach estimates and index scores for smokers were taken from 2002–2003 ConsumerStyles and HealthStyles national surveys of adults (N=11660) to estimate overall and demographic-specific exposure measures for television, radio, newspapers, and magazines.Results. Smokers viewed more television, listened to more radio, and read fewer magazines and newspapers than did nonsmokers. Nearly one third of smokers were regular daytime or late-night television viewers. Selected cable television networks (USA, Lifetime, and Discovery Channel) and selected radio genres, such as classic rock and country, had high reach and were cost-efficient channels for targeting smokers.Conclusions. Certain mass media channels offer efficient opportunities to target smoking cessation messages so they reach relatively large audiences of smokers at relatively low cost. The approach used in this study can be applied to other types of health risk factors to improve health communication planning and increase efficiency of program media expenditures.One of the basic principles of communication planning is to understand audiences better; doing so makes it possible to develop messages most likely to resonate with target audiences and reach them more frequently.1^,2 Audience segmentation is one of the core tools that enables communication and marketing planners to better understand their audiences.3^,4 One objective of audience segmentation is to identify the communication channels through which an audience receives information.5^,6 Knowledge of communication channels is especially important given the resource constraints typical in public health communication and social marketing efforts and the increasing fragmentation of media channels.3^,7 Investing time and resources in delivering messages through channels inappropriate or inefficient for reaching intended audiences is economically wasteful and unlikely to have the intended effect.1^,2^,8Surprisingly, to our knowledge no published studies have addressed the communication channels through which cigarette smokers regularly receive information, and whether channels used by smokers differ from those used by nonsmokers. Furthermore, it is not known if communication channels differ among subgroups of smokers (e.g., by demographic characteristics). If smokers pay attention to distinctive communication channels, mass media efforts designed to increase the use of cessation services, such as telephone quit lines can be better planned to target those distinctive channels.From a communication or marketing planning perspective, it is more important to know the size of the intended audience that could be exposed to messages (reach) than the extent of smoking among specific channel users (prevalence). For example, if a television show had a smoking prevalence among viewers of 15% but attracted 40% of all smokers (reach), the potential effect of a cessation message would be fairly large compared with a show for which 50% of viewers were smokers (prevalence) but who constituted only 1% of all smokers (reach). The cost for placing mass media advertisements, as well as the likelihood that a media company would permit the placement of an unpaid message such as a public service announcement, is directly related to reach: mass communication companies charge higher advertising rates to reach audiences with larger numbers of people.9 The cost for running a 30-second advertisement during the Super Bowl can exceed $2 million because of the overall large audience size10; however, this is not likely to be the most cost-efficient approach to expose smokers to cessation ads, especially given the limited budgets for many tobacco control programs.We used a nationally representative survey to examine measures of mass media channel use among respondents who smoke and respondents who don’t smoke cigarettes. The mass media channels included preferred television genres, networks, and programs; preferred radio genres; newspaper use; and magazines read regularly. Additionally, we compared mass media exposure measures by smoking status and stratified by age, gender, and race/ethnicity.