Youth targeting by tobacco manufacturers since the Master Settlement Agreement

The 1998 Master Settlement Agreement (MSA) between tobacco manufacturers and forty-six states bans manufacturers from targeting minors through advertising. To determine how youth targeting in magazine cigarette advertisements changed after the MSA, we analyzed magazine readership and cigarette ads in U.S. magazines from 1997 to 2000. In 2000 all three major manufacturers (Philip Morris, R.J. Reynolds, and Brown and Williamson) failed to comply with the MSA's youth-targeting ban, selectively increasing their youth targeting. Banning all magazine advertising of cigarettes may be necessary to eliminate youth targeting in magazines.     

The effect of the 1998 Master Settlement Agreement on prenatal smoking

The Master Settlement Agreement (MSA) between the major tobacco companies and 46 states created an abrupt 20% increase in cigarette prices in November 1998. Earlier estimates of the elasticity of prenatal smoking implied that the price rise would reduce prenatal cigarette smoking by 7-20%. Using birth records on 9.8 million US births between January 1996 and February 2000, we examined the change in smoking during pregnancy and conditional smoking intensity in response to the MSA. Overall, adjusting for secular trends in smoking, prenatal smoking declined by less than half what was predicted in response to the MSA.     

Cost-effectiveness of hospital vaccination programs in North Carolina

Although influenza and pneumonia are largely vaccine-preventable, vaccination coverage rates are well below Healthy People 2010 goals. The aim of this study was to examine the costs and cost-effectiveness of three provider-based vaccination interventions in the hospital setting: standing orders programs (SOPs), physician reminders (PRs), and pre-printed orders (PPOs). Data on program operating costs and the numbers of patients who received influenza or pneumococcal vaccinations were collected from nine North Carolina hospitals. Results demonstrated that the additional cost per patient vaccinated in 2004 was US dollars 58 for SOPs, US dollars 90 for PRs, and US dollars 412 for PPOs. These findings suggest that SOPs are a cost-effective approach for increasing adult vaccination coverage rates in hospital settings.     

Funding for programs continues through March 15

A January 27, 1996 continuing resolution funds AIDS care and housing programs through March 15, 1996. This stopgap spending bill keeps government programs running at the fiscal year 1995 level, but does not indicate how much money will be allocated for individual titles or acts. The Housing Opportunities for People with AIDS (HOPWA) program will be funded through March 15, proportionate to six weeks of annual funding at the $171 million level previously approved by the House and Senate.     

Sexual Imagery in Cigarette Advertising Before and After the Master Settlement Agreement

This study examines how the sexual imagery in cigarette magazine advertisements changed as a result of the 1998 Master Settlement Agreement (MSA). After conducting a content analysis of 657 unduplicated cigarette ads from 1994 to 2003, our results revealed that cigarette advertisements featuring suggestive/partially clad female models increased significantly from the pre-MSA period (16.0%) to the post-MSA period (24.9%). In addition, we provide empirical evidence that there was an overall increase in sexually explicit cigarette advertising after the MSA. Several implications for policymakers are discussed in detail.     

Effectiveness of school programs in tobacco control

The authors reviewed published data dealing with the effectiveness of school programs in tobacco control. Most of the evaluated school programs showed at least partial effect including namely improved knowledge level, decreased prevalence of smoking initiation and continuation. Less successful was achieving of behavioural changes and social resistance. Effect of the school programs can be significantly amplified by combination with other interventions such as mass media campaigns, parent involvement and extracurricular activities. The main problem of the studies in this field is a relatively short follow-up time not allowing considering findings as relevant evidences for long-term effects of school programs. However, even assuming only time limited decrease of prevalence of smoking among intervened students, such temporary effect leads to the decrease of a lifetime cigarette exposure having beneficial health effects. Considering social, demographic and cultural aspects of the epidemiology of smoking habit, evidence based data in this field, relevant for Central and Eastern Countries, are required. Such situation calls for authentic trials and studies respecting specific conditions in these countries.     

An examination of after school care programs in North Carolina Public Schools

Educators have become increasingly concerned about the large number of children who must provide for their own care before and/or after school hours. The mounting evidence that at least some of these “latchkey” children are harmed by such circumstances has led many public school systems to develop After School Care Programs (ASCP). Because North Carolina has the nation's highest percentage of mothers working outside of the home, efforts undertaken by this state are of particular significance. Each of the 141 public school systems in North Carolina was surveyed. Based on responses received from 138 of these systems, 48 ASCP were identified. Information is provided on location, population, operational policies, content, personnel, evaluation, and plans for future changes. A review of the literature and a discussion of pertinent issues are also provided.     

A comparison of mental health center operated detoxification programs in North Carolina

The mental health center program in North Carolina provides detoxification services for substance abusers in community-based detoxification programs. Some of these programs are licensed as “social setting” and other as “medical nonhospital.” Evaluation of one medical program and comparison with social setting programs revealed that the cost per bed in the social setting is 58% less, and that the cost for physicians and drugs constitute 17% of the medical detoxification program. However, because of the efficiency of the medical program, the costs per patient treated are comparable. Sixty-nine percent of the patients receive librium in the first 24 h after admission and 26% in the second 24 h in doses of 109 mg and 59 mg, respectively, and 62% required medication other than librium. As judged by the staff, 68% of the patients treated successfully completed the program. Follow-up of patients 30 days after discharge revealed that approximately 50% were in recovery.     

An examination of after school care programs in North Carolina Public Schools

Educators have become increasingly concerned about the large number of children who must provide for their own care before and/or after school hours. The mounting evidence that at least some of these “latchkey” children are harmed by such circumstances has led many public school systems to develop After School Care Programs (ASCP). Because North Carolina has the nation's highest percentage of mothers working outside of the home, efforts undertaken by this state are of particular significance. Each of the 141 public school systems in North Carolina was surveyed. Based on responses received from 138 of these systems, 48 ASCP were identified. Information is provided on location, population, operational policies, content, personnel, evaluation, and plans for future changes. A review of the literature and a discussion of pertinent issues are also provided.     

Correlates of alcohol and tobacco use among Mexican immigrants in rural North Carolina

This study examined the relationship among sociodemographic, cultural, and psychological factors associated with alcohol and tobacco use among Mexican immigrants in the rural south. Questionnaires including sociodemographics, alcohol and tobacco use, acculturation, and stress were administered to 173 Mexican immigrants residing in rural eastern North Carolina. Gender, preimmigration use, and occupational/economic stress were significant predictors for alcohol use, with preimmigration use significant for tobacco use, suggesting that alcohol and tobacco use may be related to previous behavior, rather than acculturation to American society. Stress, setting, and preimmigration substance use would be important factors to address in the immigrant's health history.     

Correlates of tobacco use among Native American women in western North Carolina.

OBJECTIVES: This study examined correlates of tobacco use among Cherokee women. METHODS: Prevalence rates were analyzed for 614 randomly selected Eastern Band Cherokee women. RESULTS: The prevalence rates for current smokeless tobacco use and smoking were 8% and 39%, respectively. Smokeless tobacco use correlates included lower education and having consulted an Indian healer. Smoking correlates included younger age, alcohol use, no yearly physical exam, separated or divorced marital status, and lack of friends or church participation. CONCLUSIONS: Smoking rates among these women were slightly above national rates. The association of smokeless tobacco use with having consulted an Indian healer may help in understanding Cherokee women's smokeless tobacco use.     

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?     

Attempts to undermine tobacco control: tobacco industry "youth smoking prevention" programs to undermine meaningful tobacco control in Latin America

We sought to understand how the tobacco industry uses "youth smoking prevention" programs in Latin America. We analyzed tobacco industry documents, so-called "social reports," media reports, and material provided by Latin American public health advocates. Since the early 1990s, multinational tobacco companies have promoted "youth smoking prevention" programs as part of their "Corporate Social Responsibility" campaigns. The companies also partnered with third-party allies in Latin America, most notably nonprofit educational organizations and education and health ministries. Even though there is no evidence that these programs reduce smoking among youths, they have met the industry's goal of portraying the companies as concerned corporate citizens and undermining effective tobacco control interventions that are required by the World Health Organization Framework Convention on Tobacco Control.     

Total quality management in the delivery of public health services: a focus on North Carolina WIC programs.

Principles of quality improvement have been successfully implemented in the for-profit sector of the United States economy. The purpose of this study is to test the use of quality improvement strategies including development of leadership skills, a focus on internal quality, ongoing training and staff development, and efficient use of resources in the delivery of services in the public sector. The emphasis of this study is strategies for improving the delivery of nutrition education and supplemental foods to high-risk women, infants, and children through a federally funded program called WIC.     

Predictors of incidence and prevalence of green tobacco sickness among Latino farmworkers in North Carolina, USA

STUDY OBJECTIVE: The characteristics of some populations make epidemiological measurement extremely difficult. The objective of this study is to identify risk factors that explain variation among incidence densities and proportions of one occupational illness, green tobacco sickness, within one such special population, Latino migrant and seasonal farmworkers in the United States. DESIGN: Prospective cohort study. SETTING: 37 farmworker residential sites located in Granville and Wake Counties, North Carolina, USA. PARTICIPANTS: 182 migrant and seasonal farmworkers that included 178 Latino men, three Latino women, and one non-Hispanic white man. MAIN RESULTS: Green tobacco sickness had a prevalence of 0.082, and an incidence density of events per 100 days of 1.88 among the farmworkers. Prevalence and incidence density increased from early to late agricultural season. Major risk factors included lack of work experience, work activities, and working in wet clothes. Tobacco use was protective. CONCLUSION: Green tobacco sickness has a high incidence among migrant and seasonal farmworkers. Because workers have little control over most risk factors, further research is needed to identify ways to prevent this occupational illness.