Waiting for the Opportune Moment: The Tobacco Industry and Marijuana Legalization

Context

In 2012, Washington State and Colorado legalized the recreational use of marijuana, and Uruguay, beginning in 2014, will become the first country to legalize the sale and distribution of marijuana. The challenge facing policymakers and public health advocates is reducing the harms of an ineffective, costly, and discriminatory “war on drugs” while preventing another public health catastrophe similar to tobacco use, which kills 6 million people worldwide each year.

Methods

Between May and December 2013, using the standard snowball research technique, we searched the Legacy Tobacco Documents Library of previously secret tobacco industry documents (http://legacy.library.ucsf.edu).

Findings

Since at least the 1970s, tobacco companies have been interested in marijuana and marijuana legalization as both a potential and a rival product. As public opinion shifted and governments began relaxing laws pertaining to marijuana criminalization, the tobacco companies modified their corporate planning strategies to prepare for future consumer demand.

Conclusions

Policymakers and public health advocates must be aware that the tobacco industry or comparable multinational organizations (eg, food and beverage industries) are prepared to enter the marijuana market with the intention of increasing its already widespread use. In order to prevent domination of the market by companies seeking to maximize market size and profits, policymakers should learn from their successes and failures in regulating tobacco.     

Peer Reviewed: Using Indoor Air Quality Monitoring in 6 Counties to Change Policy in North Carolina

Introduction

Indoor air quality monitoring has become a valuable tool for states wanting to assess levels of particulate matter before and after smoke-free policies are implemented. However, many states face barriers in passing comprehensive smoke-free legislation, making such study comparisons unlikely. We used indoor air monitoring data to educate decision makers about the value of comprehensive smoke-free laws in a state with strong historical ties to tobacco.

Methods

We trained teams in 6 counties in North Carolina to monitor air quality in hospitality venues with 1 of 3 possible smoking policy designations: 1) smoke-free, 2) separate smoking and nonsmoking sections (mixed), or 3) smoking allowed in all areas. Teams monitored 152 venues for respirable suspended particles that were less than 2.5 μm in diameter and collected information on venue characteristics. The data were combined and analyzed by venue policy and by county. Our findings were presented to key decision makers, and we then collected information on media publicity about these analyses.

Results

Overall, smoke-free venues had the lowest particulate matter levels (15 µg/m³), well below established Environmental Protection Agency standards. Venues with mixed policies and venues that permitted smoking in all areas had particulate matter levels that are considered unhealthy by Environmental Protection Agency standards. The media coverage of our findings included newspaper, radio, and television reports. Findings were also discussed with local health directors, state legislators, and public health advocates.

Conclusion

Study data have been used to quantify particulate matter levels, raise awareness about the dangers of secondhand smoke, build support for evidence-based policies, and promote smoke-free policies among policy makers. The next task is to turn this effort into meaningful policy change that will protect everyone from the harms of secondhand smoke.     

Strategies implemented by 20 local tobacco control agencies to promote smoke-free recreation areas, California, 2004-2007

Introduction

Since 2000, local jurisdictions in California have enacted hundreds of policies and ordinances in an effort to protect their citizens from the harmful effects of secondhand smoke. We evaluated strategies used by state-funded local tobacco control programs to enact local smoke-free policies involving outdoor recreational spaces.

Methods

The Tobacco Control Evaluation Center analyzed 23 final evaluation reports that discussed adopting local smoke-free policies in outdoor recreational facilities in California. These reports were submitted for the 2004 through 2007 funding period by local tobacco control organizations to the California Department of Public Health, Tobacco Control Program. We used a comparative technique whereby we coded passages and compared them by locale and case, focusing on strategies that led to the enactment of smoke-free policies.

Results

Our analysis found the following 6 strategies to be the most effective: 1) having a "champion" who helps to carry an objective forward, 2) tapping into a pool of potential youth volunteers, 3) collecting and using local data as a persuasive tool, 4) educating the community in smoke-free policy efforts, 5) working strategically in the local political climate, and 6) framing the policy appropriately.

Conclusion

These strategies proved effective regardless of whether policies were voluntary, administrative, or legislative. Successful policy enactment required a strong foundation of agency funding and an experienced and committed staff. These results should be relevant to other tobacco control organizations that are attempting to secure local smoke-free policy.     

Peer Reviewed: Smoke-Free Law Associated With Higher-Than-Expected Taxable Retail Sales for Bars and Taverns in Washington State

Introduction

Continued progress in implementing smoke-free laws throughout the United States would benefit from documenting positive economic effects, particularly for the hospitality industry. This study describes changes in sales revenue in bars and taverns since December 2005, when a statewide smoke-free law in Washington State went into effect.

Methods

Using 24 quarters of inflation-adjusted taxable retail sales data from 2002 through 2007, we fitted a regression model to estimate the effect of the smoke-free law on sales revenue, controlling for seasonality and other economic factors.

Results

We found no immediate change in bar revenues in the first quarter of 2006, but taxable retail sales grew significantly through the fourth quarter of 2007. In the 2 years after the smoke-free law was implemented, sales revenues were $105.5 million higher than expected for bars and taverns in Washington State.

Conclusion

The higher-than-expected revenue from taxable sales in bars and taverns after the implementation of smoke-free laws in Washington State provided extra funds to the state general fund. Potential increases in revenue in other jurisdictions that implement smoke-free indoor air policies could provide funds to benefit residents of those jurisdictions.     

Peer Reviewed: Moving Multiunit Housing Providers Toward Adoption of Smoke-Free Policies

Background

Tenants in multiunit housing are at elevated risk for exposure to secondhand smoke at home because of smoke migration from other units.

Community Context

In 2004, tobacco control advocates in the Portland, Oregon, metropolitan area began to address this issue by launching a campaign to work with landlord and tenant advocates, private- and public-sector property managers, and other housing stakeholders to encourage smoke-free policies in multiunit housing.

Methods

We outline the 6-year campaign that moved local housing providers toward adopting no-smoking policies. We used the stages of change model, which matches potential messages or interventions to a smoker''s readiness to quit smoking.

Outcome

The campaign resulted in Oregon''s largest private property management company and its largest public housing authority adopting no-smoking policies for their properties and a 29% increase in the availability of smoke-free rental units in the Portland-Vancouver metro area from 2006 through 2009.

Interpretation

We learned the importance of building partnerships with public and private stakeholders, collecting local data to shape educational messages, and emphasizing to landlords the business case, not the public health rationale, for smoke-free housing.     

Airborne Nicotine Concentrations in the Workplaces of Tobacco Farmers

Objectives

Nicotine is a natural alkaloid and insecticide in tobacco leaves. Green tobacco sickness (GTS) is known as a disease of acute nicotine intoxication among tobacco farmers. Until now, GTS has been recognized globally as a disease that results from nicotine absorption through the skin. However, we assumed that GTS might also result from nicotine inhalation as well as absorption. We aimed to measure the airborne nicotine concentrations in various work environments of Korean tobacco farmers.

Methods

We measured the nicotine concentrations in the tobacco fields, private curing barns, and joint curing barns of farmers from July to October 2010. All sampling and analyses of airborne nicotine were conducted according to the National Institute for Occupational Safety and Health manual of analytic methods.

Results

The airborne nicotine concentrations (geometric mean [geometric standard deviation]) in the tobacco field were 83.4 mg/m³ (1.2) in the upper region and 93.3 mg/m³ (1.2) in the lower region. In addition, the nicotine concentration by personal sampling was 150.1 mg/m³. Similarly, the nicotine concentrations in the private curing barn, workers in curing barns, the front yard of the curing barn, and in the joint curing barn were 323.7 mg/m³ (2.0), 121.0 mg/m³ (1.5), 73.7 mg/m³ (1.7), and 610.3 mg/m³ (1.0), respectively.

Conclusions

The nicotine concentration in the workplaces of tobacco farmers was very high. Future studies should measure the environmental concentration of nicotine that is inhaled by tobacco farmers.     

Medicaid Bed‐Hold Policies and Hospitalization of Long‐Stay Nursing Home Residents

Objective

To evaluate the effect of Medicaid bed-hold policies on hospitalization of long-stay nursing home residents.

Data Sources

A nationwide random sample of long-stay nursing home residents with data elements from Medicare claims and enrollment files, the Minimum Data Set, the Online Survey Certification and Reporting System, and Area Resource File. The sample consisted of 22,200,089 person-quarters from 754,592 individuals who became long-stay residents in 17,149 nursing homes over the period beginning January 1, 2000 through December 31, 2005.

Study Design

Linear regression models using a pre/post design adjusted for resident, nursing home, market, and state characteristics. Nursing home and year-quarter fixed effects were included to control for time-invariant facility influences and temporal trends associated with hospitalization of long-stay residents.

Principal Findings

Adoption of a Medicaid bed-hold policy was associated with an absolute increase of 0.493 percentage points (95% CI: 0.039–0.946) in hospitalizations of long-stay nursing home residents, representing a 3.883 percent relative increase over the baseline mean.

Conclusions

Medicaid bed-hold policies may increase the likelihood of hospitalization of long-stay nursing home residents and increase costs for the federal Medicare program.     

Abortion Providers' Experiences with Medicaid Abortion Coverage Policies: A Qualitative Multistate Study

Objective

To evaluate the implementation of state Medicaid abortion policies and the impact of these policies on abortion clients and abortion providers.

Data Source

From 2007 to 2010, in-depth interviews were conducted with representatives of 70 abortion-providing facilities in 15 states.

Study Design

In-depth interviews focused on abortion providers'' perceptions regarding Medicaid and their experiences working with Medicaid and securing reimbursement in cases that should receive federal funding: rape, incest, and life endangerment.

Data Extraction

Data were transcribed verbatim before being coded.

Principal Findings

In two study states, abortion providers reported that 97 percent of submitted claims for qualifying cases were funded. Success receiving reimbursement was attributed to streamlined electronic billing procedures, timely claims processing, and responsive Medicaid staff. Abortion providers in the other 13 states reported reimbursement for 36 percent of qualifying cases. Providers reported difficulties obtaining reimbursement due to unclear rejections of qualifying claims, complex billing procedures, lack of knowledgeable Medicaid staff with whom billing problems could be discussed, and low and slow reimbursement rates.

Conclusions

Poor state-level implementation of Medicaid coverage of abortion policies creates barriers for women seeking abortion. Efforts to ensure policies are implemented appropriately would improve women''s health.     

The Effect of Pay‐for‐Performance in Nursing Homes: Evidence from State Medicaid Programs

Objective

Pay-for-performance (P4P) is commonly used to improve health care quality in the United States and is expected to be frequently implemented under the Affordable Care Act. However, evidence supporting its use is mixed with few large-scale, rigorous evaluations of P4P. This study tests the effect of P4P on quality of care in a large-scale setting—the implementation of P4P for nursing homes by state Medicaid agencies.

Data Sources/Study Setting

2001–2009 nursing home Minimum Data Set and Online Survey, Certification, and Reporting (OSCAR) datasets.

Study Design

Between 2001 and 2009, eight state Medicaid agencies adopted P4P programs in nursing homes. We use a difference-in-differences approach to test for changes in nursing home quality under P4P, taking advantage of the variation in timing of implementation across these eight states and using nursing homes in the 42 non-P4P states plus Washington, DC as contemporaneous controls.

Principal Findings

Quality improvement under P4P was inconsistent. While three clinical quality measures (the percent of residents being physically restrained, in moderate to severe pain, and developed pressure sores) improved with the implementation of P4P in states with P4P compared with states without P4P, other targeted quality measures either did not change or worsened. Of the two structural measures of quality that were tied to payment (total number of deficiencies and nurse staffing) deficiency rates worsened slightly under P4P while staffing levels did not change.

Conclusions

Medicaid-based P4P in nursing homes did not result in consistent improvements in nursing home quality. Expectations for improvement in nursing home care under P4P should be tempered.     

Peer Reviewed: State Requirements and Recommendations for School-Based Screenings for Body Mass Index or Body Composition, 2010

Introduction

We present a comprehensive picture of state requirements and recommendations for body mass index (BMI) and body composition screening of children and explore the association between pediatric obesity prevalence and state screening policies.

Methods

Researchers completed telephone interviews with contacts at the departments of education for all 50 states and reviewed state content standards for physical education.

Results

Twenty states (40%) require BMI or body composition screening, and 9 states (18%) recommend BMI screening or a formal fitness assessment that includes a body composition component. The prevalence of adolescent obesity was higher in states that require BMI screening or fitness assessments with body composition than in states without requirements (16.7% vs 13.6%, P = .001).

Conclusion

Future studies should evaluate the effect and cost-effectiveness of BMI and body composition screening on child obesity.     

Using Computer‐Extracted Data from Electronic Health Records to Measure the Quality of Adolescent Well‐Care

Objective

To determine whether quality measures based on computer-extracted EHR data can reproduce findings based on data manually extracted by reviewers.

Data Sources

We studied 12 measures of care indicated for adolescent well-care visits for 597 patients in three pediatric health systems.

Study Design

Observational study.

Data Collection/Extraction Methods

Manual reviewers collected quality data from the EHR. Site personnel programmed their EHR systems to extract the same data from structured fields in the EHR according to national health IT standards.

Principal Findings

Overall performance measured via computer-extracted data was 21.9 percent, compared with 53.2 percent for manual data. Agreement measures were high for immunizations. Otherwise, agreement between computer extraction and manual review was modest (Kappa = 0.36) because computer-extracted data frequently missed care events (sensitivity = 39.5 percent). Measure validity varied by health care domain and setting. A limitation of our findings is that we studied only three domains and three sites.

Conclusions

The accuracy of computer-extracted EHR quality reporting depends on the use of structured data fields, with the highest agreement found for measures and in the setting that had the greatest concentration of structured fields. We need to improve documentation of care, data extraction, and adaptation of EHR systems to practice workflow.     

Smoking-related deaths averted due to three years of policy progress

Objective

To evaluate the global impact of adopting highest-level MPOWER tobacco control policies in different countries and territories from 2007 to 2010.

Methods

Policy effect sizes based on previously-validated SimSmoke models were applied to determine the reduction in the number of smokers as a result of policy adoption during this period. Based on previous research suggesting that half of all smokers die from smoking, we also derived the estimated smoking-attributable deaths (SADs) averted due to MPOWER policy implementation. The results from use of this simple yet powerful method are consistent with those predicted by using previously validated SimSmoke models.

Findings

In total, 41 countries adopted at least one highest-level MPOWER policy between 2007 and 2010. As a result of all policies adopted during this period, the number of smokers is estimated to have dropped by 14.8 million, with a total of 7.4 million SADs averted. The largest number of SADs was averted as a result of increased cigarette taxes (3.5 million), smoke-free air laws (2.5 million), health warnings (700 000), cessation treatments (380 000), and bans on tobacco marketing (306 000).

Conclusion

From 2007 to 2010, 41 countries and territories took action that will collectively prevent nearly 7.5 million smoking-related deaths globally. These findings demonstrate the magnitude of the actions already taken by countries and underscore the potential for millions of additional lives to be saved with continued adoption of MPOWER policies.     

Accelerated Adoption of Smoke-Free Laws After Ratification of the World Health Organization Framework Convention on Tobacco Control

Objectives. We sought to evaluate the effect of ratifying the World Health Organization Framework Convention on Tobacco Control (FCTC) on countries enacting smoke-free laws covering indoor workplaces, restaurants, and bars.Methods. We compared adoption of smoke-free indoor workplace, restaurant, and bar laws in countries that did versus did not ratify the FCTC, accounting for years since the ratification of the FCTC and for countries’ World Bank income group.Results. Ratification of the FCTC significantly (P < .001) increased the probability of smoke-free laws. This effect faded with time, with a half-life of 3.1 years for indoor workplaces and 3.8 years for restaurants and bars. Compared with high-income countries, upper-middle–income countries had a significantly higher probability of smoke-free indoor workplace laws.Conclusions. The FCTC accelerated the adoption of smoke-free indoor workplace, restaurant, and bar laws, with the greatest effect in the years immediately following ratification. The policy implication is that health advocates must increase efforts to secure implementation of FCTC smoke-free provisions in countries that have not done so.Smoke-free laws improve health by reducing exposure to secondhand smoke and the associated heart disease, cancer, and other disease.1–3 The World Health Organization’s (WHO’s) Framework Convention on Tobacco Control4 (FCTC), in force since 2005, commits the countries that have adopted the treaty to implement tobacco-control measures including smoke-free environments, strong health warning labels, increased tobacco taxes, and safeguarding the policymaking process against the tobacco industry. Article 8 of the FCTC commits countries to

adopt and implement . . . measures, providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places.^4(p8)

As of April 2015, 180 countries were parties to the FCTC.5 The FCTC has already been shown to improve the chances for certain tobacco-control policies, such as its role in accelerating the adoption of FCTC-compliant warning labels on tobacco products.6,7 Countries that previously had voluntary warning label agreements with tobacco companies starting in the 1990s,6 along with poorer countries with less state capacity,7 were less likely to have such labels. The FCTC states that countries should pursue graphic health warning labels within 3 years of ratifying the treaty and within 5 years for some other policies, but does not specify a timeframe for smoke-free laws and has no external means of enforcement. In the first 5 years after ratifying the treaty, 24 (14%) of the 175 parties as of 2012 had passed smoke-free indoor workplace laws.8We evaluated the effect of ratifying the FCTC on countries enacting national smoke-free laws. We focused on indoor workplaces, restaurants, and bars because these are the venues for which the tobacco industry internationally has fought strongly to prevent smoke-free environments.9–12     

Peer Reviewed: The Influence of School Policies on Smoking Prevalence Among Students in Grades 5-9, Canada, 2004-2005

Introduction

School characteristics may account for some of the variation in smoking prevalence among schools. The purpose of this study was to investigate the relationships between characteristics of school tobacco policies and school smoking prevalence. We also examined the relationship between these characteristics and individual smoking status.

Methods

Tobacco policy data were collected from schools in 10 Canadian provinces during the 2004-2005 school year. Written tobacco policies were collected from each school to examine policy intent, and school administrators were surveyed to assess policy enforcement. Students in grades 5 through 9 completed the Youth Smoking Survey to assess smoking behaviors and attitudes. We used negative binomial regression and multilevel logistic regression to predict the influence of school policies on smoking behavior at the school and student levels.

Results

School policies that explicitly stated purpose and goals predicted lower prevalence of smoking at the school and individual levels. Policies that prohibited smoking on school grounds at all times predicted lower smoking prevalence at the school level but not at the individual level.

Conclusions

For maximum effectiveness, school smoking policies should clearly state a purpose and goals and should emphasize smoking prohibition. These policies can help reduce smoking prevalence among youths and are part of a comprehensive school approach to tobacco control.     

Regional Growth in Medicare Spending, 1992–2010

Objective

To determine if regions with high Medicare expenditures in a given setting remain high cost over time.

Data Sources/Study Setting

One hundred percent of national Medicare Parts A and B fee-for-service beneficiary claims data and enrollment for 1992–2010.

Study Design

Patients are classified into regions. Claims are price-standardized. Risk adjustment is performed at the beneficiary level using the CMS Hierarchical Condition Categories model. Correlation analyses are conducted.

Data Collection/Extraction Methods

The data were obtained through a contract with CMS for a study performed for the Institute of Medicine.

Principal Findings

High-cost regions in 1992 are likely to remain high cost in 2010. Stability in regional spending is highest in the home health, inpatient hospital, and outpatient hospital settings over this time period. Despite the persistence of a region''s relative spending over time, a region''s spending levels in all settings except home health tend to regress toward the mean.

Conclusions

Relatively high-cost regions tend to remain so over long periods of time, even after controlling for patient health status and geographic price variation, suggesting that the observed effect reflects real differences in practice patterns.     

Tobacco smoke exposure and altered nasal responses to live attenuated influenza virus

Background

Epidemiologic evidence links tobacco smoke and increased risk for influenza in humans, but the specific host defense pathways involved are unclear.

Objective

We developed a model to examine influenza-induced innate immune responses in humans and test the hypothesis that exposure to cigarette smoke alters nasal inflammatory and antiviral responses to live attenuated influenza virus (LAIV).

Methods

This was an observational cohort study comparing nasal mucosal responses to LAIV among young adult active smokers (n = 17), nonsmokers exposed to secondhand smoke (SHS; n = 20), and unexposed controls (n = 23). Virus RNA and inflammatory factors were measured in nasal lavage fluids (NLF) serially after LAIV inoculation. For key end points, peak and total (area under curve) responses were compared among groups.

Results

Compared with controls, NLF interleukin-6 (IL-6) responses to LAIV (peak and total) were suppressed in smokers. Virus RNA in NLF cells was significantly increased in smokers, as were interferon-inducible protein 10:virus ratios. Responses in SHS-exposed subjects were generally intermediate between controls and smokers. We observed significant associations between urine cotinine and NLF IL-6 responses (negative correlation) or virus RNA in NLF cells (positive correlation) for all subjects combined.

Conclusions

Nasal inoculation with LAIV results in measurable inflammatory and antiviral responses in human volunteers, thus providing a model for investigating environmental effects on influenza infections in humans. Exposure to cigarette smoke was associated with suppression of specific nasal inflammatory and antiviral responses, as well as increased virus quantity, after nasal inoculation with LAIV. These data suggest mechanisms for increased susceptibility to influenza infection among persons exposed to tobacco smoke.     

Modeling Area‐Level Health Rankings

Objective

Rank county health using a Bayesian factor analysis model.

Data Sources

Secondary county data from the National Center for Health Statistics (through 2007) and Behavioral Risk Factor Surveillance System (through 2009).

Study Design

Our model builds on the existing county health rankings (CHRs) by using data-derived weights to compute ranks from mortality and morbidity variables, and by quantifying uncertainty based on population, spatial correlation, and missing data. We apply our model to Wisconsin, which has comprehensive data, and Texas, which has substantial missing information.

Data Collection Methods

The data were downloaded from www.countyhealthrankings.org.

Principal Findings

Our estimated rankings are more similar to the CHRs for Wisconsin than Texas, as the data-derived factor weights are closer to the assigned weights for Wisconsin. The correlations between the CHRs and our ranks are 0.89 for Wisconsin and 0.65 for Texas. Uncertainty is especially severe for Texas given the state''s substantial missing data.

Conclusions

The reliability of comprehensive CHRs varies from state to state. We advise focusing on the counties that remain among the least healthy after incorporating alternate weighting methods and accounting for uncertainty. Our results also highlight the need for broader geographic coverage in health data.     

Total Cost of Care Lower among Medicare Fee‐for‐Service Beneficiaries Receiving Care from Patient‐Centered Medical Homes

Objective

To compare health care utilization and payments between NCQA-recognized patient-centered medical home (PCMH) practices and practices without such recognition.

Data Sources

Medicare Part A and B claims files from July 1, 2007 to June 30, 2010, 2009 Census, 2007 Health Resources and Services Administration and CMS Utilization file, Medicare''s Enrollment Data Base, and the 2005 American Medical Association Physician Workforce file.

Study Design

This study used a longitudinal, nonexperimental design. Three annual observations (July 1, 2008–June 30, 2010) were available for each practice. We compared selected outcomes between practices with and those without NCQA PCMH recognition.

Data Collection Methods

Individual Medicare fee-for-service (FFS) beneficiaries and their claims and utilization data were assigned to PCMH or comparison practices based on where they received the plurality of evaluation and management services between July 1, 2007 and June 30, 2008.

Principal Findings

Relative to the comparison group, total Medicare payments, acute care payments, and the number of emergency room visits declined after practices received NCQA PCMH recognition. The decline was larger for practices with sicker than average patients, primary care practices, and solo practices.

Conclusions

This study provides additional evidence about the potential of the PCMH model for reducing health care utilization and the cost of care.