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Tobacco Prevention and Control
Evidence-based Recommendations from the Guide to Community Preventive
Services
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Introduction
• Guide to Community Preventive Services• Tobacco chapter• Recommendations from the Task Force
• Smoking bans• Provider reminder systems• Interventions to reduce minors’ access• Preview: School-based interventions
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The Community Guide
• A Task Force
• A Process– Systematic reviews of the literature– Assessments of study quality– Summary of outcomes
• A Product– Evidence-based recommendations– Book
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Why Evidence Reviews?
Decision-making
Advocacy
Defense
Program buiding
Options
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Methods
• Develop a conceptual framework
• Search for evidence
• Rate the quality of the evidence
• Summarize the information
• Translate the strength of evidence into
recommendations for use
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The Tobacco Chapter
• Recruited 20 experts• Selected 10 intervention categories• Screened 16,000 citations• Reviewed 1300 papers• Evaluated 350 studies• Summarized evidence for 15 interventions
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Prevention: Targets and Goals
Former Users (1m)
Current Users (1m)
Future Users (114k/yr)
Non Users (4m)
Increase Cessation
Reduce Initiation
Reduce ETS Exposure
Population
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Tobacco Control Policies: Settings
Goal
Increase
Cessation
Reduce
Initiation
Reduce
ETS
CommunityHealth
Care System
Yes
Yes
Yes
Yes
(No)
(Yes)
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Issues to Consider in Reviews
InterventionIntendedOutcomes
ReducedMorbidity
and/orMortality
AdditionalOutcomes
Benefits
Harms
Barriers
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Recommendations from the Community Guide Task Force
Interventions to Reduce Tobacco Use and ETS Exposure in
Communities and Health Care Systems
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In Communities
Goal Recommended Interventions
Increase
Cessation
Reduce
Initiation
Reduce
ETS Exposure
* When combined with other interventions
Increase the price (tax)
Mass media campaigns*
Telephone Quit lines*
Increase the price (tax)
Mass media campaigns*
Smoking bans
Smoking bans
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In Communities
Goal Interventions with Insufficient Evidence
Increase
Cessation
Reduce
Initiation
Reduce
ETS Exp.
Smoking cessation contests
Broadcast smoking cessation series
Community-wide efforts to reduce ETS exposure in the home
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In Health Care Systems
Goal Recommended Interventions
Increase
Cessation
Reduce
Initiation
Reduce ETS
* When combined with other interventions
Provider reminder systems*
Telephone Quit Lines*Reducing patient out-of-pocket costs (NRT)
Smoking bans (in effect)
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In Health Care Systems
Goal Interventions with Insufficient Evidence
Increase
Cessation
Reduce
Initiation
Reduce ETS
Provider education programs (alone)
Provider feedback systems
(Provider counseling to reduce home ETS exposure)
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Reviews in Progress
Goals Interventions under Evaluation
Increase
Cessation
Reduce
Initiation
Reduce
ETS
Youth access interventions
School-based interventions
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Interventions to Reduce Exposure to Environmental Tobacco Smoke
Smoking Bans and Restrictions
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Analytic Framework: Smoking Bans
ReducedMorbidity
andMortality
SmokingBans
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Smoking Bans Might Result from Community Education Efforts
ReducedMorbidity
andMortality
SmokingBans
CommunityEducation
Pre-emption
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Bans Might Reduce ETS Exposure
ReducedMorbidity
andMortality
SmokingBans
ReducedExposure to ETS
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Bans Might Increase Smoking Cessation
ReducedMorbidity
andMortality
SmokingBans
ReducedExposure to ETS
FewerTobacco
Users
Change In
Attitudes
ReducedConsumption
IncreasedQuit
Attempts
IncreasedCessation
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Bans Might Reduce Smoking Initiation
ReducedMorbidity
andMortality
SmokingBans
ReducedExposure to ETS
Change In
Attitudes
ReducedInitiation
FewerTobacco
Users
Change In
Attitudes
ReducedConsumption
IncreasedQuit
Attempts
IncreasedCessation
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Bans Might Increase ETS in the Home
ReducedMorbidity
andMortality
SmokingBans
ReducedExposure to ETS
Change In
Attitudes
ReducedInitiation
FewerTobacco
Users
Change In
Attitudes
ReducedConsumption
IncreasedQuit
Attempts
IncreasedCessation
DivertedConsumption
IncreasedHome Exposure
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Body of Evidence: Bans and Restrictions
• 56 studies reviewed
• ETS exposure: 10 of 17 studies qualified
• Tobacco use: 9 of 51 studies qualified
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Study Measurements by Outcome
ReducedMorbidity
andMortality
SmokingBans
ReducedExposure to ETS
Change In
Attitudes
ReducedInitiation
FewerTobacco
Users
Change In
Attitudes
ReducedConsumption
IncreasedQuit
Attempts
IncreasedCessation
DivertedConsumption
IncreasedHome Exposure
12
6
4591
0*0*6
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-10 0 10 20 30 40 50 60 70 80 90 100
Relative Percent Reduction Environmental
Self-reported
Study
Millar, 1988
Gottlieb, 1990
Borland, 1992
Brownson, 1995
Patten, 1995a
Etter, 1999
Becker, 1989
Mullooly, 1990
Stillman, 1990b
Borland, 1992
Broder, 1993
Patten, 1995a
Restrictions
Bans
Median = 60.5
Distribution of Observed Changes in ETS Exposure: (n=12 measurements from 10 studies)
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Smoking Bans and Tobacco Use
• Consumption (cigarettes/day) – Decreased in 8 of 9 studies– Median: -1.3 cigs/day range: -4.3 to 0
• Cessation attempts– Increased in 3 of 5 studies– Median: +1.8 pct pt (+9%: range –3.4% to +175%)
• Prevalence of self-reported smoking– Decreased in 3 of 6 studies– Median: -0.9 pct pt (-4.2%: range –33% to +5%)
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Additional Information
• Applicability – Public and private workplaces
• Additional Benefits– Reduced consumption
• Potential Harms– Refuted: Loss of revenue
• Barriers– Pre-emption
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Task Force Conclusion
• Smoking Bans and Restrictions are Recommended (strong evidence)
Because they:• Reduce exposure to ETS in a variety of
public and private workplaces
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Limitations
• Based on published research– Bans v. Restrictions
• Excluded cross-sectional evidence– Recent studies– Additional evidence of impact on tobacco use
• Preliminary link is important– Interventions to obtain smoking bans
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Interventions to Increase Tobacco Use Cessation
Provider Reminder Systems when coordinated with additional
interventions
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Provider Reminder Systems
• Prompts to health care providers– Identify patient tobacco use status– Discuss tobacco use cessation
• Search: 32 studies
• Evaluation: 27 studies– Reminder system alone: 7 studies– Combined with other interventions: 20 studies
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Analytic Framework
ProviderKnowledge
Patient Smoking
Status
Advice toQuit
Attempts to Quit
Quit
DecreasedMorbidity/Mortality
ProviderReminder
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Reported Outcomes(n=39 measurements from 20
studies)
ProviderKnowledge
Patient Smoking
Status
Advice toQuit
Attempts to Quit
Quit
DecreasedMorbidity/Mortality
ProviderReminders
0 3 15 7 14
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Understanding Study OutcomesDifferences or Changes
Quit Rate in Intervention Arm
Quit Rate in Control Arm
Difference
15% 10%
15-10=
+5 pct. pts
Absolute percent
15% 10%
5%/10%=
+50%
Relative percent
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-10 -5 0 5 10 15 20 25 30
Percentage Point Change
Study
Cohen 1989a
Cohen, 1989b
Strecher, 1991
Secker-Walker, 1998
Conger, 1987
Wilson, 1988
Cummings, 1989a
Cummings, 1989b
Petersen, 1992
Stevens, 1995
Wall, 1995
Hartmann, 1996
Morgan, 1996
Manfredi, 1999
Provider Reminder + Provider Education
Provider Reminder + Provider Education + Patient Education
Median = 4.7
(12m)
(12m)
(6m)
(12m)
(4m)
(12m)
(12m)
(12m)
(8m)
(8w)
(3m)
(<8m)
(6m)
(8w)
Differences in Patient Cessation in Studies of M ulticomponent Programs
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ProviderKnowledge
Patient Smoking
Status
Advice toQuit
Attempts to Quit Quit
DecreasedMorbidity/Mortality
ProviderReminders
+13% +20% +8% +4.7%?
*Combined with additional interventions
Median Reported Differences in Outcomes in Studies Evaluating Provider Reminder Systems*
(n=20 studies)
(+8, +13) (+5, +60) (+1, +20) (-1, +26)
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Additional Information
• Applicability– Settings (HMO, private practice, HD)– Provider populations (Medicine, OB, Dental)
• Additional Benefits– Prompts for other preventive services
• Potential Harms– None identified
• Barriers– Infrastructure– (Screening of adolescents)
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Task Force Conclusion
• Multi-component programs that include: provider reminder system + provider education program + patient education materials Recommended (Strong Evidence)
Because they:
• Increase provider delivery of advice to quit to tobacco-using patients
• Increase patient tobacco use cessation
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Interventions to Reduce Tobacco Use Initiation
Interventions to Restrict Minors’ Access to Tobacco Products
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Efforts to Restrict Minors’ Access Combined Policies with Other Interventions
• Policies– Laws directed at retailers
• Bans, restrictions, licensing
– Laws directed at youth • purchase, use, possession
– Enforcement (intent, conduct, penalties)
• Interventions– Retailer education programs– Community Education
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YouthAccessInterv.
ReducedYouth
TobaccoUse
Analytic Framework-Outcome
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YouthAccessInterv.
RetailerKnowledge
RetailerPerceptions
RetailerBehaviors
(Sales)
YouthTobacco
Use
Interventions Might Affect Retailers
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YouthAccessInterv.
RetailerKnowledge
RetailerPerceptions
RetailerBehaviors
(Sales)
YouthTobacco
Use
Interventions Might Affect Youth
YouthKnowledge
YouthPerceptions
YouthTobacco
Purchases
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YouthAccessInterv.
RetailerKnowledge
RetailerPerceptions
RetailerBehaviors
(Sales)
YouthTobacco
Use
Interventions Might Affect the Community
YouthKnowledge
YouthPerceptions
YouthTobacco
Purchases
CommunityNorms
Enforcement
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YouthAccessInterv.
RetailerKnowledge
RetailerPerceptions
RetailerBehaviors
(Sales)
YouthTobacco
Use
Youth Have Other Sources
YouthKnowledge
YouthPerceptions
YouthTobacco
Purchases
CommunityNorms
Enforcement
Other SourcesOf Tobacco
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YouthAccessInterv.
RetailerKnowledge
RetailerPerceptions
RetailerBehaviors
(Sales)
YouthTobacco
Use
The Key Outcomes
YouthKnowledge
YouthPerceptions
YouthTobacco
Purchases
CommunityNorms
Enforcement
Other SourcesOf Tobacco
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YouthAccessInterv.
RetailerKnowledge
RetailerPerceptions
RetailerBehaviors
(Sales)
YouthTobacco
Use
YouthKnowledge
YouthPerceptions
YouthTobacco
Purchases
CommunityNorms
Enforcement
Other SourcesOf Tobacco
5
13
32
0 1
0
1
1 0
26 Measurements from 13 Studies
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Five Studies Measured Changes in Youth Tobacco Use
Study
Com.
Mobiliz.
Ret.
Edu
Law Active
Enfrcmt
Other
Altman 1999 Yes Yes
Biglan 2000 Yes Yes S Edu
Forster 1998 Yes Yes Yes
Jason 1996 Yes Yes Yes Yes
Rigotti 1997 Yes Yes
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-15 -10 -5 0 5
Absolute percentage change
Changes in Self-Reported Tobacco Use: Multicomponent Interventions (n=5)
Median = - 5 pct pointsRange: -11 pct points , +2 pct points
Study
Altman 1999
Biglan 2000
Forster 1998
Jason 1996a
Rigotti 1997
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Task Force Conclusion
Number of Studies
Consistent Effect?
Sufficient Effect Size?
Strength of Evidence
4 Yes Yes Sufficient
Community mobilization when combined with additional interventions such as local laws, active enforcement of
illegal sales to minors, and community-directed education of retailers are effective in restricting minors’
access to tobacco products
Task Force Assessment: Recommended
(sufficient evidence)
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There is No Evidence that Single Interventions are Effective
• Sales laws directed at retailersInsufficient Evidence
• PPU laws directed at youthInsufficient Evidence
• Active enforcement of sales lawsInsufficient Evidence
• Retailer EducationInsufficient Evidence
• Community educationInsufficient Evidence
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Pitfalls
• Preemption
• Enforcement responsibility
• “Knowingly” / “Intentionally”
• Clerk vs owner
• Criminal penalties (judicial nullification)
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Pitfalls
• Youth purchase, possession, or use laws
– Normative diversion
“Penalize kids, not retailers”
– Resource diversion
– Compliance checks barrier
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School-Based Interventions
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Interventions Selected for Review
• Tobacco-free policies• School-based education• Smoking cessation programs• Multi-component programs that include a
school-based component• Student delivered community education
– SWAT programs
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OrganizedStudent
Advocacy
CommunityEvents or
Efforts
MassMedia
Exposure
Change in Community
Attitudes
Change in Community
Policies
ReducedTobacco
Use Initiation Fewer
TobaccoProductUsers
ReducedMorbidity
&Mortality
SchoolEvents
Change in Student
Attitudes*
Reduced/DelayedInitiation
Of TobaccoUse
Increased Tobacco
UseCessation
FewerStudent
Tobacco Users
Change inSchool Policies
StudentParticipation
Change inParticipantAttitudes*
ReducedParticipantTobacco
Use
FewerParticipantTobacco
Users
Analytic Framework: Student-delivered Community Education
*Includes changes in knowledge and skill development or enhancement
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Content of Recent Evidence Reviews
TobaccoUser
ProviderHealthCare
SystemCommunity
Community Guide Clinical Guide
PHS: Clinical Practice Guidelines
CDC Best Practices
SGR: Reducing Tobacco Use
NCI: Population Based Smoking Cessation
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Conclusions
• Evidence on effectiveness is one tool for decision-making
• There are effective interventions– For Communities– For Health Care Systems
• Building blocks of a comprehensive tobacco control program