Nina L. Alesci

Smoking visibility, perceived acceptability, and frequency in various locations among youth and adults.

OBJECTIVES This study tests whether there is an association between high visibility of smoking, perceived acceptability of smoking, and where youth smoke. METHODS Surveys of 9,762 students in grades 8-10 and 1,586 parents in 15 Minnesota communities asked about the frequency of and opinions of adult and youth smoking in various indoor and outdoor public places. Chi-square analysis and ANOVAs compared smokers and nonsmokers. RESULTS More smoking than nonsmoking youth reported often seeing adults and teens smoking in all locations. Forty-two percent of students often noticed adults and 35% often noticed teens smoking outdoors, also the most frequent location where teens report smoking. Students perceived adult and teen smoking as more acceptable in restaurants, recreation centers, and outdoor gathering places. More student smokers than nonsmokers believe that smoking is acceptable for both adults and teens. Of the parent sample, 52% often observed adults and 36% often observed youth smoking outdoors. Nonsmoking parents observed adult and teen smoking more often than parents who smoke. CONCLUSIONS The data support an association between the frequency that youth observe smoking in various locations and the perception that smoking is socially acceptable by smoking status. Policies that restrict smoking in various locations will reduce both visibility and perceived acceptability of smoking in those locations.

Physician Smoking-Cessation Actions Are They Dependent on Insurance Coverage or on Patients?

BACKGROUND Despite good evidence that their smoking-cessation actions can be very effective, physicians have not consistently used the 5A actions (being asked, advised, assessed, assisted, and arranged) recommended in the U.S. Public Health Service tobacco guidelines. We tested the hypothesis that the introduction of coverage for smoking-cessation pharmacotherapy by the health plans covering most of the population in one region would increase physician use of 5As. METHODS A cohort of smoking members of two health plans was surveyed before and after the introduction of coverage for smoking cessation. A total of 1560 current smokers with a physician visit in the last year responded to both surveys. The key outcome measures were smoker reports of the guideline 5As for smoking-cessation support during the last physician visit. RESULTS There were small significant absolute percentage increases only for reports of being assessed (+4.9%, p=0.01) and assisted (set quit date +6.5%, p=0.0004); encouraged to use medications (+8.8%, p=0.03); and given a prescription (+8.6%, p=0.0005). However, these increases were limited to smokers reporting awareness of the coverage, asking for quitting help, or both. CONCLUSION Coverage for pharmacotherapy alone appears to have had no effect on physician behavior beyond that stimulated by smokers who were aware of the coverage, perhaps because they raised the issue. More research is needed on this suggestion that patients create physician behavior change.

The Relationship of Stage of Change for Smoking Cessation to Stage of Change for Fruit and Vegetable Consumption and Physical Activity in a Health Plan Population

Purpose. The purpose of this study was to examine the relationship between stage of change for smoking cessation and stage of change for (1) fruit and vegetable consumption and (2) physical activity. Design. The data come from a cross-sectional telephone survey administered to a stratified random sample of health plan members (n = 9675). Setting. This study was conducted at a mixed-model health plan with approximately 1 million adult members. Subjects. Respondents were adults age 18 and older, who were randomly selected from five health plan product groups: commercial fully insured, commercial self-insured, two publicly subsidized plans, and Medicare supplemental insurance. Response rates ranged from 74.7% to 90.1% across these groups. Measures. The assessment included demographics and stage of change for smoking cessation, physical activity, and fruit and vegetable intake. Bivariate relationships among variables were analyzed with the use of contingency tables. Ordered logistic regression was used to examine the effects of stage of change for fruit and vegetable consumption and physical activity on stage of change for smoking while controlling for other factors. Results. Stage of change for smoking is more clearly related to stage of change for fruit and vegetable consumption (χ2 = 161.3, p < .001; Cramers V = .11, p < .001) than to stage of change for physical activity (χ2 = 89.7, p < .001; Cramers V = .08, p < .001). However, stage of change for fruit and vegetable consumption and physical activity are not strong predictors of stage of change for smoking. Conclusions. This study indicates that stage of change for both fruit and vegetable consumption and physical activity are independent constructs from stage of change for smoking cessation.

Modifiable health behaviors and short-term medical costs among health plan members.

Purpose. Describe the relationship among modifiable health behaviors and short-term medical costs. Design. Prospective study linking cross-sectional survey data that assessed modifiable risk behaviors with insurance claims. Setting. A large health plan in Minnesota. Subjects. A stratified, random sample of 10,000 yielded an analytic data set for 7983 members. Measures. The dependent variable was per-member-per-month insurance payment plus subscriber liability. Eighteen months of medical costs were analyzed. Control variables included subscriber age, sex, type of insurance plan, days of enrollment, chronic disease status, education, and marital status. Independent variables included self-reported health behaviors of smoking, heavy drinking, nutrition, and physical activity. Analysis. Linear regression was performed on the natural log of the cost variable, followed by a retransformation to dollars. Results. Physical inactivity and smoking were significant predictors of higher medical costs. Each day a member did not exercise there was a 2.9% difference in cost. Compared with never smokers, current smokers had 16% higher costs. Former smokers who had quit more than 1 year before taking the survey had 15% higher costs than never smokers. Recent former smokers cost 32% more than never smokers and more frequently experienced smoking-related medical conditions before they quit. Alcohol consumption was nonsignificant. Nutrition also was not significant but was narrowly measured by only fruit and vegetable consumption. Conclusion. Physical inactivity and smoking were associated with higher short-term medical costs among health plan members.

Does a health plan effort to increase smokers' awareness of cessation medication coverage increase utilization and cessation?

Purpose. To test whether a mailing describing new coverage for smoking cessation medications increases benefit knowledge, utilization, and quitting. Methods. This randomized controlled trial assigned participants to benefit communication via (1) standard contract changes or (2) enhanced communication with direct-to-member postcards. A sample of 1930 self-identified smokers from two Minnesota health plans took surveys before and 1 year after the benefits introduction. The follow-up response rate was 80%. A multilevel logistic estimator tested for differences in benefit knowledge and smoking behavior from baseline. Results. More enhanced than standard communication respondents knew about the benefit (39.0% vs. 22.2%, p < .0001) at follow-up. Groups did not differ on bupropion utilization (24.6% vs. 23.1%, p = .92); nicotine replacement therapy utilization (26.9% vs. 25.9%, p = .26), or cessation (12.8% vs. 15.6%, p = .32). Conclusion. Although limited by the low intervention intensity and potential social desirability bias, information about new coverage alone does not appear to increase quitting behaviors.

Culture, acculturation and smoking use in Hmong, Khmer, Laotians, and Vietnamese communities in Minnesota

BackgroundSoutheast Asian communities in the United States have suffered from high rates of tobacco use and high rates of chronic diseases associated with firsthand and secondhand smoking. Research is needed on how best to reduce and prevent tobacco use and exposure to secondhand smoke in these communities. The objective of this study was to examine how tobacco use patterns in Minnesota’s Southeast Asian communities have been shaped by culture, immigration, and adjustment to life in America in order to inform future tobacco control strategies.MethodsThe study consisted of semi-structured interviews with 60 formal and informal leaders from Minnesota’s Hmong, Khmer (Cambodian), Lao, and Vietnamese communities and incorporated principles of community-based participatory research.ResultsAmong Khmer, Lao and Vietnamese, tobacco in the homeland was a valued part of material culture and was used to signify social status, convey respect, and support social rituals among adult men (the only group for whom smoking was acceptable). Among the Hmong, regular consumption of tobacco was unacceptable and rarely seen until the civil war in Laos when a number of Hmong soldiers became smokers. In Minnesota, social norms have begun to shift, with smoking becoming less acceptable. Although older male smokers felt social pressure to quit, smoking functioned to reduce the stress of social isolation, economic hardship, prior trauma, and the loss of power and status. Youth and younger women no longer felt as constrained by culturally-rooted social prohibitions to smoke.ConclusionsLeaders from Minnesota’s Southeast Asian communities perceived key changes in tobacco-related attitudes, beliefs, and behaviors which were embedded in the context of shifting power, status, and gender roles within their communities. This has practical implications for developing policy and interventions. Older Southeast Asians are likely to benefit from culturally-tailored programs (e.g., that value politeness and the importance of acting in ways that benefit the family, community, and clan) and programs that work with existing social structures, as well as initiatives that address smokers’ psychological distress and social isolation. Leaders remained uncertain about how to address smoking uptake among youth, pointing to a need for additional research.

Did youth smoking behaviors change before and after the shutdown of Minnesota Youth Tobacco Prevention Initiative

INTRODUCTION No previous studies document the effects of both comprehensive tobacco control and its defunding on youth smoking. This study tests the effect of the youth-focused Minnesota Youth Tobacco Prevention Initiative (MYTPI) and its shutdown on youth smoking and determines whether these effects differed by age. METHODS The Minnesota Adolescent Community Cohort is a population-based, observational study designed to evaluate the MYTPI. The sample included cohorts of youth aged 12-16 years at baseline in Minnesota (N = 3,636) and a comparison group in six other Midwestern states (n = 605). Biannual surveys assessed youth smoking from October 2000, 5 months after the MYTPI launch, through October 2005, 2 years postshutdown. Adjusted piecewise linear trajectories predicted smoking stage (measured on a 1-6 continuum) comparing Minnesota with a comparison group during the MYTPI (Slope 1) and postshutdown (Slope 2) for each baseline age cohort. Analysis then compared baseline age cohorts with each other by centering their intercepts on age 16. RESULTS Neither slope of smoking stage differed between Minnesota and comparison groups, showing no period effects for the MYTPI or shutdown. However, younger cohorts, with early teen experience of MYTPI, smoked less than older cohorts by the same age. Mean smoking stage at age 16 differed by almost a half stage from the youngest (2.04) to the oldest (2.46) age cohort. DISCUSSION The study offers no evidence of period effects for the MYTPI or its shutdown. Design limitations, national or continued post-MYTPI statewide tobacco control efforts, or program flaws could explain the findings.