Medicaid coverage for tobacco dependence treatment: Enrollee awareness and use.

Medicaid-insured adults smoke at twice the rate of privately insured adults. Insurance coverage for tobacco dependence treatments (TDTs) has been shown to increase quit attempts, but few published studies have measured enrollees' awareness of Medicaid coverage. We assessed awareness of Medicaid coverage for and use of TDTs among New York State (NYS) Medicaid-insured smokers and recent quitters. In July-August 2017, we conducted a probability-based online survey of Medicaid enrollees in NYS aged 18 to 65 in fee-for-service and managed care plans (n = 266; AAPOR 4RR = 22.5%). In 2017, we estimated descriptive statistics and used Adjusted Wald tests to assess differences in awareness and use of TDTs (p < 0.05). We used logistic regression to assess correlates of coverage awareness and use of TDTs. Most participants (94.3%) were aware of TDTs, but fewer were aware that Medicaid covers them (59.7%). Most participants believed TDTs are effective in helping smokers quit, although many also believed non-evidence-based methods are effective. Awareness of Medicaid coverage was associated with awareness of a Medicaid-related antitobacco television ad (p < 0.05), moderate nicotine dependence (p < 0.05), and believing that TDTs are effective (p < 0.01). Although awareness of Medicaid coverage for TDTs was found to be high, there remains room for improvement, even in a state that actively promotes these benefits. It is important for states to not only expand Medicaid coverage of TDTs but to also promote the benefits to improve the chances of quit success. Understanding Medicaid enrollees' awareness of and perceptions of covered TDTs can inform messaging to maximize utilization of evidence-based benefits.

The Potential Impact of the New York State Smokers' Quitline on Population-Level Smoking Rates in New York.

Receiving smoking cessation services from telephone quitlines significantly increases quit success compared with no intervention or other quitting methods. To affect population-level smoking, quitlines must provide a sufficient proportion of smokers with effective interventions. Nationally, quitlines reach around 1% of adult smokers annually. From 2011 through 2016, the average annual reach of the New York State Smokers' Quitline (NYSSQL) was 2.9%. We used data on the reach and cessation outcomes of NYSSQL to estimate its current impact on population-level smoking prevalence and to estimate how much reach would have to increase to achieve population-level smoking prevalence reductions. We estimate NYSSQL is associated with a 0.02 to 0.04 percentage point reduction in smoking prevalence in New York annually. If NYSSQL achieved the recommended annual reach of 8% (CDC Best Practices) and 16% (NAQC), state-level prevalence would decrease by an estimated 0.07-0.12 and 0.13-0.24 percentage points per year, respectively. To achieve those recommended levels of reach, NYSSQL would need to provide services to approximately 3.5 to 6.9 times more smokers annually. Given their reach, quitlines are limited in their ability to affect population-level smoking. Increasing quitline reach may not be feasible and would likely be cost-prohibitive. It may be necessary to re-think the role of quitlines in tobacco control efforts. In New York, the quitline is being integrated into larger efforts to promote cessation through health systems change.

A Media Campaign to Increase Health Care Provider Assistance for Patients Who Smoke Cigarettes.

Although most smokers visit a health care provider annually, only half report being provided evidence-based assistance with quitting, defined as brief counseling and an offer of medication. The New York State Department of Health designed a provider-targeted media campaign to increase provider-assisted quitting, which was implemented in 2016. Messaging focused on the addictive nature of tobacco products and evidence-based interventions. Online surveys of 400 New York State health care providers measured advertising awareness, associations between awareness and assistance with quit attempts, and perceptions that patients expect providers to assist with quitting. Forty-three percent of providers were aware of at least 1 advertisement, and providers who had seen an advertisement were more likely to provide evidence-based assistance (AOR = 2.55, P = .01), which includes recommending or prescribing cessation medications. Provider-targeted media is a promising approach to reach health care providers and encourage evidence-based smoking cessation treatment.

Trends in Cigarette Advertising, Price-Reducing Promotions, and Policy Compliance in New York State Licensed Tobacco Retailers, 2004 to 2015.

PURPOSE: To describe the presence of licensed tobacco retailers (LTRs), cigarette advertisements, price-reducing promotions, and compliance with tobacco control policies in New York State from 2004 to 2015 and to discuss implications and lessons learned from 11 years of experience conducting LTR surveys. DESIGN: Annual surveys of tobacco advertising from cross-sectional, stratified random samples of LTRs in New York State from 2004 to 2015 were conducted by professional data collectors. Data for 2013 were unavailable as the survey was not fielded in that year. SETTING: New York State. PARTICIPANTS: Licensed tobacco retailers, which are stores licensed to sell tobacco in the state of New York. Between 3.6% (n = 800) and 19.7% (n = 3945) of all LTRs were sampled annually. MEASURES: The presence and number of cigarette advertisements and the presence of price-reducing promotions, required age-of-sale signage, and self-service tobacco displays were documented. ANALYSIS: We tested for significant differences between 2014 and 2015 and significant trends overall and by outlet type. We used logistic regression for binary outcomes and Poisson regression for count variables. RESULTS: The number of LTRs in New York State decreased 22.9% from 2004 (n = 25 740) to 2015 (n = 19 855). The prevalence and number of cigarette advertisements and the prevalence of cigarette price-reducing promotions decreased significantly over time. Compliance with posting required age-of-sale signs increased significantly from 2004 to 2015 and from 2014 to 2015. Compliance with the ban on self-service tobacco displays was consistently near 100%. CONCLUSION: The tobacco retail environment in New York State improved substantially from 2004 to 2015. The implications of these findings for youth and adult smoking and the associated social costs are unknown; however, decreases in pro-tobacco marketing, decreases in the number of LTRs, and improvements in compliance are likely to have positive impacts on youth and adult smoking outcomes, such as reduced initiation and increased cessation, given previous research findings.

Improving Tobacco Dependence Treatment Delivery: Medical Student Training and Assessment.

Tobacco dependence is a chronic condition, with cigarette smoking considered the leading cause of preventable death, disease, and disability in the U.S. Currently, the U.S. adult smoking rate is 17.8%. National surveys reveal that approximately half of all smokers who have been treated by a healthcare provider in the last 12 months received Public Health Service-recommended guideline-concordant tobacco dependence treatment. Although smoking prevalence has been declining, several disparate groups continue to smoke at rates significantly higher than the national average, including those with low income, low educational attainment, or mental health disorders. To address these disparities and more effectively address tobacco use, provision of guideline-concordant tobacco dependence treatment within the healthcare system must improve. We discuss changes to the medical licensing examination that may result in enhanced tobacco dependence treatment education and skills training for students in medical school.

Smoke-free parks and beaches: an interrupted time-series study of behavioural impact in New York City.

BACKGROUND: In 2011, New York City (NYC) parks and beaches became smoke-free. There is currently little research evaluating the impact of such laws on smoking behaviour at the population level. METHODS: We used an interrupted time-series study design to analyse data from the New York State Adult Tobacco Survey to assess the law's impact using the rest of New York State as a comparison. Trends in how frequently respondents noticed people smoking in parks and beaches were analysed between the third quarter of 2009 and the fourth quarter of 2012, comparing NYC to the rest of the state. RESULTS: The trend in the frequency of NYC residents noticing people smoking in local parks and beaches decreased significantly over the six quarters after the law took effect. There was no comparable decline among residents in the rest of the state. An increase in the number of respondents who never noticed people smoking in NYC contributed to this decline. CONCLUSIONS: These results are consistent with previous studies and provide population-level evidence that suggest the law has reduced smoking in parks and on beaches.

Quantifying the effect of changes in state-level adult smoking rates on youth smoking.

OBJECTIVE: Quantify the degree to which changes in state-level adult smoking prevalence subsequently influence youth smoking prevalence. DESIGN: Analysis of data from the Tobacco Use Supplement to the Current Population Survey (TUS-CPS) collected from 1995 to 2006 and the National Youth Tobacco Survey (NYTS) collected from 1999 to 2006. SETTING AND PARTICIPANTS: Adults 25 years or older who completed the TUS-CPS and youth in middle and high school who completed the NYTS. MAIN OUTCOME MEASURES: Current smoking among middle and high school students as a function of the change in state-level adult smoking, controlling for individual-level sociodemographic characteristics and state-level tobacco control policy variables. RESULTS: Among middle school students, declines in state-level adult smoking rates are associated with lower odds of current smoking (P < .05), and each doubling of the decline in adult smoking rates is associated with a 6.0% decrease in youth smoking. Among high school students, declines in state-level adult smoking rates are not associated with current smoking. Higher cigarette prices were associated with lower odds of smoking among middle and high school students. Greater population coverage by smoke-free air laws and greater funding for tobacco control programs were associated with lower odds of current smoking among high school students but not middle school students. Compliance with youth access laws was not associated with middle or high school smoking. CONCLUSION: By quantifying the effect of changes in state-level adult smoking rates on youth smoking, this study enhances the precision with which the tobacco control community can assess the return on investment for adult-focused tobacco control programs.

Public and policy maker support for point-of-sale tobacco policies in New York.

PURPOSE: To compare public and policy maker support for three point-of-sale tobacco policies. DESIGN: Two cross-sectional surveys--one of the public from the New York Adult Tobacco Survey and one of policy makers from the Local Opinion Leader Survey; both collected and analyzed in 2011. SETTING: Tobacco control programs focus on educating the public and policy makers about tobacco control policy solutions. SUBJECTS: Six hundred seventy-six county-level legislators in New York's 62 counties and New York City's five boroughs (response rate: 59%); 7439 New York residents aged 18 or older. Landline response rates: 20.2% to 22%. Cell phone response rates: 9.2% to 11.1%. MEASURES: Gender, age, smoking status, presence of a child aged 18 years or younger in the household, county of residence, and policy maker and public support for three potential policy solutions to point-of-sale tobacco marketing. ANALYSIS: t-tests to compare the demographic makeup for the two samples. Adjusted Wald tests to test for differences in policy support between samples. RESULTS: The public was significantly more supportive of point-of-sale policy solutions than were policy makers: cap on retailers (48.0% vs. 19.2%, respectively); ban on sales at pharmacies (49.1% vs. 38.8%); and ban on retailers near schools (53.3% vs. 42.5%). LIMITATIONS: cross-sectional data, sociodemographic differences, and variations in item wording. CONCLUSIONS: Tobacco control programs need to include information about implementation, enforcement, and potential effects on multiple constituencies (including businesses) in their efforts to educate policy makers about point-of-sale policy solutions.

Influence of retail cigarette advertising, price promotions, and retailer compliance on youth smoking-related attitudes and behaviors.

CONTEXT: Exposure to retail tobacco marketing is associated with youth smoking, but most studies have relied on self-reported measures of exposure, which are prone to recall bias. OBJECTIVE: To examine whether exposure to retail cigarette advertising, promotions, and retailer compliance is associated with youth smoking-related outcomes using observational estimates of exposure. DESIGN: Data on retail cigarette advertising and promotions were collected from a representative sample of licensed tobacco retailers in New York annually since 2004. County-level estimates of retail cigarette advertising and promotions and retailer compliance with youth access laws were calculated and linked to the New York Youth Tobacco Survey, administered to 54,671 middle and high school students in 2004, 2006, and 2008. Regression models examined whether cigarette advertising, promotions, and retailer compliance were associated with youth's awareness of retail cigarette advertising, attitudes about smoking, susceptibility to smoking, cigarette purchasing behaviors, and smoking behaviors. RESULTS: Living in counties with more retail cigarette advertisements is associated with youth having positive attitudes about smoking (odds ratio [OR] = 1.10, 95% confidence interval [CI] = 1.03-1.19, P < .01). Living in counties with more retail cigarette promotions is associated with youth current smoking (OR = 1.57, 95% CI = 1.01-2.44, P < .05). Living in counties with higher retailer compliance with youth access laws is associated with higher odds of youth being refused cigarettes when attempting to buy in stores (OR = 1.12, 95% CI = 1.01-1.25, P < .05) and lower odds of retail stores being youth's usual source of cigarettes (OR = 0.88, 95% CI = 0.80-0.97, P < .01). CONCLUSIONS: Strong retailer compliance programs and policies that eliminate cigarette advertising and promotions may help reduce youth smoking.

Promotion of smoking cessation with emotional and/or graphic antismoking advertising.

BACKGROUND: Antismoking campaigns can be effective in promoting cessation, but less is known about the dose of advertising related to behavioral change among adult smokers, which types of messages are most effective, and effects on populations disproportionately affected by tobacco use. PURPOSE: To assess the impact of emotional and/or graphic antismoking TV advertisements on quit attempts in the past 12 months among adult smokers in New York State. METHODS: Individual-level data come from the 2003 through 2010 New York Adult Tobacco Surveys. The influence of exposure to antismoking advertisements overall, emotional and/or graphic advertisements, and other types of advertisements on reported attempts to stop smoking was examined. Exposure was measured by self-reported confirmed recall and market-level gross rating points. Analyses conducted in Spring 2012 included 8780 smokers and were stratified by desire to quit, income, and education. RESULTS: Both measures of exposure to antismoking advertisements are positively associated with an increased odds of making a quit attempt among all smokers, among smokers who want to quit, and among smokers in different household income brackets (<$30,000 and ≥$30,000) and education levels (high-school degree or less education and at least some college education). Exposure to emotional and/or graphic advertisements is positively associated with making quit attempts among smokers overall and by desire to quit, income, and education. Exposure to advertisements without strong negative emotions or graphic images had no effect. CONCLUSIONS: Strongly emotional and graphic antismoking advertisements are effective in increasing population-level quit attempts among adult smokers.

The density of tobacco retailers and its association with attitudes toward smoking, exposure to point-of-sale tobacco advertising, cigarette purchasing, and smoking among New York youth.

OBJECTIVE: Estimate the association between the density of licensed tobacco retailers (LTRs) and smoking-related attitudes and behaviors among middle and high school students in New York. METHODS: The 2000-2008 New York Youth Tobacco Surveys were pooled (N=70,427) and linked with county-level density of LTRs and retailer compliance with laws restricting youth access to cigarettes. Logistic regressions tested for associations with attitudes toward smoking exposure to point-of-sale tobacco advertising, cigarette purchasing, and smoking prevalence. RESULTS: LTR density is associated with self-reported exposure to point-of-sale advertising in New York City (NYC) among all youth (OR=1.15; 95% CI: 1.02, 1.30) and nonsmokers (OR=1.14; 95% CI: 1.01, 1.30); youth believing that smoking makes them look cool, overall (OR=1.75; 95% CI: 1.22, 2.52) and among nonsmokers (OR=1.68; 95% CI: 1.11, 2.55); and a counter-intuitive negative relationship with frequent smoking in NYC (OR=0.50; 95% CI: 0.29, 0.84). Retailer compliance was negatively associated with youth reporting that a retail store is their usual source for cigarettes (OR=0.93; 95% CI: 0.88, 0.98). CONCLUSIONS: Restricting tobacco licenses and enforcing youth access laws are reasonable policy approaches for influencing youth smoking outcomes.

Association of indoor smoke-free air laws with hospital admissions for acute myocardial infarction and stroke in three states.

OBJECTIVE: To examine whether comprehensive smoke-free air laws enacted in Florida, New York, and Oregon are associated with reductions in hospital admissions for acute myocardial infarction (AMI) and stroke. METHODS: Analyzed trends in county-level, age-adjusted, hospital admission rates for AMI and stroke from 1990 to 2006 (quarterly) for Florida, 1995 to 2006 (monthly) for New York, and 1998 to 2006 (monthly) for Oregon to identify any association between admission rates and passage of comprehensive smoke-free air laws. Interrupted time series analysis was used to adjust for the effects of preexisting moderate local-level laws, seasonal variation in hospital admissions, differences across counties, and a secular time trend. RESULTS: More than 3 years after passage of statewide comprehensive smoke-free air laws, rates of hospitalization for AMI were reduced by 18.4% (95% CI: 8.8-28.0%) in Florida and 15.5% (95% CI: 11.0-20.1%) in New York. Rates of hospitalization for stroke were reduced by 18.1% (95% CI: 9.3-30.0%) in Florida. The few local comprehensive laws in Oregon were not associated with reductions in AMI or stroke statewide. CONCLUSION: Comprehensive smoke-free air laws are an effective policy tool for reducing the burden of AMI and stroke.

Developing approaches for evaluating smoke-free policies: a case study of a collaborative response to an emerging technical assistance need.

This article describes how several tobacco control organizations identified and responded to an emerging need for technical assistance on how to evaluate smoke-free policies. The authors outline the purposes of evaluating smoke-free policies and present examples of evaluation approaches and tools. Examples are provided of how evaluation has been used to advance the adoption, implementation, and defense of smoke-free policies. Opportunities for further research are identified. Finally, the authors review lessons learned and discuss their implications for evaluating policy initiatives addressing other public health issues.

Does offering more support calls to smokers influence quit success?

BACKGROUND: Previous studies have found that offering additional callback counseling support to smokers calling a telephone quit line increases quit rates. However, what is less certain is the most cost-efficient protocol for offering such a service. OBJECTIVE: This study compares the efficacy of offering 2 versus 4 counseling callbacks after an initial call from Medicaid/uninsured adult smokers contacting the New York State Smokers' Quit Line (NYSSQL). Outcomes compared are the 7- and 30-day nonsmoker prevalence rates measured at 3-month follow-up and the cost per quit. DESIGN: A 2-group randomized trial was conducted. SETTING AND PARTICIPANTS: The study population included 1923 adult (18+ years) Medicaid/uninsured current smokers (10+ cigarettes per day) who called the NYSSQL between February and March 2009 seeking help to stop smoking. At the time of the study, the NYSSQL provided Medicaid/uninsured callers with up to 6 weeks of free nicotine medications and up to 4 counseling callbacks. Half the subjects were randomized to standard care with up to 4 counseling callbacks with the remaining subjects offered only 2 counseling callbacks. All participants were sent a minimum of a 2-week supply of nicotine replacement therapy, with some receiving up to 6 weeks. Participants were recontacted 3 months after enrollment in the study to assess smoking status. MAIN OUTCOME MEASURES: Quit rates, total counseling callbacks completed, reductions in cigarette consumption, and cost per quit measures. RESULTS: There was not a significant difference between study groups in the number of callbacks completed. There was also no difference in 7- or 30-day nonsmoker prevalence rates measured after 3 months' follow-up or reported use of the free nicotine replacement therapy between those assigned to either the 2- or 4-callback protocols. The cost per quit was essentially the same in both groups (2 callbacks--$442 per quit vs 4 callbacks--$445 per quit). CONCLUSION: There was no advantage in terms of quit success or cost to offering up to 4 callbacks instead of 2 callbacks.

Costs of giving out free nicotine patches through a telephone quit line.

BACKGROUND: Many telephone quit lines provide free nicotine replacement therapy (NRT) to smokers who are trying to stop smoking. However, providing free NRT to smokers can be costly. OBJECTIVE: To compare NRT usage patterns, quit rate, and costs of giving smokers calling a telephone quit line different amounts of free NRT. DESIGN: A 3-group randomized trial was conducted. SETTING AND PARTICIPANTS: A total of 2806 adult smokers of 10+ cigarettes per day who called the New York State Smokers' Quit Line (NYSSQL) were sent different amounts of nicotine patches for free as follows: (1) a 2-week supply of nicotine patches, (2) a 4-week supply, and (3) a 6-week supply. In addition, all study participants received a free stop smoking guide plus 1 proactive follow-up call attempt conducted 2 weeks after initially contacting the NYSSQL. Of the 2806 enrolled participants, 1682 completed the 7-month follow-up to assess their use of the NRT sent to them and smoking status. MAIN OUTCOME MEASURES: Nicotine patch usage, quit rates, reductions in cigarette consumption, and cost-effectiveness measures. RESULTS: Most respondents (85%) reported using the nicotine patches sent to them, although the amount used varied in direct proportion to the amount sent. The 7- and 30-day nonsmoker prevalence rates measured at 7-month follow-up did not differ significantly between the 3 groups. The cost per attributable quit was also not significantly different between the 3 groups. CONCLUSION: Sending out more than a free 2-week supply of patches to smokers who contact a quit line is no more effective in achieving smoking cessation than sending just 2 weeks of patches.

The empire challenge: statewide initiative linking the role of dental hygienists to tobacco dependence treatment.

PURPOSE: The primary goal of this 3 year grant-funded pilot project was to determine if a specialized training program could increase the number of dental hygienists in New York state who routinely address tobacco use with their patients. METHODS: A training program based on the 2000 Clinical Practice Guideline, Treating Tobacco Use and Dependence, was developed to educate licensed and registered dental hygienists in New York. Outcome data are from cross-sectional surveys conducted before and after the training and from the New York State Smokers' Quitline. RESULTS: The formal training program was associated with a significant increase in the percentage of a sample of hygienists routinely addressing tobacco use and dependence with their patients. An increased number of calls to the Quitline were generated. CONCLUSION: A comprehensive training program based on accepted clinical guidelines, which included increased accessibility to free supplies, was associated with an increase in the proportion of dental hygienists who routinely address tobacco use and dependence with their patients.

Multiunit housing residents' experiences and attitudes toward smoke-free policies.

INTRODUCTION: Secondhand smoke (SHS) causes significant disease and death. A person's home represents a prominent source of SHS, and the potential for exposure is elevated among those who live in close proximity to smokers in multiunit housing (MUH). This study assessed the prevalence and predictors of SHS exposure and smoke-free policy support among MUH residents. METHODS: Data were obtained from 5,936 MUH residents who participated in the New York State Adult Tobacco Survey between May 2007 and May 2009. Bivariate analyses were used to assess the prevalence of smoke-free home policies, SHS incursions, and support for smoke-free policies. Logistic regression was used to identify predictors of these measures while adjusting for gender, age, ethnicity, education, region, children in household, and housing type. RESULTS: A total of 73.1% of respondents reported a personal smoke-free home policy in their home. Among these individuals, 46.2% indicated that SHS has ever entered their home in the past year, while 9.2% reported daily incursions. Overall, a majority of respondents (55.6%) support a policy that bans smoking in all areas of their building, including residential units; support was significantly higher among ethnic minorities and individuals who reside with children. DISCUSSION: Nearly half of New York MUH residents with a smoke-free home policy have experienced a SHS incursion in their home. Since a majority of MUH residents support smoke-free policies and nearly three quarters already prohibit smoking in their home, opportunities exist for initiatives to promote smoke-free building policies.

A placebo-controlled trial of phenelzine, cognitive behavioral group therapy, and their combination for social anxiety disorder.

CONTEXT: Medication and cognitive behavioral treatment are the best-established treatments for social anxiety disorder, yet many individuals remain symptomatic after treatment. OBJECTIVE: To determine whether combined medication and cognitive behavioral treatment is superior to either monotherapy or pill placebo. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Research clinics at Columbia University and Temple University. PARTICIPANTS: One hundred twenty-eight individuals with a primary DSM-IV diagnosis of social anxiety disorder. INTERVENTIONS: Cognitive behavioral group therapy (CBGT), phenelzine sulfate, pill placebo, and combined CBGT plus phenelzine. MAIN OUTCOME MEASURES: Liebowitz Social Anxiety Scale and Clinical Global Impression (CGI) scale scores at weeks 12 and 24. RESULTS: Linear mixed-effects models showed a specific order of effects, with steepest reductions in Liebowitz Social Anxiety Scale scores for the combined group, followed by the monotherapies, and the least reduction in the placebo group (Williams test = 4.97, P < .01). The CGI response rates in the intention-to-treat sample at week 12 were 9 of 27 (33.3%) (placebo), 16 of 34 (47.1%) (CBGT), 19 of 35 (54.3%) (phenelzine), and 23 of 32 (71.9%) (combined treatment) (chi(2)(1) = 8.76, P < .01). Corresponding remission rates (CGI = 1) were 2 of 27 (7.4%), 3 of 34 (8.8%), 8 of 35 (22.9%), and 15 of 32 (46.9%) (chi(2)(1) = 15.92, P < .01). At week 24, response rates were 9 of 27 (33.3%), 18 of 34 (52.9%), 17 of 35 (48.6%), and 25 of 32 (78.1%) (chi(2)(1) = 12.02, P = .001). Remission rates were 4 of 27 (14.8%), 8 of 34 (23.5%), 9 of 35 (25.7%), and 17 of 32 (53.1%) (chi(2)(1) = 10.72, P = .001). CONCLUSION: Combined phenelzine and CBGT treatment is superior to either treatment alone and to placebo on dimensional measures and on rates of response and remission.

Assessing Client Progress Session by Session in the Treatment of Social Anxiety Disorder: The Social Anxiety Session Change Index.

Frequent assessment during therapy can improve treatments and provide accountability. However, clinicians often do not monitor progress because of the time it takes to administer and score assessments. In response, the Social Anxiety Session Change Index (SASCI) was developed. The SASCI is a short, easily administered rating of subjective improvement that asks clients with social anxiety disorder how much they have changed since the beginning of therapy. Change on the SASCI was related to change in fear of negative evaluation, a core aspect of social anxiety, and to clinician-rated improvement, but not to ratings of anxiety sensitivity or depression. Because it is brief and easily interpretable, the SASCI can be used in a variety of clinical settings to monitor change across therapy. The SASCI is presented along with examples of how the information gathered from frequent administration can inform clinical practice.

Declines in hospital admissions for acute myocardial infarction in New York state after implementation of a comprehensive smoking ban.

OBJECTIVES: Reductions in exposure to environmental tobacco smoke have been shown to attenuate the risk of cardiovascular disease. We examined whether the 2003 implementation of a comprehensive smoking ban in New York State was associated with reduced hospital admissions for acute myocardial infarction and stroke, beyond the effect of moderate, local and statewide smoking restrictions, and independent of secular trends. METHODS: We analyzed trends in county-level, age-adjusted, monthly hospital admission rates for acute myocardial infarction and stroke from 1995 to 2004 to identify any association between admission rates and implementation of the smoking ban. We used regression models to adjust for the effects of pre-existing smoking restrictions, seasonal trends in admissions, differences across counties, and secular trends. RESULTS: In 2004, there were 3813 fewer hospital admissions for acute myocardial infarction than would have been expected in the absence of the comprehensive smoking ban. Direct health care cost savings of $56 million were realized in 2004. There was no reduction in the number of admissions for stroke. CONCLUSIONS: Hospital admission rates for acute myocardial infarction were reduced by 8% as a result of a comprehensive smoking ban in New York State after we controlled for other relevant factors. Comprehensive smoking bans constitute a simple, effective intervention to substantially improve the public's health.