Association of Participation in a Value-Based Insurance Design Program With Health Care Spending and Utilization.

Importance: Value-based insurance design (VBID) has mostly been used in improving medication use and adherence for certain conditions or patients, but its outcomes remain uncertain when applied to other services and to all health plan enrollees. Objective: To determine the association of participation in a California Public Employees' Retirement System (CalPERS) VBID program with its enrollees' health care spending and utilization. Design, Setting, and Participants: A retrospective cohort study with difference-in-differences propensity-weighted 2-part regression models was performed in 2021 to 2022. A VBID cohort was compared with a non-VBID cohort both before and after VBID implementation in California in 2019 with 2 years' follow-up. The study sample included CalPERS preferred provider organization continuous enrollees from 2017 through 2020. Data were analyzed from September 2021 to August 2022. Exposures: The key VBID interventions include (1) if selecting and using a primary care physician (PCP) for routine care, PCP office visit copayment is $10 (otherwise, PCP office visit copayment is $35 as for specialist visit); and (2) annual deductibles reduced by a half through completion of the following 5 activities: annual biometric screening, influenza vaccine, nonsmoking certification, second opinion for elective surgical procedures, and disease management participation. Main Outcomes and Measures: The primary outcome measures included annual per member total approved payments for multiple inpatient and outpatient services. Results: The 2 compared cohorts of 94 127 participants (48 770 were female [52%]; 47 390 were younger than 45 years old [50%]) had insignificant baseline differences after propensity-weighting adjustment. The VBID cohort had significantly lower probabilities of inpatient admissions (adjusted relative odds ratio [OR], 0.82; 95% CI, 0.71-0.95), and higher probabilities of receiving immunizations (adjusted relative OR, 1.07; 95% CI, 1.01-1.21) in 2019. Among those with positive payments, VBID was associated with higher mean total allowed amounts for PCP visits in 2019 and 2020 (adjusted relative payments ratio, 1.05; 95% CI, 1.02-1.08). There were no significant differences for inpatient and outpatient combined totals in 2019 and 2020. Conclusions and Relevance: The CalPERS VBID program achieved desired goals for some interventions with no added total costs in its first 2 years of operation. VBID may be used to promote valued services while containing costs for all enrollees.

The Health Plan Environment In California Contributed To Differential Use Of Telehealth During The COVID-19 Pandemic.

The COVID-19 pandemic has led to substantial increases in the use of telehealth and virtual care in the US. Differential patient and provider access to technology and resources has raised concerns that existing health disparities may be extenuated by shifts to virtual care. We used data from one of the largest providers of employer-sponsored insurance, the California Public Employees' Retirement System, to examine potential disparities in the use of telehealth. We found that lower-income, non-White, and non-English-speaking people were more likely to use telehealth during the period we studied. These differences were driven by enrollment in a clinically and financially integrated care delivery system, Kaiser Permanente. Kaiser's use of telehealth was higher before and during the pandemic than that of other delivery models. Access to integrated care may be more important to the adoption of health technology than patient-level differences.

Findings From a Commercial ACO Patient Experience Survey.

Accountable care organizations (ACO) emerge each year aiming to improve care quality while controlling rising health care costs. This cross-sectional study examined whether ACO arrangements within a Preferred Provider Organization and a Health Maintenance Organization (HMO) effected patient experience. A modified Consumer Assessment of Healthcare Providers and Systems ACO survey was used to assess care domain differences overall and by product. The association between ACO and non-ACO populations and items in each significant care domain, flu vaccination, and delayed and emergency department care are explored using multivariable logistic regression. Accountable care organizations patients were more likely to report it was easy to get a specialist appointment (adjusted odds ratio [AOR], 1.54; 95% CI = 1.11-2.13), less likely to report visiting the emergency department for care (AOR, 0.70; 95% CI = 0.55-0.90) and communicating with their provider using technology (AOR, 0.79; 95% CI = 0.65-0.96). Reported experience differed for Access to Specialists between ACO and non-ACO groups among overall and HMO respondents (79.4% vs 74.7% and 79.9% vs 75.5%, P < .05, respectively). The ACO patient experience was not substantially better. Strategies incorporating satisfaction and experience, whether linked to contracts or not, should be encouraged given ACOs goal to optimize patient care. Survey instruments must be improved to capture nuances of provider care and patient bond that is vital in ACO integrated systems.

Impact of a commercial accountable care organization on prescription drugs.

OBJECTIVE: To determine the long-run impact of a commercial accountable care organization (ACO) on prescription drug spending, utilization, and related quality of care. DATA SOURCES/STUDY SETTING: California Public Employees' Retirement System (CalPERS) health maintenance organization (HMO) member enrollment data and pharmacy benefit claims, including both retail and mail-order generic and brand-name prescription drugs. STUDY DESIGN: We applied a longitudinal retrospective cohort study design and propensity-weighted difference-in-differences regression models. We examined the relative changes in outcome measures between two ACO cohorts and one non-ACO cohort before and after the ACO implementation in 2010. The ACO directed provider prescribing patterns toward generic substitution for brand-name prescription drugs to maximize shared savings in pharmacy spending. DATA COLLECTION/EXTRACTION METHODS: The study sample included members continuously enrolled in a CalPERS commercial HMO from 2008 through 2014 in the Sacramento area. PRINCIPAL FINDINGS: The cohort differences in baseline characteristics of 40 483 study participants were insignificant after propensity-weighting adjustment. The ACO enrollees had no significant differential changes in either all or most of the five years of the ACO operation for the following measures: (1) average total spending and (2) average total scripts filled and days supplied on either generic or brand-name prescription drugs, or the two combined; (3) average generic shares of total prescription drug spending, scripts filled or days supplied; (4) annual rates of 10 outpatient process quality of care metrics for medication prescribing or adherence. CONCLUSIONS: Participation in the commercial ACO was associated with negligible differential changes in prescription drug spending, utilization, and related quality of care measures. Capped financial risk-sharing and increased generics substitution for brand names are not enough to produce tangible performance improvement in ACOs. Measures to increase provider financial risk-sharing shares and lower brand-name drug prices are needed.

Five-year Impact of a Commercial Accountable Care Organization on Health Care Spending, Utilization, and Quality of Care.

BACKGROUND: Accountable Care Organizations (ACOs) have proliferated after the passage of the Affordable Care Act in 2010. Few longitudinal ACO studies with continuous enrollees exist and most are short term. OBJECTIVE: The objective of this study was to evaluate the long-term impact of a commercial ACO on health care spending, utilization, and quality outcomes among continuously enrolled members. RESEARCH DESIGN: Retrospective cohort study design and propensity-weighted difference-in-differences approach were applied to examine performance changes in 2 ACO cohorts relative to 1 non-ACO cohort during the commercial ACO implementation in 2010-2014. SUBJECTS: A total of 40,483 continuously enrolled members of a commercial health maintenance organization from 2008 to 2014. MEASURES: Cost, use, and quality metrics for various type of services in outpatient and inpatient settings. RESULTS: The ACO cohorts had (1) increased inpatient and outpatient total spending in the first 2 years of ACO operation, but insignificant differential changes for the latter 3 years; (2) decreased outpatient spending in the latter 2 years through reduced primary care visits and lowered spending on specialists, testing, and imaging; (3) no differential changes in inpatient hospital spending, utilization, and quality measures for most of the 5 years; (4) favorable results for several quality measures in preventive and diabetes care domains in at least one of the 5 years. CONCLUSIONS: The commercial ACO improved outpatient process quality measures modestly and slowed outpatient spending growth by the fourth year of operation, but had a negligible impact on inpatient hospital cost, use, and quality measures.

Comparing The Effects Of Reference Pricing And Centers-Of-Excellence Approaches To Value-Based Benefit Design.

Various health insurance benefit designs based on value-based purchasing have been promoted to steer patients to high-value providers, but little is known about the designs' relative effectiveness and underlying mechanisms. We compared the impact of two designs implemented by the California Public Employees' Retirement System on inpatient hospital total hip or knee replacement: a reference-based pricing design for preferred provider organizations (PPOs) and a centers-of-excellence design for health maintenance organizations (HMOs). Payment and utilization data for the procedures in the period 2008-13 were evaluated using pre-post and quasi-experimental designs at the system and health plan levels, adjusting for demographic characteristics, case-mix, and other confounders. We found that both designs prompted higher use of designated low-price high-quality facilities and reduced average replacement expenses per member at the plan and system levels. However, the designs used different routes: The reference-based pricing design reduced average replacement payments per case in PPOs by 26.7 percent in the first year, compared to HMOs, but did not lower PPO members' utilization rates. In contrast, the centers-of-excellence design lowered HMO members' utilization rates by 29.2 percent in the first year, compared to PPOs, but did not reduce HMO average replacement payments per case. The reference-based pricing design appears more suitable for reducing price variation, and the centers-of-excellence design for addressing variation in use.

Offering A Price Transparency Tool Did Not Reduce Overall Spending Among California Public Employees And Retirees.

Insurers, employers, and states increasingly encourage price transparency so that patients can compare health care prices across providers. However, the evidence on whether price transparency tools encourage patients to receive lower-cost care and reduce overall spending remains limited and mixed. We examined the experience of a large insured population that was offered a price transparency tool, focusing on a set of "shoppable" services (lab tests, office visits, and advanced imaging services). Overall, offering the tool was not associated with lower shoppable services spending. Only 12 percent of employees who were offered the tool used it in the first fifteen months after it was introduced, and use of the tool was not associated with lower prices for lab tests or office visits. The average price paid for imaging services preceded by a price search was 14 percent lower than that paid for imaging services not preceded by a price search. However, only 1 percent of those who received advanced imaging conducted a price search. Simply offering a price transparency tool is not sufficient to meaningfully decrease health care prices or spending.

Patients' views on price shopping and price transparency.

OBJECTIVES: Driven by the growth of high deductibles and price transparency initiatives, patients are being encouraged to search for prices before seeking care, yet few do so. To understand why this is the case, we interviewed individuals who were offered access to a widely used price transparency website through their employer. STUDY DESIGN: Qualitative interviews. METHODS: We interviewed individuals enrolled in a preferred provider organization product through their health plan about their experience using the price transparency tool (if they had done so), their past medical experiences, and their opinions on shopping for care. All interviews were transcribed and manually coded using a thematic coding guide. RESULTS: In general, respondents expressed frustration with healthcare costs and had a positive opinion of the idea of price shopping in theory, but 2 sets of barriers limited their ability to do so in reality. The first was the salience of searching for price information. For example, respondents recognized that due to their health plan benefits design, they would not save money by switching to a lower-cost provider. Second, other factors were more important than price for respondents when choosing a provider, including quality and loyalty to current providers. CONCLUSIONS: We found a disconnect between respondents' enthusiasm for price shopping and their reported use of a price transparency tool to shop for care. However, many did find the tool useful for other purposes, including checking their claims history. Addressing the barriers to price shopping identified by respondents can help inform ongoing and future price transparency initiatives.

Direct-To-Consumer Telehealth May Increase Access To Care But Does Not Decrease Spending.

The use of direct-to-consumer telehealth, in which a patient has access to a physician via telephone or videoconferencing, is growing rapidly. A key attraction of this type of telehealth for health plans and employers is the potential savings involved in replacing physician office and emergency department visits with less expensive virtual visits. However, increased convenience may tap into unmet demand for health care, and new utilization may increase overall health care spending. We used commercial claims data on over 300,000 patients from three years (2011-13) to explore patterns of utilization and spending for acute respiratory illnesses. We estimated that 12 percent of direct-to-consumer telehealth visits replaced visits to other providers, and 88 percent represented new utilization. Net annual spending on acute respiratory illness increased $45 per telehealth user. Direct-to-consumer telehealth may increase access by making care more convenient for certain patients, but it may also increase utilization and health care spending.

Access and Quality of Care in Direct-to-Consumer Telemedicine.

BACKGROUND: Direct-to-consumer (DTC) telemedicine serves millions of patients; however, there is limited research on the care provided. This study compared the quality of care at Teladoc ( www.teladoc.com ), a large DTC telemedicine company, with that at physician offices and compared access to care for Teladoc users and nonusers. MATERIALS AND METHODS: Claims from all enrollees 18-64 years of age in the California Public Employees' Retirement System health maintenance organization between April 2012 and October 2013 were analyzed. We compared the performance of Teladoc and physician offices on applicable Healthcare Effectiveness Data and Information Set measures. Using geographic information system analyses, we compared Teladoc users and nonusers with respect to rural location and available primary care physicians. RESULTS: Of enrollees offered Teladoc (n = 233,915), 3,043 adults had a total of 4,657 Teladoc visits. For the pharyngitis performance measure (ordering strep test), Teladoc performed worse than physician offices (3% versus 50%, p < 0.01). For the back pain measure (not ordering imaging), Teladoc and physician offices had similar performance (88% versus 79%, p = 0.20). For the bronchitis measure (not ordering antibiotics), Teladoc performed worse than physician offices (16.7 versus 27.9%, p < 0.01). In adjusted models, Teladoc users were not more likely to be located within a healthcare professional shortage area (odds ratio = 1.12, p = 0.10) or rural location (odds ratio = 1.0, p = 0.10). CONCLUSIONS: Teladoc providers were less likely to order diagnostic testing and had poorer performance on appropriate antibiotic prescribing for bronchitis. Teladoc users were not preferentially located in underserved communities. Short-term needs include ongoing monitoring of quality and additional marketing and education to increase telemedicine use among underserved patients.

Quitline utilization rates of African-American and white smokers: the California experience.

PURPOSE: To compare the utilization rate of a statewide tobacco quitline by African-American smokers to that of white smokers. DESIGN, SETTING, AND SUBJECTS: Observational study of 18 years of state quitline operation in California. Subjects were 61,096 African-American and 279,042 white smokers who called the quitline from August 1992 to December 2009. Data from six California Tobacco Surveys, 1993, 1996, 1999, 2002, 2005, and 2008 were also used. MEASURE: Callers' answers to the question how they heard about the quitline were grouped into four categories: media, health care providers, friends/family, and others. ANALYSIS: The averaged annual quitline call volume for each ethnic group was divided by the total number of smokers in that group, based on California Tobacco Surveys, to produce the annual quitline utilization rate. RESULTS: In five out of six periods of comparison, African-American smokers had a higher annual utilization rate than white smokers. The odds ratios [ORs] ranged from 1.44 to 2.40 (all p < .05). In the 1996 comparison, the OR was .90 (p <.05). The difference in utilization rates that is attributed to media, accounts for most of the difference in total utilization rates between the two ethnic groups. CONCLUSIONS: Within the context of California's comprehensive tobacco control program, which includes a strong media campaign, African-American smokers were significantly more likely to call the state quitline than white smokers were. Promoting the quitline as part of antismoking media campaigns can help reduce disparity in cessation service utilization.

Prevalence of heavy smoking in California and the United States, 1965-2007.

CONTEXT: The intensity of smoking, not just prevalence, is associated with future health consequences. OBJECTIVE: To estimate smoking intensity patterns over time and by age within birth cohorts for California and the remaining United States. DESIGN, SETTING, AND PARTICIPANTS: Two large population-based surveys with state estimates: National Health Interview Surveys, 1965-1994; and Current Population Survey Tobacco Supplements, 1992-2007. There were 139,176 total respondents for California and 1,662,353 for the remaining United States. MAIN OUTCOME MEASURE: Number of cigarettes smoked per day (CPD), high-intensity smokers (≥20 CPD); moderate-intensity smokers (10-19 CPD); low-intensity smokers (0-9 CPD). RESULTS: In 1965, 23.2% of adults in California (95% confidence interval [CI], 19.6%-26.8%) and 22.9% of adults in the remaining United States (95% CI, 22.1%-23.6%) were high-intensity smokers, representing 56% of all smokers. By 2007, this prevalence was 2.6% (95% CI, 0.0%-5.6%) or 23% of smokers in California and 7.2% (95% CI, 6.4%-8.0%) or 40% of smokers in the remaining United States. Among individuals (US residents excluding California) born between 1920-1929, the prevalence of moderate/high-intensity smoking (≥10 CPD) was 40.5% (95% CI, 38.3%-42.7%) in 1965. Moderate/high-intensity smoking declined across successive birth cohorts, and for the 1970-1979 birth cohort, the highest rate of moderate/high-intensity smoking was 9.7% (95% CI, 7.7%-11.7%) in California and 18.3% (95% CI, 16.4%-20.2%) in the remaining United States. There was a marked decline in moderate/high-intensity smoking at older ages in all cohorts, but this was greater in California. By age 35 years, the prevalence of moderate/high-intensity smoking in the 1970-1979 birth cohort was 4.6% (95% CI, 3.0%-6.1%) in California and 13.5% (95% CI, 11.8%-15.1%) in the remaining United States. CONCLUSIONS: Between 1965 and 2007, the prevalence of high-intensity smoking decreased greatly in the United States. The greater decline in high-intensity smoking prevalence in California was related to reduced smoking initiation and a probable increase in smoking cessation.

Forty years of faster decline in cigarette smoking in California explains current lower lung cancer rates.

BACKGROUND: Declining lung cancer rates in California have been attributed to the California Tobacco Control Program, but may reflect earlier declines in smoking. METHODS: Using state-taxed sales and three survey series, we assessed trends in smoking behavior for California and the rest of the nation from 1960 to 2008 and compared these with lung cancer mortality rates. We tested the validity of recent trends in state-taxed sales by projecting results from a model of the 1960 to 2002 data. RESULTS: From 1960 to 2002, the state-taxed sales and survey data are consistent. Californians initially smoked more than the rest of the nation, but cigarette consumption declined earlier, dropping lower in 1971 with an ever widening gap over time. Lung cancer mortality follows a similar pattern, after a lag of 16 years. Introduction of the California Tobacco Control Program doubled the rate of decline in cigarette consumption. From 2002 to 2008, differences in enforcement and tax evasion may compromise the validity of the taxed sales data. In 2010, smoking prevalence is estimated to be 9.3% in California and 17.8% in the rest of the nation. However, in 2008, for the first time, both cigarette price and tobacco control expenditures were lower in California than the rest of the nation, suggesting that the gap in smoking behavior will start to narrow. CONCLUSION: An effective Tobacco Control Program means that California will have faster declines in lung cancer than the rest of the nation for the next 2 decades, but possibly not beyond. IMPACT: Tobacco control interventions need further dissemination.

An evaluation of the California community intervention.

AIM: We conducted this study to determine key community-level factors associated with higher tobacco control programme performance. METHODS: A combination of surveys, administrative and fiscal data were collected to measure local county-level health department performance over a 7-year period. Longitudinal analyses were performed using generalised estimating equations to examine whether counties that exerted higher effort were successful in creating more tobacco retail licensing (TRL) and secondhand smoke policies. Several social, political and contextual factors were examined as confounders. RESULTS: Local county health departments (CHDs) that demonstrated high effort on their work plans increased the proportion of residents covered by TRL policies (7.2%; 95% CI -1.7 to 16.1%) compared to CHDs with lower levels of effort. Having legislators who voted in favour of tobacco control bills was found to significantly increase the passage of local TRL policies. CHDs demonstrating higher efforts also increased the proportion of residents covered by secondhand smoke policies (9.2%; 95% CI -3.5 to 21.9%). CONCLUSION: There was strong evidence that higher county-level efforts predicted an increasing number of local tobacco control policies. Evaluations using integrated designs are recommended as effective strategies to provide a more accurate assessment of how well community-level interventions catalyse community-wide change.

Assessing the relationship between ad volume and awareness of a tobacco education media campaign.

BACKGROUND: The relation between aided ad recall and level of television ad placement in a public health setting is not well established. We examine this association by looking back at 8 years of the California's Tobacco Control Program's (CTCP) media campaign. METHODS: Starting in July 2001, California's campaign was continuously monitored using five telephone series of surveys and six web-based series of surveys immediately following a media flight. We used population-based statewide surveys to measure aided recall for advertisements that were placed in each of these media flights. Targeted rating points (TRPs) were used to measure ad placement intensity throughout the state. RESULTS: Cumulative TRPs exhibited a stronger relation with aided ad recall than flight TRPs or TRP density. This association increased after log-transforming cumulative TRP values. We found that a one-unit increase in log-cumulative TRPs led to a 13.6% increase in aided ad recall using web-based survey data, compared to a 5.3% increase in aided ad recall using telephone survey data. CONCLUSIONS: In California, the relation between aided ad recall and cumulative TRPs showed a diminishing return after a large volume of ad placements These findings may be useful in planning future ad placement for CTCP's media campaign.

The impact of social norm change strategies on smokers' quitting behaviours.

OBJECTIVE: Using a social norm change paradigm model that reflects the California Tobacco Control Program's (CTCP) priorities, we compare the strength of the relationship of the social norm constructs to key smoking behavioural outcomes. METHODS: Social norm constructs that correspond to CTCP's priority areas were created from selected California Adult Tobacco Survey knowledge, attitude and belief questions using confirmatory factor analysis. We then examined the relationship between these constructs and quitting behaviours using logistic regression. RESULTS: The secondhand smoke (SHS) and countering pro-tobacco influences'(CPTI) constructs followed a dose-response curve with quitting behaviours. Respondents who rated high on the SHS construct were about 70% more likely to have made a recent quit attempt in the last 12 months and about 100% more likely to intend to quit in the next 6 months than respondents who rated low on the SHS construct. For CPTI, respondents who rated high on this construct were 67% more likely to have made a recent quit attempt in the last 12 months and 62% more likely to have intentions to quit in the next 6 months than respondents who rated low on the CPTI construct. CONCLUSION: Social norm change constructs represent CTCP's priorities and are strongly related to desired individual behaviour outcomes. This analysis provides strong support for the framework underlying CTCP--namely, that changing social norms affects behaviour change at the individual level through changing population-level smoking-related behaviours.

Using a cessation-related outcome index to assess California's cessation progress at the population level.

BACKGROUND: The California Tobacco Control Program (CTCP) has employed strategies to change social norms around smoking in order to decrease the prevalence of smoking and tobacco-related diseases. Research is scarce on CTCP's impact on overall smoking cessation in California. METHODS: Tobacco Use Supplement to the Current Population Survey (TUS-CPS) data from 1992-1993 to 2006-2007 was used to create a cessation-related outcome index (CROI), which was a summarised z score of the following determinants: plan to quit, quit attempt and recent quit rate for each of the 50 US states. CROI trends over the period of six separate TUS-CPSs were plotted for California and other comparison states, for 18-34 year olds and for those 35 years or older separately in the context of historical cigarette price z score trend. RESULTS: California had a consistently high CROI for both age groups. The CROI trend line increased moderately in California for both age groups despite a declining cigarette price z score trend. In contrast, other selected states with a declining cigarette price z score trend had a declining CROI trend for both age groups. CONCLUSIONS: The increase of CROI in California while cigarette price z score trend declined suggests that the implementation of CTCP, even without a significant direct cessation component, has had a profound impact on cessation outcomes.

Smoking-attributable cancer mortality in California, 1979-2005.

BACKGROUND: The adult smoking prevalence has declined more in California than the rest of the US in the past 2 decades. Further, California has faster declines in cancer mortality, lung cancer incidence and heart disease mortality. However, no study has examined smoking-related cancer mortality between California and the rest of the US. METHODS: The smoking-attributable cancer mortality rate (SACMR) from 1979 to 2005 in California and the rest of the US are calculated among men and women 35 years of age or older using the Joinpoint regression model to calculate the SACMR annual percentage change. The SACMR is the sum of the smoking-attributable death rates of 10 smoking-attributable cancers. RESULTS: The SACMR has declined more in California (25.7%) than the rest of the US (8.9%) from 1979 to 2005. California men had a lower SACMR than the rest of the US over the entire study period, with the difference tripling from 7.4% in 1979 to 23.9% in 2005. The difference of female SACMR between California and the rest of the US went from 17.9% higher in 1979 to 13.4% lower in 2005. CONCLUSIONS: California's SACMR decrease started 7 years earlier than the rest of the US (1984 vs 1991), and California experienced an accelerated decline of SACMR compared to the rest of the US overall and among men and women from 1979 to 2005. Although the SACMR started declining before the creation of the California Department of Public Health, California Tobacco Control Program, the SACMR rate of decline in California accelerated after the programme's inception.

Is adolescent smoking related to the density and proximity of tobacco outlets and retail cigarette advertising near schools?

OBJECTIVE: To examine the quantity (density) and location (proximity) of tobacco outlets and retail cigarette advertising in high school neighborhoods and their association with school smoking prevalence. METHODS: Data from the 135 high schools that participated in the 2005-2006 California Student Tobacco Survey were combined with retailer licensing data about the location of tobacco outlets within walking distance (1/2 mi or 805 m) of the schools and with observations about the quantity of cigarette advertising in a random sample of those stores (n=384). Multiple regressions, adjusting for school and neighborhood demographics, tested the associations of high school smoking prevalence with the density of tobacco outlets and retail cigarette advertising and with the proximity of tobacco outlets to schools. RESULTS: The prevalence of current smoking was 3.2 percentage points higher at schools in neighborhoods with the highest tobacco outlet density (>5 outlets) than in neighborhoods without any tobacco outlets. The density of retail cigarette advertising in school neighborhoods was similarly associated with high school smoking prevalence. However, neither the presence of a tobacco outlet within 1000 ft of a high school nor the distance to the nearest tobacco outlet from school was associated with smoking prevalence. CONCLUSIONS: Policy efforts to reduce adolescent smoking should aim to reduce the density of tobacco outlets and retail cigarette advertising in school neighborhoods. This may be achieved through local zoning ordinances, including limiting the proximity of tobacco outlets to schools.