The impact of smoking and quitting on health care use.

BACKGROUND: The magnitude and timing of the impact of effects of smoking cessation on inpatient and outpatient health care use are uncertain. METHODS: Comparison of the use of outpatient and hospital services over time of 2440 persistent smokers and 244 biochemically verified quitters, all of whom were participants in two independent randomized trials of smoking cessation interventions. RESULTS: Continued smokers in both trials experienced a 7% to 15% increase in outpatient visits and a 30% to 45% increase in hospital admissions over 5 to 6 years of follow-up. The positive slopes approached or reached statistical significance for all use variables in both trial populations. Among quitters, all health care use rates significantly increased during the year in which they quit; after that, the rates declined progressively. By the fourth year after quitting, all use rates among quitters were lower than those for smokers. The increase in hospitalizations during the year of quitting was more often a cause rather than a consequence of successful smoking cessation. CONCLUSION: Successful smoking cessation appears to halt the progressive increase in the use of health services associated with continued smoking within a 4-year period.

ASPO Joseph W. Cullen Memorial Award Lecture. Bridging the clinical and public health perspectives in tobacco treatment research: scenes from a tobacco treatment research career.

This paper, delivered as the 2000 Joseph W. Cullen Memorial Award Lecture, reviews smoking cessation treatment research conducted over the past 15 years at the Center for Health Studies, Group Health COOPERATIVE: The research program includes assessment, treatment, and health services research that addressed four main questions: (a) What motivates people to quit smoking? (b) Are self-help interventions effective? (c) Can health care benefits impact the utilization of smoking cessation services? and (d) Does smoking cessation impact health care utilization and costs? In the area of motivation for smoking cessation, an intrinsic-extrinsic model of type of motivation for smoking cessation was used to develop and validate a reasons for quitting scale. Results from administration of the scale across different samples of smokers show that higher levels of intrinsic relative to extrinsic motivation predicts successful cessation. A series of five randomized trials of self-help interventions indicate that self-help interventions accompanied by motivational feedback and/or outreach telephone counseling can be effective. However, the same interventions did not improve long-term abstinence rates in non-volunteer samples of smokers. With regard to health care benefits, we find that full coverage of smoking cessation services improves the reach of proven interventions into the general population of smokers with no significant reductions in effectiveness. Furthermore, studies of smoking cessation and health care utilization find that, although quitters have higher initial costs, their costs go down at the same time that those of continuing smokers' begin to accelerate. Cessation appears to reverse a trajectory of higher health care costs.

Application of a behavioral approach to measuring dietary change: the fat- and fiber-related diet behavior questionnaire.

This study reports the validity, reliability, and responsiveness of a 33-item fat- and fiber-related behavior questionnaire (FFB) and describes how this instrument provides insight into the process of adopting healthy diets. Data are from the Eating Patterns Study, a randomized clinical trial of a physician-delivered, self-help intervention to reduce fat and increase fiber intake. Intervention (n = 850) and control participants (n = 945) completed both a food frequency questionnaire and the FFB at baseline and at 3 and 12 months postintervention. Validity, as assessed by correlation of the FFB with the food frequency questionnaire at baseline, was 0.53 for fat (fat scale with percentage energy from fat) and 0.50 for fiber (fiber scale with fiber g/1000 kcal; both P < 0.001). Reliability, as assessed by the intraclass correlation in controls across all three time points, was 0.77 for the fat scale and 0.74 for the fiber scale (both P < 0.001). The largest changes in fat-related behavior were in avoiding fat as a flavoring and in using specially manufactured low-fat foods, and the largest changes in fiber-related behavior were in substituting high-fiber versions of common foods. Overall, the FFB was a reasonably valid and reliable measure of dietary intake, which provided insight into the behavioral effects of the dietary intervention.

Exploring environmental barriers to participation in mammography screening in an HMO.

Despite an upward trend in mammography screening rates, rates among some demographic subgroups and rates of annual mammography remain low. Behavioral-based interventions which move beyond invitational strategies to help women overcome their personal barriers may be necessary to increase participation. We developed a heuristic model based on the Health Belief Model and Social Learning Theory with the central hypothesis that the relative importance of environmental barriers in predicting screening behavior is a function of the woman's perceived risk, preventive orientation, and/or concerns about mammography. We completed telephone interviews with 313 women who did not obtain a mammogram and 350 women who had a mammogram within 365 days of an invitation from a Health Maintenance Organization-based breast cancer screening program. Results of multivariate analyses indicated that perceived risk did not mitigate the influence of logistic inconveniences associated with obtaining a mammogram. Preventive orientation as measured by smoking status interacted with belief that symptoms are a necessary prerequisite to a mammogram as a powerful predictor of participation; the greatest negative impact of concerns on participation was found among smokers. A similar relationship between concerns and participation, although only marginally significant, was observed among those who perceived it to be difficult to get to the screening center. Implications of the results for development of behavioral interventions and additional research are discussed.

Organizational interventions to encourage guideline implementation.

Evidence-based guidelines hold considerable promise for continued improvement of health-care delivery. However, the availability of clinical practice guidelines does not automatically lead to changes in practice patterns. Using a "push-pull-capacity" model, this article describes strategies to improve guideline implementation for three types of organizations: national organizations, insurer and health-care organizations, and health-care purchasers. Push strategies focus on the guideline development process and include rigorous review and meta-analysis of peer-reviewed research, and use of multidisciplinary expert teams, subjecting guidelines to peer review and comment and using measurable clinical outcomes to define guidelines. PULL: strategies focus on creating a demand for guideline implementation and include professional organization endorsement, quality measures based on guideline-related outcomes, and guideline-based performance objectives in purchaser contracts and physician compensation agreements. Capacity strategies focus on systems that facilitate guideline implementation. Example strategies are providing benefit coverage and reimbursement for guideline-based treatment protocols, and implementing clinical information systems for population-based tracking, outcomes monitoring, and benchmarking feedback.

Perceived barriers and recommendations concerning hormone replacement therapy counseling among primary care providers.

OBJECTIVE: To increase our understanding of the factors that impede or promote counseling about hormone replacement therapy, we asked clinicians to provide information concerning barriers and strategies to promote counseling. DESIGN: We asked clinicians to consider two different scenarios: (1) what they do in they current practice and (2) what they would do if their health care systems implemented the United States Preventive Services Task Force recommendation regarding hormone replacement therapy counseling. A total of 49 of 50 invited clinicians participated in one of six focus group interviews (three women's groups and three men's groups). Our analysis consisted of four steps: (1) identifying segments and classifying them into themes, (2) categorizing themes into topic areas, (3) establishing a final consensus of themes and topics, and (4) ascertaining similarities and contrasts among groups. Transcripts of sessions were analyzed across groups for themes using a text-based analysis system. Conceptualization of themes was derived using a system model of preventive care. Interrater agreement before consensus was good: Kappa (kappa) ranged from 0.70 to 1.00. RESULTS: For current practice, identified barriers included lack of information about risks and benefits, unique challenges of counseling, and lack of resources to conduct counseling. The major strategies suggested were to develop and distribute patient education materials. Discussions about barriers to implementing the United States Task Force recommendation focused on lack of information and resources. CONCLUSIONS: Suggested strategies were multiple, involving individual-, relationship-, and system-level interventions. We expect the strategies identified to be supportive of future efforts to promote counseling for hormone replacement therapy.

Promoting smoking cessation among women who seek cervical cancer screening.

OBJECTIVE: To determine whether 1) women smokers are aware that smoking increases their risk for cervical cancer; 2) awareness of risk factors and its impact on motivation to quit smoking vary by age; and 3) providers are advising smokers to quit smoking during routine gynecologic visits. METHODS: Women aged 18 years and older who had a Papanicolaou test in the prior month were identified from a managed care cytology database. Four weeks after receiving their test result, women were called to complete a health behavior survey in which their smoking status, sexual history, knowledge of risk factors for cervical cancer, and motivation to quit smoking were assessed. RESULTS: Only 49% of the 613 smokers surveyed were aware that smoking increased their risk of cervical cancer. Women aged 34 years and younger were significantly more likely to agree that smoking increased their risk for cervical cancer than women aged 45 years or older (54% versus 40%). Concern that smoking might cause cervical cancer or other cancers was endorsed highly by women as a motivator for cessation, particularly for women smokers aged 18-26 (mean 8.1 and 7.6 on 10-point scales, respectively). About 50% of the women reported that their provider had asked about smoking and had encouraged cessation. Only about 30% of smokers were aware of well-established risk factors for cervical cancer such as the number of lifetime sexual partners and not using a condom. CONCLUSION: Routine gynecologic screening visits represent an important and underutilized clinical opportunity to intervene with young women smokers.

Assessment of community-level influences on individuals' attitudes about cigarette smoking, alcohol use, and consumption of dietary fat.

A basic premise of community-based health promotion is that enduring changes in health behaviors are facilitated by changing community norms or the standards of acceptable behavior in the community. We examine whether community-level influences on individuals' normative attitudes can be related to cigarette smoking, alcohol consumption, and dietary fat intake. We conducted a random-digit dialing survey of 8,849 adults in 15 communities in the western United States as part of the evaluation of the Henry J. Kaiser Family Foundation Community Health Promotion Grant Program. We found independent associations among attitudes for tobacco, alcohol, and diet and both individual-level and community-level characteristics. A significant community effect on attitudes remained even when we controlled for individual demographics and health behaviors, as well as for the overall prevalence of the target health behavior in the community. The specific community characteristics that account for this effect were not clear in our analyses, suggesting that influential characteristics vary from community to community.

Tobacco, alcohol, and caffeine use and cessation in early pregnancy.

OBJECTIVES: Little is known about what happens when individuals attempt to make multiple behavior changes simultaneously. Pregnant women in particular are often in the position of needing to change several behaviors at once, including giving up more than one pleasurable substance. We investigated the success of pregnant women in spontaneously quitting tobacco, alcohol, or caffeine, alone or in combination. METHODS: Pregnant women (n = 7489) were identified in the practices of large health maintenance organizations in Seattle and Minneapolis and were interviewed by telephone. Analyses examined the patterns of using and quitting more than one substance, and the extent to which using more than one substance predicts ability to quit other substances. RESULTS: Use of the three substances tended to cluster within individuals. Users of multiple substances were less likely to quit each substance than users of single substances. However, in the subgroup of multiple substance users who had quit one substance, having quit a second substance was more, rather than less, common. In multivariate analyses predicting quitting, demographic variables, and not having been pregnant previously were significant predictors of quitting each substance; being a nonsmoker predicted quitting alcohol, and being a nonsmoker and nondrinker predicted quitting caffeine. CONCLUSIONS: The reasons for difficulty in quitting more than one substance are unknown but may include the difficulty of formulating appropriate behavioral strategies or less concern about healthy behavior in pregnancy. Many women in the study successfully quit using two substances, however, and counseling should focus on achieving that outcome.

Colorectal cancer screening participation by older women.

OBJECTIVE: Although recent screening guidelines recommend annual fecal occult blood testing (FOBT) for adults aged > or = 50, a number of studies report that these tests are underused. Systematic efforts to increase awareness of colorectal cancer (CRC) and to promote screening participation are needed to meet national objectives for CRC control. METHODS: This study examined CRC-screening practices and evaluated factors related to recent participation in screening by FOBT in a sample of women aged 50 to 80 who were surveyed about their use of clinical preventive services at Group Health Cooperative, a managed care organization in western Washington State. RESULTS: Of the 931 women eligible for analysis, 75% reported ever having been screened by FOBT and 48% reported having been screened within 2 years before the survey. Participation in screening did not vary by demographic characteristics or by perceived or actual risk of CRC. Women with a positive attitudes toward CRC screening had sevenfold greater odds of recent screening by FOBT (odds ratio=7.1; 95% confidence interval, 4.4 to 11.6). Only 58% of study women reported that their physicians encouraged CRC screening, but this factor was strongly related to participation (odds ratio=12.7; 95% confidence interval, 6.6 to 24.4). CONCLUSIONS: We identified several areas in which understanding of CRC risk may be low. As a whole, these findings suggest that effective strategies to control CRC may include efforts to improve knowledge of risk and prevention, but must also appeal directly to primary care physicians to identify and address their barriers to screening recommendations.

A comparison of alternative theoretical approaches to smoking cessation and relapse.

Two theoretical approaches to smoking cessation were compared. Participants were randomly assigned either to (a) a traditional treatment program that used contingency contracting and that emphasized the necessity for absolute abstinence (AA) or to (b) a relapse-prevention (RP) treatment that focused on gradual acquisition of nonsmoking skills. It was hypothesized that participants in the RP treatment would be less successful initially but would have better maintenance skills and thus would relapse less during a 1-year follow-up period. Each program was evaluated in two formats: group-based treatment and self-help materials. Results indicated comparable 1-year abstinence rates for all treatments, although more participants dropped out of the self-help formats. Participants in the RP intervention were more likely to lapse sooner after quitting and were more likely to quit again during the 1-year maintenance period. Exploratory analyses of successful participants suggested that women were more successful in the RP program and that men had greater success with the AA approach.

Partner smoking status and pregnant smoker's perceptions of support for and likelihood of smoking cessation.

Perceptions of support for cessation of smoking during pregnancy, likelihood of quitting, and partner smoking status were explored in a sample of 688 pregnant smokers (372 baseline smokers and 316 baseline quitters). Women with nonsmoking partners were significantly more likely to be baseline quitters than women with partners who smoked. Baseline quitters reported significantly more positive support from their partners than did continuing smokers (p = .02). Neither partner smoking status nor partner support at baseline was associated with cessation or relapse later in pregnancy. Women reported greater support, both positive and negative, from nonsmoking partners than from partners who smoked (p = .001). Among partner smokers, those who were trying to quit were perceived to be particularly supportive. Cessation interventions for expectant fathers may increase pregnant women's success at quitting.

Predicting participation in a dietary intervention to lower cholesterol among individuals with hyperlipidemia.

Adult men and women (N = 8,748) were given blood cholesterol tests and completed a measure of fat intake and a staging questionnaire that assessed readiness to adopt a cholesterol-lowering diet. Eligibility for the trial was based on plasma cholesterol levels and self-reported dietary intake. Of 772 eligible participants, 545 (70.6%) agreed to join. In multivariate analyses, joiners did not differ from nonjoiners by age, total cholesterol levels, or self-reported dietary fat intake. Women were more likely than men to join the study. Individuals in the preparation stage (defined on the basis of a staging algorithm derived from the transtheoretical model of change) were more likely to join the trial than were precontemplators. An understanding of the determinants of participation in a dietary intervention may be important in the enhancement of high-risk individuals' acceptance of recommendations to make dietary changes.

Stress, depressive symptoms, and smoking cessation among pregnant women.

Perceived stress and depressive symptoms were examined as correlates and predictors of smoking cessation during pregnancy in a sample of 819 pregnant smokers (454 baseline smokers and 365 baseline quitters). Women who quit early in pregnancy had lower levels of stress and depressive symptoms than baseline smokers. Adjusting for level of addiction and other demographic factors related to stress and depressive symptoms eliminated the significant association between depressive symptoms and smoking cessation. Lower levels of stress and depressive symptoms were not predictive of cessation in later pregnancy. Prenatal healthcare providers should continue to assess level of addiction and provide targeted intensive cessation interventions. Interventions that reduce stress and depression may also be of benefit to women who are continuing smokers in early pregnancy.

Self-help interventions for smoking cessation.

Self-help interventions for smoking cessation are an important bridge between the clinical and public health approaches to smoking cessation. The current literature on self-help interventions is encouraging but incomplete. Although their quit rates are lower than those of more intensive programs, self-help interventions could have a large public health impact because of their potential for widespread distribution. Studies comparing self-help to more intensive treatment suggest that long-term cessation rates for self-help programs are potentially as high as rates for face-to-face interventions, with lower quit rates for self-help programs that are likely due to differences in program adherence. Tailored materials and personalized adjuncts (e.g., written feedback or telephone counseling) that promote program adherence may increase cessation rates.

Evaluation of intrinsic and extrinsic motivation interventions with a self-help smoking cessation program.

Personalized feedback and a financial incentive, developed from an intrinsic/extrinsic motivation framework, were evaluated as adjuncts to self-help materials for smoking cessation. Ss (N = 1,217) were randomized to 4 treatment groups and were followed up at 3 and 12 months. Consistent with hypotheses derived from the motivation framework, the financial incentive increased the use of self-help materials, did not increase cessation rates among program users, and was associated with higher relapse rates among those who did manage to quit. The personalized feedback increased both smoking cessation and use of the materials 3 months after distribution of the materials. Continuous abstinence (abstinence at 3 and 12 months) in the group that received the personalized feedback alone was twice the rate of the other groups.

A randomized trial of self-help materials, personalized feedback, and telephone counseling with nonvolunteer smokers.

The incremental effects of (a) a self-help booklet alone, (b) self-help booklet with computer-generated personalized feedback, and (c) self-help booklet, personalized feedback, and outreach telephone counseling were evaluated in a population-based, nonvolunteer sample of smokers. Smokers (N = 1,137) were identified through a telephone survey of a random sample of 5,903 enrollees in a health maintenance organization and randomized to a no-treatment control group or 1 of the 3 intervention conditions. Smoking status was ascertained 3, 12, and 21 months postrandomization. Cotinine validation of self-reported cessation was obtained at the 12-month follow-up. Overall, the telephone counseling significantly increased smoking cessation at the 3-month follow-up, but not at 12 or 21 months. Among smokers who were precontemplative at baseline, telephone counseling significantly increased prevalent abstinence at 3 and 12 months and continuous abstinence at 21 months (defined as self-reported abstinence at 3, 12, and 21 months).

The Kaiser Family Foundation Community Health Promotion Grants Program: findings from an outcome evaluation.

OBJECTIVES: To present results from an outcome evaluation of the Henry J. Kaiser Family Foundation's Community Health Promotion Grants Program (CHPGP) in the West, which represented a major community-based initiative designed to promote improved health by changing community norms, environmental conditions, and individual behavior in 11 western communities. METHODS: The evaluation design: 14 randomly assigned intervention and control communities, 4 intervention communities selected on special merit, and 4 matched controls. Data for the outcome evaluation were obtained from surveys, administered every two years at three points in time, of community leaders and representative adults and adolescents, and from specially designed surveys of grocery stores. Outcomes for each of the 11 intervention communities were compared with outcomes in control communities. RESULTS: With the exception of two intervention communities-a largely Hispanic community and a Native American reservation-we found little evidence of positive changes in the outcomes targeted by the 11 intervention communities. The programs that demonstrated positive outcomes targeted dietary behavior and adolescent substance abuse. CONCLUSIONS: Improvement of health through community-based interventions remains a critical public health challenge. The CHPGP, like other prominent community-based initiatives, generally failed to produce measurable changes in the targeted health outcomes. Efforts should focus on developing theories and methods that can improve the design and evaluation of community-based interventions.

Promoting smoking abstinence in pregnant and postpartum patients: a comparison of 2 approaches.

OBJECTIVE: To compare the implementation, delivery, and implications for dissemination of 2 different maternal smoking-cessation/relapse-prevention interventions in managed care environments. STUDY DESIGN: Healthy Options for Pregnancy and Parenting (HOPP) was a randomized, controlled efficacy trial of an intervention that bypassed the clinical setting. Stop Tobacco for OuR Kids (STORK) was a quasi-experimental effectiveness study of a point-of-service intervention. Both incorporated prenatal and postnatal components. PATIENTS AND METHODS: Subjects in both studies were pregnant women who either smoked currently or had quit recently. The major intervention in HOPP was telephone counseling delivered by trained counselors, whereas the STORK intervention was delivered by providers and staff during prepartum, inpatient postpartum, and well-baby visits. RESULTS: In HOPP, 97% of telephone intervention participants reported receiving 1 or more counselor calls. The intervention delayed but did not prevent postpartum relapse to smoking. Problems with intervention delivery related primarily to identification of the target population and acceptance of repeated calls. STORK delivered 1 or more cessation contacts to 91% of prenatal smokers in year 1, but the rate of intervention delivery declined in years 2 and 3. Modest differences were obtained in sustained abstinence between 6 and 12 months postpartum, but not in point prevalence abstinence at 12 months. CONCLUSIONS: The projects were compared using 4 of the 5 dimensions of the RE-AIM model including reach, adoption, implementation, and maintenance. It was difficult to apply the fifth dimension, efficacy, because of the differences in study design and purpose of the interventions. The strengths and limitations of each project were identified, and it was concluded that a combined intervention that incorporates elements of both HOPP and STORK would be optimal if it could be implemented at reasonable cost.

Implementing a dietary intervention in primary care practice: a process evaluation.

OBJECTIVES: Physicians acknowledge the need to advise their patients about dietary habits, but they may not have the training or tools to do this efficiently. In the context of a randomized trial, we investigated the feasibility of enlisting physicians to implement a dietary intervention in the primary care setting. METHODS: Physicians from 14 primary care practices were assigned via randomization to introduce a self-help booklet to promote dietary change at routine appointments. Delivery of the booklet was recorded by these intervention physicians at the clinic appointment; intervention participants were asked 3 months later in a telephone interview about whether they received and used the booklet. RESULTS: According to physician documentation, 95% of intervention participants who kept an appointment (n = 935) received the booklet; among participants completing a 3-month interview (n = 890), 96% reported the same. However, only about 50% of participants reported receiving the booklet from their physician; the remainder received the booklet from other clinic staff. Overall, 93% reported reading at least part of the booklet. Use of the booklet varied little whether it was delivered by a physician or staff person, but it was more likely to be read as time spent discussing the booklet increased. CONCLUSIONS: Physician cooperation and evidence of intervention effectiveness support the use of primary care for the delivery of interventions to change diet; training the entire health team and repeating dietary advice at subsequent visits may improve the success of such interventions.