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

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

Disparities in tobacco cessation medication orders and fills among special populations.

BACKGROUND: There is considerable interest in measuring and eliminating health care disparities among various special populations, but there is limited understanding of their extent, causes, or potential remedies. To improve this for tobacco cessation, we measured differences in the frequency of receiving and filling cessation medication prescriptions by race, ethnicity, age, language preference, health insurance, and pregnancy. METHODS: The relevant variables for all patients of a Minnesota medical group aged 18 years and older with clinician visits were extracted from the electronic medical records of 1 large medical group from March 2006 to February 2007. This was combined with claims data from 1 insurance plan that covered most of these individuals. Order and fill rates for cessation medications were then adjusted for each of the other variables. RESULTS: There were 32,733 current users of tobacco, 18,047 of whom had both health insurance and pharmacy claims data available. After adjustment, 15.4% overall had received an order for cessation medications during this year, but only 78% had filled it. Groups receiving fewer orders than their comparison groups were aged 18-34 years or older than 65 years, men, pregnant women, Asians and Hispanics, and those with non-English-language preference, on Medicaid, or with fewer visits. The same groups were less likely to fill that prescription, except patients with non-English preference or Medicaid. DISCUSSION: There are disparities in both the receipt of cessation medication orders and the likelihood of filling them for some special populations. The causes are likely to be complex, but this information provides a starting point for learning to improve this problem.

A surveillance source of tobacco use differences among immigrant populations.

INTRODUCTION: Tobacco use disproportionately affects some ethnic minority populations. Important gains in understanding the relationship between acculturation and tobacco use have been hindered by the lack of available data, large samples of specific immigrant groups. This study is among the first to use electronic medical record (EMR) data to examine differences in tobacco use associated with acculturation among various population groups. METHODS: Relevant variables for all medical group patients aged 18 years and older with clinician visits were extracted from the EMR of one large medical group from March 2006 to February 2007. Preferred language and country of origin data from the EMR were used to create distinct cultural groupings. Adjusted prevalences were computed. RESULTS: One hundred thousand [corrected] three hundred [corrected] twenty nine patients reported [corrected] languages as English, Hmong, Vietnamese, Oromo, Amharic, Somali, and Spanish and were categorized as U.S. born or non-U.S. born. After adjusting for age, utilization, and insurance status, more acculturated Mexican and Hmong women were more likely to be tobacco users compared with less acculturated women. Among non-English speaking, current tobacco use was more prevalent among men compared with women. DISCUSSION: Interpreted language and country of origin data collected in a clinical setting were useful for describing tobacco use differences between and within cultural groups. Using preferred language and country of origin as a proxy for acculturation status may help understand some of the within and between cultural differences in tobacco use. These novel data sources have potential usefulness for tobacco surveillance of relatively small cultural groups.

Exploring the relationship between acculturation and smoking behavior within four Southeast Asian communities of Minnesota.

OBJECTIVES: This study sought to measure the prevalence of smoking among the Hmong, Vietnamese, Lao, and Cambodian communities of Minnesota and explore the relationship between smoking and acculturation within these communities. METHODS: A community-based participatory research framework was used through all phases of this study. Standard as well as community-developed measures of acculturation were used. Data were obtained by face-to-face and telephone interviews with 1,628 respondents from July 2006 to March 2007. RESULTS: Vietnamese and Cambodian men smoke at higher rates than men in the U.S. general population (35% and 58% compared with 20%, respectively). Most men across the Vietnamese, Cambodian, and Lao populations started smoking prior to immigration to the United States, although most former smokers quit smoking after immigration to the United States. Most male Hmong respondents started smoking after immigration. Education was predictive of smoking status across genders, with less education associated with greater odds of being a smoker. Logistic regression found some acculturation measures to be predictive of smoking status across both genders: Less acculturated male respondents and more acculturated female respondents are more likely to be smokers. DISCUSSION: Results of this study suggest that the role of acculturation in tobacco use may not be straightforward as has been presented previously. Other factors, such as social norms and cultural or linguistic isolation, may also be playing a role in tobacco use patterns and may play different roles for different subgroups. Further research is needed within each population and subgroups within those populations to understand these relationships and how they affect smoking behavior.

The economic impact of exposure to secondhand smoke in Minnesota.

OBJECTIVES: Using the risk categories established by the 2006 US surgeon general's report, we estimated medical treatment costs related to exposure to secondhand tobacco smoke (SHS) in the state of Minnesota. METHODS: We estimated the prevalence and costs of treated medical conditions related to SHS exposure in 2003 with data from Blue Cross and Blue Shield (Minnesota's largest insurer), the Current Population Survey, and population attributable risk estimates for these conditions reported in the scientific literature. We adjusted treatment costs to the state level by health insurance category by using the Medical Expenditure Panel Survey. RESULTS: The total annual cost of treatment in Minnesota for conditions for which the 2006 surgeon general's report found sufficient evidence to conclude a causal link with exposure to SHS was $228.7 million in 2008 dollars-equivalent to $44.58 per Minnesota resident. Sensitivity analyses showed a range from $152.1 million to $330.0 million. CONCLUSIONS: The results present a strong rationale for regulating smoking in public places and were used to support the passage of Minnesota's Freedom to Breathe Act of 2007.

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

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

The impact of smoking-cessation intervention by multiple health professionals.

BACKGROUND: Smokers have contact with many different types of health professionals. The impact of tobacco intervention by multiple types of heath professionals is not known. METHODS AND MATERIALS: As part of the 2003 Minnesota Adult Tobacco Survey, smokers (n=1723) reported on tobacco treatment by medical doctors, nurses, dentists, pharmacists, or other health professionals. This analysis examined: (1) smokers' report of tobacco intervention by different types of healthcare providers, (2) the proportion of smokers who report intervention by multiple provider types, and (3) the relationship between smokers' report of intervention by multiple provider types and readiness to quit, quit attempts, and recent quitting. RESULTS: Among past-year smokers, 65% had visits with two or more types of health professionals. Among smokers who visited health professionals (n=1523), only 34% reported being asked about smoking by two or more types of professionals. Among current smokers (n=1324), advice or assistance from more than one type of professional was uncommon (26% and 7%, respectively). Being asked about smoking by two or more types of professionals substantially increased the odds of recent quitting (OR=2.37; 95% CI=1.15-4.88). Among current smokers, being advised to quit by two or more types of professionals increased the odds of having made a quit attempt in the past year (OR=2.92; 95% CI=1.56-5.45) or intending to quit in the next 6 months (OR=2.17; 95% CI=1.10-4.29). CONCLUSIONS: Smoking-cessation interventions by more than one type of health professional have the potential to substantially increase quitting and readiness to quit in the population.

Medicaid Savings From The New York University Caregiver Intervention for Families with Dementia.

Purpose of the study: The economic burden of dementia is substantially borne by state Medicaid programs. We estimated savings, from the state payer perspective, from offering the New York University Caregiver Intervention (NYUCI), a well-studied caregiver support and counseling program, to eligible Minnesota Medicaid enrollees. Design and Methods: A population-based microsimulation Markov model predicted and compared costs over 15 years with and without implementation of the NYUCI for family caregivers of community-based Medicaid eligibles with dementia. The model was informed by primary analysis of Minnesota Department of Human Services (MN DHS) data, and literature on the epidemiology, natural history, costs, and evidence-based management of the disease. Primary outcomes were predicted cumulative total direct costs, including medical, facility, and waiver-program payments for eligibles, and estimated costs of providing the NYUCI. Results: Approximately 5-6% more eligibles with dementia would remain in the community annually from year 3 (2014) on, so that over 15 years 17% fewer would die in nursing homes (NH) if their caregivers received the NYUCI. After 15 years, MN DHS could realize savings of $40.4 million (2011 dollars, discounted at 3%) if all eligibles/caregivers enrolled. Savings were expected 5 years after implementation. Multiple sensitivity analyses, including best-and worst-case scenarios, estimated results ranging from 15-year cumulative savings of $178.9 million to a cumulative loss of $7.3 million, respectively, driven largely by assumed program effectiveness. Implications: State payers can use enhanced caregiver support to moderate the growing tax burden of dementia, even without a breakthrough in the pharmacologic treatment of the disease.

The relationship of stage of change for smoking cessation to stage of change for fruit and vegetable consumption and physical activity in a health plan population.

PURPOSE: The purpose of this study was to examine the relationship between stage of change for smoking cessation and stage of change for (1) fruit and vegetable consumption and (2) physical activity. DESIGN: The data come from a cross-sectional telephone survey administered to a stratified random sample of health plan members (n = 9675). SETTING: This study was conducted at a mixed-model health plan with approximately 1 million adult members. SUBJECTS: Respondents were adults age 18 and older, who were randomly selected from five health plan product groups: commercial fully insured, commercial self-insured, two publicly subsidized plans, and Medicare supplemental insurance. Response rates ranged from 74.7% to 90.1% across these groups. MEASURES: The assessment included demographics and stage of change for smoking cessation, physical activity, and fruit and vegetable intake. Bivariate relationships among variables were analyzed with the use of contingency tables. Ordered logistic regression was used to examine the effects of stage of change for fruit and vegetable consumption and physical activity on stage of change for smoking while controlling for other factors. RESULTS: Stage of change for smoking is more clearly related to stage of change for fruit and vegetable consumption (chi2 = 161.3, p < .001; Cramer's V = .11, p < .001) than to stage of change for physical activity (chi2 = 89. 7, p < .001; Cramer's V = .08, p < .001). However, stage of change for fruit and vegetable consumption and physical activity are not strong predictors of stage of change for smoking. CONCLUSIONS: This study indicates that stage of change for both fruit and vegetable consumption and physical activity are independent constructs from stage of change for smoking cessation.

Estimating the potential cost savings from the New York University Caregiver Intervention in Minnesota.

No therapies are known to substantially alter the course of dementia and associated treatment costs. However, enhanced support services for caregivers of people with dementia have been shown to improve caregivers' capabilities and well-being and delay patients' institutionalization. Using a model that simulated disease progression, place of residence, and direct costs of care, we estimated the potential savings to Minnesota from offering the New York University Caregiver Intervention, a program of enhanced support services for spouse and adult child caregivers of community-dwelling people with dementia, to all eligible people in the state from 2010 to 2025. Results indicate that approximately 5 percent more people with dementia would remain in the community from year 3 (2013) on and that 19.3 percent fewer people with dementia would die in institutions over fifteen years. During those years Minnesota could save $996 million in direct care costs (with a range of nearly $100 million to $2.64 billion under worst- and best-case scenarios, respectively). These findings suggest that broader access to enhanced caregiver supports could produce a positive return on investment or be cost-effective--assuming widespread implementation, reasonable program costs, and substantial caregiver participation.

The prevalence of unrecognized tobacco use among young adults.

OBJECTIVE: To evaluate the prevalence of smoking among young adults and to describe their characteristics. METHODS: Data were examined from the Minnesota Adult Tobacco Survey, a telephone survey of 8821 residents with a sample of 1205 young adults. RESULTS: Prevalence was 39% using the adolescent definition and 32% using the adult definition. Nearly 1 in 5 young adult smokers may be considered a "previously unrecognized smoker" who would not have been identified as a cigarette user according to the standard adult definition. CONCLUSIONS: Future studies assessing prevalence should use both adolescent and adult measures.

The relationship between acculturation and knowledge of health harms and benefits associated with smoking in the Latino population of Minnesota.

OBJECTIVES: This study sought to examine the relationship between acculturation and the knowledge of smoking and health and perception of benefits associated with smoking within the Latino population of Minnesota. In addition to standard acculturation measures, this study employed a multidimensional model and measures of acculturation. METHODS: A telephone and in-person administered survey was conducted across the state of Minnesota with Latino men and women. RESULTS: A total of 804 participants completed the survey, 54% were men. The average age of respondents was 37 years; 81% were foreign born and 68% completed the interview in Spanish. Knowledge of the relationship between smoking and lung cancer (99%) and heart disease (93%) was high. Acculturated respondents indicate a more refined knowledge of the relationship between smoking and health conditions not related to smoking (poor vision and arthritis). Smokers identify more benefits associated with smoking than do non-smokers, with gender (male), education (less than high school) and greater acculturation being significant predictors of perceiving benefits.

Tobacco-use prevalence in special populations taking advantage of electronic medical records.

BACKGROUND: It is difficult and expensive to use surveys to obtain the repeatable information that is needed to understand and monitor tobacco prevalence rates and to evaluate cessation interventions among various subgroups of the population. Therefore, the electronic medical record database of a large medical group in Minnesota was used to demonstrate the potential value of that approach to accomplish those goals. METHODS: The relevant variables for all medical group patients aged 18 and over were extracted from the record from a 1-year period. Rates of smoking prevalence were computed for the entire population as well as for those with various characteristics and combinations of characteristics of interest to tobacco-cessation advocates. These prevalence rates were also adjusted to control for the other characteristics in the analysis. RESULTS: From March 2006 to February 2007, there were 183,982 unique patients with at least one office visit with a clinician, and a record of their tobacco-use status (90%). Overall, 19.7% with recorded status were tobacco users during this year, as were 24.2% of those aged 18-24 years, 16.0% of pregnant women, 34.3% of those on Medicaid, 40.0% of American Indians, 9.5% of Asians, and 8.5% of those whose preferred language was other than English. Combining characteristics allowed greater understanding of those differences. CONCLUSIONS: Although there are limitations in these data, the level of detail available for this large population and the ease of repeat analysis should greatly facilitate targeted interventions and evaluation of the impact.

A randomized trial of a pay-for-performance program targeting clinician referral to a state tobacco quitline.

BACKGROUND: Tobacco quitlines offer clinicians a means to connect their patients with evidence-based treatments. Innovative methods are needed to increase clinician referral. METHODS: This is a clinic randomized trial that compared usual care (n = 25 clinics) vs a pay-for-performance program (intervention) offering $5000 for 50 quitline referrals (n = 24 clinics). Pay-for-performance clinics also received monthly updates on their referral numbers. Patients were eligible for referral if they visited a participating clinic, were 18 years or older, currently smoked cigarettes, and intended to quit within the next 30 days. The primary outcome was the clinic's rate of quitline referral (ie, number of referrals vs number of smokers seen in clinic). RESULTS: Pay-for-performance clinics referred 11.4% of smokers (95% confidence interval [CI], 8.0%-14.9%; total referrals, 1483) compared with 4.2% (95% CI, 1.5%-6.9%; total referrals, 441) for usual care clinics (P = .001). Rates of referral were similar in intervention vs usual care clinics (n = 9) with a history of being very engaged with quality improvement activities (14.1% vs 15.1%, respectively; P = .85). Rates were substantially higher in intervention vs usual care clinics with a history of being engaged (n = 22 clinics; 10.1% vs 3.0%; P = .001) or less engaged (n = 18 clinics; 10.1% vs 1.1%; P = .02) with quality improvement. The rate of patient contact after referral was 60.2% (95% CI, 49.7%-70.7%). Among those contacted, 49.4% (95% CI, 42.8%-55.9%) enrolled, representing 27.0% (95% CI, 21.3%-32.8%) of all referrals. The marginal cost per additional quitline enrollee was $300. CONCLUSION: A pay-for-performance program increases referral to tobacco quitline services, particularly among clinics with a history of less engagement in quality improvement activities.

The role of health plans in tobacco control.

Health plans play an important role in tobacco control. In this chapter we present an overview of the scientific research on health plan involvement in clinical and community interventions regarding tobacco use. Also included are interventions that have been undertaken by health plans to lower smoking rates among their members and the general population. We conclude with a new model that can be used to engage health plans in tobacco control efforts and a case study that outlines how one health plan has implemented this new model.

Which enrollees bypass their gatekeepers in a point-of-service plan?

BACKGROUND AND OBJECTIVES: Like Health Maintenance Organizations, point-of-service (POS) health plans use primary care gatekeepers, and they permit self-referral to specialists at increased costs to the enrollee. The main objective of this study was to contrast patients who self-referred with those referred by their primary care physician. RESEARCH DESIGN: We conducted a cross-sectional telephone survey of 606 recent users of specialists in a large Midwestern POS health plan; response rate was 65%. We compared 148 enrollees who self-referred with 458 who had a physician referral. RESULTS: Self-referral was most common among those with a long-term relationship with a specialist (odds ratio [OR] = 2.08) and those dissatisfied with their primary care physician (OR = 3.65), and was rare among those with a long-standing relationship with a primary care physician (OR = 0.46). Most self-referred enrollees (68%) thought paying the additional cost for self-referral was worthwhile, and they were more dissatisfied with the quality and variety of the plan's specialist network. CONCLUSIONS: Continuity with a single physician influences how patients access specialty care. Expanding the panel of specialists in-network and encouraging long-term relationships with primary care physicians are likely to limit self-referral in a POS plan.

Comorbidity: implications for the importance of primary care in 'case' management.

BACKGROUND: Although comorbidity is very common in the population, little is known about the types of health service that are used by people with comorbid conditions. METHODS: Data from claims on the nonelderly were classified by diagnosis and extent of comorbidity, using a case-mix measure known as the Johns Hopkins Adjusted Clinical Groups, to study variation in extent of comorbidity and resource utilization. Visits of patients (adults and children) with 11 conditions were classified as to whether they were to primary care physicians or to other specialists, and whether they involved the chosen condition or other conditions. RESULTS: Comorbidity varied within each diagnosis; resource use depended on the degree of comorbidity rather than the diagnosis. When stratified by degree of comorbidity, the number of visits for comorbid conditions exceeded the number of visits for the index condition in almost all comorbidity groups and for visits to both primary care physicians and to specialists. The number of visits to primary care physicians for both the index condition and for comorbid conditions almost invariably exceeded the number of visits to specialists. These patterns differed only for uncommon conditions in which specialists played a greater role in the care of the condition, but not for comorbid conditions. CONCLUSIONS: In view of the high degree of comorbidity, even in a nonelderly population, single-disease management does not appear promising as a strategy to care for patients. In contrast, the burden is on primary care physicians to provide the majority of care, not only for the target condition but for other conditions. Thus, management in the context of ongoing primary care and oriented more toward patients' overall health care needs appears to be a more promising strategy than care oriented to individual diseases. New paradigms of care that acknowledge actual patterns of comorbidities as well as the need for close coordination between generalists and specialists require support.

Treatment of tobacco use as a chronic medical condition: primary care physicians' self-reported practice patterns.

BACKGROUND: The goal of this study is to better understand factors related to physician treatment of tobacco as a chronic medical condition. METHODS: In the fall of 2000, we conducted a mail survey of primary care physicians in a large mid-western health plan. The response rate was 61% (750/1235). The survey assessed physician attitude, perceived clinic support, training, and self-reported tobacco treatment practices. RESULTS: Twenty-nine percent of physicians reported incomplete or minimal care. Thirty-nine percent reported providing assistance without follow-up, while 21% reported providing follow-up to tobacco users making quit attempts. Only 12% of physicians reported assistance and follow-up for all tobacco users. Controlling for differences in physician and clinic characteristics, more positive physician attitudes decreased incomplete or minimal care (OR = 4.62 most positive tertile vs. least positive, P < 0.001) but did not increase follow-up activities. Higher perceived clinic support increased follow-up care (OR = 2.69, highest tertile vs. lowest, P < 0.001). Physician training was associated with increased provision of ongoing care (OR = 1.88 per additional hour of training, P < 0.001). CONCLUSIONS: Physician attitudes, clinic support, and training are related to different steps in the adoption of more complete tobacco use treatment. These findings support the need for multifaceted approaches to improve tobacco treatment as a chronic medical condition.