Assessment of tobacco control advocacy behavioural capacity among public health faculty and students: a cluster intervention study.

OBJECTIVES: This study assessed the outcomes of a tobacco control advocacy behavioural capacity (ABC)-building programme among public health faculty and students in China. STUDY DESIGN: This is a cluster intervention study with subjects matching in the different stages of the intervention and observation. METHODS: Public health students (n = 1046) and faculty (n = 199) were recruited in the intervention group. The intervention included a series of tobacco control advocacy curriculum and activities that were developed and implemented at schools or departments of public health in 22 universities across China. The control group participants (n = 540) were public health undergraduate students from another 11 universities selected from the different geographic regions. A comprehensive assessment tool was used to measure the tobacco control ABC and perceived stress level to compare changes at baseline, midterm and 12-month follow-up. Repeated measures analysis of variance, paired t tests and chi-squared tests, general linear model and generalized estimating equation were used to determine the time effect for targeted students and faculty. Multivariate analysis of variance and logistic regression model were conducted to evaluate the treatment effects for students between intervention and control sites. RESULTS: Nine hundred and thirty-seven students and 170 faculty members in the intervention group and 469 students in the control group were valid for the final evaluation. Findings from treatment effect analyses show that the capacity-building programme significantly improved public health students' ABC, including awareness of tobacco control messages (F = 107.65, P < 0.01), general and public heath tobacco control attitudes (F = 7.52, P < 0.01; F = 8.53, P < 0.01), advocacy interest and motivation (F = 10.11, P < 0.01) and public advocacy behaviour for both family members and relatives or friends. The perceived stress in the intervention group students was also reduced significantly in comparison with the control group students (F = 4.99, P < 0.01). For faculty members, their ABC except advocacy for family members was all increased by time effect analyses. The training programme did not impact faculty and students' smoking behaviour. CONCLUSIONS: This study provided evidence to support the implementation of tobacco control advocacy capacity training among public health professionals and students to curb the tobacco epidemic in China.

Reducing cigarette sales to minors in an urban setting: issues and opportunities for merchant intervention.

INTRODUCTION: Intervention studies to reduce cigarette sales to minors have been conducted primarily in suburban settings. Little is known about sociocultural factors influencing cigarette sales to minors in urban settings. This study sought to determine sociodemographic and cultural factors that may play a role in cigarette sales and in efforts to reduce sales to minors in urban areas. METHODS: Merchant education and follow-up surveys were conducted in small local stores in predominantly African-American urban census tracts in Baltimore. The stores had prior evidence of cigarette sales to minors. RESULTS: Merchants reported hostility (66%) and foul language (64%) when they requested youth identification. Youthful-oriented advertising of cigarettes was highly prevalent in all stores and moreso in stores owned and staffed by Asian merchants. Advertising with specific youthful content was predictive (OR = 3.97; 95% CI = 1.70, 9.23; P = .0014) of higher requests for cigarettes from minors. CONCLUSIONS: Youth-oriented cigarette advertising is a prevalent environmental risk for urban youth. Differences between Asian and African-American merchants suggest socioethnic factors may be an influential component of illegal sales and educational campaigns to reduce smoking among minors.

Development of a model of the tobacco industry's interference with tobacco control programmes.

OBJECTIVE: To construct a conceptual model of tobacco industry tactics to undermine tobacco control programmes for the purposes of: (1) developing measures to evaluate industry tactics, (2) improving tobacco control planning, and (3) supplementing current or future frameworks used to classify and analyse tobacco industry documents. DESIGN: Web based concept mapping was conducted, including expert brainstorming, sorting, and rating of statements describing industry tactics. Statistical analyses used multidimensional scaling and cluster analysis. Interpretation of the resulting maps was accomplished by an expert panel during a face-to-face meeting. SUBJECTS: 34 experts, selected because of their previous encounters with industry resistance or because of their research into industry tactics, took part in some or all phases of the project. RESULTS: Maps with eight non-overlapping clusters in two dimensional space were developed, with importance ratings of the statements and clusters. Cluster and quadrant labels were agreed upon by the experts. CONCLUSIONS: The conceptual maps summarise the tactics used by the industry and their relationships to each other, and suggest a possible hierarchy for measures that can be used in statistical modelling of industry tactics and for review of industry documents. Finally, the maps enable hypothesis of a likely progression of industry reactions as public health programmes become more successful, and therefore more threatening to industry profits.

Creating a smoke-free hospital: attitudes and smoking behaviors of nurses and physicians.

PURPOSE: To assess smoking prevalence and attitudes of physicians and nurses before a smoking ban. The relationship between pre-ban attitudes and post-ban smoking behavior was also studied. DESIGN: This is a prospective descriptive study of a cohort of nurses and physicians who were surveyed six months before and six months after a ban on smoking was implemented. SETTING: A large, 1,000-bed teaching hospital in the Northeast of the United States. SUBJECTS: All full-time members of the medical (n = 1,496) and nursing staff (n = 1,500) were surveyed. The overall response rate for the cohort was 41% for physicians and 39% for nurses. MEASURES: Surveys included standardized questions on current smoking behavior, and sociodemographic variables. Attitudes toward quitting and the smoking policy and attitudes about implementation and enforcement of the smoking ban were included. RESULTS: Both physicians and nurses were supportive of a smoke-free policy, but the two groups differed significantly on attitudes related to implementation and enforcement, with nurses being more accommodating toward smoking and less likely to enforce a ban on smoking. Physicians were more likely than nurses to quit smoking after implementation of the ban. Pre-ban attitudes were not predictive of post-ban changes in smoking behavior. CONCLUSIONS: Physicians and nurses agreed with establishing a smoke-free environment but disagreed over the efforts needed to maintain the smoke-free environment. Quitting behavior was not influenced by pre-ban attitudes.

A comparison of education methods and their impact on behavioral change in patients with hyperlipidemia.

We sought to determine the efficacy of a hospital-based, professionally-taught program emphasizing cardiovascular health. Similar programs are in existence throughout the country without documentation of their long-term benefits. Thirty-six hyperlipidemic individuals were treated as a control group or participated in one of two intensive educational interventions. The educational program was based on information obtained from focus group methodology to elicit attitudes about dietary change and learning style preferences. Behavioral changes in smoking, dietary salt and saturated fat intake, stress and tension, physical activity, and departure from ideal body weight were documented using health questionnaires and Lifestyle Risk Indices. At three months of follow-up, there was no change in serum lipids, total fat intake, or cardiovascular risk behavior in either the control or intervention group. We conclude that a one-day program, whether designed by the target population or experts, did not improve cardiovascular risk behaviors, suggesting that more innovative methods are required to address health behaviors in this high risk group.

A partnership with minority populations: a community model of effectiveness research.

This paper describes a community-based approach, including a partnership of an academic medical institution and a high-risk, urban, African-American population, directed at decreasing premature morbidity and mortality and enhancing health and functional status. The intervention approach is based on a model of community-based leadership and "ownership" of interventions and programs to enhance sustainability of effective approaches, and it follows specific stages to assure appropriate assessment and evaluation. Initial efforts were directed at the control of hypertension and were coordinated through decentralized mayor's stations in Baltimore, Maryland. This approach was successful in significantly enhancing control of hypertension and reducing related morbidity and mortality. Over time, an enhanced partnership has been coordinated through churches in the community and organized around a program entitled "Heart, Body, and Soul." Current efforts are directed at the major risk factors and preventable and/or controllable problems in the population, such as hypertension, smoking, obesity, diabetes, hyperlipidemia, and cervical and breast cancer. Key components include the training of neighborhood health workers to provide screening, counseling, monitoring, support, and follow-up; enhanced access to care; training of high school students as health counselors; and use of media to promote healthier life-styles.

Smoking cessation for the hospitalized cardiac patient: rationale for and report of a model program.

Smoking is the leading cause of preventable death in the United States, and smoking-related diseases are involved in more than one third of all hospital admissions. Smoking cessation has immediate and major health benefits for all individuals. Studies have demonstrated that a substantial reduction in mortality and morbidity can be achieved by abstinence from smoking. Interventions to reduce smoking must become a priority for health care providers, as physicians and nurses have the opportunity to interact with millions of smokers each year. The purpose of this article is to outline intervention strategies that nurses can use with smokers to encourage compliance with hospital smoking policies and to facilitate long-term abstinence from smoking.

The status of restrictive smoking policies: a survey of medical schools in the United States and Canada.

All schools of medicine in the United States (N = 128) and Canada (N = 16) were surveyed by telephone to determine if they had instituted policies to restrict smoking. Some policy restricting smoking was reported by 80.56 percent of US schools (N = 103) and by 93.8 percent of Canadian schools (N = 15). However, only 52.3 percent of US (N = 67) and 56.3 percent of Canadian medical schools (N = 9) indicated they had formal written policy statements. Only 13 percent of US schools and 19 percent of Canadian schools had banned smoking totally.

Heart, body, and soul: a church-based smoking-cessation program for Urban African Americans.

BACKGROUND: This article provides a descriptive overview of the implementation process of the Heart, Body, and Soul program. The program objective was to test strategies to reduce the prevalence of cigarette smoking among urban African Americans in East Baltimore. METHOD: This study constitutes a prospective randomized trial among inner-city African Americans designed to improve quit rates among church attenders. A random-digit-dialing survey was conducted to establish baseline levels of self-reported cigarette smoking, examine attendant attitudes, and determine the presence of known cardiovascular risk factors among community residents of the catchment area. A similar survey was conducted among churchgoers to establish a baseline. Twenty-two churches were recruited and randomly assigned to either intensive or minimal (self-help) intervention strategies. Baseline health screenings were held in all participating churches. Innovative culturally specific smoking cessation strategies mediated through lay volunteers from participating churches were implemented in the intensive intervention churches. RESULTS: Pastors of all churches were directly involved in all aspects of the planning and implementation process. A total of 29 volunteer lay smoking-cessation specialists were trained and successfully implemented the intensive interventions in churches. An additional 272 church members were trained to conduct their church's health screenings. CONCLUSION: The essential component of this successful implementation process were building trust and acceptance and providing the technical support to encourage smoking-cessation strategies. This description of the project is presented to assist others involved in church-based trials in urban African American communities.

Can media advocacy influence newspaper coverage of tobacco: measuring the effectiveness of the American stop smoking intervention study's (ASSIST) media advocacy strategies.

OBJECTIVE: To compare the rate and slant of local tobacco control print media coverage in ASSIST (American stop smoking intervention study) states as compared with non-ASSIST states. METHODS: Local tobacco control policy articles, editorials, and letters to the editors published from 1994 to 1998 clipped from all daily local newspapers in the USA were analysed (n = 95 911). The main hypothesis tested for the existence of an interaction between ASSIST intervention and time. This interaction would represent a change in the difference between ASSIST and non-ASSIST states over the course of the intervention. RESULTS: No evidence of an ASSIST-year interaction was found. However, a main effect for ASSIST was significant for the percentage of articles with the model predicting higher rates of articles for ASSIST states. Similarly the rate of letters to the editor expressing protobacco control views was higher in ASSIST states than non-ASSIST states. No main effects or interactions were found for analyses of percentage of protobacco control editorials. Models controlled for a measure of preintervention tobacco control conditions at baseline. CONCLUSIONS: The presence of an ASSIST main effect should be interpreted with caution because of the quasi-experimental design and the lack of information on article rates before the ASSIST intervention. Nonetheless, these preliminary findings suggest some possible effects of the media advocacy activities of ASSIST when controlling for differences in states' initial tobacco control conditions.

The feasibility of a street-intercept survey method in an African-American community.

OBJECTIVES: This study evaluates the feasibility of a nonquota, street-intercept survey method that utilized random selection of interview sites. METHODS: The street-intercept survey was compared with a random digit-dial telephone survey conducted in the same catchment area among African-American adults aged 18 or older. RESULTS: The street-intercept survey's response rate was 80.2%; residence rate, 85.3%; interview completion rate, 97.9%; interference rate, 4.0%; and yield rate, 2.5 interviews per interviewer per hour. The street-intercept method produced more representative distributions of age and sex than the random-digit-dial survey. CONCLUSIONS: The street-intercept method is a feasible alternative to traditional population survey methods and may provide better access to harder-to-reach segments of the urban population in a safe manner.

Ending smoking at the Johns Hopkins Medical Institutions. An evaluation of smoking prevalence and indoor air pollution.

An empiric evaluation of a policy ending smoking in a large urban medical center was conducted. The study included a prospective cohort tracking of employees to measure changes in smoking behavior, environmental fires, smoking-related litter, and environmental tobacco pollution exposure. A 25% decrease in employee smoking prevalence was found (21.7% vs 16.2% before vs after policy implementation, respectively). The daily number of cigarettes reportedly smoked by employees who continued smoking and the total number smoked at work decreased across all occupational categories by an average of 25%. Significant reductions were noted in the level of public smoking and the amount of cigarette remnants. Nicotine vapor concentrations decreased significantly in all areas except restrooms. These findings suggest that visible smoking and environmental tobacco smoke exposure can be markedly decreased by instituting a policy eliminating smoking in a large medical center.

Opportunities for improving inpatient smoking cessation programs: a community hospital experience.

BACKGROUND: This cohort study examined the role of smoking during hospitalization, duration of cessation counseling, patient awareness of the hospital's smoke-free policy, belief that smoking is associated with a current symptom or disease, and the presence of withdrawal symptoms with 12-month smoking cessation among inpatients enrolled in a smoking cessation program. METHODS: Inpatients in four community hospitals (N = 1,317) participated in a smoking cessation intervention consisting of face-to-face counseling at baseline and four follow-up counseling phone calls. Patients were classified as nonsmokers only if they reported not smoking at both the 6- and the 12-month interviews. All patients lost to follow-up were considered smokers. RESULTS: At 1 year the smoking cessation rate was 22.5%. Cessation was independently associated with reporting no smoking during hospitalization, noting no withdrawal symptoms at baseline, and believing that a current illness or symptom is related to smoking. Length of counseling interview and awareness of the hospital's smoke-free policy were not independently associated with cessation. CONCLUSIONS. Smoking cessation programs and hospital policies that decrease smoking during hospitalization, address withdrawal symptoms during hospitalization, and make clear the connection between a patient's health and cigarette smoking may increase the effectiveness of their smoking cessation efforts.

Index for US state tobacco control initial outcomes.

Public health tobacco control efforts have increasingly targeted communities in addition to individuals. Before population smoking decreases, effectiveness might be detected from initial outcomes reflecting these efforts, such as higher cigarette prices or more workplace and home smoking restrictions. Presumably, these initial outcomes will eventually influence smoking behavior. State-specific estimates of percentages of the population working or living under smoking bans are available from the 1992-1993 tobacco use supplement to the Current Population Survey, conducted annually by the US Bureau of the Census. In addition, the tobacco industry reports the average state cigarette price yearly. The authors constructed a tobacco control initial outcomes index (IOI) by using values of these variables for each state and correlated it with state-specific adult (aged > or =25 years) and youth (aged 15-24 years) smoking prevalence computed from the Current Population Survey and per capita cigarette consumption data computed from sales and Census Bureau data. Both adult smoking prevalence (r = -0.70) and per capita consumption (r = -0.73) were significantly correlated with the IOI; youth smoking prevalence correlated less well (r = -0.34). Although the analysis is not definitive, deseasonalized 1983-1997 consumption trends for IOI-based tertile groups were divergent beginning in 1993, with the high IOI group showing the greatest decrease. A high relative IOI index may be predictive of future smoking decreases and should be considered when tobacco control efforts are evaluated.

Cigarette sales to African-American and white minors in low-income areas of Baltimore.

OBJECTIVES: This study documented illegal sales of cigarettes to minors in low-income African-American and White urban areas in East Baltimore. METHODS: Six youths, aged 14 through 16 years, were sent to a random sample of 83 corner stores to attempt to purchase cigarettes. The youths provided the investigators with data on merchant, store, and purchase characteristics. RESULTS: The youths successfully purchased cigarettes in 85.5% of the stores; 58% of the stores displayed five or more cigarette advertisements outside their premises. CONCLUSIONS: Cigarette sales to minors and associated advertising remain prevalent in this urban community.

Heart, body, and soul: impact of church-based smoking cessation interventions on readiness to quit.

BACKGROUND: Given the relatively low spontaneous quit rates and poor treatment outcomes among African American smokers, this study was designed to evaluate the effects of a multimodal culturally relevant intervention for smoking behavior change compared with a self-help strategy among urban African Americans in Baltimore churches. METHOD: This randomized controlled trial in urban African American churches used the stages of change model to compare the effectiveness of two interventions in moving smokers along a continuum toward smoking cessation. Twenty-two churches were randomly assigned to either an intensive culturally specific intervention or a minimal self-help intervention. Smokers were interviewed at baseline church health fairs and at a 1-year follow-up. Self-reported quitters at follow-up were evaluated using saliva cotinine and exhaled carbon monoxide levels (CO). Stages of change were measured by applying a standardized stages of change instrument to individual interview response sequences. Analysis compared the two intervention groups at 1-year follow-up with baseline stages. Outcomes included quit rates and positive progress along the stages of change. RESULTS: Multiple logistic regression results, controlling for intrachurch correlation and demographic and baseline smoking characteristics, showed that the multimodal cultural intervention group was more likely to make positive progress along the stages of change continuum, compared with self-help intervention group (OR = 1.68; P = 0.04). Church denomination and intervention status interacted in the multivariate model; Baptists in the intensive intervention were three times (OR = 3.23; P = 0.010) more likely to make progress than all the other denomination groups. CONCLUSION: The multimodal culturally relevant intervention was more likely than a self-help intervention to positively influence smoking behavior. This is the first community-based intervention study to report progress along the stages of change as a process-oriented measure of success. It is notable that a spiritually based model focusing on environmental sanctions was more likely than a standard church disseminated self-help intervention to positively influence smoking behavior in an urban African American population.