Tobacco harm reduction: what do the experts think?

OBJECTIVE: To assess experts' opinions about the future of, and potential to improve individual and public health through "tobacco harm reduction" (THR), the use of novel nicotine containing products purporting to reduce the health risks from cigarette smoking. DESIGN: Semi-structured telephone interviews on nine topic areas, with qualitative content analysis of coded transcripts. PARTICIPANTS: 29 professionals with expertise related to tobacco and interest in THR, including prominent tobacco control advocates (7), pharmaceutical (3) and tobacco industry scientists/officials (5), non-industry scientists (12), and Congressional staff (2). RESULTS: Respondents agreed that harm reduction is at minimum theoretically plausible, that characteristics of "good" and "bad" THR products can be identified, that government regulation is essential but not likely in the foreseeable future, and that additional scientific data are very much needed. However, there was no consensus on specifics, such as preferred regulatory strategies or examples of ideal THR products. Disagreement was seen not only across but also within respondent categories. Mistrust of key stakeholders-for example, tobacco control advocates distrust of tobacco industry scientists and vice versa-was pervasive, and cited frequently as a barrier to regulation and collaboration. CONCLUSIONS: Continued dialogue and debate are essential as we enter a new and uncertain era of products purporting to reduce tobacco produced harm. Experts have concluded that effective government regulation is crucial to minimising the risks associated with THR and maximising potential benefits.

Smoking on the rise among young adults: implications for research and policy.

This paper investigates hypotheses regarding the cause of the recent apparent increase in young adult smoking, compares trends in smoking among young adults with trends in the use of other substances, and considers the implications for youth tobacco control research and policy. Time series analyses of national data suggest that the recent observed increase in smoking among young adults is primarily an artefact of the almost simultaneous increase in smoking among high school students. In addition, however, it also appears that there have been real changes in smoking patterns among young adults. While many questions remain regarding recent trends in tobacco and other drug use among adolescents and young adults, what is known leads to a clarion call for increased intervention and policy action for the prevention and control of tobacco use among young adults in the USA.

Correlates of surgical treatment type for women with noninvasive and invasive breast cancer.

There is concern that breast-conserving surgery is underused in some breast cancer patient subpopulations, including women with ductal carcinoma in situ (DCIS), an early-stage form of the disease. We conducted a population-based study to identify correlates of surgical treatment type and patient satisfaction, comparing women with DCIS and those with invasive disease. We used telephone interview and mailed survey of 183 women recently diagnosed with breast cancer (oversampling for women with DCIS), identified from the Metropolitan Detroit Cancer Surveillance System (response rate 71.2%). Overall, 52.5% of study subjects received a mastectomy (48.9%, 45.8%, and 73.5% of women with DCIS, local disease, and regional disease, respectively, p < 0.05). One third of women did not perceive that they were given a choice between surgical types, and an additional one third of women received a surgeon recommendation, most of whom received the treatment recommended. Patient attitudes, such as concerns about the clinical benefits and risks of specific surgery options, were important correlates of treatment choice but did not vary by stage of disease. Knowledge about differences in clinical benefits and risks between surgery options was low. Finally, satisfaction with the decision-making process was significantly lower in women who did not perceive a choice between surgery options. Correlates of breast cancer surgery type appeared to be similar for women with DCIS and invasive breast cancer, with surgeons playing a dominant role in the process. Results also suggested that the decision-making process may be as important for patient satisfaction as the treatment chosen.

Can communities and academia work together on public health research? Evaluation results from a community-based participatory research partnership in Detroit.

This article reports the results of a formative evaluation of the first 4 years of the Detroit Community-Academic Urban Research Center (URC), a community-based participatory research partnership that was founded in 1995 with core funding from the Centers for Disease Control and Prevention (CDC). Several organizations are members of this partnership, including a university, six community-based organizations, a city health department, a health care system, and CDC. The Detroit URC is a strong partnership that has accomplished many of its goals, including the receipt of over $11 million in funding for 12 community-based participatory research projects during its initial 4 years. Detroit URC Board members identified a number of facilitating factors for their growth and achievements, such as (1) developing a sound infrastructure and set of processes for making decisions and working together, (2) building trust among partners, (3) garnering committed and active leadership from community partners, and (4) receiving support from CDC. Board members also identified a number of ongoing challenges, including organizational constraints, time pressures, and balancing community interests in interventions and academic research needs. Overall, the Detroit URC represents a partnership approach to identifying community health concerns and implementing potential solutions.

Socioeconomic disparities in health change in a longitudinal study of US adults: the role of health-risk behaviors.

This study investigated the hypothesis that socioeconomic differences in health status change can largely be explained by the higher prevalence of individual health-risk behaviors among those of lower socioeconomic position. Data were from the Americans' Changing Lives study, a longitudinal survey of 3,617 adults representative of the US non-institutionalized population in 1986. The authors examined associations between income and education in 1986, and physical functioning and self-rated health in 1994, adjusted for baseline health status, using a multinomial logistic regression framework that considered mortality and survey nonresponse as competing risks. Covariates included age, sex, race, cigarette smoking, alcohol consumption, physical activity, and Body Mass Index. Both income and education were strong predictors of poor health outcomes. The four health-risk behaviors under study statistically explained only a modest portion of the socioeconomic differences in health at follow-up. For example, after adjustment for baseline health status, those in the lowest income group at baseline had odds of moderate/severe functional impairment in 1994 of 2.11 (95% C.I.: 1.40, 3.20) in an unadjusted model and 1.89 (95% C.I.: 1.23, 2.89) in a model adjusted for health-risk behaviors. The results suggest that the higher prevalence of major health-risk behaviors among those in lower socioeconomic strata is not the dominant mediating mechanism that can explain socioeconomic disparities in health status among US adults.

Excess mortality among urban residents: how much, for whom, and why?

OBJECTIVES: The goals of this study were to estimate prospective mortality risks of city residence, specify how these risks vary by population subgroup, and explore possible explanations. METHODS: Data were derived from a probability sample of 3617 adults in the coterminous United States and analyzed via cross-tabular and Cox proportional hazards methods. RESULTS: After adjustment for baseline sociodemographic and health variables, city residents had a mortality hazard rate ratio of 1.62 (95% confidence interval [CI] = 1.21, 2.18) relative to rural/small-town residents; suburbanites had an intermediate but not significantly elevated hazard rate ratio. This urban mortality risk was significant among men (hazard rate ratio: 2.25), especially non-Black men, but not among women. Among Black men, and to some degree Black women, suburban residence carried the greatest risk. All risks were most evident for those younger than 65 years. CONCLUSIONS: The mortality risk of city residence, at least among men, rivals that of major psychosocial risk factors such as race, low income, smoking, and social isolation and merits comparable attention in research and policy.

Measurement error in prenatal care utilization: evidence of attenuation bias in the estimation of impact on birth weight.

OBJECTIVE: Errors in the measurement of the timing and number of prenatal care visits may produce downward bias in estimates of the impact of prenatal care use on birth outcomes. This paper examines the extent of attenuation bias from measurement error in the estimation of the effect of prenatal care use on birth weight. METHODS: Data were analyzed from the 1980 National Natality Survey, a nationally representative sample of live births with information on prenatal care utilization from three sources: birth certificates, medical provider surveys, and maternal surveys. The extent of attenuation bias in estimates of the impact of different measures of prenatal care use on birth weight was examined by comparing estimates robust to measurement error (including instrumental variables) with ordinary least squares results. RESULTS: There is considerable disagreement in measures of prenatal care across the three data sources, with correlations in the utilization measures computed from different sources around 0.5. The results also show evidence of attenuation bias from measurement error in estimates of the impact of prenatal care on birth weight for both White and Black mothers. Attenuation bias was least severe for information from the birth certificate report of prenatal care. CONCLUSIONS: Because of measurement error, previous studies may have underestimated the effect of prenatal care utilization on birth weight. Corrected estimates, however, do not suggest that prenatal care is a major predictor of birth weight. In addition, part of what previous analyses have interpreted as adverse selection bias may in fact be attenuation bias due to measurement error.

Mass screening in low-income populations: the challenges of securing diagnostic and treatment services in a national cancer screening program.

Funding for many mass screening programs for low-income and uninsured populations provides resources for screening tests, yet only rarely does it provide coverage for necessary follow-up diagnostic and treatment services. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP), a federally funded initiative that provides cancer screening to low-income uninsured and underinsured women, covers some diagnostic follow-up tests and no treatment services. We conducted in-depth case studies of seven state programs participating in the NBCCEDP to investigate the strategies and approaches being used to secure diagnostic and treatment services. The results suggest that the program relies on a patchwork of resources--at state and local levels--to provide diagnostic and treatment services. This includes a number of components of local safety nets, all of which are unstable and have uncertain futures. Public health disease-screening initiatives need to reconsider the feasibility of continued reliance on case-by-case appeals to the local safety net for diagnostic follow-up and treatment services.

Maternal smoking and adverse birth outcomes among singletons and twins.

OBJECTIVES: This study assessed the effects of maternal smoking on birth outcomes among singletons and twins. METHODS: An algorithm was developed to link twins with their siblings in the 1995 Perinatal Mortality Data Set. A random-effects logistic regression model was then used to estimate the association between maternal smoking and several adverse outcomes for a random sample of singletons and for all twins with available maternal smoking information. RESULTS: The algorithm successfully linked sibling pairs for 91% of the twin sample. Maternal smoking was associated with a significantly increased risk of low birthweight, very low birthweight, and gestation of less than 33 weeks for both singletons and twins and with an increased risk of gestation of less than 38 weeks, infant mortality, and placental abruption for singletons. Among smokers, negative impacts on the risk of low birthweight, very low birthweight, and extreme premature delivery were significantly higher for women carrying twins. CONCLUSIONS: Some of the negative effects of smoking on low birthweight and preterm delivery are greater for twins than for singletons. Women carrying twins should be warned that smoking increases their already high risk of serious infant health problems.

Investing in youth tobacco control: a review of smoking prevention and control strategies.

OBJECTIVE: To provide a comprehensive review of interventions and policies aimed at reducing youth cigarette smoking in the United States, including strategies that have undergone evaluation and emerging innovations that have not yet been assessed for efficacy. DATA SOURCES: Medline literature searches, books, reports, electronic list servers, and interviews with tobacco control advocates. DATA SYNTHESIS: Interventions and policy approaches that have been assessed or evaluated were categorised using a typology with seven categories (school based, community interventions, mass media/public education, advertising restrictions, youth access restrictions, tobacco excise taxes, and direct restrictions on smoking). Novel and largely untested interventions were described using nine categories. CONCLUSIONS: Youth smoking prevention and control efforts have had mixed results. However, this review suggests a number of prevention strategies that are promising, especially if conducted in a coordinated way to take advantage of potential synergies across interventions. Several types of strategies warrant additional attention and evaluation, including aggressive media campaigns, teen smoking cessation programmes, social environment changes, community interventions, and increasing cigarette prices. A significant proportion of the resources obtained from the recent settlement between 46 US states and the tobacco industry should be devoted to expanding, improving and evaluating "youth centred" tobacco prevention and control activities.

Strategies for follow-up and treatment services in state breast and cervical cancer screening programs.

This report describes strategies used to provide diagnostic follow-up and treatment services to low-income women screened through the National Breast and Cervical Cancer Early Detection Program.

Maternal substance abuse and infant health: policy options across the life course.

Maternal substance abuse is a significant contributor to infant morbidity and mortality. The setting of prenatal care has long been the focus of interventions and policies to prevent these adverse outcomes. However, substance abuse programs and policies that are designed for women who are not yet pregnant can have a significant impact upon this problem. Thus it is essential to view the female life course from a broader perspective in order to consider the full range of policy options for reducing the infant mortality and morbidity caused by maternal substance abuse. This framework also allows comparisons across and between substances and offers new directions for policy development.

Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults.

CONTEXT: A prominent hypothesis regarding social inequalities in mortality is that the elevated risk among the socioeconomically disadvantaged is largely due to the higher prevalence of health risk behaviors among those with lower levels of education and income. OBJECTIVE: To investigate the degree to which 4 behavioral risk factors (cigarette smoking, alcohol drinking, sedentary lifestyle, and relative body weight) explain the observed association between socioeconomic characteristics and all-cause mortality. DESIGN: Longitudinal survey study investigating the impact of education, income, and health behaviors on the risk of dying within the next 7.5 years. PARTICIPANTS: A nationally representative sample of 3617 adult women and men participating in the Americans' Changing Lives survey. MAIN OUTCOME MEASURE: All-cause mortality verified through the National Death Index and death certificate reviews. RESULTS: Educational differences in mortality were explained in full by the strong association between education and income. Controlling for age, sex, race, urbanicity, and education, the hazard rate ratio of mortality was 3.22 (95% confidence interval [CI], 2.01-5.16) for those in the lowest-income group and 2.34 (95% CI, 1.49-3.67) for those in the middle-income group. When health risk behaviors were considered, the risk of dying was still significantly elevated for the lowest-income group (hazard rate ratio, 2.77; 95% CI, 1.74-4.42) and the middle-income group (hazard rate ratio, 2.14; 95% CI, 1.38-3.25). CONCLUSION: Although reducing the prevalence of health risk behaviors in low-income populations is an important public health goal, socioeconomic differences in mortality are due to a wider array of factors and, therefore, would persist even with improved health behaviors among the disadvantaged.

The social construction of the breast cancer epidemic.

The age-adjusted incidence of breast cancer among U.S. women rose by over 30% during the 1980s. Several population-based studies have concluded that most or all of this observed increase is an artifact of the lead time afforded by mammography screening rather than an indication of a true increase in the rate at which women develop the disease. We conducted a study of the social construction of breast cancer trends as a public health problem in popular U.S. magazines. We documented trends in popular magazine article coverage of breast cancer between 1980 and 1995. In addition, we analyzed the content of a convenience sample of 228 popular magazine articles published between 1987 and 1995, focusing on a subsample of articles (n = 91) that mention the increase in breast cancer incidence. Our results show that the increase in incidence is commonly portrayed as a mysterious, unexplained epidemic occurring primarily among young, professional women in their prime years. Many articles suggest that recent changes in women's behavior such as increases in delayed childbearing, nulliparity, the use of oral contraceptives, induced abortion, and the use of tobacco and alcohol are related to the recent upsurge in the disease. The portrayal of the breast cancer epidemic in the U.S. popular press reflects a strong social desire to create order and control over a frightening disease. In the process, a common message is that the behaviors and choices of young, nontraditional women especially those related to fertility control-have led to pathological repercussions within their bodies, which in turn may be responsible for great disorder and pathology at the societal level in the epidemic of breast cancer.

Education and income differentials in breast and cervical cancer screening. Policy implications for rural women.

OBJECTIVES: Despite substantial evidence of socioeconomic differences in the use of breast and cervical cancer screening, the mechanisms explaining these differences, and therefore their policy implications are not well understood. We investigated the way that education and income influence rural women's use of mammograms and Pap tests, including financial barriers to medical care, knowledge and attitudinal barriers, and nonfinancial factors related to health-care access. METHODS: Data were from a population-based telephone survey of 2,346 rural Wisconsin women aged 40 years and older. Logistic regression analyses and simulation exercises were conducted. RESULTS: The strongest barriers to screening in this rural population were nonfinancial impediments to access. Removing economic barriers did not lead to significant increases in screening when other types of barriers were present. CONCLUSIONS: Policies and interventions that focus on the most visible differences that exist between rural women of differing socioeconomic levels (ie, differences in the ability to afford health services) and do not simultaneously address knowledge, attitudinal, and health-care access barriers will fall short of their goal to increase breast and cervical cancer screening.

Implementation issues and costs associated with a proven strategy for increasing breast and cervical cancer screening among low-income women.

Results from a randomized controlled trial demonstrated that a physician reminder letter combined with telephone counseling from a health educator significantly increased women's use of both mammograms and Pap tests in a low-income population in a managed care setting. This article presents results from a process evaluation and cost analysis of the intervention. An average of 35 minutes was spent preparing each of 304 intervention letters for mailing, including the time needed to secure signatures from 110 physicians. The results of an economic analysis suggested that this intervention cost $11.44 per recipient and $28.93 per screening test received above expected. However, intervention costs can be reduced significantly if one physician signs all letters (rather than each woman's own primary care physician) and if the health educator labor costs are diminished (e.g., by using student interns). Overall, the women under study reported that they are comfortable with both mailed and telephone reminders when they are post due for a clinical preventive service.

Breast and cervical cancer screening in a low-income managed care sample: the efficacy of physician letters and phone calls.

A randomized trial was conducted to evaluate the combined impact of a physician reminder letter and a telephone contact on the use of Pap tests and mammograms in a low-income managed care program. Women 40 to 79 years of age who were past due for cancer screening were randomly assigned to an intervention or control group. Medical claims were reviewed after 6 months to determine intervention effectiveness. The odds of receiving all needed cancer screening tests during follow-up were four times higher in the intervention group. Women who reported having to take time off from work to see a doctor had lower odds of getting screened.