Cost effectiveness of a community based research project to help women quit smoking.

OBJECTIVE: To estimate the cost effectiveness of a four year, multifaceted, community based research project shown previously to help women quit smoking. DESIGN: A quasi-experimental matched control design. SETTING: Two counties in Vermont and two in New Hampshire, USA. SUBJECTS: Women aged 18-64 years. METHODS: Costs were the grant related expenditures converted to 2002 US dollars. Survey results at the end of the intervention were used to estimate the numbers of never smokers, former smokers, light smokers, and heavy smokers in the intervention and comparison counties, and 1986 life tables for populations of US women categorised by smoking status to estimate the gain in life expectancy. MAIN OUTCOME MEASURES: Cost effectiveness ratios, as dollars per life-year saved, for the intervention only and for total grant costs (intervention, evaluation and indirect costs). RESULTS: The cost effectiveness ratio for the intervention, in 2002 US dollars per life-year saved, discounted at 3%, was 1156 dollars (90% confidence interval (CI) 567 dollars to infinity), and for the total grant, 4022 dollars (90% CI 1973 dollars to infinity). When discounted at 5%, these ratios were 1922 dollars (90% CI 1024 dollars to 15,647 dollars), and 6683 dollars (90% CI 3555 dollars to 54,422 dollars), respectively. CONCLUSION: The cost effectiveness ratios of this research project are economically attractive, and are comparable with other smoking cessation interventions for women. These observations should encourage further research and dissemination of community based interventions to reduce smoking.

Factors associated with arm swelling after breast cancer surgery.

PURPOSE: As life expectancy improves for women with breast cancer, more women will be living with symptoms of lymphedema. This study reports the incidence of arm or hand swelling and associated risk factors in women with invasive breast cancer following surgery. METHODS: Data were obtained from baseline and follow-up interviews of women with invasive breast cancer (n = 145), and mammography and pathology records. The Kaplan-Meier method was used to estimate the probability of developing arm or hand swelling over time. Univariate and multivariate logistic regression analyses were conducted to identify risk factors for arm or hand swelling. RESULTS: Of women in this study, 38% self-reported arm or hand swelling. There was a significantly increased risk of arm swelling if women were under 50 years of age, had axillary node dissection, received chemotherapy, worked outside the home, and had a high household income. There was no association of body weight with swelling. A significantly decreased risk of arm swelling was found in women who were on treatment for high blood pressure. After adjustment for nodal dissection, only age had a significant independent effect. CONCLUSIONS: Our study highlights two important areas of future research that could reduce the incidence of lymphedema. There is a need to better understand the role that treatment for high blood pressure may play in protecting women from arm edema. Second, the potential effect of weight as a modifiable lymphedema risk factor needs to be studied in more detail in light of the conflicting results of different studies.

Community interventions for reducing smoking among adults.

BACKGROUND: Since smoking behaviour is determined by social context, the best way to reduce the prevalence of smoking may be to use community-wide programmes which use multiple channels to provide reinforcement, support and norms for not smoking. OBJECTIVES: To assess the effectiveness of community interventions for reducing the prevalence of smoking. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group specialised register, MEDLINE (1966-August 2001) and EMBASE (1980-August 2001) and reference lists of articles. SELECTION CRITERIA: Controlled trials of community interventions for reducing smoking prevalence in adult smokers. The primary outcome was smoking behaviour. DATA COLLECTION AND ANALYSIS: Data were extracted by one person and checked by a second. MAIN RESULTS: Thirty two studies were included, of which seventeen included only one intervention and one comparison community. Only four studies used random assignment of communities to either the intervention or comparison group. The population size of the communities ranged from a few thousand to over 100,000 people. Change in smoking prevalence was measured using cross-sectional follow-up data in 27 studies. The estimated net decline ranged from -1.0% to 3.0% for men and women combined (10 studies). For women, the decline ranged from -0.2% to + 3.5% per year (n=11), and for men the decline ranged from -0.4% to +1.6% per year (n=12). Cigarette consumption and quit rates were only reported in a small number of studies. The two most rigorous studies showed limited evidence of an effect on prevalence. In the US COMMIT study there was no differential decline in prevalence between intervention and control communities, and there was no significant difference in the quit rates of heavier smokers who were the target intervention group. In the Australian CART study there was a significantly greater quit rate for men but not women. REVIEWER'S CONCLUSIONS: The failure of the largest and best conducted studies to detect an effect on prevalence of smoking is disappointing. A community approach will remain an important part of health promotion activities, but designers of future programmes will need to take account of this limited effect in determining the scale of projects and the resources devoted to them.

Free nicotine patches plus proactive telephone peer support to help low-income women stop smoking.

BACKGROUND: This study tested the impact of free nicotine patches plus proactive telephone peer support to help low-income women stop smoking. METHODS: A total of 214 Medicaid-eligible women smokers of childbearing age were randomized to receive free nicotine patches through the mail or free nicotine patches through the mail plus the provision of proactive support by telephone from a woman ex-smoker for up to 3 months. Assessments were conducted by telephone at baseline, 10 days, and 3 and 6 months after enrollment. RESULTS: At the 3-month follow-up, significantly more women in the patch plus proactive telephone support condition were abstinent (42%) compared to the patch only condition (28%) (P = 0.03). Similarly, more women in the experimental condition were abstinent at both the 10-day and 3-month assessments (32 v 19%, P = 0.02). However, differences were not found at the 6-month follow-up, suggesting that the addition of proactive telephone peer support enhanced short-term, but not long-term cessation. CONCLUSIONS: This is the first study to demonstrate a beneficial effect for the addition of proactive telephone support as an adjunct to free nicotine replacement in a low-income population.

Helping women quit smoking: results of a community intervention program.

OBJECTIVES: This intervention was implemented to reduce the prevalence of cigarette smoking among women. METHODS: We used community organization approaches to create coalitions and task forces to develop and implement a multicomponent intervention in 2 counties in Vermont and New Hampshire, with a special focus on providing support to help women quit smoking. Evaluation was by pre-intervention and post-intervention random-digit-dialed telephone surveys in the intervention counties and the 2 matched comparison counties. RESULTS: In the intervention counties, compared with the comparison counties, the odds of a woman being a smoker after 4 years of program activities were 0.88 (95% confidence interval = 0.78, 1.00) (P = .02, 1-tailed); women smokers' perceptions of community norms about women smoking were significantly more negative (P = .002, 1-tailed); and the quit rate in the past 5 years was significantly greater (25.4% vs 21.4%; P = .02, 1-tailed). Quit rates were significantly higher in the intervention counties among younger women (aged 18 to 44 years); among women with household annual incomes of $25,000 or less; and among heavier smokers (those who smoked 25 or more cigarettes daily). CONCLUSIONS: In these rural counties, community participation in planning and implementing interventions was accompanied by favorable changes in women's smoking behavior.

The role of health professionals in a community-based program to help women quit smoking.

BACKGROUND: Health professionals are credible sources of smoking cessation advice. This study describes changes in health professionals' reported provision of smoking cessation counseling activities for women during a community health education project that took place in two intervention counties (I) and compares these to reports from health professionals in two similar comparison counties (C). METHODS: Specific smoking cessation activities reported by physicians (I n = 73, C n = 73), dentists (I n = 51, C n = 46), dental hygienists (I n = 38, C n = 44), family planning and WIC (Special Supplemental Food Program for Women, Infants and Children) counselors (I n = 14 C n = 16), and community mental health counselors (I n = 57, C n = 23) were assessed by mailed surveys at baseline, after 4 years of countywide interventions, and 2 years later. RESULTS: Compared with health professionals in the comparison counties, significant increases in smoking cessation training (P < 0.01) and in reported referral of women to stop smoking groups, support groups, and one-to-one support were noted for physicians, family planning, and WIC counselors (P < 0.001); in training and referral to stop smoking groups and support groups by dentists and dental hygienists (P < 0.05); and in referral to support groups by community mental health counselors (P < 0.05). Significant increases in setting quit dates (P < 0.05) and providing self-help materials (P < 0.01) were also noted for family planning and WIC counselors. These effects were no longer demonstrable 2 years after external support for the countywide interventions was withdrawn. CONCLUSIONS: We suggest that an important aspect of facilitating consistent smoking cessation advice and counseling from health professionals in the future will be the provision of a broader range of regularly available smoking cessation support systems within communities than is generally available at this time in the United States.

Life expectancy estimation with breast cancer: bias of the declining exponential function and an alternative to its use.

BACKGROUND: Life expectancy gain (LEG) is an outcome measure commonly estimated with a declining exponential function in a Markov model. The accuracy of such estimates has not been objectively evaluated. PURPOSE: To compare LEGs from declining exponential function estimates with those calculated from population data, using published screening mammography studies as examples. METHOD: SEER-based population data are used to compare LEG calculation with declining exponential function estimation and empiric population data in a new model, the "nested" Markov. RESULTS: Analyses of the LEG of mammographic screening based on the declining exponential function significantly overestimate LEGs for younger women and underestimate them for older women. Because of offsetting errors, all-age analyses paradoxically appear accurate. CONCLUSION: Declining exponential function estimates of LEGs for chronic diseases with low mortality rates and long time horizons are liable to significant bias, especially with limited age cohorts.

Screening for breast cancer: time, travel, and out-of-pocket expenses.

BACKGROUND: We estimated the personal costs to women found to have a breast problem (either breast cancer or benign breast disease) in terms of time spent, miles traveled, and cash payments made for detection, diagnosis, initial treatment, and follow-up. METHODS: We analyzed data from personal interviews with 465 women from four communities in Florida. These women were randomly selected from those with a recent breast biopsy (within 6-8 months) that indicated either breast cancer (208 women) or benign breast disease (257 women). One community was the site of a multifaceted intervention to promote breast screening, and the other three communities were comparison sites for evaluation of that intervention. All P values are two-sided. RESULTS: In comparison with time spent and travel distance for women with benign breast disease (13 hours away from home and 56 miles traveled), time spent and travel distance were statistically significantly higher (P<.001) for treatment and follow-up of women with breast cancer (89 hours and 369 miles). Personal financial costs for treatment of women with breast cancer were also statistically significantly higher (breast cancer = $604; benign breast disease = $76; P < .001) but were statistically significantly lower for detection and diagnosis (breast cancer = $170; benign breast disease = $310; P < .001). Among women with breast cancer, time spent for treatment was statistically significantly lower (P = .013) when their breast cancer was detected by screening (68.9 hours) than when it was detected because of symptoms (84.2 hours). Personal cash payments for detection, diagnosis, and treatment were statistically significantly lower among women whose breast problems were detected by screening than among women whose breast problems were detected because of symptoms (screening detected = $453; symptom detected = $749; P = .045). CONCLUSION: There are substantial personal costs for women who are found to have a breast problem, whether the costs are associated with problems identified through screening or because of symptoms.

Estimated gains in birth weight associated with reductions in smoking during pregnancy.

OBJECTIVE: To compare the estimated effect on birth weight of reductions in maternal cigarette consumption and urinary cotinine during pregnancy. STUDY DESIGN: An observational study of 641 women with complete data on cigarette consumption, urinary cotinine and infant birth weight. Correlation and regression analyses were used to examine relationships between birth weight, cigarette consumption and urinary cotinine at first and last prenatal visits. RESULTS: Correlations of cigarette consumption and urinary cotinine with infant birth weight were -.23 and -.30 (first visit) and -.26 and -.31 (last visit); all P values were < .001. The regression equation relating urinary cotinine concentrations at first and last visits to infant birth weight explained a significantly larger proportion of the variability in birth weight than the equation relating cigarette consumption at these visits to infant birth weight, 11% vs. 7%, P = .04. Among continuing smokers, both equations predicted gains in birth weight in association with reductions in cigarette consumption, but quitting smoking before the first visit was associated with the most weight gain. As compared to the average infant birth weight of a woman who smoked 20 cigarettes per day throughout pregnancy, the estimated gain in birth weight would be 105 g if she cut down by 10 cigarettes per day after the first visit, 210 g if she quit after this visit and 310 g if she quit before the first visit. CONCLUSION: For women still smoking at their first prenatal visit, infant birth weight is already compromised, but subsequent reductions in cigarette consumption are associated with gains in birth weight. For women who cannot quit smoking, these reductions need to be substantial if increases in birth weight of > 100 g are to be achieved.

Smoking relapse prevention during pregnancy. A trial of coordinated advice from physicians and individual counseling.

INTRODUCTION: Our objective was to examine the efficacy of physicians' advice and referral to individual counseling in preventing relapse to smoking among women who were smokers early in pregnancy, but quit prior to their first prenatal visit. DESIGN: A randomized controlled trial of prompted physician's advice and individual relapse prevention counseling during pregnancy compared to usual physician advice. Smoking status was assessed by self-report, exhaled carbon monoxide, and urinary cotinine during pregnancy and by self-report 1 year postpartum. RESULTS: There were no significant differences in relapse rates between the intervention and usual-care groups during pregnancy, nor at 1 year postpartum. Relapse rates were 23% in both groups at the 36-week visit, and 32% and 22%, respectively, 1 year postpartum. Younger age, higher motivation to resume smoking, and higher levels of exhaled carbon monoxide at the first prenatal visit were predictive of relapse to smoking during pregnancy. With the conservative assumption that all those lost to follow-up relapsed, the combined 1-year postpartum relapse rate, 51%, was 17 percentage points lower than we observed in an earlier relapse prevention trial, and 15 percentage points lower than that observed nationally a decade earlier. CONCLUSION: Prompting physicians to provide supportive advice combined with referral to individual relapse prevention counseling did not reduce smoking relapse rates during pregnancy, or postpartum. However, the level of attention paid to smoking by physicians in both intervention and usual-care groups during pregnancy may have contributed to the relatively low relapse rates seen 1-year postpartum.

Reducing smoking during pregnancy and postpartum: physician's advice supported by individual counseling.

BACKGROUND: Physicians' advice to help pregnant women quit smoking during prenatal care has had mixed results. Training and prompting physicians to provide consistent advice and referral to on-site support might improve cessation rates. METHODS: Pregnant women who smoked were randomly assigned to receive structured advice from their physician and referral to individual behavior change counseling during prenatal care or to receive brief advice to stop smoking and a quit smoking booklet at their first visit. Smoking status was measured by self-report, exhaled carbon monoxide, and urinary cotinine. RESULTS: Compared with usual care, greater proportions of intervention group women reported not smoking at the 36th-week visit (14% vs 10%) and at 1 year postpartum (18% vs 11%), but these differences were not significant. However, significantly greater proportions of intervention group women reported either not smoking or reducing their cigarette consumption by 50% or more at their second visit (43% vs 29%, P = 0.02), at their 36th-week visit (40% vs 25%, P < 0.01), and at 1 year postpartum (26% vs 14%, P = 0.02). CONCLUSIONS: Physician training on how to gain a pregnant smoker's commitment to change her smoking behavior, an office prompt system, and individualized smoking behavior change counseling show promise in reducing smoking during pregnancy and postpartum, but practical methods to assist pregnant smokers between regular prenatal visits, as they attempt to quit, need to be developed.

A mass media programme to prevent smoking among adolescents: costs and cost effectiveness.

OBJECTIVE: To examine costs and cost-effectiveness ratios of a four-year mass media programme previously shown to prevent the onset of smoking among adolescents. DESIGN: A matched control design. SETTING: Two cities in Montana, one in New York and one in Vermont, USA. SUBJECTS: Students in grades 10-12 (ages 15-18). INTERVENTION: A four-year mass media campaign to prevent the onset of smoking. MAIN OUTCOME MEASURES: Cost per student potentially exposed to the mass media campaign; cost per student smoker potentially averted; and cost per life-year gained. Cost estimates were also made for a similar campaign that would be broadcast nationally in the United States. RESULTS: In 1996 dollars, the cost of developing and broadcasting the mass media campaign was $759,436, and the cost per student potentially exposed to the campaign (n = 18,600) was $41. The cost per student smoker averted (n = 1023) was $754 (95% confidence interval (CI) = $531-$1296). The cost per life-year gained discounted at 3% over the life expectancy for young adult smokers was $696 (95% CI = $445-$1269). The estimated cost of developing and broadcasting a similar four-year mass media campaign in all 209 American media markets would be approximately $84.5 million, at a cost of $8 per student potentially exposed to a national campaign, $162 per student smoker averted, and $138 (95% CI = $88-$252) per life-year gained. CONCLUSION: Estimates of the cost-effectiveness ratios of this mass media campaign in preventing the onset of smoking showed it to be economically attractive and to compare favourably with other preventive and therapeutic strategies.

Exhaled carbon monoxide and urinary cotinine as measures of smoking in pregnancy.

We examined the relationships among self-reported cigarette consumption, exhaled carbon monoxide, and urinary cotinine/creatinine ratio in pregnant women. Information on these measures of smoking was collected at first and 36th week prenatal visits. Correlations between cigarette consumption and exhaled carbon monoxide were .65 at the first visit and .70 at the 36th-week visit. For urinary cotinine/creatinine ratio, the correlations were .61 and .65, respectively, at these visits. Correlations with change in cigarette consumption between the two visits were .37 for change in carbon monoxide and .33 for change in urinary cotinine/creatinine ratio. Urinary cotinine/creatinine ratio had slightly higher overall agreement with self-reported smoking status and was less likely to misclassify smokers than carbon monoxide. We conclude that urinary cotinine/creatinine ratio is the more accurate measure for validating smoking status among pregnant women, but exhaled carbon monoxide is the better measure of cigarette consumption and of changes in consumption.

Smoking in pregnancy, exhaled carbon monoxide, and birth weight.

OBJECTIVE: To examine the relation of cigarette consumption and exhaled carbon monoxide levels during pregnancy and to assess the effect of these smoking measures on birth weight. METHODS: Cigarette consumption and exhaled carbon monoxide levels were recorded at the first prenatal visit and the 36-week visit from women who smoked early in pregnancy. Analysis of variance was used to compare birth weights for differing levels of cigarette consumption and exhaled carbon monoxide. Correlation and regression analyses were used to estimate the effects of the smoking measures at both prenatal visits on birth weight. RESULTS: Cigarette consumption and exhaled carbon monoxide levels at both visits were associated significantly with birth weight. After the first prenatal visit, a reduction in cigarette consumption of at least nine cigarettes per day or in exhaled carbon monoxide of 8 parts per million (ppm) was associated with gains in birth weight of 100 g or more. The proportion of low birth weight (LBW) infants increased significantly with increasing levels of cigarette consumption and with increasing concentrations of exhaled carbon monoxide. CONCLUSION: Substantial reductions in cigarette consumption or in exhaled carbon monoxide levels after the first prenatal visit are needed to achieve gains in birth weight. Not smoking, or having an exhaled carbon monoxide level less than 5 ppm minimizes the likelihood of having an LBW infant.

Long-term responses of higher and lower risk youths to smoking prevention interventions.

BACKGROUND: Adolescents at risk for cigarette smoking are difficult to reach with conventional interventions but have substantial exposure to the mass media. This study is the first to show that smoking prevention messages presented through the mass media can have large and durable effects on higher risk adolescents. METHODS: Students in two communities received media and school interventions beginning in grades 5-7; those in matched comparison communities received school interventions. Media interventions were targeted to higher risk youths. School surveys were conducted before and after the interventions, in grades 4-6 and grades 8-10. Two years after interventions ended, when participants were in grades 10-12, school and telephone surveys were conducted to assess smoking status. Survey participants (n = 2,860) were classified at baseline as having higher or lower risk for becoming a smoker. RESULTS: Smoking prevalence within the higher risk sample was significantly lower for those receiving media-school interventions than for those receiving school interventions only (odds ratio = 0.71). Effects on the lower risk sample were similar in magnitude but marginally significant. CONCLUSIONS: Mass media and school interventions achieved lower smoking rates among higher risk youngsters 2 years following completion of the interventions. This strategy represents a uniquely effective method for communicating with a high-priority group.

Modeling smoking cessation: exploring the use of a videotape to help pregnant women quit smoking.

This exploratory study examined the acceptability and efficacy of a videotape modeling smoking cessation as an adjunct to smoking cessation advice delivered during prenatal care. In a randomized controlled trial involving 60 women, we compared the delivery of brief smoking cessation advice and a tipsheet to the same advice and tipsheet plus provision of the videotape. Outcomes included opinions about content and acceptability of the videotape, and smoking behavior change during pregnancy. The most highly endorsed features of the videotape were seeing other women quitting smoking (77%), dealing with stress and bad feelings (69%), talking about what to do with urges to smoke (69%), and discussing ways to get support from families and friends (54%). The reported quit rate in the last month of pregnancy, validated by exhaled carbon monoxide levels, and including women lost to follow-up as smokers, was 19.2% in the intervention group and 0% in the comparison group (p = .02). This study suggests that the use of videotapes modeling smoking behavior change may increase the effectiveness of the assistance in quitting smoking that is generally available in obstetric and family practices or public maternity clinics.

Using mass media to prevent cigarette smoking among adolescent girls.

This article describes the development of a mass media smoking prevention intervention targeted primarily toward adolescent girls at increased risk for smoking and assesses its outcomes. A cohort of 5,458 students was surveyed at baseline in Grades 4-6 and annually for 4 years. Through diagnostic and formative research, media messages were created to appeal especially to girls. Students beginning in Grades 5-7 received the 4-year media intervention and a school program in two communities, while students in two matched communities received the school program alone. Media targeting techniques resulted in high levels of message appeal and exposure consistent with effects on mediating variables and 40% lower weekly smoking at Grades 8-10 for girls receiving the media and school interventions compared to school alone. Smoking behavior effects were maintained at Grades 10-12. These results indicate that mass media interventions targeting specific audience segments can reduce substance use behavior for those segments.