Program, policy, and price interventions for tobacco control: quantifying the return on investment of a state tobacco control program.

OBJECTIVES: We examined health effects associated with 3 tobacco control interventions in Washington State: a comprehensive state program, a state policy banning smoking in public places, and price increases. METHODS: We used linear regression models to predict changes in smoking prevalence and specific tobacco-related health conditions associated with the interventions. We estimated dollars saved over 10 years (2000-2009) by the value of hospitalizations prevented, discounting for national trends. RESULTS: Smoking declines in the state exceeded declines in the nation. Of the interventions, the state program had the most consistent and largest effect on trends for heart disease, cerebrovascular disease, respiratory disease, and cancer. Over 10 years, implementation of the program was associated with prevention of nearly 36,000 hospitalizations, at a value of about $1.5 billion. The return on investment for the state program was more than $5 to $1. CONCLUSIONS: The combined program, policy, and price interventions resulted in reductions in smoking and related health effects, while saving money. Public health and other leaders should continue to invest in tobacco control, including comprehensive programs.

Demonstrating the importance and feasibility of including sexual orientation in public health surveys: health disparities in the Pacific Northwest.

OBJECTIVES: We identified health disparities for a statewide population of lesbian, gay, and bisexual (LGB) men and women compared with their heterosexual counterparts. METHODS: We used data from the 2003-2006 Washington State Behavioral Risk Factor Surveillance System to examine associations between sexual orientation and chronic health conditions, health risk behaviors, access to care, and preventive services. RESULTS: Lesbian and bisexual women were more likely than were heterosexual women to have poor physical and mental health, asthma, and diabetes (bisexuals only), to be overweight, to smoke, and to drink excess alcohol. They were also less likely to have access to care and to use preventive services. Gay and bisexual men were more likely than were heterosexual men to have poor mental health, poor health-limited activities, and to smoke. Bisexuals of both genders had the greatest number and magnitude of disparities compared with heterosexuals. CONCLUSIONS: Important health disparities exist for LGB adults. Sexual orientation can be effectively included as a standard demographic variable in public health surveillance systems to provide data that support planning interventions and progress toward improving LGB health.

Smoke-free law associated with higher-than-expected taxable retail sales for bars and taverns in Washington State.

INTRODUCTION: Continued progress in implementing smoke-free laws throughout the United States would benefit from documenting positive economic effects, particularly for the hospitality industry. This study describes changes in sales revenue in bars and taverns since December 2005, when a statewide smoke-free law in Washington State went into effect. METHODS: Using 24 quarters of inflation-adjusted taxable retail sales data from 2002 through 2007, we fitted a regression model to estimate the effect of the smoke-free law on sales revenue, controlling for seasonality and other economic factors. RESULTS: We found no immediate change in bar revenues in the first quarter of 2006, but taxable retail sales grew significantly through the fourth quarter of 2007. In the 2 years after the smoke-free law was implemented, sales revenues were $105.5 million higher than expected for bars and taverns in Washington State. CONCLUSION: The higher-than-expected revenue from taxable sales in bars and taverns after the implementation of smoke-free laws in Washington State provided extra funds to the state general fund. Potential increases in revenue in other jurisdictions that implement smoke-free indoor air policies could provide funds to benefit residents of those jurisdictions.

Smoking-related knowledge, attitudes and behaviors in the lesbian, gay and bisexual community: a population-based study from the U.S. Pacific Northwest.

OBJECTIVE: Several studies have shown that lesbian, gay and bisexual (LGB) persons have higher smoking prevalence than heterosexuals. However, few population-based studies have explored whether smoking-related knowledge, attitudes and behaviors also differ between the communities. METHODS: We used Behavioral Risk Factor Surveillance System data for 2003 to 2005 from two states (Washington and Oregon) to compare smoking-related indicators between the self-identified LGB population and their heterosexual counterparts. RESULTS: Lesbians, gays and bisexuals were more likely to be current or ever smokers than their heterosexual counterparts. All except bisexual men and had lower quit ratios than heterosexuals. Among successful quitters, bisexual men were less likely to be long-term quitters than heterosexuals. For all groups, attitudes and behaviors regarding secondhand smoke (SHS) were similar to those of heterosexuals, except for bisexual women, who were more likely to be exposed to SHS. CONCLUSIONS: Despite a disparity in smoking prevalence, the LGB population in these two states appeared to have similar levels of knowledge and attitudes toward tobacco control as their heterosexual counterparts. Nevertheless, tobacco control programs should continue to focus on this population to prevent smoking initiation, promote cessation, and reduce secondhand smoke exposure.

Is a statewide tobacco quitline an appropriate service for specific populations?

OBJECTIVE: To assess whether smoking quit rates and satisfaction with the Washington State tobacco quitline (QL) services varied by race/ethnicity, socioeconomic status, area of residence (that is, urban versus non-urban), or sex of Washington QL callers. METHODS: From October 2004 into October 2005, we conducted telephone surveys of Washington QL callers about three months after their initial call to the QL. Analyses compared 7-day quit rates and satisfaction measures by race/ethnicity, education level, area of residence and sex (using alpha = 0.05). RESULTS: We surveyed half (n = 1312) of the 2638 adult smokers we attempted to contact. The 7-day quit rate among survey participants at the 3-month follow-up was 31% (CI: 27.1% to 34.2%), 92% (CI: 89.9% to 94.1%) were somewhat/very satisfied overall with the QL programme, 97% (CI: 95.5% to 98.2%) indicated that they would probably/for sure suggest the QL to others and 95% (CI: 92.9% to 96.4%) were somewhat/very satisfied with the QL specialist. Quit rate did not vary significantly by race/ethnicity, education level, area of residence or sex. Satisfaction levels were high across subpopulations. Almost all participants (99%) agreed that they were always treated respectfully during interactions with QL staff. CONCLUSIONS: The Washington QL appeared effective and well received by callers from the specific populations studied. States choosing to promote their QL more aggressively should feel confident that a tobacco QL can be an effective and well received cessation service for smokers who call from a broad range of communities.

Effective tobacco control in Washington State: a smart investment for healthy futures.

BACKGROUND: Tobacco use remains the leading cause of preventable death in the United States. Following the 1998 Master Settlement Agreement with the tobacco industry, Washington State dedicated substantial funding to the creation of a statewide, comprehensive tobacco control program. This report documents the history and observed effectiveness of that program. CONTEXT: In 2000, the Washington legislature allocated $100 million out of the first Master Settlement payment of $320 million to tobacco control. The comprehensive tobacco control program was launched late that same year with an annual budget of $15 million. METHODS: We used existing data from state and national health behavior surveillance systems to describe smoking prevalence among adults and youth. For adult measures, we used data from the Washington State Behavioral Risk Factor Surveillance System and the National Health Interview Survey. For youth measures, we used data from the Washington State Healthy Youth Survey and the national Monitoring the Future survey. We used the National Cancer Institute's "Joinpoint" software to compare trends. CONSEQUENCES: Between 1990 and 2001, adult smoking prevalence in Washington was nearly unchanged, as it was in the United States as a whole. However, from 2001, one year after Washington instituted its comprehensive tobacco control program, to 2005, the prevalence of smoking among adults in Washington declined significantly from 22.5% to 17.6%, and by a significantly larger amount than it did nationally during the same period (22.7% to 20.9%). In addition, the prevalence of youth smoking also declined faster in Washington than it did nationally; for example, from 2000 to 2004, smoking prevalence among 8th graders declined from 12.5% in 2000 to 7.8% in 2004 in Washington but only from 12.2% in to 9.3% nationally. INTERPRETATION: Significant reductions in smoking prevalence among Washington residents following the implementation of a comprehensive tobacco control program funded at a level near that recommended by the Centers for Disease Control and Prevention indicate that tobacco control programs are an effective investment for states committed to improving public health.

Are Latinos really less likely to be smokers? Lessons from Oregon.

Our objective was to identify factors associated with current cigarette smoking among Latino adults in Oregon. We used data from 1,356 Latino participants and, for comparison, 18,593 non-Latino White participants in the 2000-2002 Oregon Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is a random-digit-dialed, cross-sectional survey of noninstitutionalized, English- or Spanish-speaking adults who live in Oregon households with a telephone. We examined relationships between current smoking and gender, age, education, and survey language (a measure of acculturation) among Latinos and used the .05 level of significance. The prevalence of current smoking was significantly lower among Latinos (18.1%) than non-Latino Whites (20.8%). Latino men were significantly more likely than Latina women to be smokers (23.1% vs. 11.4%), and some evidence indicated that less education was associated with smoking among Latino men. Taking the survey in English was strongly and significantly associated with smoking among Latina women: Smoking prevalence was 20.5% among those taking the survey in English and 3.3% for those taking it in Spanish. Our results suggest that the lower smoking prevalence among Latinos was driven by Latina women taking the survey in Spanish. Hence, it is essential for tobacco control programs to examine their local Latino smoking prevalence by gender and acculturation to avoid incorrectly concluding that Latinos are at decreased risk. Although programs for Latinos should reinforce protective aspects of Latino culture, decreasing the smoking prevalence in the U.S. mainstream culture might mitigate the negative impact of acculturation on smoking behaviors.