The Real Cost: Alaska's innovative media campaign to raise awareness about the direct and indirect costs of smoking to society.

Smoking incurs heavy financial costs for direct medical expenditures and lost productivity related to premature death. The Alaska Tobacco Prevention and Control Program designed a media campaign called 'The Real Cost' to raise awareness of the economic cost of smoking to all Alaskans, regardless of their smoking status. The campaign presented this information through television and radio ads between December 2012 and March 2013. The first ad, 'Dream Scene', focused on overall cost of smoking to Alaska. The second ad, 'Oil Change', focused on lost productivity. We conducted three cross-sectional telephone surveys, one prior to the campaign and one after each ad was run to assess changes in beliefs associated with the main campaign messages. At Survey 2, we observed increased adjusted odds of agreement with the main campaign message, 'I am affected financially by other people's smoking' (adjusted odds ratio = 4.5, 95% confidence interval = 3.0-6.7). At Survey 3, we observed elevated adjusted odds of agreement for beliefs related to all campaign messages. This campaign was successful in raising knowledge and awareness of the cost of smoking on a societal level among adult, nonsmoking residents of Alaska.

Implementation of a smoke-free policy in subsidized multiunit housing: effects on smoking cessation and secondhand smoke exposure.

INTRODUCTION: We studied the impact of implementing a comprehensive smoke-free policy in multiunit housing in the Portland, Oregon metropolitan area. Among low-income tenants living in a subset of subsidized multiunit buildings, we evaluated cessation-related behaviors, policy knowledge and compliance, and secondhand smoke (SHS) exposure. METHODS: We mailed a self-administered questionnaire to a random sample of 839 current tenants of 17 subsidized buildings 4 months after policy implementation in January 2008 and sent another questionnaire to participants 1 year later. Results are based on 440 tenants who completed both surveys. RESULTS: We observed a self-reported annualized quit rate of 14.7% over the study period (95% CI = 7.9%-21.6%) compared with a historical quit rate in this population of 2.6% (95% CI = 0.6%-4.5%). Almost half of ongoing smokers reduced their cigarette consumption. More smokers correctly reported policy rules for indoor settings than for outdoor settings; self-reported indoor smoking decreased significantly from 59% to 17%. Among nonsmokers, frequent indoor SHS exposure (multiple times per week) decreased significantly from 41% prepolicy to 17% postpolicy. CONCLUSIONS: The implementation of a smoke-free policy was associated with positive changes in cessation-related behaviors and reduced SHS exposure in this population of low-income adults.

Moving multiunit housing providers toward adoption of smoke-free policies.

BACKGROUND: Tenants in multiunit housing are at elevated risk for exposure to secondhand smoke at home because of smoke migration from other units. COMMUNITY CONTEXT: In 2004, tobacco control advocates in the Portland, Oregon, metropolitan area began to address this issue by launching a campaign to work with landlord and tenant advocates, private- and public-sector property managers, and other housing stakeholders to encourage smoke-free policies in multiunit housing. METHODS: We outline the 6-year campaign that moved local housing providers toward adopting no-smoking policies. We used the stages of change model, which matches potential messages or interventions to a smoker's readiness to quit smoking. OUTCOME: The campaign resulted in Oregon's largest private property management company and its largest public housing authority adopting no-smoking policies for their properties and a 29% increase in the availability of smoke-free rental units in the Portland-Vancouver metro area from 2006 through 2009. INTERPRETATION: We learned the importance of building partnerships with public and private stakeholders, collecting local data to shape educational messages, and emphasizing to landlords the business case, not the public health rationale, for smoke-free housing.

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.

The acceptability of comprehensive smoke-free policies to low-income tenants in subsidized housing.

Our objective was to evaluate the acceptability of a comprehensive smoke-free policy among low-income tenants in a group of subsidized, multiunit buildings. We conducted a mixed-methods evaluation that included questionnaires mailed to 839 tenants and follow-up telephone interviews with 23 tenants who were current, former, and never smokers. Most never and former smokers supported the policy, citing improved health, fire safety, and building cleanliness; most current smokers disliked the policy and did not follow it. Messages focusing on shared community-level concerns, accompanied by smoking cessation resources, may support the transition to smoke-free policies in subsidized housing.

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.

Smoking cessation patterns by socioeconomic status in Alaska.

The ongoing disparity in smoking prevalence across levels of socioeconomic status (SES) is a significant concern in the tobacco control field, and surveillance of cessation-related activity is key to understanding progress. Historically, lower SES smokers have had much lower quit ratios but this measure can be insensitive to recent quit-related behavior. It is therefore important to examine recent quit-related behavior to assess progress toward addressing this disparity, especially in states with tobacco control programs that focus on this priority population. We compared recent quit attempts and successes among non-Native lower SES Alaska smokers to those of higher SES using data from the 2012-2013 Alaska Behavioral Risk Factor Surveillance System (BRFSS). We assessed quit ratios, one-year and five-year quit rates, and six-month abstinence between the two groups. Cessation-related measures restricted to those who smoked in the previous one year did not significantly vary by SES. However, five year quit rates were significantly lower for persons of lower SES vs. higher SES (14% vs. 32% respectively, p < .001). Results were consistent after adjustment for age, sex, and other factors. Results showed that in the previous year, smokers of lower SES in Alaska were trying to quit and succeeding at similar rates as their higher SES counterparts. However, the equivalent pattern of quit success was not reflected in the five-year time frame. Tobacco control programs should monitor cessation trends using both recent and longer-term time frames for this population. More research is needed on reasons for fewer long-term quits among lower SES smokers.

The impact of clean indoor air exemptions and preemption policies on the prevalence of a tobacco-specific lung carcinogen among nonsmoking bar and restaurant workers.

OBJECTIVES: We studied the impact of clean indoor air law exemptions and preemption policies on the prevalence of a tobacco-specific lung carcinogen-4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK)--among nonsmoking bar and restaurant workers. METHODS: secondhand smoke were compared with results from participants who were exposed to it. RESULTS: Participants exposed to workplace secondhand smoke were more likely to have any detectable level of NNAL (P=.005) and higher mean levels of NNAL (P < .001) compared with nonexposed participants. Increased levels of NNAL were also associated with hours of a single workplace exposure (P=.005). CONCLUSIONS: Nonsmoking employees left unprotected from workplace secondhand smoke exposure had elevated levels of a tobacco-specific carcinogen in their bodies. All workers--including bar and restaurant workers--should be protected from indoor workplace exposure to cancer-causing secondhand smoke.

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.

Smoking-related knowledge, attitudes, and behaviors among Alaska Native people: a population-based study.

BACKGROUND: Several studies have shown that Alaska Native people have higher smoking prevalence than non-Natives. However, no population-based studies have explored whether smoking-related knowledge, attitudes, and behaviors also differ among Alaska Native people and non-Natives. OBJECTIVE: We compared current smoking prevalence and smoking-related knowledge, attitudes, and behavior of Alaska Native adults living in the state of Alaska with non-Natives. METHODS: We used Alaska Behavioral Risk Factor Surveillance System data for 1996 to 2010 to compare smoking prevalence, consumption, and cessation- and second-hand smoke-related knowledge, attitudes, and behaviors among self-identified Alaska Native people and non-Natives. RESULTS: Current smoking prevalence was 41% (95% CI: 37.9%-44.4%) among Alaska Native people compared with 17.1% (95% CI: 15.9%-18.4%) among non-Natives. Among current every day smokers, Alaska Natives were much more likely to smoke less than 10 cigarettes per day (OR = 5.0, 95% CI: 2.6-9.6) than non-Natives. Compared with non-Native smokers, Alaska Native smokers were as likely to have made a past year quit attempt (OR = 1.4, 95% CI: 0.9-2.1), but the attempt was less likely to be successful (OR = 0.5, 95% CI: 0.2-0.9). Among current smokers, Alaska Natives were more likely to believe second-hand smoke (SHS) was very harmful (OR = 4.5, 95% CI: 2.8-7.2), to believe that smoking should not be allowed in indoor work areas (OR = 1.9, 95% CI: 1.1-3.1) or in restaurants (OR = 4.2, 95% CI: 2.5-6.9), to have a home smoking ban (OR = 2.5, 95% CI: 1.6-3.9), and to have no home exposure to SHS in the past 30 days (OR = 2.3, 95% CI: 1.5-3.6) than non-Natives. CONCLUSION: Although a disparity in current smoking exists, Alaska Native people have smoking-related knowledge, attitudes, and behaviors that are encouraging for reducing the burden of smoking in this population. Programs should support efforts to promote cessation, prevent relapse, and establish smoke-free environments.

Social marketing, stages of change, and public health smoking interventions.

As a "thought experiment," the authors used a modified stages of change model for smoking to define homogeneous segments within various hypothetical populations. The authors then estimated the population effect of public health interventions that targeted the different segments. Under most assumptions, interventions that emphasized primary and secondary prevention, by targeting the Never Smoker, Maintenance, or Action segments, resulted in the highest nonsmoking life expectancy. This result is consistent with both social marketing and public health principles. Although the best thing for an individual smoker is to stop smoking, the greatest public health benefit is achieved by interventions that target nonsmokers.

Smoking patterns in Oregon youth: effects of funding and defunding of a comprehensive state tobacco control program.

PURPOSE: Comprehensive tobacco control programs have included school-based prevention programs as a key strategy to reach adolescents. Unfortunately, these programs have undergone extensive budget reductions in recent years. In 2003, funding for the Oregon Tobacco Prevention and Education Program was reduced by about 70%, and the school component was entirely defunded. To assess the effects of program funding and subsequent defunding on smoking prevalence within targeted Oregon schools, we compared the change in 30-day smoking prevalence between grades 8 and 11 in school districts in two periods: namely, during funding and after funding was eliminated. METHODS: We used annual school-based survey data for grades 8 and 11 to describe district-level changes in smoking prevalence in five age cohorts: two during the funding period and three after defunding. Each cohort was comprised of districts whose 8th-graders completed the survey and participated again 3 years later. Using mixed models, we compared the change in 30-day adjusted smoking prevalence among cohorts in funded districts, defunded districts, and districts that never received funding. RESULTS: Smoking prevalence growth was significantly higher among cohorts from the defunded period than for cohorts from the funded period (p=.04) and was not significantly different from schools that were never-funded (p=.79). CONCLUSIONS: In Oregon, funding a school component of a comprehensive tobacco control strategy was associated with depressed uptake of smoking. Gains were quickly lost upon program defunding. School programs are an important strategy if they are long term, comprehensive, and reinforced in the larger environment.

Longitudinal study of household smoking ban adoption among households with at least one smoker: associated factors, barriers, and smoker support.

We conducted a longitudinal study among Oregon households with at least one smoker to assess smoking-related associations with ban adoption, to examine smoker support for bans, and to examine barriers to ban establishment. We followed a cohort of 1,604 baseline survey respondents for a median time of 21 months and re-interviewed 825 respondents (51.4% response rate). Of these, 512 did not have a full household ban in place at baseline. Thirty-two percent of the respondents without a ban at baseline adopted a full ban. Baseline smoking-related factors associated with ban adoption were: longer time until first cigarette, stage of change, and attitudes towards respondent's smoking. Associated follow-up factors included cessation and reduced consumption. Ninety-one percent of respondents reported smoker support of a ban. Future work should focus on ban establishment in households with more highly addicted smokers.

Support for spirituality in smoking cessation: results of pilot survey.

Patient spiritual resources are increasingly included in the treatment of medical conditions such as cancers and alcohol and drug dependence, but use of spiritual resources is usually excluded from tobacco dependence treatment. We hypothesized that this omission may be linked to perceived resistance from smokers. To examine this hypothesis, we conducted a pilot survey to assess whether current smokers would consider spiritual, including religious, resources helpful if they were planning to quit. Smokers at least 18 years of age at Oregon Health & Science University in Portland, Oregon, (N=104) completed a brief survey of smoking behaviors and spiritual beliefs. None were attempting to quit. Of these individuals, 92 (88%) reported some history of spiritual resources (spiritual practice or belief in a Higher Power), and of those respondents, 78% reported that using spiritual resources to quit could be helpful, and 77% reported being open to having their providers encourage use of spiritual resources when quitting. Results of logistic regression analysis indicated that those aged 31-50 years (OR=3.3), those over age 50 years (OR=5.4), and women (OR=3.4) were significantly more likely to have used spiritual resources in the past. Of the 92 smokers with any history of spiritual resources, those smoking more than 15 cigarettes/day were significantly more receptive to provider encouragement of spiritual resources in a quit attempt (OR=5.4). Our data are consistent with overall beliefs in the United States about spirituality and recent trends to include spirituality in health care. We conclude that smokers, especially heavier smokers, may be receptive to using spiritual resources in a quit attempt and that spirituality in tobacco dependence treatment warrants additional investigation and program development.

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.

Household smoking bans: which households have them and do they work?

BACKGROUND: This study characterized Oregon households according to type and degree of restrictions on smoking and explored whether smoking restrictions are associated with decreased environmental tobacco smoke (ETS) exposure. METHODS: A population-based, random-digit-dialed cross-sectional telephone survey of 6,199 adult Oregonians was performed in 1997 to provide baseline data on tobacco use in Oregon. RESULTS: Seventy percent of Oregon households were composed of nonsmokers only, and 85% of those had a full ban on smoking inside the home. Of the households containing one or more smokers, 38% had a full household ban on smoking. Among respondents with a full ban in place, 99% of nonsmoker-only households reported that no one smoked in the home in the previous month, compared with 91% of households with at least one smoker. In both nonsmoker-only households and those with at least one smoker, full bans were strongly associated with awareness of the harm of ETS (OR = 12.8, 95% CI 7.3-22.3, and OR = 6.6, 95% CI 3.6-12.3, respectively). The presence of children in the household was also closely associated with full bans in the two types of households (OR = 4.6, 95% CI 2.8-7.6, and OR = 3.0, 95% CI 2.1-4.4, respectively). Nevertheless, 50% of households with children and a smoker present did not have a full ban in place. CONCLUSIONS: While the prevalence of household smoking restrictions is high in Oregon, there remains room for improvement, since 50% of households with a smoker and a child present do not have a full ban on indoor smoking. Public health messages that focus on household smoking restrictions may help protect nonsmokers from exposure to ETS.