Tobacco Prevention and Control Evidence-based Recommendations from the Guide to Community Preventive Services.

Tobacco Prevention and Control

Evidence-based Recommendations from the Guide to Community Preventive

Services

Introduction

• Guide to Community Preventive Services• Tobacco chapter• Recommendations from the Task Force

• Smoking bans• Provider reminder systems• Interventions to reduce minors’ access• Preview: School-based interventions

The Community Guide

• A Task Force

• A Process– Systematic reviews of the literature– Assessments of study quality– Summary of outcomes

• A Product– Evidence-based recommendations– Book

Why Evidence Reviews?

Decision-making

Advocacy

Defense

Program buiding

Options

Methods

• Develop a conceptual framework

• Search for evidence

• Rate the quality of the evidence

• Summarize the information

• Translate the strength of evidence into

recommendations for use

The Tobacco Chapter

• Recruited 20 experts• Selected 10 intervention categories• Screened 16,000 citations• Reviewed 1300 papers• Evaluated 350 studies• Summarized evidence for 15 interventions

Prevention: Targets and Goals

Former Users (1m)

Current Users (1m)

Future Users (114k/yr)

Non Users (4m)

Increase Cessation

Reduce Initiation

Reduce ETS Exposure

Population

Tobacco Control Policies: Settings

Goal

Increase

Cessation

Reduce

Initiation

Reduce

ETS

CommunityHealth

Care System

Yes

Yes

Yes

Yes

(No)

(Yes)

Issues to Consider in Reviews

InterventionIntendedOutcomes

ReducedMorbidity

and/orMortality

AdditionalOutcomes

Benefits

Harms

Barriers

Recommendations from the Community Guide Task Force

Interventions to Reduce Tobacco Use and ETS Exposure in

Communities and Health Care Systems

In Communities

Goal Recommended Interventions

Increase

Cessation

Reduce

Initiation

Reduce

ETS Exposure

* When combined with other interventions

Increase the price (tax)

Mass media campaigns*

Telephone Quit lines*

Increase the price (tax)

Mass media campaigns*

Smoking bans

Smoking bans

In Communities

Goal Interventions with Insufficient Evidence

Increase

Cessation

Reduce

Initiation

Reduce

ETS Exp.

Smoking cessation contests

Broadcast smoking cessation series

Community-wide efforts to reduce ETS exposure in the home

In Health Care Systems

Goal Recommended Interventions

Increase

Cessation

Reduce

Initiation

Reduce ETS

* When combined with other interventions

Provider reminder systems*

Telephone Quit Lines*Reducing patient out-of-pocket costs (NRT)

Smoking bans (in effect)

In Health Care Systems

Goal Interventions with Insufficient Evidence

Increase

Cessation

Reduce

Initiation

Reduce ETS

Provider education programs (alone)

Provider feedback systems

(Provider counseling to reduce home ETS exposure)

Reviews in Progress

Goals Interventions under Evaluation

Increase

Cessation

Reduce

Initiation

Reduce

ETS

Youth access interventions

School-based interventions

Interventions to Reduce Exposure to Environmental Tobacco Smoke

Smoking Bans and Restrictions

Analytic Framework: Smoking Bans

ReducedMorbidity

andMortality

SmokingBans

Smoking Bans Might Result from Community Education Efforts

ReducedMorbidity

andMortality

SmokingBans

CommunityEducation

Pre-emption

Bans Might Reduce ETS Exposure

ReducedMorbidity

andMortality

SmokingBans

ReducedExposure to ETS

Bans Might Increase Smoking Cessation

ReducedMorbidity

andMortality

SmokingBans

ReducedExposure to ETS

FewerTobacco

Users

Change In

Attitudes

ReducedConsumption

IncreasedQuit

Attempts

IncreasedCessation

Bans Might Reduce Smoking Initiation

ReducedMorbidity

andMortality

SmokingBans

ReducedExposure to ETS

Change In

Attitudes

ReducedInitiation

FewerTobacco

Users

Change In

Attitudes

ReducedConsumption

IncreasedQuit

Attempts

IncreasedCessation

Bans Might Increase ETS in the Home

ReducedMorbidity

andMortality

SmokingBans

ReducedExposure to ETS

Change In

Attitudes

ReducedInitiation

FewerTobacco

Users

Change In

Attitudes

ReducedConsumption

IncreasedQuit

Attempts

IncreasedCessation

DivertedConsumption

IncreasedHome Exposure

Body of Evidence: Bans and Restrictions

• 56 studies reviewed

• ETS exposure: 10 of 17 studies qualified

• Tobacco use: 9 of 51 studies qualified

Study Measurements by Outcome

ReducedMorbidity

andMortality

SmokingBans

ReducedExposure to ETS

Change In

Attitudes

ReducedInitiation

FewerTobacco

Users

Change In

Attitudes

ReducedConsumption

IncreasedQuit

Attempts

IncreasedCessation

DivertedConsumption

IncreasedHome Exposure

12

6

4591

0*0*6

-10 0 10 20 30 40 50 60 70 80 90 100

Relative Percent Reduction Environmental

Self-reported

Study

Millar, 1988

Gottlieb, 1990

Borland, 1992

Brownson, 1995

Patten, 1995a

Etter, 1999

Becker, 1989

Mullooly, 1990

Stillman, 1990b

Borland, 1992

Broder, 1993

Patten, 1995a

Restrictions

Bans

Median = 60.5

Distribution of Observed Changes in ETS Exposure: (n=12 measurements from 10 studies)

Smoking Bans and Tobacco Use

• Consumption (cigarettes/day) – Decreased in 8 of 9 studies– Median: -1.3 cigs/day range: -4.3 to 0

• Cessation attempts– Increased in 3 of 5 studies– Median: +1.8 pct pt (+9%: range –3.4% to +175%)

• Prevalence of self-reported smoking– Decreased in 3 of 6 studies– Median: -0.9 pct pt (-4.2%: range –33% to +5%)

Additional Information

• Applicability – Public and private workplaces

• Additional Benefits– Reduced consumption

• Potential Harms– Refuted: Loss of revenue

• Barriers– Pre-emption

Task Force Conclusion

• Smoking Bans and Restrictions are Recommended (strong evidence)

Because they:• Reduce exposure to ETS in a variety of

public and private workplaces

Limitations

• Based on published research– Bans v. Restrictions

• Excluded cross-sectional evidence– Recent studies– Additional evidence of impact on tobacco use

• Preliminary link is important– Interventions to obtain smoking bans

Interventions to Increase Tobacco Use Cessation

Provider Reminder Systems when coordinated with additional

interventions

Provider Reminder Systems

• Prompts to health care providers– Identify patient tobacco use status– Discuss tobacco use cessation

• Search: 32 studies

• Evaluation: 27 studies– Reminder system alone: 7 studies– Combined with other interventions: 20 studies

Analytic Framework

ProviderKnowledge

Patient Smoking

Status

Advice toQuit

Attempts to Quit

Quit

DecreasedMorbidity/Mortality

ProviderReminder

Reported Outcomes(n=39 measurements from 20

studies)

ProviderKnowledge

Patient Smoking

Status

Advice toQuit

Attempts to Quit

Quit

DecreasedMorbidity/Mortality

ProviderReminders

0 3 15 7 14

Understanding Study OutcomesDifferences or Changes

Quit Rate in Intervention Arm

Quit Rate in Control Arm

Difference

15% 10%

15-10=

+5 pct. pts

Absolute percent

15% 10%

5%/10%=

+50%

Relative percent

-10 -5 0 5 10 15 20 25 30

Percentage Point Change

Study

Cohen 1989a

Cohen, 1989b

Strecher, 1991

Secker-Walker, 1998

Conger, 1987

Wilson, 1988

Cummings, 1989a

Cummings, 1989b

Petersen, 1992

Stevens, 1995

Wall, 1995

Hartmann, 1996

Morgan, 1996

Manfredi, 1999

Provider Reminder + Provider Education

Provider Reminder + Provider Education + Patient Education

Median = 4.7

(12m)

(12m)

(6m)

(12m)

(4m)

(12m)

(12m)

(12m)

(8m)

(8w)

(3m)

(<8m)

(6m)

(8w)

Differences in Patient Cessation in Studies of M ulticomponent Programs

ProviderKnowledge

Patient Smoking

Status

Advice toQuit

Attempts to Quit Quit

DecreasedMorbidity/Mortality

ProviderReminders

+13% +20% +8% +4.7%?

*Combined with additional interventions

Median Reported Differences in Outcomes in Studies Evaluating Provider Reminder Systems*

(n=20 studies)

(+8, +13) (+5, +60) (+1, +20) (-1, +26)

Additional Information

• Applicability– Settings (HMO, private practice, HD)– Provider populations (Medicine, OB, Dental)

• Additional Benefits– Prompts for other preventive services

• Potential Harms– None identified

• Barriers– Infrastructure– (Screening of adolescents)

Task Force Conclusion

• Multi-component programs that include: provider reminder system + provider education program + patient education materials Recommended (Strong Evidence)

Because they:

• Increase provider delivery of advice to quit to tobacco-using patients

• Increase patient tobacco use cessation

Interventions to Reduce Tobacco Use Initiation

Interventions to Restrict Minors’ Access to Tobacco Products

Efforts to Restrict Minors’ Access Combined Policies with Other Interventions

• Policies– Laws directed at retailers

• Bans, restrictions, licensing

– Laws directed at youth • purchase, use, possession

– Enforcement (intent, conduct, penalties)

• Interventions– Retailer education programs– Community Education

YouthAccessInterv.

ReducedYouth

TobaccoUse

Analytic Framework-Outcome

YouthAccessInterv.

RetailerKnowledge

RetailerPerceptions

RetailerBehaviors

(Sales)

YouthTobacco

Use

Interventions Might Affect Retailers

YouthAccessInterv.

RetailerKnowledge

RetailerPerceptions

RetailerBehaviors

(Sales)

YouthTobacco

Use

Interventions Might Affect Youth

YouthKnowledge

YouthPerceptions

YouthTobacco

Purchases

YouthAccessInterv.

RetailerKnowledge

RetailerPerceptions

RetailerBehaviors

(Sales)

YouthTobacco

Use

Interventions Might Affect the Community

YouthKnowledge

YouthPerceptions

YouthTobacco

Purchases

CommunityNorms

Enforcement

YouthAccessInterv.

RetailerKnowledge

RetailerPerceptions

RetailerBehaviors

(Sales)

YouthTobacco

Use

Youth Have Other Sources

YouthKnowledge

YouthPerceptions

YouthTobacco

Purchases

CommunityNorms

Enforcement

Other SourcesOf Tobacco

YouthAccessInterv.

RetailerKnowledge

RetailerPerceptions

RetailerBehaviors

(Sales)

YouthTobacco

Use

The Key Outcomes

YouthKnowledge

YouthPerceptions

YouthTobacco

Purchases

CommunityNorms

Enforcement

Other SourcesOf Tobacco

YouthAccessInterv.

RetailerKnowledge

RetailerPerceptions

RetailerBehaviors

(Sales)

YouthTobacco

Use

YouthKnowledge

YouthPerceptions

YouthTobacco

Purchases

CommunityNorms

Enforcement

Other SourcesOf Tobacco

5

13

32

0 1

0

1

1 0

26 Measurements from 13 Studies

Five Studies Measured Changes in Youth Tobacco Use

Study

Com.

Mobiliz.

Ret.

Edu

Law Active

Enfrcmt

Other

Altman 1999 Yes Yes

Biglan 2000 Yes Yes S Edu

Forster 1998 Yes Yes Yes

Jason 1996 Yes Yes Yes Yes

Rigotti 1997 Yes Yes

-15 -10 -5 0 5

Absolute percentage change

Changes in Self-Reported Tobacco Use: Multicomponent Interventions (n=5)

Median = - 5 pct pointsRange: -11 pct points , +2 pct points

Study

Altman 1999

Biglan 2000

Forster 1998

Jason 1996a

Rigotti 1997

Task Force Conclusion

Number of Studies

Consistent Effect?

Sufficient Effect Size?

Strength of Evidence

4 Yes Yes Sufficient

Community mobilization when combined with additional interventions such as local laws, active enforcement of

illegal sales to minors, and community-directed education of retailers are effective in restricting minors’

access to tobacco products

Task Force Assessment: Recommended

(sufficient evidence)

There is No Evidence that Single Interventions are Effective

• Sales laws directed at retailersInsufficient Evidence

• PPU laws directed at youthInsufficient Evidence

• Active enforcement of sales lawsInsufficient Evidence

• Retailer EducationInsufficient Evidence

• Community educationInsufficient Evidence

Pitfalls

• Preemption

• Enforcement responsibility

• “Knowingly” / “Intentionally”

• Clerk vs owner

• Criminal penalties (judicial nullification)

Pitfalls

• Youth purchase, possession, or use laws

– Normative diversion

“Penalize kids, not retailers”

– Resource diversion

– Compliance checks barrier

School-Based Interventions

Interventions Selected for Review

• Tobacco-free policies• School-based education• Smoking cessation programs• Multi-component programs that include a

school-based component• Student delivered community education

– SWAT programs

OrganizedStudent

Advocacy

CommunityEvents or

Efforts

MassMedia

Exposure

Change in Community

Attitudes

Change in Community

Policies

ReducedTobacco

Use Initiation Fewer

TobaccoProductUsers

ReducedMorbidity

&Mortality

SchoolEvents

Change in Student

Attitudes*

Reduced/DelayedInitiation

Of TobaccoUse

Increased Tobacco

UseCessation

FewerStudent

Tobacco Users

Change inSchool Policies

StudentParticipation

Change inParticipantAttitudes*

ReducedParticipantTobacco

Use

FewerParticipantTobacco

Users

Analytic Framework: Student-delivered Community Education

*Includes changes in knowledge and skill development or enhancement

Content of Recent Evidence Reviews

TobaccoUser

ProviderHealthCare

SystemCommunity

Community Guide Clinical Guide

PHS: Clinical Practice Guidelines

CDC Best Practices

SGR: Reducing Tobacco Use

NCI: Population Based Smoking Cessation

Conclusions

• Evidence on effectiveness is one tool for decision-making

• There are effective interventions– For Communities– For Health Care Systems

• Building blocks of a comprehensive tobacco control program