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The question of how to evaluate lost consumer surplus in benefit-cost analyses has been contentious. There are clear health benefits of regulations that curb consumption of goods with health risks, such as tobacco products and foods high in fats, calories, sugar, and sodium. Yet, if regulations cause consumers to give up goods they like, the health benefits they experience may be offset by some utility loss, which benefit-cost analyses of regulations need to take into account. This paper lays out the complications of measuring benefits of regulations aiming to curb consumption of addictive and habitual goods, rooted in the fact that consumers' observed demand for such goods may not be in line with their true preferences. Focusing on the important case of tobacco products, the paper describes four possible approaches for estimating benefits when consumers' preferences may not be aligned with their behavior, and identifies one as having the best feasibility for use in applied benefit-cost analyses in the near term.

Background Tobacco use is still the leading preventable cause of death and morbidity in the U.S. Web-assisted tobacco interventions are an effective but underutilized tool in assisting smokers with quitting. The dental visit is an excellent opportunity to assist smokers in quitting by referring them to these tobacco-cessation online programs. Purpose The study purpose was to test two patient referral methods—paper referrals (information prescriptions) versus paper plus e-referrals—to a web-assisted smoking-cessation induction system. Design RCT that used implementation research methods. Participants/setting A total of 100 community-based dental practices were enrolled and 1814 smokers were referred to the web-assisted tobacco induction system. Intervention The study intervention was a proactive e-referral of smokers to a web-assisted tobacco induction system called Decide2Quit.org, and the control group used paper referrals (information prescriptions) to refer smokers to the Decide2Quit.org. Main outcome measurements The outcome measurements were the referral numbers, Decide2Quit registration numbers, and the smokers' quit rate. Data were collected in 2010–2011 and analyses were completed in 2012. Results Although total referrals from intervention practices was lower than control, subsequent proportions of registrations among smokers referred to Decide2Quit.org were nearly fourfold higher (adjusted mean percentages: 29.5% vs 7.6%, p p =0.03) in intervention practices as compared with control. Conclusions Intervention practices using the e-referral system had higher smoker registration numbers and higher quit smoking rates than the control practices. This study finds that e-referrals are effective in getting smokers to the web-assisted smoking-cessation induction system and in assisting with quitting that more than compensates for any additional effort that e-referrals require on the part of the practitioner. Clinical Trial Registration DPBRN Hygienists Internet Quality Improvement in Tobacco Cessation (HiQuit); NCT01108432

Only large increases in adult cessation will rapidly reduce population smoking prevalence. Evidence-based smoking-cessation treatments and treatment policies exist but are underutilized. More needs to be done to coordinate the widespread, efficient dissemination and implementation of effective treatments and policies. This paper is the first in a series of three to demonstrate the impact of an integrated, comprehensive systems approach to cessation treatment and policy. This paper provides an analytic framework and selected literature review that guide the two subsequent computer simulation modeling papers to show how critical leverage points may have an impact on reductions in smoking prevalence. Evidence is reviewed from the U.S. Public Health Service 2008 clinical practice guideline and other sources regarding the impact of five cessation treatment policies on quit attempts, use of evidence-based treatment, and quit rates. Cessation treatment policies would: (1) expand cessation treatment coverage and provider reimbursement; (2) mandate adequate funding for the use and promotion of evidence-based state-sponsored telephone quitlines; (3) support healthcare systems changes to prompt, guide, and incentivize tobacco treatment; (4) support and promote evidence-based treatment via the Internet; and (5) improve individually tailored, stepped-care approaches and the long-term effectiveness of evidence-based treatments. This series of papers provides an analytic framework to inform heuristic simulation models in order to take a new look at ways to markedly increase population smoking cessation by implementing a defined set of treatments and treatment-related policies with the potential to improve motivation to quit, evidence-based treatment use, and long-term effectiveness.

Tobacco use is still the leading preventable cause of death and morbidity in the U.S. Web-assisted tobacco interventions are an effective but underutilized tool in assisting smokers with quitting. The dental visit is an excellent opportunity to assist smokers in quitting by referring them to these tobacco-cessation online programs.The study purpose was to test two patient referral methods-paper referrals (information prescriptions) versus paper plus e-referrals-to a web-assisted smoking-cessation induction system.RCT that used implementation research methods.A total of 100 community-based dental practices were enrolled and 1814 smokers were referred to the web-assisted tobacco induction system.The study intervention was a proactive e-referral of smokers to a web-assisted tobacco induction system called Decide2Quit.org, and the control group used paper referrals (information prescriptions) to refer smokers to the Decide2Quit.org.The outcome measurements were the referral numbers, Decide2Quit registration numbers, and the smokers' quit rate. Data were collected in 2010-2011 and analyses were completed in 2012.Although total referrals from intervention practices was lower than control, subsequent proportions of registrations among smokers referred to Decide2Quit.org were nearly fourfold higher (adjusted mean percentages: 29.5% vs 7.6%, p0.01) in intervention compared with control practices. Subsequent rates of cessation among referred smokers were threefold higher (adjusted mean percentages: 3.0% vs 0.8%, p=0.03) in intervention practices as compared with control.Intervention practices using the e-referral system had higher smoker registration numbers and higher quit smoking rates than the control practices. This study finds that e-referrals are effective in getting smokers to the web-assisted smoking-cessation induction system and in assisting with quitting that more than compensates for any additional effort that e-referrals require on the part of the practitioner.DPBRN Hygienists Internet Quality Improvement in Tobacco Cessation (HiQuit); NCT01108432.

The rapid growth of smartphone ownership and broadband access has created new opportunities to reach smokers with cessation information and support using digital technologies. These technologies can both complement and be integrated with traditional support modalities such as telephone quitlines and 1-on-1 clinical cessation counseling. The National Cancer Institute's Smokefree.gov Initiative provides free, evidence-based cessation support to the public through a multimodal suite of digital interventions, including several mobile-optimized websites, text messaging programs, and 2 mobile applications. In addition to digital resources directed at the general population, the Smokefree.gov Initiative includes population-specific resources targeted to adolescents, women, military veterans, Spanish speakers, older adults, and other populations. This paper describes the reach and use of the Smokefree.gov Initiative's resources over a 5-year period between 2014 and 2018, including how users interact with the program's digital content in ways that facilitate engagement with live counseling support. Use of Smokefree.gov Initiative resources has grown steadily over time; in 2018 alone, approximately 7-8 million people accessed Smokefree.gov Initiative web- and mobile-based resources. Smokefree.gov Initiative utilization data show that people take advantage of the full range of technology tools and options offered as part of the Smokefree.gov Initiative's multiplatform intervention. The Smokefree.gov Initiative experience suggests that offering different, complementary technology options to meet the needs and preferences of smokers has the potential to meaningfully expand the reach of cessation treatment.

This article summarizes the vaping research literature as it pertains to tobacco quitlines and describes vaping assessment, treatment, and evaluation quitline practices. It also presents 2014-2018 registration data (vaping in the past 30 days, number of use days, use for quitting smoking, and intentions to quit vaping) from 24 public quitlines (23 states and District of Columbia) and 110,295 enrollees to employer-sponsored quitlines. Trends in vaping rates over time, by state, and by age group are described. Approximately 57,000 adult public quitline enrollees in the U.S. reported vaping at registration in 2018 (14.7% of enrollees). Most quitline participants who vape also smoke cigarettes and contact the quitline for smoking cessation support. Rates of reporting vaping and no combustible or smokeless tobacco use in the past 30 days are 0.5% of all public quitline participants (3% of public quitline vaping product users). Data are not systematically available regarding the number of quitline participants who are seeking help quitting vaping and only vape (do not use combustible or smokeless tobacco). Few quitline participants (1%) are youth aged18 years, but more than a third (35%) report vaping. This paper outlines research and evaluation priorities to inform the future quitline treatment landscape with respect to vaping. The quitline community is positioned to increase the likelihood that vaping has a positive impact for adults who smoke through harm reduction or supporting cessation and has opportunities to expand impacts on youth and young adult vaping prevention and cessation.

This paper estimated the association between the U.S. Food and Drug Administration's 2009 ban on flavored cigarettes (which did not apply to menthol cigarettes or tobacco products besides cigarettes) and adolescents' tobacco use.Regression modeling was used to evaluate tobacco use before and after the ban. The analyses controlled for a quadratic time trend, demographic variables, prices of cigarettes and other tobacco products, and teenage unemployment rate. Data from the 1999-2013 National Youth Tobacco Surveys were collected and analyzed in 2016. The sample included 197,834 middle and high schoolers. Outcomes were past 30-day cigarette use; cigarettes smoked in the past 30 days among smokers; rate of menthol cigarette use among smokers; and past 30-day use of cigars, smokeless tobacco, pipes, any tobacco products besides cigarettes, and any tobacco products including cigarettes.Banning flavored cigarettes was associated with reductions in the probability of being a cigarette smoker (17%, p0.001) and cigarettes smoked by smokers (58%, p=0.005). However, the ban was positively associated with the use by smokers of menthol cigarettes (45%, p0.001), cigars (34%, p0.001), and pipes (55%, p0.001), implying substitution toward the remaining legal flavored tobacco products. Despite increases in some forms of tobacco, overall there was a 6% (p0.001) reduction in the probability of using any tobacco.The results suggest the 2009 flavored cigarette ban did achieve its objective of reducing adolescent tobacco use, but effects were likely diminished by the continued availability of menthol cigarettes and other flavored tobacco products.

Introduction The general efficacy of quitlines has been widely demonstrated, but uncertainty exists regarding how quitlines might best intervene for persons with mental health conditions. A total of 1 in 5 people in the U.S. has a diagnosable psychiatric disorder. These individuals smoke at 2‒4 times the rate of smoking among those without a mental health condition and face high rates of related death and disability. About half of quitline callers self-report a mental health condition, but until recently, quitline protocols tailored to these smokers did not exist. Methods This paper provides initial results for tailored mental health programs from the largest quitline providers in the U.S., Optum and National Jewish Health. From 2017 to 2018, cohorts of callers with a mental health condition who enrolled in tailored programs were compared with cohorts with a mental health condition who received standard care. Both mental health programs offered participants additional calls, longer duration of combination nicotine-replacement therapy, and attention to mental health issues. Analyses were conducted in 2018–2019. Results Findings suggest that callers with a mental health condition benefit from both standard care and tailored mental health services. Tailored programming did well in engaging people with mental health conditions. At the same time, there were no significant differences in abstinence rates when comparing mental health programs with standard care. Mental health cohorts did receive significantly greater service durations, more counseling calls, and longer nicotine-replacement therapy duration. Conclusions Tailored mental health quitline programs present a promising framework for testing the services that address psychiatric symptoms as well as other frequent population characteristics such as chronic illness. Implications for increasing reach to the often underserved population with a mental health condition are discussed.

The 2013 U.S. Preventive Services Task Force (USPSTF) concluded that behavioral interventions are effective in reducing initiation of smoking in youth, recommending primary care clinicians provide education or brief counseling to prevent initiation, and that there are promising trends toward behavioral interventions improving cessation in this population. Our primary care-based intervention RCT conducted between 2000 and 2004, Air It Out, informed these USPSTF recommendations. Our trial was designed to determine whether a pediatric primary care practice-based smoking prevention and cessation intervention would be effective in increasing abstinence rates among adolescents under usual clinic conditions, to inform clinical practice. Therefore, the trial was designed to be largely a pragmatic trial. In this paper, we describe where each of the Air It Out study components falls along the pragmatic-explanatory continuum regarding participant eligibility criteria, intervention and comparison condition design, follow-up and outcomes, compliance and adherence assessments, and analysis. Such an assessment assists researchers by providing a framework to guide decisions regarding study design and implementation. We then share a few principles and lessons learned in developing and implementing the primary care-based intervention trial, focusing on study setting selection, engaging providers who will be delivering the intervention and the target population who will be receiving it in designing the trial and interventions to be tested, and the need to carefully plan recruitment and retention procedures. The hope is to increase the number of well-designed studies that can be included in the evidence reviews to guide future USPSTF recommendation statements.

Background Research in tobacco control demonstrating best practices is widely disseminated; however, application at the local level is often difficult. Translating research into practice requires a concerted effort to develop an understanding of the evidence and how it can be applied within diverse contexts. Purpose A strategic planning infrastructure was developed to support the translation of evidence-based interventions into community practice. This paper highlights the strategic process of turning "know-what" into "know-how" to facilitate the strategic planning and implementation of tobacco control best practices at the local level. Design The purpose, people, process, and product strategies of knowledge management and translation provided a framework for the strategic planning infrastructure. The knowledge translation concepts of audience, motivations, and mechanisms were synergized in the neo-strategic planning component design. Setting/participants The participants were 20 community coalitions funded to implement local tobacco control programs. Intervention From 2004 to 2011, the strategic planners facilitated a cyclical process to translate research into practice using a trio of integrated tools, skill-building workshops on strategic planning, and grantee-driven technical assistance and consultation. Main outcome measures In the short term, the usefulness of the strategic planning components to the programs was measured. The intermediate outcome was the successful movement of the community programs from the planning stage to the implementation stage. The achievement of community-level changes in planned tobacco control efforts was the overall outcome measure for the success of the local coalitions. Results Seventeen of 20 communities that began the planning process implemented strategic plans. All 17 of the programs implemented evidence-based practices, resulting in numerous tobacco-free policies, increased cessation, and increased support from the media and community. Conclusions Bridging the gap between research and practice can enhance the practicality, efficiency, and effectiveness of tobacco control programs at the local level, maximizing the potential positive health impact.

Context: Smokefree legislation is a powerful public health intervention. Despite progress in smoke- free legislation, over half of U.S. adults remain unprotected by comprehensive smokefree legislation. Evidence acquisition: This paper reviews the scientific literature on health and economic out- come studies of smokefree legislation from the past decade, 2000 to early 2010, using MEDLINE and key search terms: smoking, smoking cessation, smoking/legislation and jurisprudence, smoking cessa- tion/legislation and jurisprudence, and health policy. Evidence synthesis: There is a wealth of research showing the health benefits to entire popula- tions when communities implement comprehensive smokefree laws and/or regulations. These laws improve the health of hospitality workers and the general population by improving indoor air quality, reducing acute myocardial infarctions and asthma exacerbations, and improving infant and birth outcomes. Some studies report reduced smoking prevalence and cigarette consumption and improved cessation outcomes after smokefree legislation. In addition to the health benefits, eco- nomic studies confirm that smokefree laws do not adversely affect business revenues or operating costs. Conclusions: While there is an abundance of smokefree policy outcomes research showing both the health and economic impacts of smokefree legislation, these outcomes may have more to do with implementation effectiveness than adoption, especially among subpopulations. An emerging body of literature documents not only that disparities in health protections remain among subpopulations, but that health outcomes of smokefree legislation may vary by gender, race/ethnicity, SES, and age. Further research is needed on implementation effectiveness of smokefree legislation and differential effects on subpopulations. (Am J Prev Med 2010;39(6S1):S66 -S76) © 2010 American Journal of Preventive Medicine

Background An estimated one fifth of all U.S. adult smokers receive health benefits through insurance plans administered by Taft–Hartley Health and Welfare Funds. Most funds do not offer comprehensive tobacco-cessation services to fund participants despite evidence that doing so would be cost effective and save lives. Purpose This paper examines the decision-making processes of Minnesota-based fund trustees and advisors to identify factors that influence decisions about modifications to benefits. Methods Formative data about the process by which funds make health benefit modifications were collected in 2007–2008 from 25 in-depth key informant interviews with fund trustees and a cross-section of fund advisors, including administrators, attorneys, and healthcare business consultants. Analyses were performed using a general inductive approach to identify conceptual themes, employing qualitative data analysis software. Results The most commonly cited factors influencing trustees' decisions about health plan benefit modifications—including modifications regarding tobacco-cessation benefits—were benefit costs, participants' demand for services, and safeguarding participants' health. Barriers included information gaps, concerns about participants' response, and difficulty projecting benefit utilization and success. Advisors wielded considerable influence in decision-making processes. Conclusions Trustees relied on a small pool of business, legal, and administrative advisors to provide guidance and recommendations about possible health plan benefit modifications. Providing advisors with evidence-based information and resources about benefit design, cost/return-on-investment (ROI), effectiveness, and promotion may be an effective means to influence funds to provide comprehensive tobacco-cessation benefits.

Background There remains an ongoing need to reduce tobacco use in the U.S. Physician organizations, such as medical groups, can support healthcare providers to be more effective in their delivery of tobacco cessation by adopting practices recommended in the Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence (PHS Guideline). Purpose To document the extent to which activities to reduce tobacco use, as recommended in the PHS Guideline as system-level interventions, are provided within large medical groups in the U.S. Methods During 2006–2007, data were collected on 339 medical groups operating in the U.S., with 20 or more physicians treating at least one of four chronic conditions. Organizations were surveyed regarding activities to reduce tobacco use as recommended in the PHS Guideline as system-level interventions (i.e., tobacco-use status documentation, policies to promote provider interventions, and staff dedicated to treating tobacco dependence). Between 2008 and 2009, bivariate associations and multivariate logistic regression models assessed the relationship of organizational characteristics and external incentives with adoption of systems strategies for treating tobacco dependence. Results Nearly 83% of medical groups with 20 or more physicians operating in the U.S. in 2006–2007 have adopted one or more strategies recommended as effective to support the treatment of tobacco dependence. However, only 5.6% of medical groups engage in all eight tobacco control activities examined in this study. The two factors that were associated most consistently with medical group policies to treat tobacco dependence were the patient-centeredness of the organization and participation in a quality demonstration program. Conclusions There is much room for improvement in increasing medical group adoption of systems strategies to reduce tobacco use. The findings in this paper suggest recommendations to achieve these improvements.

Background Smoking-cessation treatment policies could yield substantial increases in adult quit rates in the U.S. Purpose The goals of this paper are to model the effects of individual cessation treatment policies on population quit rates, and to illustrate the potential benefits of combining policies to leverage their synergistic effects. Methods A mathematical model is updated to examine the impact of five cessation treatment policies on quit attempts, treatment use, and treatment effectiveness. Policies include: (1) expand cessation treatment coverage and provider reimbursement; (2) mandate adequate funding for the use and promotion of evidence-based, state-sponsored telephone quitlines; (3) support healthcare system changes to prompt, guide, and incentivize tobacco treatment; (4) support and promote evidence-based treatment via the Internet; and (5) improve individually tailored, stepped-care approaches and the long-term effectiveness of evidence-based treatments. Results The annual baseline population quit rate is 4.3% of all current smokers. Implementing any policy in isolation is projected to increase the quit rate to between 4.5% and 6%. By implementing all five policies in combination, the quit rate is projected to increase to 10.9%, or 2.5 times the baseline rate. Conclusions If fully implemented in a coordinated fashion, cessation treatment policies could reduce smoking prevalence from its current rate of 20.5% to 17.2% within 1 year. By modeling the policy impacts on the components of the population quit rate (quit attempts, treatment use, treatment effectiveness), key indicators are identified that need to be analyzed in attempts to improve the effect of cessation treatment policies.

Tobacco-cessation product packaging and instruction materials may not be appropriate for some smokers and may contribute to the underuse and misuse of evidence-based treatments. The dual goals of this project are to analyze literacy levels of Food and Drug Administration (FDA)-approved and non-approved tobacco-cessation product packaging, directions, and claims, and to identify and categorize claims found on product packaging. The Campaign for Tobacco Free Kids (CTFK) maintains the Quitting and Reducing Tobacco Use Inventory of Products (QuiTIP) database, which catalogs products marketed and sold to consumers to reduce or quit use of tobacco products. It also includes all medications approved by the FDA for tobacco cessation as well as a sample of non-approved products such as homeopathic, herbal, nutritional, or dietary supplements commonly marketed as either cessation aids or alternative tobacco/nicotine products. This paper assesses the reading levels required to understand product packaging, labeling, and instructions using the Simple Measure of Gobbledygook (SMOG) and identifies claims on the product package labels using standard qualitative methods. Key findings show that the average reading levels needed to understand instructions for both FDA-approved and non-approved cessation products are above the reading levels recommended to ensure maximum comprehension. Improving the packaging and directions of evidence-based tobacco-cessation products so that they are preferably at or below a fifth-grade reading level, along with using consumer-based design principles to develop packaging, may help smokers take advantage of and correctly use products that will greatly increase their chances of successful quitting.

Many innovative and effective smoking-cessation treatments, both behavioral and pharmacologic, have been developed over the past several decades. However, these treatments traditionally have been developed for use with populations of healthy smokers. Despite the disease management implications, efforts to design and evaluate cessation interventions targeting smokers diagnosed with chronic diseases are reported infrequently in the literature. The purpose of this paper is to provide a brief overview of the evidence linking continued smoking to disease progression and adverse treatment outcomes across a range of common chronic diseases: cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD), diabetes, asthma, cancer, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Where studies are available, the efficacy of smoking-cessation interventions specifically developed or applied to these patient populations is reviewed. Finally, limitations and gaps in smoking research and treatment with chronically ill patients are discussed, and future research priorities are recommended.

More adults in the United States have quit smoking than remain current smokers. But 45 million adults (20.9%) continue to smoke, with highest rates among low socioeconomic status (SES), blue-collar, and Native American populations. More than two thirds (70%) of adult smokers want to quit, and approximately 40% make a serious quit attempt each year, but only 20%-30% of quitters use an effective behavioral counseling or pharmacologic treatment. The lowest rates of treatment use are seen in the populations with the highest rates of tobacco use. Fully harvesting the last 4 decades of progress in tobacco-control science and policy to increase smokers' demand for and use of cessation treatments represents an extraordinary opportunity to extend lives and reduce healthcare costs and burden in the next 30-40 years. This paper uses the "push-pull capacity" model as a framework for illustrating strategies to achieve this goal. This model recommends: (1) improving and communicating effective treatments for wide population use; (2) building the capacity of healthcare and other systems to deliver effective treatments; and (3) boosting consumer, health plan, and insurer demand for them through policy interventions shown to motivate and support quitting (e.g., clean indoor-air laws, tobacco tax increases, expanded insurance coverage/reimbursement) and efforts to improve treatment access and appeal, especially for smokers who use them least. Innovations recommended by the National Consumer Demand Roundtable for achieving "breakthrough" improvements in cessation treatment demand and use are described.

Objectives This paper investigates the association between implementing a personal space smoking restriction for the home or automobile, and various sociodemographic, social, behavioral, and attitudinal variables. Methods Approximately 1000 African-American adults (aged >18 years) residing in non-institutionalized settings were randomly selected using a cross-sectional stratified cluster sample of ten U.S. congressional districts represented by African Americans. Results A 62.0% and 70.4% ban was found, respectively, on smoking in homes and cars. Multivariate analysis revealed that region, marital status, number of friends who smoked, beliefs about environmental tobacco smoke (ETS), and smoking status predicted home smoking bans, while age, number of children in household, number of friends who smoked, and beliefs about ETS and smoking status predicted car smoking bans. Conclusions Results suggest that a substantial segment of African Americans have accepted and translated public policy concerns about ETS into practice and reveal other variables that could be targeted in future interventions to increase implementation of personal space smoking restrictions.

Background: Information to judge both the internal and external validity of health behavior research conducted in healthcare settings is vital to translate research findings to practice. This paper reviews the extent to which this research has reported on elements of internal and external validity, with emphasis on the extent to which research has been conducted in representative settings with representative populations. Methods: A comprehensive review was conducted of controlled interventions for dietary change, physical activity, or smoking cessation conducted in healthcare settings and published in 12 leading health behavior journals between 1996 and 2000. Using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, the characteristics and results of these studies were summarized to document the extent to which intervention reach, adoption, implementation, and maintenance were reported and what has been learned about each of these dimensions. Results: A total of 36 studies qualified for review. Participation rates among eligible patients were reported in 69% of studies and were generally quite high; in contrast, only 30% of studies reported on participation rates among either healthcare settings or providers. Implementation data were reported in 77% of the studies and these rates were generally high, with the caveat that intervention was often delivered by paid research staff. Long-term maintenance results were reported very consistently at the individual level, but program continuation was almost never reported at the setting level. Conclusions: We conclude that a much stronger emphasis needs to be placed on the representativeness of providers and settings that are studied. Examples of how this can be done and recommendations for future research are provided.

Introduction: The Centers for Disease Control and Prevention’s Guidelines for School Health Programs to Prevent Tobacco Use and Addiction were developed, in part, to help state and local education agencies implement effective school-based tobacco control programs. This paper: (1) reports on school tobacco policies, one facet of a larger investigation conducted to examine the consistency between WV’s school-based tobacco control policies and programs and the CDC Tobacco Guidelines and (2) describes the impact this investigation had on state policy in WV. Methods: A content analysis was conducted on all (n = 55) county tobacco policies using a coding protocol developed by the authors. This protocol was designed to enable judgment about whether the county policies addressed particular elements specified in the CDC Tobacco Guidelines. Additionally, data about school-level policies, collected from a telephone survey of a sample of school principals (n = 421), are presented. Since the purpose of the needs assessment was to describe current practice, frequencies were computed for both the county and school-level analyses. Results: Both county- and school-level tobacco policies were found lacking in many of the elements recommended in CDC’s Tobacco Guidelines, particularly in the areas of enforcement procedures and access to cessation programs. Conclusions: Two major outcomes resulted from this needs assessment: (1) the WV State Board of Education’s Tobacco Control Policy was revised to be more consistent with CDC’s Tobacco Guidelines and (2) increased attention is now being focused on providing cessation options for WV schools.

Since the onset of the Somali civil war in 1991, more than 1 million Somalis have been displaced from Somalia. Minnesota has the largest Somali population in the U.S. Informal tobacco prevalence estimates among Somali populations in the U.S. and the United Kingdom range from 13% to 37%, respectively. Little research has been conducted to determine the extent of Somali tobacco use.This paper reports the results from a knowledge, attitudes, and practices (KAP) survey conducted and analyzed in 2009 that explores tobacco use and estimates prevalence among Somali adults aged ≥ 18 years in Minnesota.Modeled after validated state and national tobacco use surveys, the survey was adapted for Somalis and administered to ethnically Somali adults (N=392) from 25 neighborhood clusters in Minnesota. Participants were chosen through probability proportional to size and multistage random sampling methods.Estimated prevalence for cigarette use among Somalis was 24% (44% among men, 4% among women). Ever users were significantly more likely to be men, have attended college, and have friends who used cigarettes (p0.0001). Belief in Islamic prohibition of tobacco was protective and affected current use and future intention to use tobacco (p0.0001). The majority of Somali smokers were unwilling to use current cessation programs.Estimated cigarette use prevalence was lower than perceived prevalence (37%). Contrary to typical results, greater smoking prevalence was found among Somalis with higher education levels. Positive peer pressure and religion are protective factors from tobacco use and should be integrated into prevention and cessation programs.

Smokefree legislation is a powerful public health intervention. Despite progress in smokefree legislation, over half of U.S. adults remain unprotected by comprehensive smokefree legislation.This paper reviews the scientific literature on health and economic outcome studies of smokefree legislation from the past decade, 2000 to early 2010, using MEDLINE and key search terms: smoking, smoking cessation, smoking/legislation and jurisprudence, smoking cessation/legislation and jurisprudence, and health policy.There is a wealth of research showing the health benefits to entire populations when communities implement comprehensive smokefree laws and/or regulations. These laws improve the health of hospitality workers and the general population by improving indoor air quality, reducing acute myocardial infarctions and asthma exacerbations, and improving infant and birth outcomes. Some studies report reduced smoking prevalence and cigarette consumption and improved cessation outcomes after smokefree legislation. In addition to the health benefits, economic studies confirm that smokefree laws do not adversely affect business revenues or operating costs.While there is an abundance of smokefree policy outcomes research showing both the health and economic impacts of smokefree legislation, these outcomes may have more to do with implementation effectiveness than adoption, especially among subpopulations. An emerging body of literature documents not only that disparities in health protections remain among subpopulations, but that health outcomes of smokefree legislation may vary by gender, race/ethnicity, SES, and age. Further research is needed on implementation effectiveness of smokefree legislation and differential effects on subpopulations.

An estimated one fifth of all U.S. adult smokers receive health benefits through insurance plans administered by Taft-Hartley Health and Welfare Funds. Most funds do not offer comprehensive tobacco-cessation services to fund participants despite evidence that doing so would be cost effective and save lives.This paper examines the decision-making processes of Minnesota-based fund trustees and advisors to identify factors that influence decisions about modifications to benefits.Formative data about the process by which funds make health benefit modifications were collected in 2007-2008 from 25 in-depth key informant interviews with fund trustees and a cross-section of fund advisors, including administrators, attorneys, and healthcare business consultants. Analyses were performed using a general inductive approach to identify conceptual themes, employing qualitative data analysis software.The most commonly cited factors influencing trustees' decisions about health plan benefit modifications-including modifications regarding tobacco-cessation benefits-were benefit costs, participants' demand for services, and safeguarding participants' health. Barriers included information gaps, concerns about participants' response, and difficulty projecting benefit utilization and success. Advisors wielded considerable influence in decision-making processes.Trustees relied on a small pool of business, legal, and administrative advisors to provide guidance and recommendations about possible health plan benefit modifications. Providing advisors with evidence-based information and resources about benefit design, cost/return-on-investment (ROI), effectiveness, and promotion may be an effective means to influence funds to provide comprehensive tobacco-cessation benefits.

The U.S. Public Health Service 1, the WHO 2 and many other organizations have stated that treatment to help smokers stop smoking is one of the most, if not the most, effective clinical interventions to prevent early death. Despite this, many have underestimated the magnitude of this benefit 3. A prior paper quantified this benefit in terms of cost per life year gained from treatment 4; however, a probably more widely used measure of clinical benefit is the number-needed-to-treat (NNT) to avoid an excess (or early) death 5 (www.medicine.ox.ac.uk/bandolier). I am unaware of a prior calculation of the NNT for smoking cessation treatment. To calculate an NNT for treatment of smoking, assume that 100 smokers try to quit. Then assume that 5% of those who do not receive treatment will quit.6 Then assume two scenarios: one in which smokers receive minimal treatment (e.g., brief physician advice or use of over-the-counter medication) and one in which smokers receive optimal therapy (e.g., combined NRT or prescription medication plus intensive counseling). In the minimal treatment approach, the quit rate should increase to about 10% 1;7. In the optimal treatment it should increase to about 20% 8;9. Thus, if 100 smokers were treated, an extra 5 would stop with minimal treatment and an extra 15 with optimal treatment. To determine how many of these 5 or 15 avoided an excess death from smoking, assume that if they continued to smoke, half would have died 10. Then assume half of these smokers stopped before age 30 years and almost all of this risk was avoided, and that half stopped at age 50 years and half of this risk was avoided 11. With these assumptions, minimal treatment would avoid 1.9 excessive deaths and, thus, the NNT for minimal treatment would be 52 smokers (100/1.9). The optimal treatment would avoid 5.7 deaths and the NNT is 18 smokers. If these assumptions were more conservative (e.g., only 3% quit on their own, only 6% quit with minimal treatment, only 12% quit with optimal treatment, and all quit after age 50 years) the NNTs would be 67 for minimal and 22 for optimal treatments. For comparison, daily aspirin treatment for a lifetime has an NNT of 40 to prevent an early death from heart disease (www.medicine.ox.ac.uk/bandolier). As another example, the NNT for ten annual mammograms to prevent an early death ranges from 377 for women aged 60–69 years to 1904 for women aged 39–49 years12. The NNT statistic can be misleading; it does not take into account cost of the intervention in time and money, years of life avoided, quality of life, harm from the intervention, or other such considerations5. However, treatments for smoking cessation are inexpensive compared to most clinical interventions, require little time on the part of the clinician or patient, substantially decrease morbidity as well as mortality 10, and very rarely cause harm. In summary, if the early prevention of death is a major aim of clinicians or organizations, these results suggest that allocation of resources to promote smoking cessation should be a top priority.

Tobacco-cessation product packaging and instruction materials may not be appropriate for some smokers and may contribute to the underuse and misuse of evidence-based treatments. The dual goals of this project are to analyze literacy levels of Food and Drug Administration (FDA)-approved and non-approved tobacco-cessation product packaging, directions, and claims, and to identify and categorize claims found on product packaging. The Campaign for Tobacco Free Kids (CTFK) maintains the Quitting and Reducing Tobacco Use Inventory of Products (QuiTIP) database, which catalogs products marketed and sold to consumers to reduce or quit use of tobacco products. It also includes all medications approved by the FDA for tobacco cessation as well as a sample of non-approved products such as homeopathic, herbal, nutritional, or dietary supplements commonly marketed as either cessation aids or alternative tobacco/nicotine products. This paper assesses the reading levels required to understand product packaging, labeling, and instructions using the Simple Measure of Gobbledygook (SMOG) and identifies claims on the product package labels using standard qualitative methods. Key findings show that the average reading levels needed to understand instructions for both FDA-approved and non-approved cessation products are above the reading levels recommended to ensure maximum comprehension. Improving the packaging and directions of evidence-based tobacco-cessation products so that they are preferably at or below a fifth-grade reading level, along with using consumer-based design principles to develop packaging, may help smokers take advantage of and correctly use products that will greatly increase their chances of successful quitting.