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To read the cigarette manufacturers' Web sites, one would think the industry must be a wholly owned subsidiary of the Public Health Service. The sites warn about the dangers of smoking, say smoking is addictive, list chemicals added in manufacturing cigarettes, encourage smoke-free environments for nonsmokers, and offer smokers Web-based quitting resources.1–3 Industry leader Philip Morris sounds downright altruistic in its enunciated commitment to youth smoking prevention: the company wants “to work with those who share our goal of reducing youth smoking. If collaborative efforts to solve this problem are successful, and this leads to a smaller adult consumer base in the future, we say ‘so be it.’”4 The other major producers—runner-up R. J. Reynolds, bronze medallist Brown & Williamson, and last-place Lorillard—all pledge allegiance to youth smoking prevention as well.1–3,5 This is the face of the “new” tobacco industry, they tell us, committed to public health and to America's children. They have finally come clean, they would have us believe, after half a century of targeting kids and deceiving the public about their products' dangers. Their social commitment extends well beyond the issue of smoking, they inform us. Each company devotes millions of dollars to a variety of causes, including feeding the hungry, aiding victims of natural disasters, and protecting women who are victims of abuse (of the nonsmoking kind). In 2000, industry behemoth Philip Morris, with domestic tobacco revenues of $23 billion, spent $115 million on such worthy endeavors—and then spent an additional $150 million on a national advertising campaign to inform the public about the company's largesse.6 Consistent with the spirit of a liberal society, of course, these companies defend their right to market cigarettes, a legal product, to the tens of millions of adult Americans who “enjoy” smoking.

OBJECTIVES. Improving the health of minority adolescents will require a better understanding of factors that influence their access to and use of health care. This study describes the differences in health care access and use among White, Black and Hispanic adolescents and evaluates how such differences are influenced by insurance. METHODS. We used data on 7465 10- to 17-year-olds included in the child health supplement to the 1988 National Health Interview Survey. RESULTS. Much higher proportions of Blacks (16%) and Hispanics (28%) than of Whites (11%) were uninsured. Despite having worse reported health status, Black and Hispanic adolescents made notably fewer doctor visits in the past year than their White peers, and were more apt to lack usual sources of routine and acute care as well as continuity between sources of care. Having health insurance was associated with greater increase in access and usage measures for minority youth than for White youth. However, racial differences persisted even after adjusting for health insurance, family income, need, and other factors. CONCLUSIONS. Minority adolescents are particularly vulnerable to the problems of health care access that affect all youth. While health insurance is especially important for increasing appropriate health care use among minority youth, nonfinancial methods of enabling more equitable use also deserve further study.

“Cigarettes and the US Public Health Service in the 1950s”1 in the Journal's February issue is not only interesting history. It is also a useful reminder of how outside forces and strongly held individual beliefs can influence what we would like to believe are purely scientific considerations in the promotion of health and the prevention of disease. But I think Dr Parascandola is too dismissive of the importance of the Surgeon General's Report Smoking and Health2 when he notes that the report did not meet some new “evidentiary threshold.” Although it is true that there was little new data, the manner in which the evidence was marshaled, in particular the presentation and elucidation of the 5 criteria for judging the causal significance of an association—that is, the consistency, strength, specificity, temporal relationship, and coherence of the association—made it possible to overcome the resistance of those who insisted—out of honorable or venal motives—that the absence of a blinded prospective trial precluded a judgment of causation. Despite advances in statistical analysis, the 5 criteria continue to serve as a useful basis for epidemiologic studies where an experimental approach is neither feasible nor ethical. Smoking and Health remains excellent reading for introductory courses in epidemiology.

The health status of long-term survivors of out-of-hospital cardiac arrest was studied six months after the event. Although Sickness Impact Profile scores for arrest survivors were higher (worse) than scores of enrollees in a prepaid closed panel health plan, in most cases problems of survivors were not incapacitating. Approximately three-fifths of survivors reported same or better memory function and stair climbing ability compared to that at time of arrest. Three-fifths of those who had been working continued to do so.

We interviewed 308 survivors of out-of-hospital cardiac arrest and matched controls who had suffered a myocardial infarction. The Sickness Impact Profile (SIP) scores of controls were somewhat lower (better) than those of cases, but responses of cases and controls to additional questions about stair climbing, irritability and mood were virtually identical. Half as many (18 per cent) controls as cases (38 per cent) reported poorer memory function; nevertheless, 63 per cent of cases and 79 per cent of controls who had been working outside the home at the time of the event were employed at the time of the interview.

We initiated a program of telephone CPR (cardiopulmonary resuscitation) instruction provided by emergency dispatchers to increase the percentage of bystander-initiated CPR for out-of-hospital cardiac arrest. Cardiac arrests in King County, Washington were studied for 20 months before and after the telephone CPR program began. Bystander-initiated CPR increased from 86 of 191 (45 per cent) cardiac arrests before the program to 143 of 255 (56 per cent) cardiac arrests after the program. During the after period, 58 patients received CPR as a result of telephone instruction, 12 of whom were discharged. We estimate that four lives may have been saved by the program. A review of hospital records revealed no excess morbidity in the group of patients receiving dispatcher-assisted CPR.

Dr. Betty Gilson is Associate Professor and Associate Dean, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, Washington 98195. Dr. John Gilson is Director of Medical Education, Group Health Cooperative of Puget Sound, Seattle, Washington. Dr. Bergner is Assistant Professor, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, Washington. Dr. Bobbitt is Research Professor, Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, Washington. Ms. Kressel is Senior Administrative Analyst, Health Policy Program, San Francisco, California. Dr. Pollard is a postdoctoral fellow, Department of Psychology, Northwestern University, Evanston, Illinois. Dr. Vesselago's address is: 2012 Tenth Avenue East, Seattle, Washington. This investigation was supported by the HMO Service of the Health Services and Mental Health Administration, Contract HSM 110-72-420. This paper was presented, in abbreviated form, at the American Public Health Association Annual Meeting, San Francisco, 1974. It was accepted for publication July 21, 1975. costly services. The proliferation of innovative organizational patterns for providing health services makes it necessary to obtain data demonstrating the relative benefits of available alternatives. Evaluators use three types of measures to assess health care services: measures of structure, measures of process, and measures of outcome. 1 2 Measures of structure or process assess factors that are presumably directly related to outcome. Measures of outcome are designed to assess the effects of the health care services on the population served. Often, structure or process measures are used because no adequate or efficient measure of outcome is available. While it has been assumed that these three types of evaluation measures are highly related and that structure and process measures can serve as proxies for outcome measures, the substitution will be legitimate only when the relationship between structure or process and outcome has been established. For example, one can assess the outcome of a program such as polio immunization by examining the number of immunizations administered (a process measure), since it has been demonstrated that such immunization leads to less polio (an outcome measure). On the other hand, since it is not known whether the number of clinician visits decreases illness, measuring numbers of visits does not provide knowledge of outcome.

As part of an evaluation of whether the addition of paramedic services can reduce mortality from out-of-hospital cardiac arrest compared to previously existing emergency medical technician (EMT) services, factors associated with successful resuscitation were studied. A surveillance system was established to identify cardiac arrest patients receiving emergency care and to collect pertinent information associated with the resuscitation. Outcomes (death, admission, and discharge) were compared in two areas with different types of prehospital emergency care (basic emergency medical technician services vs. paramedic services). During the period April 1976 through August 1977, 604 patients with out-of-hospital cardiac arrest received emergency resuscitation. Eighty-one per cent of these episodes were attributed to primary heart disease. Considered separately, four factors were found to have a significant association with higher admission and discharge rates :1) paramedic service, 2) rapid time to initiation of cardiopulmonary resuscitation (CPR), 3) rapid time to definitive care, and 4) bystander-initiated CPR. Using multivariate analysis, rapid time to initiation of CPA and rapid time to definitive care were most predictive of admission and discharge. Age was also weakly predictive of discharge. These findings suggest that if reduction in mortality is to be maximized, cardiac arrest patients must have CPR initiated within four minutes and definitive care provided within ten minutes.

Out-of-hospital cardiac arrest was studied in suburban King County, Washington in an attempt to determine the impact of paramedic services on community cardiac mortality. A portion of the study area received paramedic services and the remainder received basic emergency medical technician (EMT) services. A surveillance system identified all prehospital cardiac arrest incidents. The etiology and outcome were determined. Deaths due to primary heart disease (ICDA) codes 410-414) were compared to community cardiac mortality figures for the same period of time and in the paramedic and EMT areas. Between April 1, 1976 and August 31, 1977, 1,449 deaths due to primary heart disease occurred (annual rate of 19.2/10,000 in the EMT area and 13.4/10,000 in the paramedic area). For the same period, 487 patients with out-of-hospital cardiac arrest received emergency resuscitation. The annual incidence of out-of-hospital cardiac arrest was similar in the EMT and paramedic areas (5.6 and 6.0/10,000 respectively). Proportionately more lives of persons with cardiac arrest were saved in the paramedic area than in the MET area. During this 17 month period, the reduction in community cardiac mortality was 8.4 per cent in the paramedic area and 1.3 per cent in the EMT area. These findings suggest that paramedic services have a small but measurable effect on community cardiac mortality.

The extent to which the values attached to health states are similar in different cultures or social groups is important for understanding health and illness behaviors and for developing standardized health status measures. A cross-cultural study was conducted to compare the health status values obtained in a United States population (Seattle, Washington) with those from another English-speaking culture (London, England) on the Sickness Impact Profile, a standardized measure composed of 136 items. London judges rated the severity of dysfunction described in each item on an equal interval scale using the same methods of scaling and analysis employed in the Seattle study. A regression of English mean item values on US mean values yielded a slope of 1.00 and an intercept of -0.07, indicating that judges gave strikingly similar ratings to most items. Agreement was higher at the more severe end of the dysfunction continuum than at the least severe end, a finding consistent with the notion that what constitutes health is more difficult to define than what constitutes illness. While a universal conception of dysfunction may exist in English-speaking societies, the social and cultural determinants of health status values deserve more systematic study.

One hundred and twenty-six dental offices in Washington State kept a record of each time an expanded function was performed by the dentist, hygienist, or assistant. There were five two-week recording periods starting in February 1979 and ending in February 1981. Consistent with increasing productivity, dentists most frequently delegate tasks to dental assistants rather than dental hygienists and delegate an individual task consistently if it is delegated at all. For tasks that may be delegated to the assistant, a relationship was found between the per cent of dentists delegating an individual task and the amount of the dentist's time that is freed through delegating that task. From the perspective of quality of care, the per cent of dentists who delegate a task was inversely related to the complexity of the task.