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The high costs of cigarette smoking to society should be reduced by stricter tobacco industry controls, more anti-smoking legislation, higher cigarette taxes and more intense public education. Smoking is costly to society because of medical expenses incurred by smokers, loss of work days and labor productivity, and fire damage and injuries related to careless smoking. The tobacco industry should be restricted from advertisements aimed at children, sports sponsorship and exportation of cigarettes. The Dept of Agriculture should not subsidize the tobacco industry but rather provide incentives to convert to other profitable and needed crops. Making cigarettes more expensive through higher taxes should reduce consumption, especially among teenagers. Laws restricting the sale of tobacco to minors should be toughened and enforced. Also, more cities and states should restrict smoking in public places.

Cigarette smoking is the major cause of preventable illness and early death in the US. About 46.3 million adults (26% of the population) are smokers. About 6 million teenagers and 100,000 children under the age of 13 smoke. By 1991, 31% of Native Americans and Alaskan natives, 29% of blacks and 20% of Hispanics smoked. In 1990, smoking-related illnesses were implicated in almost one out of five deaths in the US. Cigarette smoking increases the risk of cardiovascular diseases, including stroke, sudden death and heart attack. Increased total blood cholesterol levels and reduced high density lipoprotein cholesterol levels have also been associated with smoking. Smoking is responsible for more than 85% of lung cancers and is associated with cancers of the mouth, pharynx, larynx, esophagus, stomach, pancreas, cervix, kidney, ureter and bladder. Smoking caused 84,475 deaths from lung disease such as pneumonia, influenza, bronchitis and emphysema in 1990.

Abstract Background Most studies of diabetes self-management that show improved clinical outcome performance involve multiple, time-intensive educational sessions in a group format. Most provider performance feedback interventions do not improve intermediate outcomes, yet lack targeted, patient-level feedback. Methods 5,457 low-income adults with diabetes at eight federally-qualified community health centers participated in this nested randomized trial. Half of the patients received report card mailings quarterly; patients at 4 of 8 clinics received report cards at every clinic visit; and providers at 4 of 8 clinics received quarterly performance feedback with targeted patient-level data. Expert-recommended glycemic, lipid, and blood pressure outcomes were assessed. Assessment of report card utility and patient and provider satisfaction was conducted through mailed patient surveys and mid- and post-intervention provider interviews. Results Many providers and the majority of patients perceived the patient report card as being an effective tool. However, patient report card mailings did not improve process outcomes, nor did point-of-care distribution improve intermediate outcomes. Clinics with patient-level provider performance feedback achieved a greater absolute increase in the percentage of patients at target for glycemic control compared to control clinics (6.4% vs 3.8% respectively, Generalized estimating equations Standard Error 0.014, p < 0.001, CI -0.131 - -0.077). Provider reaction to performance feedback was mixed, with some citing frustration with the lack of both time and ancillary resources. Conclusions Patient performance report cards were generally well received by patients and providers, but were not associated with improved outcomes. Targeted, patient-level feedback to providers improved glycemic performance. Provider frustration highlights the need to supplement provider outreach efforts. Trial Registration ClinicalTrials.gov: NCT00827710

Background: There is a need for randomized, prospective trials of case management interventions with resource utilization analyses., Objectives: To determine whether algorithm-driven telephone care by nurses improves lipid control in patients with diabetes., Design: Prospective, randomized, controlled trial., Participants: Adults with diabetes at a federally funded community health center were randomly assigned to intervention (n = 381) or usual-care (n = 381) groups., Interventions: Nurses independently initiated and titrated lipid therapy and promoted behavioral change through motivational interviewing and self-management techniques. Other parameters of diabetes care were addressed based on time constraints., Main Measures: The primary outcome was the proportion of patients with a low-density lipoprotein (LDL) less than 100 mg/dL. Secondary outcomes included the number of hospital admissions, total hospital charges per patient, and the proportion of patients meeting other lipid, glycemic, and blood pressure guidelines., Key Results: The percent of patients with an LDL < 100 mg/dL increased from 52.0% to 58.5% in the intervention group and decreased from 55.6% to 46.7% in the control group (P < .01). Average cost per patient to the healthcare system was less for the intervention group ($6600 vs $9033, P = .03). Intervention patients trended toward fewer hospital admissions (P = .06). The intervention did not affect glycemic and blood pressure outcomes., Conclusions: Nurses can improve lipid control in patients with diabetes in a primarily indigent population through telephone care using moderately complex algorithms, but a more targeted approach is warranted. Telephone-based outreach may decrease resource utilization, but more study is needed.

Objectives: To assess the feasibility of engaging adults with diabetes in self management behaviors between clinic visits by using cell phone text messaging to provide blood sugar measurement prompts and appointment reminders., Study Design: Quasi-experimental pilot among adult diabetic patients with cell phones who receive regular care at a federally qualified community health center in Denver, Colorado, which serves a population that is predominantly either uninsured (41%) or on Medicaid or Medicare (56%)., Methods: Patients (N = 47) received text message prompts over a 3-month period. Blood sugar readings were requested 3 times per week (Monday, Wednesday, and Friday). Reminders were sent 7, 3, and 1 day(s) before each scheduled appointment. Acknowledgments were returned for all patient-sent messages. Focus groups were conducted in English and Spanish with selected patients (n = 8)., Results: Patients of all ages were active participants. Correctly formatted responses were received for 67.3% of 1585 prompts. More than three-fourths (79%) of the cohort responded to more than 50% of their prompts. The appointment analysis was underpowered to detect significant changes in attendance. Participants reported increased social support, feelings that the program "made them accountable," and increased awareness of health information. Two-thirds (66%) of patients provided glucose readings when prompted during the study, compared with 12% at 2 preceding clinic visits., Conclusions: For certain patients, cell phone-based text messaging may enhance chronic disease management support and patient-provider communications beyond the clinic setting.

Introduction: Little has been published on the impact of telephone visits on diabetes outcome performance., Research Design and Methods: An attending and resident physician prioritized telephone visits based on glycemic, blood pressure, and lipid performance. The resident and attending panel was compared with all other diabetic patients at the clinic for baseline and end-intervention performance., Results: The intervention patients had an absolute percentage of increase versus control patients of 14.9 (p<0.01), 13.9 (p<0.01), and 8.3 (p=0.01) for HbA1c <9%, low-density lipoprotein <100 mg/dL, and blood pressure <130/80 mm Hg, respectively., Conclusions: This pilot study suggests that provider-driven telephone visits may be a means for healthcare systems to improve chronic disease outcomes as they transition to new paradigms of chronic care delivery., Limitations: This study was neither randomized nor blinded, was susceptible to an interventionist effect, and did not analyze for differences in baseline medication use.