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

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Presentation on theme: "Tobacco Prevention and Control Evidence-based Recommendations from the Guide to Community Preventive Services."— Presentation transcript:

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

3 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

4 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

5 Why Evidence Reviews? Decision-making Advocacy Defense Program buiding Options

6 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

7 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

8 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

9 Tobacco Control Policies: Settings Goal Increase Cessation Reduce Initiation Reduce ETS Community Health Care System Yes (No) (Yes)

10 Issues to Consider in Reviews Intervention Intended Outcomes Reduced Morbidity and/or Mortality Additional Outcomes Benefits Harms Barriers

11 Recommendations from the Community Guide Task Force Interventions to Reduce Tobacco Use and ETS Exposure in Communities and Health Care Systems

12 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

13 In Communities GoalInterventions 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

14 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)

15 In Health Care Systems GoalInterventions with Insufficient Evidence Increase Cessation Reduce Initiation Reduce ETS Provider education programs (alone) Provider feedback systems (Provider counseling to reduce home ETS exposure)

16 Reviews in Progress Goals Interventions under Evaluation Increase Cessation Reduce Initiation Reduce ETS Youth access interventions School-based interventions

17 Interventions to Reduce Exposure to Environmental Tobacco Smoke Smoking Bans and Restrictions

18 Analytic Framework: Smoking Bans Reduced Morbidity and Mortality Smoking Bans

19 Smoking Bans Might Result from Community Education Efforts Reduced Morbidity and Mortality Smoking Bans Community Education Pre-emption

20 Bans Might Reduce ETS Exposure Reduced Morbidity and Mortality Smoking Bans Reduced Exposure to ETS

21 Bans Might Increase Smoking Cessation Reduced Morbidity and Mortality Smoking Bans Reduced Exposure to ETS Fewer Tobacco Users Change In Attitudes Reduced Consumption Increased Quit Attempts Increased Cessation

22 Bans Might Reduce Smoking Initiation Reduced Morbidity and Mortality Smoking Bans Reduced Exposure to ETS Change In Attitudes Reduced Initiation Fewer Tobacco Users Change In Attitudes Reduced Consumption Increased Quit Attempts Increased Cessation

23 Bans Might Increase ETS in the Home Reduced Morbidity and Mortality Smoking Bans Reduced Exposure to ETS Change In Attitudes Reduced Initiation Fewer Tobacco Users Change In Attitudes Reduced Consumption Increased Quit Attempts Increased Cessation Diverted Consumption Increased Home Exposure

24 Body of Evidence: Bans and Restrictions 56 studies reviewed ETS exposure: 10 of 17 studies qualified Tobacco use:9 of 51 studies qualified

25 Study Measurements by Outcome Reduced Morbidity and Mortality Smoking Bans Reduced Exposure to ETS Change In Attitudes Reduced Initiation Fewer Tobacco Users Change In Attitudes Reduced Consumption Increased Quit Attempts Increased Cessation Diverted Consumption Increased Home Exposure 12 6 4591 0* 6

26 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)

27 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%)

28 Additional Information Applicability –Public and private workplaces Additional Benefits –Reduced consumption Potential Harms –Refuted: Loss of revenue Barriers –Pre-emption

29 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

30 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

31 Interventions to Increase Tobacco Use Cessation Provider Reminder Systems when coordinated with additional interventions

32 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

33 Analytic Framework Provider Knowledge Patient Smoking Status Advice to Quit Attempts to Quit Quit Decreased Morbidity/ Mortality Provider Reminder

34 Reported Outcomes (n=39 measurements from 20 studies) Provider Knowledge Patient Smoking Status Advice to Quit Attempts to Quit Quit Decreased Morbidity/ Mortality Provider Reminders 0315714

35 Understanding Study Outcomes Differences 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

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37 Provider Knowledge Patient Smoking Status Advice to Quit Attempts to Quit Quit Decreased Morbidity/ Mortality Provider Reminders + 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)

38 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)

39 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

40 Interventions to Reduce Tobacco Use Initiation Interventions to Restrict Minors Access to Tobacco Products

41 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

42 Youth Access Interv. Reduced Youth Tobacco Use Analytic Framework-Outcome

43 Youth Access Interv. Retailer Knowledge Retailer Perceptions Retailer Behaviors (Sales) Youth Tobacco Use Interventions Might Affect Retailers

44 Youth Access Interv. Retailer Knowledge Retailer Perceptions Retailer Behaviors (Sales) Youth Tobacco Use Interventions Might Affect Youth Youth Knowledge Youth Perceptions Youth Tobacco Purchases

45 Youth Access Interv. Retailer Knowledge Retailer Perceptions Retailer Behaviors (Sales) Youth Tobacco Use Interventions Might Affect the Community Youth Knowledge Youth Perceptions Youth Tobacco Purchases Community Norms Enforcement

46 Youth Access Interv. Retailer Knowledge Retailer Perceptions Retailer Behaviors (Sales) Youth Tobacco Use Youth Have Other Sources Youth Knowledge Youth Perceptions Youth Tobacco Purchases Community Norms Enforcement Other Sources Of Tobacco

47 Youth Access Interv. Retailer Knowledge Retailer Perceptions Retailer Behaviors (Sales) Youth Tobacco Use The Key Outcomes Youth Knowledge Youth Perceptions Youth Tobacco Purchases Community Norms Enforcement Other Sources Of Tobacco

48 Youth Access Interv. Retailer Knowledge Retailer Perceptions Retailer Behaviors (Sales) Youth Tobacco Use Youth Knowledge Youth Perceptions Youth Tobacco Purchases Community Norms Enforcement Other Sources Of Tobacco 5 13 32 01 0 1 10 26 Measurements from 13 Studies

49 Five Studies Measured Changes in Youth Tobacco Use Study Com. Mobiliz. Ret. Edu LawActive Enfrcmt Other Altman 1999 Yes Biglan 2000 Yes S Edu Forster 1998 Yes Jason 1996 Yes Rigotti 1997 Yes

50 Changes in Self-Reported Tobacco Use: Multicomponent Interventions (n=5) Median = - 5 pct points Range: -11 pct points, +2 pct points Study Altman 1999 Biglan 2000 Forster 1998 Jason 1996a Rigotti 1997

51 Task Force Conclusion Number of Studies Consistent Effect? Sufficient Effect Size? Strength of Evidence 4Yes 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)

52 There is No Evidence that Single Interventions are Effective Sales laws directed at retailers Insufficient Evidence PPU laws directed at youth Insufficient Evidence Active enforcement of sales laws Insufficient Evidence Retailer Education Insufficient Evidence Community education Insufficient Evidence

53 Pitfalls Preemption Enforcement responsibility Knowingly / Intentionally Clerk vs owner Criminal penalties (judicial nullification)

54 Pitfalls Youth purchase, possession, or use laws –Normative diversion Penalize kids, not retailers –Resource diversion –Compliance checks barrier

55 School-Based Interventions

56 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

57 Organized Student Advocacy Community Events or Efforts Mass Media Exposure Change in Community Attitudes Change in Community Policies Reduced Tobacco Use Initiation Fewer Tobacco Product Users Reduced Morbidity & Mortality School Events Change in Student Attitudes* Reduced/ Delayed Initiation Of Tobacco Use Increased Tobacco Use Cessation Fewer Student Tobacco Users Change in School Policies Student Participation Change in Participant Attitudes* Reduced Participant Tobacco Use Fewer Participant Tobacco Users Analytic Framework: Student-delivered Community Education *Includes changes in knowledge and skill development or enhancement

58 Content of Recent Evidence Reviews Tobacco User Provider Health Care System Community Community GuideClinical Guide PHS: Clinical Practice Guidelines CDC Best Practices SGR: Reducing Tobacco Use NCI: Population Based Smoking Cessation

59 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


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