Quitting cigarettes completely or switching to smokeless tobacco: do US data replicate the Swedish results?

BACKGROUND: Swedish male smokers are more likely than female smokers to switch to smokeless tobacco (snus) and males' smoking cessation rate is higher than that of females. These results have fuelled international debate over promoting smokeless tobacco for harm reduction. This study examines whether similar results emerge in the United States, one of few other western countries where smokeless tobacco has long been widely available. METHODS: US DATA SOURCE: national sample in Tobacco Use Supplement to Current Population Survey, 2002, with 1-year follow-up in 2003. Analyses included adult self-respondents in this longitudinal sample (n = 15,056). Population-weighted rates of quitting smoking and switching to smokeless tobacco were computed for the 1-year period. RESULTS: Among US men, few current smokers switched to smokeless tobacco (0.3% in 12 months). Few former smokers turned to smokeless tobacco (1.7%). Switching between cigarettes and smokeless tobacco, infrequent among current tobacco users (<4%), was more often from smokeless to smoking. Men quit smokeless tobacco at three times the rate of quitting cigarettes (38.8% vs 11.6%, p<0.001). Overall, US men have no advantage over women in quitting smoking (11.7% vs 12.4%, p = 0.65), even though men are far likelier to use smokeless tobacco. CONCLUSION: The Swedish results are not replicated in the United States. Both male and female US smokers appear to have higher quit rates for smoking than have their Swedish counterparts, despite greater use of smokeless tobacco in Sweden. Promoting smokeless tobacco for harm reduction in countries with ongoing tobacco control programmes may not result in any positive population effect on smoking cessation.

State-specific trends in smoke-free workplace policy coverage: the current population survey tobacco use supplement, 1993 to 1999.

We examined trends in smoke-free workplace policies among all indoor workers in the United States using the National Cancer Institute's Tobacco Use Supplement to the Census Bureau's Current Population Survey (total n = 270,063). Smoke-free was defined as smoking not permitted in public or common areas or in work areas of a worksite. Nationally, we found that nearly 70% of the US workforce worked under a smoke-free policy in 1999. At the state level, a greater than 30-percentage-point differential existed in the proportion of workers with such policies. Although significant progress has been made to reduce worker exposure to environmental tobacco smoke on the job, we predict further progress may be difficult unless comprehensive regulations to protect all workers are implemented at the national, state, or local level.

Sex differences in workplace smoking policies: results from the current population survey.

OBJECTIVE: To determine the prevalence of smoking policies in indoor work environments in the United States, with a special focus on sex differences in the provision of these policies. METHOD: Information on the prevalence and restrictiveness of workplace smoking policies was obtained from 86,490 currently employed indoor workers (50,865 women and 35,625 men) 15 years of age and older who responded to the National Cancer Institute's Tobacco Use Supplement to the Current Population Survey, a cross-sectional survey of households in all 50 states and the District of Columbia conducted between 1995 and 1996. RESULTS: Eighty-six percent of respondents reported that their workplaces had official smoking policies, and 63% reported that their workplaces were smoke free. Women reported significantly higher rates of both official smoking policies and smoke-free workplaces than men, regardless of racial/ethnic or age group. CONCLUSION: The overall rates of worksite smoking restrictions, including the establishment of smoke-free workplaces, were higher than those reported in earlier surveys. Disparities in coverage will need to be reduced if all workers, regardless of sex, race, age, or industry of employment, are to be protected from the demonstrated hazards of environmental tobacco smoke.

Index for US state tobacco control initial outcomes.

Public health tobacco control efforts have increasingly targeted communities in addition to individuals. Before population smoking decreases, effectiveness might be detected from initial outcomes reflecting these efforts, such as higher cigarette prices or more workplace and home smoking restrictions. Presumably, these initial outcomes will eventually influence smoking behavior. State-specific estimates of percentages of the population working or living under smoking bans are available from the 1992-1993 tobacco use supplement to the Current Population Survey, conducted annually by the US Bureau of the Census. In addition, the tobacco industry reports the average state cigarette price yearly. The authors constructed a tobacco control initial outcomes index (IOI) by using values of these variables for each state and correlated it with state-specific adult (aged > or =25 years) and youth (aged 15-24 years) smoking prevalence computed from the Current Population Survey and per capita cigarette consumption data computed from sales and Census Bureau data. Both adult smoking prevalence (r = -0.70) and per capita consumption (r = -0.73) were significantly correlated with the IOI; youth smoking prevalence correlated less well (r = -0.34). Although the analysis is not definitive, deseasonalized 1983-1997 consumption trends for IOI-based tertile groups were divergent beginning in 1993, with the high IOI group showing the greatest decrease. A high relative IOI index may be predictive of future smoking decreases and should be considered when tobacco control efforts are evaluated.

Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy.

A possible association between interruptions and distractions and the occurrence of dispensing errors was investigated. Fourteen pharmacists and 10 technicians in an ambulatory care pharmacy at a general medical-surgical hospital were tested for distractibility by using the group embedded figures test (GEFT) as well as for visual acuity and hearing. They were videotaped as they filled prescriptions during a 23-day period in 1992. A study investigator compared each filled prescription with the physician's written order, noted details of deviations, verified with the pharmacist any errors that occurred, and asked the pharmacist to correct the error if necessary. Interruptions and distractions were detected and characterized by reviewing the videotapes. None of the study participants had significant hearing or visual impairment. There was a significant association between GEFT scores and error rates. A total of 5072 prescriptions were analyzed, and 164 errors were detected, for an overall error rate of 3.23%. Wrong label information was the most common type of error (80% of errors detected). A total of 2022 interruptions (mean +/- S.D. per half hour per subject, 2.99 +/- 2.70) and 2457 distractions (mean +/- S.D. per half hour per subject, 3.80 +/-3.17) were detected. The error rate for sets of prescriptions with one or more interruptions was 6.65% and for sets during which there were one or more distractions, 6.55%. Interruptions and distractions per half hour were both significantly associated with errors. In an ambulatory care pharmacy, interruptions and distractions over a half-hour period were associated with dispensing errors, a majority of which involved incorrect label information.

Empiric investigation on direct costs-of-illness and healthcare utilization of Medicaid patients with diabetes mellitus.

OBJECTIVE: To determine total direct costs-of-illness and to study the influence of different factors affecting these costs. In addition, we examined each type of service (e.g., hospitalization, outpatient care, prescription drugs, physician encounters, and laboratory tests) for diabetic Medicaid patients to provide evidence about the relationship between diabetic patients' healthcare utilization and their related predictors. PATIENTS AND METHODS: A total of 7931 patients with diabetes who were 65 years or younger in the Alabama Medicaid program from 1992 to 1995 were studied. Using a relational database created from Medicaid claims, multiple regression and canonical correlation methods were used to analyze the patients' direct costs-of-illness, including the costs associated with each healthcare service used by each patient. RESULTS: The costs of hospitalization, outpatient care, prescription drugs, and physician encounters were the four largest components of the direct costs-of-illness for diabetic Medicaid patients, comprising 29.9%, 21.3%, 28.2%, and 14.3%, respectively. After controlling for other factors in an empiric model, the direct costs-of-illness for a patient with insulin-dependent diabetes mellitus was $5160 higher than for a patient with noninsulin-dependent diabetes mellitus during the 3-year study. The cost for a patient with renal dysfunction was $59,920 higher than for other diabetic patients. Each increase in the number of different prescribing physicians per patient was associated with a cost increase of $450. Each additional comorbidity increased the cost by $735 per patient. The cost for a male patient was $2140 higher than that for a female patient, and the cost for a white patient was $1330 higher than that for a non-white patient. For a patient who relied on diet to control diabetes, there were $2750 less in costs compared with other patients during the study period. More than 20% of the variability in patients' healthcare utilization costs was explained by the set of predictive factors. CONCLUSIONS: The direct costs-of-illness and healthcare utilization for Medicaid diabetic patients were significantly accounted for by the number of comorbidities, the number of different physicians visited, insulin-dependent diabetes mellitus, and complications (especially renal dysfunction). Patients who relied on dietary therapy and exercise to control their diabetes had lower healthcare costs and utilization than other patients. A significant amount of healthcare costs and utilization might be controlled or reduced if diabetes disease management can successfully be aimed at preventing diabetic complications, controlling comorbidities, and minimizing the number of different physicians visited.

Workplace smoking policies in the United States: results from a national survey of more than 100,000 workers.

OBJECTIVE: To determine the prevalence of smoking policies in indoor work environments as reported by a nationally representative sample of workers in the United States. DESIGN: Cross-sectional survey of households within the United States. SETTING: All 50 state and the District of Columbia, 1992-93. PARTICIPANTS: Currently employed indoor workers 15 years of age and older who responded to the National Cancer Institute's Tobacco Use Supplement to the Current Population Survey (n = 100,561). MAIN OUTCOME MEASURES: The prevalence and restrictiveness of workplace smoking policies as reported by workers currently employed in indoor workplaces in the United States. RESULTS: Most of the indoor workers surveyed (81.6%) reported that their place of work had an official policy that addressed smoking in the workplace; 46.0% reported that their workplace policy did not permit smoking in either the public/common areas--for example, restrooms and cafeterias--or the work areas of the workplace. The reporting of these "smoke-free" policies varied significantly by gender, age, race/ethnicity, smoking status, and occupation of the worker. CONCLUSIONS: Although nearly half of all indoor workers in this survey reported that they had a smoke-free policy in their workplace, significant numbers of workers, especially those in blue-collar and service occupations, reported smoke-free rates well below the national average. If implemented, the US Occupational Safety and Health Administration's proposed regulation to require worksites to be smoke-free has the potential to increase significantly the percentage of American workers covered by these policies and to eliminate most of the disparity currently found across occupational groups.

Relationships between ambient sounds and the accuracy of pharmacists' prescription-filling performance.

Associations between ambient sounds and accuracy of pharmacists' prescription-filling performance in a pharmacy was studied. Pharmacists were videotaped as they filled prescriptions each workday for 23 days. Each filled prescription was inspected by the investigator. Deviations from the physician's written order were considered errors. Videotape analysis was used to detect unpredictable, predictable, uncontrollable, and controllable sounds. A within-subjects case control study design was employed to determine whether the frequency of ambient sounds was significantly different when prescriptions with errors, compared with those without errors, were filled. Loudness, in terms of equivalent sound levels (Leq) for each half hour, was analyzed for a relationship to dispensing error rate. A mean dispensing error rate of 3.23% was found. Unpredictable sounds, controllable sounds, and noise had a significant effect on pharmacists which resulted in a decreased dispensing error rate. These results suggest that the quality of pharmacists' performance is not adversely affected by ambient sound. As equivalent sound levels increased, the error rate increased to a point, then decreased.

Cigarette smoking among U.S. adults by state and region: estimates from the current population survey.

BACKGROUND: Cigarette smoking is responsible for at least one third of all cancer deaths annually in the United States. Few sources exist in the peer-reviewed literature documenting state and regional differences in smoking behavior, despite the fact that cancer prevention and control efforts are increasingly being implemented below the national level. PURPOSE: Our goals were to determine smoking prevalence rates among men and women, by region, and for each of the 50 states and the District of Columbia from census survey data collected in 1992 and 1993 and to compare these rates with rates determined in 1985. METHODS: Every month, the U.S. Bureau of the Census collects labor force statistics on more than 100000 individuals on its Current Population Survey (CPS). For the September 1992, January 1993, and May 1993 CPS, the National Cancer Institute sponsored a 40-item Tobacco Use Supplement. The definition of a current smoker changed slightly between 1985 and 1992-1993. For the 1985 CPS, individuals were considered current smokers if they had smoked 100 cigarettes in their lifetime and were smoking at the time of interview; for the 1992-1993 CPS, current smokers included anyone who had smoked 100 cigarettes and was currently smoking every day or just on some days. We calculated current smoking rates (every day and some days combined) based on more than a quarter million adults (n = 266988) interviewed in 1992-1993. RESULTS: Substantial geographic variation exists in rates of current cigarette use among adults within the United States. In general, adults in the southern United States have higher rates of smoking and adults in the western states have lower rates of smoking and adults in the rest of the country, although differences in smoking behavior between men and women and among various racial and ethnic populations strongly influence these patterns. Only two states, Kentucky and West Virginia, exhibited adult smoking rates (men and women combined) of 30% or higher in 1992-1993; in contrast, in 1985, such rates were reported from 20 states. The only states in which the prevalence was below 20% in 1992-1993 were Utah (17.1%) and California (19.5%). Rates approaching 20% were reported from New Jersey (20.7%), Massachusetts (21.5%), and Nebraska, New York, and Hawaii (22.0% each) in 1992-1993. Rhode Island experienced the greatest relative decline in smoking prevalence from 1985 to 1992-1993, with a calculated relative change of -30.7% (based on a change in rate from 33.5% to 23.2%), followed by Delaware (-25.9%) the District of Columbia and New Jersey (-23.9% each), Connecticut (-23.2%), California (-22.9%), Alaska (-22.8%), Georgia (-22.6%), Massachusetts (-22.1%), and New York (-22.0%). CONCLUSIONS: Smoking rates are not uniform in the United States but vary considerably from state to state, even within the same region of the country. The CPS is the only mechanism currently capable of simultaneously monitoring smoking trends nationally, regionally, and on a state-by-state basis.

Retrospective drug utilization review and the behavior of Medicaid prescribers: an empirical marginal analysis.

The objectives of this study were to evaluate the effectiveness of drug utilization review (DUR) letter intervention on reducing the cost of medications under Medicaid. The target drugs in this study were six antiulcer agents prescribed for Alabama Medicaid recipients. The study group consisted of 100 prescribers who received DUR intervention. A total of 3776 prescribers who did not receive DUR intervention served as the comparison group. Using an interrupted time series design, these 3876 prescribers were studied before and after the implementation of the DUR program. The study found that prescribers' behavior changed after the DUR letter were sent out, resulting in a reduction in the average marginal days of drug therapy and drug reimbursement per recipient. For the target drugs, there was an average savings of $112.73 per prescriber per month and a total of $136,370.82 savings per month for the Alabama Medicaid program.

Gender and culture: reported problems, coping strategies and selected helpers of male and female adolescents in 17 countries.

PIP: This is the second report of a multinational project undertaken in 1988 by the International Round Table for the Advancement of Counseling that sought, among other things, to compare and contrast the reported problems, coping strategies, and help-seeking behavior of 2129 male and 2307 female adolescents from a total of three different socioeconomic backgrounds in each of 16 countries (Australia, Brazil, Canada, Greece, Hong Kong, India, Israel, Japan Kuwait, the Netherlands, the Philippines, China, Puerto Rico, Turkey, the US, and Venezuela) and from a "classless" background in Russia. The first report described the study and research methodology and cited preliminary findings that 1) problems and coping strategies tended to be universal and age-related; 2) impoverished subjects from Brazil, India, the Philippines, and Venezuela had more problems than any other adolescents; 3) problems were usually related to school, family, and identity rather than to sexuality; and 4) the most common coping strategy was individual problem-solving. This report compares male/female identification of up to three problems that cause worry, response to such problems, and help-seeking behavior. All adolescents cited problems in school, identity, and family. Males and females reported similar coping strategies and showed a strong dependence on individual coping strategies. Both males and females choose personal friends and family members as those most likely to help with problems. Males exhibited a higher percentage of problems related to school and a lower percentage of family problems. Russian adolescents reported more problems relating to altruism than any other group, especially males. These results imply that strong similarities exist for males and females, and the findings are worrisome in that problems related to sexuality were not cited. Counselors should expect the concerns of adolescents to be developmentally related and to overwhelm gender differences.^ieng

Illumination and errors in dispensing.

The relationship between the level of illumination and the prescription-dispensing error rate in a high-volume Army outpatient pharmacy was investigated. The prescription error rate was determined by direct, undisguised observation and retrospective prescription review under three levels of illumination (45, 102, and 146 foot-candles) during 21 consecutive weekdays. Illumination was controlled in the prescription-checking area of the pharmacy by using additional fluorescent lamps and filters. The three levels of illumination were randomly assigned to the 21 days to provide a total of 7 days of observations per level. The final sample consisted of 10,888 prescriptions dispensed by five pharmacists. The overall prescription error rate (including both content and labeling errors) was 3.39% (369 prescriptions). An illumination level of 146 foot-candles was associated with a significantly lower error rate (2.6%) than the baseline level of 45 foot-candles (3.8%). There was a linear relationship between each pharmacist's error rate and that pharmacist's corresponding daily prescription workload for all three illumination levels. The effect of the observer was minimal. The rate of prescription-dispensing errors was associated with the level of illumination. Ergonomics can affect the performance of professional tasks.

Quality and comprehensiveness of the National Drug Code Directory on magnetic tape.

The quality and comprehensiveness of the FDA's National Drug Code Directory (NDCD) in magnetic tape form was evaluated. The internal quality of the tape was measured by performing cross-checks of the four record types found on the tape and by checking for the presence of "illegal" characters. The comprehensiveness of the tape was evaluated by determining the extent to which a sample of items from nine community and hospital pharmacies could be matched with code numbers on the NDCD tape. A second test of comprehensiveness measured the match rate between the shelf stock sample and National Drug Code (NDC) numbers in a magnetic tape supplied by a regional wholesaler. External quality was measured by comparing the NDC numbers on the containers of items from the shelf sample with the corresponding information in the NDCD tape. More than 300 discrepancies among the four types of records were discovered, and more than 100 "illegal" characters were present in each of the four record types. Matches on the NDCD tape could be found for 80% of the items in the shelf stock sample and 69.5% of the items in the tape supplied by the wholesaler. A total of 156 errors were discovered when the codes on containers in the shelf sample were matched with the NDCD tape information, yielding an error rate of 6.5%. Because of the 6.5% error rate, the usefulness of the NDCD tape is questionable. Since only 80% of an off-the-shelf sample of drugs had matches on the NDCD tape, about 20% of drug products would have to be matched with some other information source. How these figures for the NDCD tape compare with figures for proprietary tapes is not known.