Health care access and seven-year change in cigarette smoking. The CARDIA Study.

OBJECTIVES: To determine associations among health care access, cigarette smoking, and change in cigarette smoking status over 7 years. METHODS: A cohort of 4,086 healthy young adults was followed from 1985-1986 through 1992-1993. Participants were recruited from four urban sites balanced on gender, race (African Americans and whites), education (high school or less, and more than high school), and age (18-23 and 24-30). Outcome measures were smoking status at Year 7, as well as 7-year rates of smoking cessation and initiation. RESULTS: For each of three access barriers reported at Year 7 (lack of health insurance, lack of regular source of medical care, and expense), participants experiencing the barrier had a higher prevalence of smoking, quit smoking less frequently, and started smoking more frequently; e.g., only 15% of participants with health insurance lapses quit smoking over the 7-year period, compared with 26% of those with insurance (P < 0.001). Results were similar for each race/gender stratum, and persisted after adjustment for usual markers of socioeconomic status: education, income, employment, and marital status. CONCLUSIONS: Health care access was associated with lower prevalence of smoking and beneficial 7-year changes in smoking, independent of socioeconomic status. The possibility that this is a causal relationship has implications in the prevention of cardiovascular disease, cancer and multiple other smoking-related diseases, and deserves further exploration.

A hypertension control program tailored to unskilled and minority workers.

PURPOSE: A comprehensive worksite health promotion program designed to reduce risk factors for cardiovascular disease among 4000 city of Birmingham employees was used to develop and implement a tailored antihypertensive educational intervention. The mean age of the underlying population was 36 years, 89% were blue-collar or unskilled workers, 50% were African Americans and 20% were female. METHODS: First, we identified barriers to hypertension control: low literacy, difficulty understanding the need for treatment of asymptomatic disease, and wide variability of health beliefs and priorities. We then tailored an educational program, which offered employees health education sessions on a variety of different topics, including heart disease, cancer, sleep disorders and back injury. All program materials focused on lifestyle changes and the need to seek medical care. This program was offered to all hypertensive workers; 130 chose to enroll, and 81 completed the program. These 81 participants were matched by age, sex, race and baseline BP with nonparticipating hypertensive workers (controls). Changes in SBP and DBP from before to after the educational program were used to evaluate the program. RESULTS: Overall, intervention participants had a decrease of 4.5 mm Hg in mean SBP (different from zero, [p = 0.03]). African American participants showed a significant decrease (7.4 mm Hg, [p = 0.004]), as did unskilled intervention participants (SBP changes = 7.7 mm Hg, [p = 0.004]). Although not statistically significant, controls showed decreases in BP in the same direction. CONCLUSION: An educational intervention tailored to the specific health perceptions and working conditions of a low literacy population is feasible, and may have a significant effect on hypertension control.