Minors' tobacco possession law violations and intentions to smoke: implications for tobacco control.

OBJECTIVES: To test: (1) whether citation under the Minors in Possession (MIP) law, vicarious citation (knowing someone who was cited), and threat of driving licence suspension are associated with decreased intentions to smoke next year; and (2) whether the policy is differentially enforced. SUBJECTS: 28,249 white, Hispanic, and African American students in grades 6-12 (11-18 years old) participated in the study. METHOD: The 86 item anonymous Texas Youth Tobacco Survey was completed by students attending 37 schools in 14 east and central Texas communities. RESULTS: Hierarchical linear modelling showed that MIP citation was unrelated to the future smoking intentions of most youth. However, there was a negative association between citation and smoking intentions for ever daily smoking youth at four schools. Threat of licence suspension was associated with a lower likelihood of future smoking intentions among ever daily smoking youth and vicarious citation did not deter youth from future smoking. African American and Hispanic youth had a higher probability of being cited than their peers. CONCLUSIONS: Threat of driving licence suspension has the intended effect upon youth who are/were committed smokers and MIP citation has the intended effect upon committed smokers at only four schools. However, differential enforcement of the law based on ethnicity may be occurring. Before drawing firm conclusions, current findings must be replicated with longitudinal data to determine the consequences of citation on subsequent tobacco use.

Individual and contextual factors related to family practice residents' assessment and counseling for tobacco cessation.

BACKGROUND: Tobacco use is the chief avoidable cause of death in the United States. Physicians, however, are not routinely assessing this risk and providing counseling for risk reduction. This study examines tobacco cessation counseling practices among family practice residents and explores the determinants of residents' smoking-counseling behaviors and counseling duration. METHODS: One hundred ten family practice residents (response rate = 93.2%) from four Texas residency training programs completed a survey designed to assess tobacco cessation counseling practices. RESULTS: A high proportion of residents reported that they usually or always assessed tobacco use (59.3%) and advised their patients to quit smoking (80.9%), with a lower proportion reporting specific counseling behaviors (7.3% - 21.9%), referrals (1.8%), or follow-up visits (1.8%). Year of residency, perceived effectiveness, and the interaction between perceived effectiveness and residency year were significantly associated with number of counseling behaviors, and year of residency and perceived effectiveness were significantly associated with counseling duration. CONCLUSIONS: Faculty physicians should assist residents to implement the Public Health Service-sponsored clinical practice guideline for tobacco control. There is a need to increase behavioral skills and perceived effectiveness for assessing and counseling smokers among first-year residents.

The impact of Put Prevention into Practice on selected clinical preventive services in five Texas sites.

OBJECTIVE: To determine whether the implementation of the Put Prevention Into Practice (PPIP) office-based system would increase the delivery rates of specific clinical preventive services among demonstration clinics. METHODS: Chart review was conducted before (n=372) and 33 to 39 months after (n=376) the implementation of the PPIP office-based system in two community health centers and three family practice residency programs in Texas. The population included all adult patients aged > or = 19 years who had presented to the clinic during the study periods. RESULTS: Documentation of timely cholesterol screening increased from 70% to 84%; smoking assessment, from 56% to 80%; for women, up-to-date Papanicolaou smear, from 70% to 81%; annual mammograms (women aged > or =51), from 30% to 48%; and up-to-date tetanus-diphtheria immunizations, from 19% to 59%. For adults aged > or =66 years, documentation of pneumococcal immunization increased from 22% to 48%, while influenza immunizations improved, although not significantly (45% to 49%). Blood pressure screening was almost universal (99%) at baseline and at 33- to 39-month follow-up. CONCLUSION: PPIP system changes were associated with an observed increase in delivery of selected clinical preventive services.

Comparison of participation in federal worksite and community health promotion programs.

The extent to which employees rely on the worksite exclusively for health promotion programs was examined in a cross-sectional study of 10 federal worksites. Responses were received from 3,403 of the 5,757 employees surveyed (59%). Fewer than 10% of employees exclusively used agency programs for physical fitness, nutrition, substance abuse, smoking cessation, and support group meetings. A higher percentage participated in health risk assessment (27%), health and disease risk education activities (17%), medical care services (23%), personal safety and first aid training 26%, and stress management programs (17%) only at the worksite. Men were more likely than women to participate exclusively in workplace programs.

Maintaining prevention in practice: survival of PPIP in primary care settings. Put Prevention Into Practice.

INTRODUCTION: Put Prevention Into Practice (PPIP) consists of a kit of office-based tools intended to support the provision of preventive services by primary care providers. The purpose of this study was to examine the institutionalization of PPIP within five primary care clinics funded by the Texas Department of Health to implement PPIP, and to examine the organizational determinants of program institutionalization. METHODS: We utilized an adaptation of the Level of Institutionalizaton (LoIn) scales for qualitative data collection and for development of an institutionalization score for each site. The determinants of institutionalization were derived from the organizational behavior and health promotion literatures and used as categories for analysis. In addition, for purposes of triangulation, chart audit data for three documentation behaviors were also collected. RESULTS: PPIP has been maintained--at varying degrees of integration--in four of the five sites studied, for 6 years after adoption. Organizational factors that facilitated the institutionalization process were the site's institutional strength, the integration of PIPP within extant programs and services, visibility of the program within and outside the site, planning for the termination of grant funding, and presence of a program champion with mid- to upper-level managerial authority. Successful initiation of the program was not a predictor of institutionalization outcomes. CONCLUSIONS: We have highlighted the need to consider organizational determinants of institutionalization in relation to their specific sociopolitical contexts, and in relation to each other, not in isolation.

Partnerships for comprehensive school health: collaboration among colleges/universities, state-level organizations, and local school districts.

A qualitative survey on the collaborative experiences of colleges and universities, state-level organizations, and school districts related to comprehensive school health programs in 12 states found four primary collaborative outcomes: training, consultation, research, and networking. Five common dimensions of collaboration also were identified: interpersonal and organizational interactions, level of awareness and understanding of comprehensive school health programs, organizational priorities and reward systems, political forces, and availability and sharing of resources. The potential for such linkages to advance comprehensive school health programs remains largely untapped. Recommendations for developing such collaborations are presented.

Chart documentation of clinical preventive services at 9 Texas clinics.

Documentation of clinical preventive services at 9 Texas family practice residency programs, community health centers, and public health regional clinics was examined. Assessment of 11 risks, counseling on those risks, and timeliness of 8 screening tests and immunizations were abstracted. Documentation of clinicians' risk assessment focused on tobacco use (56.4%), alcohol/drug abuse (45.8%), and excess weight (21.6%). Counseling was documented most often for nutrition (20.5%), family planning (11.6%), and physical activity (10.3%). Of the sites studied, public health regional clinics had the highest documentation of assessment and counseling. Community health centers were most up-to-date for diabetes and cholesterol screening. Family practice residencies documented the highest rate of counseling for obesity risk. Clinicians do not document risk assessment, counseling, or up-to-date screening tests and immunizations for most of their adult patients. Texas practitioners may need support or assistance to provide universal access to clinical preventive services.

Put prevention into practice. Evaluation of program initiation in nine Texas clinical sites.

INTRODUCTION: Put Prevention Into Practice (PPIP) is a program designed to improve the delivery of clinical preventive services by primary care providers, through the use of specific office materials for providers and clinic staff, as well as an educational booklet for patients. The purpose of this study was to identify potential predictors of successful initiation of PPIP among 9 Texas public health clinics participating in a demonstration project funded by the Texas Department of Health (TDH). METHODS: The PRECEDE model was utilized as a theoretical framework for the study. A qualitative, case study methodology was employed, with structured interviews and open-ended questions asked of each site's PPIP personnel. Information from the sites' report to the TDH on the number of charts containing PPIP forms was also used for purposes of data triangulation. RESULTS: Sites that initiated PPIP successfully were characterized by a medium patient load, the ability to serve low-resource populations, prior attempts to implement categorical programs, existence of a philosophy of prevention, and pre-implementation planning. Barriers to successful initiation were identified as systems-related, patient-related, and staff-related. CONCLUSIONS: We identified factors that might predict the successful initiation of PPIP in public health primary care settings. Implications of present findings for implementation of similar health promotion programs in clinical settings are discussed.

Measures of American Indian traditionality and its relationship to cervical cancer screening.

The goal of this study was to evaluate the relationship between culture and attitudes about cervical cancer screening among young American Indian women living and working in northeast Oklahoma. A cohort of 199 American Indian women, ages 18-40, were surveyed to determine their blood quantum, self-identification, and beliefs and practices regarding traditional behavior in order to develop a traditional behavior scale (the degree to which an individual maintained traditional tribal ways or behaviors). The use of this scale indicated that the degree of American Indian blood quantum, blood quantum for primary tribe, and self-identification are correlated to the traditional behavior scale. The scale, however, was unable to predict intention to get a Pap test. Results indicate that it is useful to understand the variation of traditional behavior within the specific population group to be served when planning and implementing culturally appropriate interventions for American Indian women. It is also useful to evaluate which segments of the population current programs are reaching.

Predictors of state legislators' intentions to vote for cigarette tax increases.

BACKGROUND: This study analyzed influences on state legislators' decisions about cigarette tax increase votes using a research strategy based on political science and social-psychological models. METHODS: Legislators from three states representing a spectrum of tobacco interests participated in personal interviews concerned with tobacco control legislation (n = 444). Measures of potential predictors of voting intention were based on the consensus model of legislative decision-making and the theory of planned behavior. Multiple logistic regression methods were used to identify social-psychological and other predictors of intention to vote for cigarette tax increases. RESULTS: General attitudes and norms concerning cigarette tax increases predicted legislators' intention to vote for cigarette tax increases. More specific predictors included perceptions of public health impact and retail sales impact of cigarette tax increases. Constituent pressure was the strongest perceived social influence. Political party and state also were strong predictors of intention. Results were consistent with related research based on political science models. CONCLUSIONS: Legislators' votes on cigarette tax increases may be influenced by their perceptions of positive and negative outcomes of a cigarette tax increase and by perceived constituent pressures. This research model provides useful insights for theory and practice and should be refined in future tobacco control research.

A review of the health impact of smoking control at the workplace.

PURPOSE: To summarize and provide a critical review of worksite health promotion program evaluations published between 1968 and 1994 that addressed the health impact of worksite smoking cessation programs and smoking policies. METHODS: A comprehensive literature search conducted under the auspices of the Centers for Disease Control and Prevention identified 53 smoking cessation program evaluation reports, of which 41 covered worksite single-topic cessation programs. Nine additional reports were located through manual search of citations from published reports and reviews. These 50 reports covered 52 original data-based studies of cessation programs. The search produced 19 reports for tobacco policy evaluations, of which 12 addressed health impact. An additional 17 reports were located by the authors. These 29 reports covered 29 studies of policy impact. SUMMARY OF IMPORTANT FINDINGS: Smoking cessation group programs were found to be more effective than minimal treatment programs, although less intensive treatment, when combined with high participation rates, can influence the total population. Tobacco policies were found to reduce cigarette consumption at work and worksite environmental tobacco smoke (ETS) exposure. CONCLUSIONS: The literature is rated suggestive for group and incentive interventions; indicative for minimal interventions, competitions, and medical interventions; and acceptable for the testing of incremental effects. Because of the lack of experimental control, the smoking policy literature is rated as weak, although there is strong consistency in results for reduced cigarette consumption and decreased exposure to ETS at work.

State legislators' attitudes and voting intentions toward tobacco control legislation.

OBJECTIVES: This study describes state legislators' knowledge, attitudes, and voting intentions with regard to tobacco-related issues. METHODS: A cross-sectional survey of state legislators was conducted in North Carolina, Texas, and Vermont in 1994. RESULTS: Most legislators agreed that secondhand smoke can cause lung cancer in nonsmokers, and a majority believed that smokers are addicted to nicotine. More than 75% stated that they would support a measure to enforce laws preventing tobacco sales to youth. A majority of Texas and Vermont legislators supported an increase in the state cigarette excise tax; 43% of North Carolina legislators would support an increase if revenues were directed toward tobacco farmer diversification. CONCLUSIONS: State legislators believe tobacco to be addictive, and they support policies to protect youth from tobacco. Support for other legislative measures differs significantly across states.

State legislators' intentions to vote and subsequent votes on tobacco control legislation.

The predictive validity of state legislators' behavioral intentions in relation to their votes on tobacco control legislation was assessed by using the theory of planned behavior (I. Ajzen, 1991). Intentions to vote for cigarette tax increases were measured through interviews in the summer of 1994. A bill containing cigarette tax increases was considered about 8 months later. Votes were compared with intentions and were found to be consistent for 78% of these legislators (N = 120). Multiple logistic regression analyses showed a strong independent relationship between intentions and voting and a similar effect of political party; results suggested but did not confirm that votes were predicted by interactions between intentions and perceived control. Legislator surveys that use this conceptual model can provide results relevant to understanding tobacco policy development.

State legislators' perceptions of lobbyists and lobbying on tobacco control issues.

OBJECTIVE: To determine state legislators' perceptions about health and tobacco lobbyists, their frequency of contact with these lobbyists, and the amount of campaign contributions from health professional organisations and the tobacco industry. DESIGN: Cross-sectional study. SUBJECTS: State legislators from North Carolina, Texas, and Vermont (USA), serving in 1994. MAIN OUTCOME MEASURES: Perceptions about lobbyists representing the tobacco industry, non-profit health organisations, and state medical societies with respect to their credibility, importance as sources of information, and persuasiveness; extent of lobbying activities; campaign contributions from health professional organisations and the tobacco industry. RESULTS: Almost all legislators reported that medical society and non-profit health organisation lobbyists are credible on tobacco issues and just over half believed that these lobbyists are important sources of information. More legislators said they could be persuaded by medical and health lobbyists than by tobacco lobbyists. Although health professional Political Action Committees (PACs) gave campaign contributions to more state legislators, and gave higher amounts on average, than tobacco PACs, legislators reported less contact with medical society lobbyists than tobacco lobbyists about tobacco issues. CONCLUSIONS: State legislators have positive attitudes toward lobbyists for non-profit health organisations and state medical societies regarding tobacco issues. These groups may be an underused resource for educating legislators about tobacco control measures.

Settings as an important dimension in health education/promotion policy, programs, and research.

Settings--community, worksite, schools, and healthcare sites--constitute an important dimension of health education/health promotion policy and programs and for research about program needs, feasibility, efficacy, and effectiveness. These settings vary in the extent of coverage of and relationships with their respective constituencies, valued outcomes, and quantity and quality of evidence about the effectiveness of setting-specific and cross-setting programs. Main sources of evidence for program efficacy and effectiveness are summarized, leading to the conclusion that strides have been made toward building a strong evidentiary base for health education/health promotion in these settings. Gaps in research exist, especially for diffusion of effective programs, new technologies, the influence of policy, relations between settings, and approaches to marginal and special subgroups. Recommendations are offered for cross-setting and within-setting research related to intervention.

Diffusion of an effective tobacco prevention program. Part I: Evaluation of the dissemination phase.

As health promotion methods are proven effective, the diffusion and widespread implementation of successful programs can significantly reduce behaviors that pose risks to health within a targeted population. The Smart Choices Diffusion Project developed and evaluated a dissemination intervention program that targeted 128 school districts in east Texas. The project employed a theory-based model to disseminate information about a proven tobacco prevention program to opinion leaders in each district. These opinion leaders were asked to personally communicate the program information within their district using a videotape and printed materials, and advocate for program adoption. In addition to personal communication, a newsletter linked school districts. Opinion leaders in 52% of the districts showed the videotape, which modeled program adoption. A quasi-experimental design was used to evaluate the impact of the dissemination phase on teachers' and administrators' readiness to adopt a tobacco prevention program. Evaluation of the dissemination phase revealed no differences between the intervention and comparison districts in a district's readiness to adopt a tobacco prevention program. However, in intervention districts where school administrators viewed the videotape, the administrators were more likely to perceive the innovative program as having a relative advantage and to perceive their district's organizational and social environment as supportive of adopting the program.

Diffusion of an effective tobacco prevention program. Part II: Evaluation of the adoption phase.

This paper presents the results of theory-based intervention strategies to increase the adoption of a tobacco prevention program. The adoption intervention followed a series of dissemination intervention strategies targeted at 128 school districts in Texas. Informed by Social Cognitive Theory, the intervention provided opportunities for districts to learn about and model themselves after 'successful' school districts that had adopted the program, and to see the potential for social reinforcement through the knowledge that the program had the potential to have an important influence on students' lives. The proportion of districts in the Intervention condition that adopted the program was significantly greater than in the Comparison condition (P < 0.001). Stepwise logistic regression indicated that the variables most closely related to adoption among intervention districts were teacher attitudes toward the innovation and organizational considerations of administrators. Recommendations for the development of effective strategies for the diffusion of innovations are presented.

Increasing teacher receptivity toward use of tobacco prevention education programs.

An empirical examination of teacher receptivity to and practice of tobacco prevention education provides the foundation for comprehensive staff development to increase diffusion of drug prevention education curricula. Randomly-selected first grade Texas teachers (n = 313) were asked to complete a questionnaire during the first and second years of the Smoke-Free Class of 2000 (SFC2000) project. Initially 64 percent of recipients used materials. However, two of every five first-year users did not maintain use one year later, and many who intended use never implemented. Principal components analysis of fourteen items pertaining to receptivity resulted in four scales with acceptable reliability scores: general receptivity to tobacco prevention education, personal support for teaching tobacco prevention education, personal involvement, and school involvement in tobacco prevention. Scales were predictive of initial and continued use and provide a teacher receptivity measure to guide staff development.

A community view of smoking cessation counseling in the practices of physicians and dentists.

The practice norms of community physicians and dentists in the Lehigh Valley of Pennsylvania for counseling about smoking cessation were surveyed. In addition, 1,373 residents in the valley were interviewed by telephone about the smoking counseling behaviors of their dentists and physicians. These activities were conducted as part of the planning for an intervention by the Coalition for a Smoke-Free Valley, a coalition of 100 persons and organizations in the area. The survey response rate for 172 physicians was 77 percent, and for 103 dentists, it was 76 percent. More physicians than dentists advised patients to quit, counseled patients, provided materials, and helped the patient to set a quit date. However, there was a clear discrepancy between what physicians say they do and what smokers say they hear.