Smokeless tobacco products sold in Massachusetts from 2003 to 2012: trends and variations in brand availability, nicotine contents and design features.

BACKGROUND: Sales of smokeless tobacco products have increased in the USA. More than one in eight males in the 12th grade are current users of smokeless tobacco. Surveillance data examining nicotine levels of smokeless tobacco subsequent to 2006 have not been reported in the literature. METHODS: Data on nicotine levels and design features (eg, pH, moisture content, leaf cut and flavour) of smokeless tobacco products sold in Massachusetts were obtained from manufacturers between 2003 and 2012. Design features, levels and temporal trends in unionised (free) nicotine and nicotine content of smokeless tobacco products were analysed overall and by manufacturer and product type. RESULTS: The annual total number of moist snuff products increased from 99 in 2003 to 127 in 2012. The annual total number of reported snus products increased from 4 in 2003 to the highest level of 62 in 2011, before decreasing to 26 in 2012. Overall, mean unionised (free) nicotine remained relatively stable (ß=0.018 (95% CI -0.014 to 0.050) mg/g dry weight/year) from 2003 to 2012. However, both levels and temporal trends of mean free nicotine varied significantly among manufacturers (p<0.001). Since 2003, the free nicotine content of snus has increased at an overall rate of 0.192 (95% CI 0.138 to 0.246) mg/g dry weight/year, but varied by manufacturer (p<0.001). CONCLUSIONS: The number of smokeless tobacco products increased in the Massachusetts market. Further, mean unionised (free) nicotine levels in smokeless tobacco products of several manufacturers continued to rise despite decreasing levels from other manufacturers. The current success in tobacco control is very likely undermined without government surveillance, regulation and widespread public disclosure of nicotine levels in these products.

Real-world impact of quitline interventions for provider-referred smokers.

BACKGROUND: The healthcare provider-referral quitline model has potential to help identify and connect more smokers to effective cessation services as compared to the self-referral model alone. However, research is limited as to whether provider-referred smokers, who may have more barriers to quitting, can have similar rates of quit success using traditional quitline interventions as self-referred smokers. PURPOSE: To (1) determine how provider-referred smokers may differ from self-referred smokers in their demographics, service utilization, and quit rates and (2) quantify the impact of traditional quitline services on provider-referred smokers' ability to quit. METHODS: Data were collected for 2,737 provider-referred and 530 self-referred Massachusetts quitline clients between November 2007 and February 2012. Analysis was performed in 2012. Wald chi-square tests and two-sample t-tests were used to identify differences between the two referral populations. A multivariable logistic regression model was used for each referral population, and smoker quit status at follow-up was the primary outcome. Tests and models were weighted using inverse probability of treatment weights propensity score weighting method. RESULTS: Compared with self-referred smokers, provider-referred smokers were more likely to be non-white, less educated, and have public insurance. They were less ready to quit and had lower service utilization and quit rates. In both referral populations, clients who used services had greater odds of quitting than those who did not. CONCLUSIONS: Expanding the provider-referral model may require quitlines to address the various risk factors associated with this population. Providers serve critical roles in preparing patients for quitline participation prior to referral.

Recent increases in efficiency in cigarette nicotine delivery: implications for tobacco control.

INTRODUCTION: Recent increases in nicotine yield of cigarettes sold in the United States have been attributed by tobacco manufacturers to natural variation in agricultural products. We tested this assertion using data reported by the manufacturers. METHODS: Data were collected from the annual reports filed with the Massachusetts Department of Public Health by 4 major manufacturers of cigarettes from 1997 to 2012. Reportable measures included nicotine yield (mg/cig) in smoke generated by a smoking machine based on the Massachusetts smoking regimen and nicotine content in the unburned tobacco per cigarette (mg/cig). We used multilevel linear mixed-effect models to examine temporal trends in and predictors of these measures, overall and by brand style and by brand family. RESULTS: While nicotine content remained relatively stable in the range of 12-14 mg/cig between 1998 and 2012, average nicotine yield increased significantly (p < .01) over time and ranged from the lowest level of 1.65 mg/cigarette in 1999 to the highest level of 1.89 mg/cigarette in 2011. Nicotine yield and yield-to-content ratio varied significantly among manufacturers and brand families. When controlling for market category and all available design features, the yield-to-content ratio of all manufacturers except Lorillard increased significantly over time. CONCLUSIONS: The data provided by tobacco manufacturers suggest that the increasing trend in yield is not related to variations in nicotine content but to the yield-to-content ratio, which contradicts their assertions of agricultural variations. Nicotine yield and yield-to-content ratio are controllable features of cigarettes, and they should be monitored and regulated by government agencies.

Integrating tobacco cessation quitlines into health care: Massachusetts, 2002-2011.

QuitWorks is a Massachusetts referral program that links health care organizations, providers, and patients to the state's tobacco cessation quitline and provides feedback reporting. Designed collaboratively with all major Massachusetts health plans, QuitWorks was launched in April 2002. In 2010, approximately 340 institutions and practices used QuitWorks. Between April 2002 and March 2011, approximately 3,000 unique providers referred patients and 32,967 tobacco users received referrals. An analysis of QuitWorks data showed 3 phases in referrals between April 2002 and March 2011: referrals increased from April 2002 through November 2005, plateaued during December 2005 through January 2009, then substantially increased during February 2009 through March 2011. Factors responsible include partnerships with stakeholders, periodic program promotions, hospital activities in response to Joint Commission tobacco use measures, service evolutions, provision of nicotine replacement therapy for referred patients, and electronic referral options. QuitWorks' history demonstrates that tobacco cessation referral programs can be successfully sustained over time; reach substantial numbers of tobacco users, benefit providers and health care organizations; and contribute to sustainable systems-level changes in health care.

A longitudinal study of medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in hospitalizations for cardiovascular disease.

BACKGROUND: Insurance coverage of tobacco cessation medications increases their use and reduces smoking prevalence in a population. However, uncertainty about the impact of this coverage on health care utilization and costs is a barrier to the broader adoption of this policy, especially by publicly funded state Medicaid insurance programs. Whether a publicly funded tobacco cessation benefit leads to decreased medical claims for tobacco-related diseases has not been studied. We examined the experience of Massachusetts, whose Medicaid program adopted comprehensive coverage of tobacco cessation medications in July 2006. Over 75,000 Medicaid subscribers used the benefit in the first 2.5 years. On the basis of earlier secondary survey work, it was estimated that smoking prevalence declined among subscribers by 10% during this period. METHODS AND FINDINGS: Using claims data, we compared the probability of hospitalization prior to use of the tobacco cessation pharmacotherapy benefit with the probability of hospitalization after benefit use among Massachusetts Medicaid beneficiaries, adjusting for demographics, comorbidities, seasonality, influenza cases, and the implementation of the statewide smoke-free air law using generalized estimating equations. Statistically significant annualized declines of 46% (95% confidence interval 2%-70%) and 49% (95% confidence interval 6%-72%) were observed in hospital admissions for acute myocardial infarction and other acute coronary heart disease diagnoses, respectively. There were no significant decreases in hospitalizations rates for respiratory diagnoses or seven other diagnostic groups evaluated. CONCLUSIONS: Among Massachusetts Medicaid subscribers, use of a comprehensive tobacco cessation pharmacotherapy benefit was associated with a significant decrease in claims for hospitalizations for acute myocardial infarction and acute coronary heart disease, but no significant change in hospital claims for other diagnoses. For low-income smokers, removing the barriers to the use of smoking cessation pharmacotherapy has the potential to decrease short-term utilization of hospital services.

The impact of Massachusetts' smoke-free workplace laws on acute myocardial infarction deaths.

OBJECTIVES: We examined the rate of acute myocardial infarction (AMI) deaths in Massachusetts before and after the implementation of a comprehensive smoke-free workplace law in July 2004. METHODS: We used Poisson regression models to examine the impact of the state law in cities and towns with and without previous local smoking bans and the effect of the local laws for the period of 1999 through 2006. RESULTS: The AMI mortality rate decreased by 7.4% (95% confidence interval [CI] = 3.3%, 11.4%) after implementation of the state law. The state ban had an impact in cities and towns with no prior local smoking ban (9.2% decrease; P < .001) but not cities and towns with a prior local smoking ban. However, there was a nonsignificant 4.9% (95% CI = -5.0%, 13.9%) decrease associated with the local smoking ban that preceded the effect of the state ban. The effect of the state ban was modest (-1.6%) in the first 12 months after implementation but much larger after the first 12 months (-18.6%; P < .001). CONCLUSIONS: Comprehensive statewide smoke-free workplace laws in Massachusetts were associated with an estimated 270 fewer AMI deaths per year. These results add to the evidence suggesting that smoke-free air laws are associated with lower rates of AMI.

Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence.

BACKGROUND: Approximately 50% of smokers die prematurely from tobacco-related diseases. In July 2006, the Massachusetts health care reform law mandated tobacco cessation coverage for the Massachusetts Medicaid population. The new benefit included behavioral counseling and all medications approved for tobacco cessation treatment by the U.S. Food and Drug Administration (FDA). Between July 1, 2006 and December 31, 2008, a total of 70,140 unique Massachusetts Medicaid subscribers used the newly available benefit, which is approximately 37% of all Massachusetts Medicaid smokers. Given the high utilization rate, the objective of this study is to determine if smoking prevalence decreased significantly after the initiation of tobacco cessation coverage. METHODS AND FINDINGS: Smoking prevalence was evaluated pre- to post-benefit using 1999 through 2008 data from the Massachusetts Behavioral Risk Factor Survey (BRFSS). The crude smoking rate decreased from 38.3% (95% C.I. 33.6%-42.9%) in the pre-benefit period compared to 28.3% (95% C.I.: 24.0%-32.7%) in the post-benefit period, representing a decline of 26 percent. A demographically adjusted smoking rate showed a similar decrease in the post-benefit period. Trend analyses reflected prevalence decreases that accrued over time. Specifically, a joinpoint analysis of smoking prevalence among Massachusetts Medicaid benefit-eligible members (age 18-64) from 1999 through 2008 found a decreasing trend that was coincident with the implementation of the benefit. Finally, a logistic regression that controlled for demographic factors also showed that the trend in smoking decreased significantly from July 1, 2006 to December 31, 2008. CONCLUSION: These findings suggest that a tobacco cessation benefit that includes coverage for medications and behavioral treatments, has few barriers to access, and involves broad promotion can significantly reduce smoking prevalence.

Small-area estimation and prioritizing communities for tobacco control efforts in Massachusetts.

OBJECTIVES: We developed a method to evaluate geographic and temporal variations in community-level risk factors and prevalence estimates, and used that method to identify communities in Massachusetts that should be considered high priority communities for smoking interventions. METHODS: We integrated individual-level data from the Behavioral Risk Factor Surveillance System from 1999 to 2005 with community-level data in Massachusetts. We used small-area estimation models to assess the associations of adults' smoking status with both individual- and community-level characteristics and to estimate community-specific smoking prevalence in 398 communities. We classified communities into 8 groups according to their prevalence estimates, the precision of the estimates, and temporal trends. RESULTS: Community-level prevalence of current cigarette smoking among adults ranged from 5% to 36% in 2005 and declined in all but 16 (4%) communities between 1999 and 2005. However, less than 15% of the communities met the national prevalence goal of 12% or less. High smoking prevalence remained in communities with lower income, higher percentage of blue-collar workers, and higher density of tobacco outlets. CONCLUSIONS: Prioritizing communities for intervention can be accomplished through the use of small-area estimation models. In Massachusetts, socioeconomically disadvantaged communities have high smoking prevalence rates and should be of high priority to those working to control tobacco use.

Industry research on the use and effects of levulinic acid: a case study in cigarette additives.

Public health officials and tobacco researchers have raised concerns about the possible contributions of additives to the toxicity of cigarettes. However, little attention has been given to the process whereby additives promote initiation and addiction. Levulinic acid is a known cigarette additive. Review of internal tobacco industry documents indicates that levulinic acid was used to increase nicotine yields while enhancing perceptions of smoothness and mildness. Levulinic acid reduces the pH of cigarette smoke and desensitizes the upper respiratory tract, increasing the potential for cigarette smoke to be inhaled deeper into the lungs. Levulinic acid also may enhance the binding of nicotine to neurons that ordinarily would be unresponsive to nicotine. These findings held particular interest in the internal development of ultralight and so-called reduced-exposure cigarette prototypes. Industry studies found significantly increased peak plasma nicotine levels in smokers of ultralight cigarettes following addition of levulinic acid. Further, internal studies observed changes in mainstream and sidestream smoke composition that may present increased health risks. The use of levulinic acid illustrates the need for regulatory authority over tobacco products as well as better understanding of the role of additives in cigarettes and other tobacco products.

One size does not fit all: how the tobacco industry has altered cigarette design to target consumer groups with specific psychological and psychosocial needs.

AIMS: To identify whether the tobacco industry has targeted cigarette product design towards individuals with varying psychological/psychosocial needs. DESIGN: Internal industry documents were identified through searches of an online archival document research tool database using relevancy criteria of consumer segmentation and needs assessment. FINDINGS: The industry segmented consumer markets based on psychological needs (stress relief, behavioral arousal, performance enhancement, obesity reduction) and psychosocial needs (social acceptance, personal image). Associations between these segments and smoking behaviors, brand and design preferences were used to create cigarette brands targeting individuals with these needs. CONCLUSIONS: Cigarette brands created to address the psychological/psychosocial needs of smokers may increase the likelihood of smoking initiation and addiction. Awareness of targeted product development will improve smoking cessation and prevention efforts.