Changes in adult cigarette smoking in the Minnesota Heart Health Program

OBJECTIVES

The Minnesota Heart Health Program was a research and demonstration project designed to reduce risk factors for heart disease in whole communities. This paper describes smoking-specific interventions and outcomes.

METHODS

Three pairs of matched communities were included in the study. After baseline surveys, one community in each pair received a 5-year education program, while both cross-sectional and cohort surveys continued in all sites. Adult education programs for smoking cessation included Quit and Win contests, classes, self-help materials, telephone support, and home correspondence programs.

RESULTS

Encouraging short-term results were obtained for several adult education programs. Overall long-term outcomes were mixed, with evidence of an intervention effect only for women in cross-sectional survey data. Unexpectedly strong secular declines in smoking prevalence were observed in comparison communities.

CONCLUSIONS

The findings suggest that community education may be unlikely to exceed dramatic secular reductions in smoking prevalence. The success of several key interventions and the incorporation of Minnesota Heart Health Program interventions by education communities are encouraging, however.

Readiness to quit as a predictor of smoking changes in the Minnesota Heart Health Program

The relation between two indexes of readiness to quit smoking obtained at baseline and subsequent quitting 2-7 years later was examined. Baseline data from the Minnesota Heart Health Program were used to construct 3-item composites of interest in quitting (alpha = .76) and past quitting behavior (alpha = .64). With baseline smoking controlled, both measures predicted quitting at the 2- and 7-year follow-ups but not at 4 years. Only interest in quitting was significant at the 7-year follow-up when both indexes entered the model. Given the representative community sample and the long interval from baseline to the final assessment, the findings provide support for the readiness construct.

Readiness to quit as a predictor of smoking changes in the Minnesota Heart Health Program

The relation between two indexes of readiness to quit smoking obtained at baseline and subsequent quitting 2-7 years later was examined. Baseline data from the Minnesota Heart Health Program were used to construct 3-item composites of interest in quitting (alpha = .76) and past quitting behavior (alpha = .64). With baseline smoking controlled, both measures predicted quitting at the 2- and 7-year follow-ups but not at 4 years. Only interest in quitting was significant at the 7-year follow-up when both indexes entered the model. Given the representative community sample and the long interval from baseline to the final assessment, the findings provide support for the readiness construct.

Restrictive smoking policies in the workplace: effects on smoking prevalence and cigarette consumption

BACKGROUND

Thirty-two worksites participating in a randomized trial of worksite health promotion aimed at reducing smoking and obesity were categorized at baseline and 2 years later as having either restrictive or unrestrictive smoking policies. Between the two assessment points, 16 sites received health promotion interventions.

RESULTS

At baseline 15 sites had restrictive policies and 17 unrestrictive policies. Smoking restrictions were associated with significantly lower smoking prevalence and higher lifetime quit rates among ever smokers. They also were associated with more recent quit attempts and lower daily cigarette consumption, although these effects were not significant. Between baseline and follow-up, 9 of the 17 worksites that had few smoking restrictions at baseline became restrictive. Although neither baseline smoking policies nor changes in smoking policy predicted change in smoking prevalence or in the frequency of quit attempts, smokers in sites changing from unrestrictive to restrictive policies reported a significant reduction in daily cigarette consumption.

CONCLUSIONS

The worksite health promotion program was successful in reducing smoking prevalence in intervention sites compared to controls. However, the existence of restrictive smoking policies neither helped nor hindered these intervention efforts. The present data are believed to support the idea that restrictive smoking policies have beneficial effects on the smoking habits of employees, but that the magnitude of this effect is modest.

Effects of work-site health promotion on illness-related absenteeism

This study examined the effects of work-site health promotion on employee absenteeism. Thirty-two work sites were randomized to programs for weight control and smoking cessation or to no treatment for 2 years. The prevalence of self-reported absences from work was assessed at baseline and follow-up. Results using work site as the unit of analysis showed a net reduction in the percent of workers reporting a sick day in the last month in treatment versus control work sites of 3.7% (P = .04) and 3.4% (P = .06) in cross-sectional and cohort analysis, respectively. Further analyses found that the rate of participation in smoking (P = .09) but not weight programs (P = .72) was positively associated with change in sick day prevalence and that this effect was strongest in baseline smokers (P = .002). It is concluded that work-site smoking cessation programs may yield important short-term economic benefits by reducing employee absenteeism.

Correlates of high fat/calorie food intake in a worksite population: the Healthy Worker Project

Behavioral and sociodemographic correlates of high fat/calorie food consumption were examined in a population-based sample of working adults (N = 2038 men; N = 2335 women). Relative weight, dieting history, and cigarette smoking were significantly related to total energy intake from high fat/calorie foods. Relative weight was positively related to the intake of meat, eggs, fried potatoes, and fats. Current dieting to lose weight was associated with a lower intake of all foods, except alcohol and fats. These foods were unrelated to dieting status in men and positively related to dieting status in women. Physical activity and smoking were related to higher intake of high fat/calorie foods. Smokers consumed fewer sweet foods than nonsmokers, however. These results underscore the importance of controlling for dieting status, as well as other behavioral and demographic variables, in population studies of dietary intake. They also suggest factors that may be important in the etiology of unhealthy eating patterns and potential targets for dietary intervention.

Biochemical validation of smoking status: pros, cons, and data from four low-intensity intervention trials

Biochemical validation of smoking status has long been considered essential, but recent reports have questioned its utility in certain kinds of field trials. We describe efforts to biochemically validate self-reports of smoking cessation from participants in four large-scale randomized trials in outpatient clinics, hospitals, worksites, and dental clinics. These studies included over 5,000 adults smokers who participated in the population-based low-intensity intervention evaluations. At a 1-year follow-up, 798 subjects reported no tobacco use. We attempted to verify these reports using saliva continine/carbon monoxide validation procedures. Overall, there was a moderately high nonparticipation rate (27%), a low disconfirmation rate (4%), and a high self-reported relapse rate (12%) in the interval between survey and biochemical validation. There were no differences between intervention and control conditions on any of the above variables. Longer durations of self-reported abstinence were strongly related to increased probability of biochemical confirmation. Differences in results across projects were related to how biochemical validation was conducted. These results, as well as statistical power considerations, raise questions about whether biochemical validation procedures are practical, informative, or cost-effective in such population-based, low-intensity intervention research.

Factors influencing participation in worksite smoking cessation and weight loss programs: the Healthy Worker Project

Worksite intervention for health behavior change has attracted much recent interest as a potentially cost-effective way to promote healthier behaviors in the general population. In evaluating the impact of health promotion activities, it is essential to consider the entire work force rather than just self-selected participants. Overall, recruitment results reported to date have varied widely. There are a large number of factors pertaining to both employee and worksite characteristics that could contribute to variability in how well worksite health promotion programs attract employees. A critical issue that has received little research attention is the dynamics of participation in employee health promotion programs as they are offered repeatedly over time. The present study examined participation rates and contributing factors in worksite health promotion programs for weight loss and smoking cessation in the Healthy Worker Project, a randomized trial of worksite intervention conducted among 16 intervention and 16 control worksites in the Minneapolis/St. Paul metropolitan area between 1987 and 1990. Data analyses focused on characterizing individuals enrolling in worksite health promotion programs in comparison to those in the worksite population as a whole who would be considered in need of such programs.

The Healthy Worker Project: a work-site intervention for weight control and smoking cessation

OBJECTIVES

A randomized trial was conducted to evaluate the effectiveness of a work-site health promotion program in reducing obesity and the prevalence of cigarette smoking.

METHODS

Thirty-two work sites were randomized to treatment or no treatment for 2 years. Treatment consisted of health education classes combined with a payroll-based incentive system. Evaluation was based on cohort and cross-sectional surveys.

RESULTS

Of 10,000 total employees in treatment work sites, 2041 and 270 participated in weight control and smoking cessation programs, respectively. Weight losses averaged 4.8 lbs, and 43% of smoking participants quit. Net 2-year reductions in smoking prevalence in treatment vs control work sites were 4.0% and 2.1% in cross-sectional and cohort surveys, respectively. No treatment effect was found for weight. Treatment effects for smoking prevalence and weight were both positively correlated with participation rates in the intervention programs (r = .45 for smoking and r = .55 for weight).

CONCLUSIONS

This work-site health promotion program was effective in reducing smoking prevalence at a cost that is believed to make the investment worthwhile.

Brief supportive telephone outreach as a recruitment and intervention strategy for smoking cessation

BACKGROUND

Formal efforts to recruit smokers into cessation programs have failed to reach large segments of the smoking population. Telephone intervention may represent a viable strategy to promote smoking cessation. An even more promising approach may be a combination of brief telephone support and outreach to identified smokers.

METHODS

Telephone support for smoking cessation was provided to four identified smoker populations in Bloomington, Minn, one of three Minnesota Heart Health Program education communities. Smokers were randomly assigned to an intervention consisting of two 15-minute telephone calls approximately 1 to 3 weeks apart or to a nonintervention control.

RESULTS

At the 6-month follow-up, a significant overall effect was found in favor of the intervention condition for both self-reported and cotinine-validated quitting. Differences between intervention and control conditions were no longer significant at 18 months.

CONCLUSIONS

Smokers' receptivity to telephone intervention was at least moderately encouraging. The cost of intervention could be relatively low if trained volunteers initiated telephone calls. However, more intensive telephone intervention and support may be needed to produce lasting changes in smoking prevalence.

Urban Indians' smoking patterns and interest in quitting

Little is known about smoking patterns of urban American Indians and their interest in quitting. Most published research has focused upon American Indians who live on rural reservations. In this study, personal interviews were conducted with a convenience sample of patients at Urban Indian Health Clinics in four geographically diverse sites: Milwaukee, WI, Minneapolis, MN, and Seattle and Spokane, WA. A total of 419 current smokers and 173 ex-smokers completed interviews. Current smokers reported a median cigarette consumption of 11 per day. Smokers indicated both a moderate desire to quit (mean 5.97, on a scale 0-10) and moderate confidence in their ability to do so (mean 5.56, on a scale 0-10). More than 70 percent of current smokers indicated having previously tried to quit. The most common reasons cited for relapse included craving, social situations, stress, and nervousness. The most common reasons for quitting given by ex-smokers included being "sick" of smoking, health concerns, respiratory problems, and pregnancy. The estimated quit-ratio (former smokers divided by current+former smokers) was 29.7 percent. This quit-ratio, although substantial, is lower than the 45 percent quit-ratio reported for the general U.S. population. Perhaps the most striking findings are the similarities between American Indians and the overall population in both interest in quitting and reasons for doing so. Smoking cessation previously has been viewed as a low priority for this population. The current results suggest the viability of systematic efforts to encourage urban American Indians to quit smoking.

An assessment of nicotine gum as an adjunct to freedom from smoking cessation clinics

The Freedom from Smoking clinic programs offered by the American Lung Association are in widespread use. These programs were developed in the 1970s prior to the availability of nicotine gum in the United States. It was hypothesized that the addition of nicotine gum to these clinics (thereby including both behavioral and pharmacologic intervention) would boost abstinence outcome significantly. Two-hundred and seventy-three persons were randomly assigned to Freedom from Smoking clinics with or without prescription of nicotine gum. Abstinence outcomes at one week favored the nicotine gum conditions (86.3% of nicotine gum subjects were abstinent as opposed to 70.9% of comparison subjects, chi 2(1) = 9.79, p = .002). Effects for gum were no longer significant at later follow-ups, however, Overall duration and level of nicotine gum use were considerably less than optimal. In the absence of a placebo gum control group, expectancy cannot be eliminated as a possible explanation of the short-term results.

Results of a long-term community smoking cessation contest

BACKGROUND

Successive quit smoking contests undertaken as part of the Minnesota Heart Health Program had generated diminishing impact. The 1988 contest attempted to rejuvenate community interest and participation through a substantially extended enrollment period.

METHOD

Smokers were eligible for monthly prize drawings and a grand prize drawing by entering the contest at any point between June 1988 and January 1989 and remaining abstinent for at least one month. The contest was promoted through newspaper advertisements, contest flyers, schools, and a community-wide direct mail campaign.

RESULTS

A total of 1,328 smokers returned initial interest cards and 918 (69.1%) of these smokers returned quit pledges. Self-reported abstinence for pledgers and nonpledgers was 16.7% and 9.2%, respectively. Survival analysis indicated significantly longer periods of abstinence for pledgers (p = .0001).

DISCUSSION

The extended contest was successful in recruiting smokers (almost 7% of the entire Bloomington smoking population vs. 1% for a previous one-month contest), especially those with less than a high school education. The current contest required substantial expenditures. However, these costs could be dramatically reduced through innovative use of donated resources.

Toward a comprehensive strategy for reducing the health burden of tobacco

In the absence of concerted worldwide action, the annual death toll from tobacco may reach 10 million by the middle of the next century. Smoking cessation approaches represent an important, but limited, means of reducing this death toll. Needed are co-ordinated strategies that address all facets of the tobacco issue. Especially important are advocacy campaigns targeting the tobacco industry and its supporters. Just as the Broad Street pump was isolated as the source of a cholera epidemic, the tobacco industry must be isolated as the source of a far greater epidemic.

Providing an integrated program of low intensity tobacco cessation services in a health maintenance organization

This paper reports on the development, promotion and use of a coordinated program of low intensity intervention services designed to appeal to smokers (and smokeless tobacco users) at various stages of change. An initial package of four components: a telephone advice line, self-help materials, single session group meetings and bi-monthly newsletter was offered to subjects in a variety of different settings (outpatient clinics, dental offices, worksites, hospitals) within a health maintenance (HMO) program project. Based upon consumer response and formative evaluations, these components were modified during the course of the year-long intervention. Results revealed differences in use of the various components of the program, with greatest use of self-help materials (manuals, 'tobacco substitutes' and a computerized smoking cessation aid) and least response to group meetings and the advice line. Most encouraging was the finding that it was possible to reach heavy smokers and to engage them in tobacco cessation activities through a centralized program of low intensity services. Data are presented on member characteristics associated with use/non-use of the various low intensity resources and suggestions are made for wider use of such interventions in other health care systems.

Survey of smoking patterns, attitudes, and interest in quitting

We conducted a survey of 875 smokers in a Minnesota Heart Health Program community who were nonparticipants in screening and intervention. We found particular levels of interest in quitting and in formal cessation topics and programs among these smokers. Also, we collected information on smoking history, social environment, and anticipated barriers to quitting. Most noteworthy was the finding that more than half of the respondents indicated a desire to be contacted by telephone to receive information on materials on, classes on and ways of quitting smoking. Topics of particular interest to smokers included physical addiction, stress reduction, and (for women) methods of avoiding weight gain after quitting. Only 7% of respondents reported that they definitely did not want to quit, and approximately one-third of those interested in quitting indicated that they would seek outside help in doing so. The findings support the viability of "reverse" helpline procedures in which smokers are contacted directly and offered assistance in quitting.

Reduced nicotine exposure and abstinence outcome in two nicotine fading methods

Two methods of nicotine fading as a smoking cessation preparation technique were compared. A brand-switching procedure and a three-stage set of "Nicotine Faders" graduated filters were the preparation strategies. Both methods implemented a putative 30-50-80% nicotine exposure reduction schedule in three weekly phases. There were a total of 110 study participants (57 in brand switching) enrolled in eight clinic groups. Results indicated that at the 80% reduction level, meaningful reductions in nicotine (measured by its metabolite cotinine) and carbon monoxide (CO) exposure were measurable with both nicotine fading procedures. Overall pooled nicotine and CO exposure drops from baselines of 48.2% and 35.5%, respectively, were recorded. The abstinence outcome measures (pooled 1-year abstinence prevalence = 30.9%) were not significantly different between the two preparation strategies. Trends in nicotine and CO exposure drops, and abstinence outcome measures, however, were consistently in favor of the graduated filters. Potential advantages of filters in the context of a preparation-for-quitting strategy were suggested.

A comparison of self-help approaches to smoking cessation

The current study evaluated the effectiveness of widely used self-help materials for quitting smoking. Five hundred and seventy smokers volunteered during a baseline survey to participate in the evaluation. After random assignment, 200 were mailed National Cancer Institute (NCI) "Quit for Good" materials, 200 the Minnesota "Quit and Win" program, and the remaining 170 were assigned to a nonintervention control condition. Results at 7-month follow-up failed to indicate treatment effects either for abstinence or for reported quit attempts. A number of smokers quit prior to the mailing of self-help materials, suggesting that a telephone prompt in itself may have been an important stimulus to cessation. Overall abstinence at follow-up was 10%. Contrary to expectation, successful participants were less likely to use a number of specific preparation strategies for quitting. The results are instructive in providing a large-scale assessment of self-help materials in a population of smokers that was not specifically seeking treatment.

Use of carbon monoxide breath validation in assessing exposure to cigarette smoke in a worksite population

Assessed the usefulness of carbon monoxide (CO) breath validation of self-reported smoking status in a large worksite population (N = 4,647). CO assessment was performed as part of a baseline survey procedure. CO levels differed substantially in relation to self-reported smoking status and amount smoked. Correcting for ambient exposure (estimated by mean CO levels among never smokers) produced more satisfactory results than uncorrected CO levels. Striking company differences were observed in mean CO exposures among self-reported never smokers. An unexpected finding was that 17.1% of current smokers reported smoking less than daily. Although the CO measure was excellent in detecting moderate and heavy smokers, it was inadequate in detecting occasional and light smokers. If detection of occasional or lighter smoking is critical to the purposes of the study, the more expensive (but more accurate) cotinine measure is preferred.

The influence of group cohesion on the behavioral treatment of smoking: a failure to replicate

The present investigation undertook a large-scale replication of an apparently successful group cohesion manipulation reported by Etringer, Gregory, and Lando (1984)l A 2 x 2 factorial design was initiated in which subjects were to be randomly assigned to enriched or standard cohesion and to satiation or nicotine fading. However, subject resistance to the satiation technique necessitated the abandoning of this part of the experimental procedure. Subjects assigned to nicotine fading (enriched or standard cohesion) included 184 women and 169 men. In contrast to the Etringer et al. study, there was virtually no evidence of a treatment effect on either group cohesion scores or abstinence outcome. Future work might attempt to establish more powerful manipulations of cohesion, which could then be applied especially to groups that fail to coalesce on their own.

Relapse and risk perception among members of a smoking cessation clinic

Assessed perceptions of the health risks associated with smoking in comparison with not smoking among members of smoking cessation clinics. We measured these perceptions at three different time periods during the clinic, and then again at a 6-month follow-up. Results indicated that members who were abstinent at the follow-up had lowered their perceptions of the likelihood of contracting smoking-related illnesses (e.g., emphysema) if they were not smoking. In contrast, those who had relapsed lowered their perceptions of the health risks associated with smoking, but not their perceptions of nonsmoking disease vulnerability. The implications of these changes in risk perception for therapy involvement are discussed.

Employee and organizational factors associated with participation in an incentive-based worksite smoking cessation program

This study investigated employee and worksite characteristics prospectively predictive of participation among 474 smokers in nine different worksites taking part in a year-long incentive-based smoking cessation program. Several different ways of defining participation (e.g., joining versus level of attendance, first 6 months versus entire program) were studied. A consistent pattern of results was observed across two of the participation indices, joining the program and participating in one or more monthly follow-up meetings. Both worksite (number of employees, previous health promotion history, degree of support from management) and employee (gender, motivation, previous quit attempts) variables were predictive of participation. Logistic regression analyses revealed that each set of variables, worksite and employee characteristics, was significantly related to participation after controlling for the effects of the other set. We were less able to predict level of attendance among participants who joined the program. Implications of these findings for future studies of participation in health promotion programs are discussed.

Comparative evaluation of American Cancer Society and American Lung Association smoking cessation clinics

We compared the effectiveness of American Cancer Society, FreshStart, American Lung Association, Freedom from Smoking, and laboratory clinic methods in subjects (N = 1041) from three communities. Three-month follow-up results favored the laboratory method over the two public service approaches on both a prevalence and a sustained abstinence measure. At one-year follow-up, treatment effects for smoking prevalence were no longer significant. However, sustained abstinence results at one-year remained highly significant and favored the more intensive laboratory and Freedom from Smoking clinics over the FreshStart method. FreshStart fared less well than the other interventions both in producing initial quit attempts and in sustaining abstinence among initial quitters. It should be noted, however, that FreshStart requires considerably less facilitator contact than do the other approaches. Unexpected outcome effects occurred for treatment location. Future clinic programs should include a specific target date for quitting and should place more emphasis upon recycling participants who fail to sustain abstinence.

Community impact of a localized smoking cessation contest

The present study assessed the effectiveness of a localized community contest timed to coincide with a statewide smoking cessation contest. Follow-up interviews were conducted with 218 local contest participants and 198 participants from the statewide contest. Overall cessation impact (participation rate x abstinence) was 0.39 percent for the local contest and 0.09 percent for the statewide contest. Localized community contests offered in conjunction with statewide or national campaigns may represent cost-effective methods of reaching large numbers of smokers.

Behavioral self-help materials as an adjunct to nicotine gum

The present study assessed the incremental effectiveness of behavioral self-help materials specifically written to accompany nicotine gum. Subjects (187 women and 117 men) were randomly assigned either behavioral self-help booklets or a factual information pamphlet. All subjects received prescriptions for Nicorette from study physicians. Contrary to prediction, subjects provided self-help booklets fared no better than did subjects provided comparison pamphlets. Overall abstinence levels were encouraging, however. Nicotine gum users were far more likely than nonusers to maintain abstinence through 6-month follow-up. Perhaps self-help materials could be improved by condensing and simplifying content and by adopting a more attractive multicolored pictorial format.

Lay facilitators as effective smoking cessation counselors

The present study assessed the relative effectiveness of doctoral counseling students and lay facilitators in conducting smoking cessation programs. Subjects (55 women and 61 men) were randomly assigned to doctoral or to lay facilitators. Consistent with prediction, lay facilitators were at least as effective as doctoral students. Overall results were comparable to those obtained in previous work in this laboratory. Allowing a choice of preparation technique may in itself enhance treatment outcome. The ability of lay facilitators to achieve clinically effective results provides further support for the generalizability of treatment to community settings.

Nicotine fading as a nonaversive alternative in a broad-spectrum treatment for eliminating smoking

The present investigation assessed the effectiveness of nicotine fading as a non-aversive alternative to oversmoking. Subjects (66 women and 64 men) were randomly assigned to oversmoking, nicotine fading, nicotine fading/smokeholding, and a nonmaintenance control. Results failed to indicate the expected superiority of nicotine fading/maintenance over the control condition. Instead, the addition of smokeholding appeared to produce a significant incremental effect over nicotine fading alone. Unfortunately, 12-month follow-up revealed considerable relapse across conditions and no significant treatment effects. Even so, absolute outcome for nicotine fading/smokeholding was encouraging. This procedure is both safe and apparently very acceptable to subjects. If the current results can be replicated, a clinically effective technique will have been established with applicability in both clinic and self-help settings.

Three-year data on a behavioral treatment for smoking: a follow-up note

A study reported by Lando (1981) compared two-stage treatment (aversion, maintenance) against three-stage treatment (preparation, aversion, and maintenance) under conditions of either intensive or minimal experimenter contact. One-year follow-up data indicated the superiority of the two-stage intensive contact procedure. The present article reports additional follow-up data at 12, 18, 24, and 36 months. Results continued to favor two-stage intensive contact. Long-term abstinence in this condition consistently exceeded 40% as opposed to less than 25% in the other conditions.

Inexpensive methods for recruiting subjects to smoking cessation programs

Researchers in the area of smoking cessation have often been plagued with difficulties in securing adequate subject samples. The present investigation assessed the effectiveness of specific publicity techniques (e.g., standard news releases, taped public service announcements, posters, letters to employers) in recruiting subjects. Studies were conducted in a metropolitan area of approximately 250,000 residents and in a university community of approximately 40,000 residents. Results were extremely encouraging, with the greatest impact apparently resulting from new releases, letters to employers, and word of mouth.

A factorial analysis of preparation, aversion, and maintenance in the elimination of smoking

The present investigation initiated a dismantling strategy in which subjects were assigned to treatment stages (preparation, aversion, maintenance) or to combinations of stages in a factorial design. It was hypothesized that multistage conditions would be superior to single stage conditions and that maintenance would retard relapse. Forty men and 33 women were randomly assigned to one of seven conditions. Results supported both hypotheses although significant effects were no longer evident at 12-month follow-up. Considerable relapse occurred in all conditions. Specific treatment components appeared to be of limited importance as indicated by generally very similar results for preparation and aversion. Booster sessions appeared to be ineffective. Interpretation of the findings is limited, however, by a relatively small subject enrollment in each condition. It was concluded that attempts to isolate extremely precise treatment elements are unlikely to be successful. Suggestions for further research included adoption of more structured maintenance strategies emphasizing coping skills and a more systematic focus upon potentially important process variables, notably group cohesiveness.