Alcohol, tobacco and local control: A comparison of several community-based prevention trials

In North America there are significant similarities and differences in attitudes with regard to alcohol and tobacco on several dimensions, including the view taken of producers, suppliers and retailers, the products, and in the patterns of use. There are also contrasting as well as overlapping tendencies with regard to perceived problems associated with alcohol versus tobacco consumption, intervention initiatives and the resources available. These secular developments and forces provide a context for examining 10 community-based prevention trials which have sought to reduce harm from alcohol or tobacco using a range of strategies. The strategies have included education and information campaigns, media advocacy, counter-advertising and health promotion, controls on selling and consumption venues and other regulations reduced access to alcohol or tobacco, enhanced law enforcement and surveillance, and community organizing and coalition development. The paper outlines the challenges of undertaking community-based trials and interpreting their findings. It notes that interventions which show promise are those that pay particular attention to controls on access, include the environmental contexts of where the products are sold and distributed, and involve enforcement of public health polices. Controlling tobacco use may be made somewhat easier, than is the case for alcohol, with the vilification of the tobacco industry and marginalization and victimization of smokers. Nevertheless, the community trial provides opportunities for reducing harm related to alcohol and tobacco, particularly if resources are oriented in a coordinated way to those control measures and policies with the widest scope and greatest effectiveness.

Integration of the Ecological Approach in Tobacco Programs for Youth: A Survey of Canadian Public Health Organizations

This study assessed the level of integration of the ecological approach in Canadian public health organizations’ tobacco control programs for youth. The study used a model that identified intervention settings, targets, and strategies as key dimensions of an ecological approach to programs. An inventory of the tobacco youth programs implemented by regional public health organizations identified 148 organizations conducting such programs, 129 of which agreed to participate. Program descriptions were obtained through telephone interviews. The mean number of settings in which programs were implemented was 3 (SD = 1.3), with schools and communities being the most often-used settings. The mean number of different intervention strategies was 3.6 (SD = 1.7). Most frequently, programs directly targeted youths themselves, followed by interpersonal and organizational environment. Overall, the level of integration of the ecological approach was deemed high. Canadian public health organizations’ tobacco control programs aimed at youth are evolving toward a more comprehensive agenda.

Poor patient awareness of the relationship between smoking and periodontal diseases

OBJECTIVE

To investigate patients' knowledge of the effects of smoking on periodontal health.

DESIGN

Patient answered questionnaires, which were anonymous.

SETTING

Patients who attended GKT Dental Institute, King's College, London for dental treatment.

SUBJECTS

One thousand patients attending Restorative Consultant Clinics and Primary Dental Care.

RESULTS

Seventy-eight per cent of patients were aware that smoking had a negative impact on health. However, 52% of these patients who were aware could not state what the negative effects were on oral health. Seven per cent of patients stated that smoking affected the gums but did not state how it affected the gums. Only 6% of respondents knew specifically of the link between smoking and periodontal disease. The only statistically significant factors associated with increased awareness were smoking status, ie being a non-smoker and being registered with a general dental practitioner. Non-smokers and those registered with GDPs were more likely to be aware of the association between smoking and periodontal diseases.

CONCLUSIONS

This study highlights patients' lack of awareness of the relationship between smoking and periodontal diseases, with only 6% of respondents knowing of the link between tobacco and periodontal diseases.

Family, friend or foe? Critical reflections on the relevance and role of social capital in health promotion and community development

Social capital has been the focus of considerable academic and policy interest in recent years. Despite this interest, the concept remains undertheorized: there is an urgent need for a critical engagement with this literature that goes beyond summary. This paper lays a foundation for a critical dialogue between social capital and health promotion, by examining problematics in the conceptualization and practice of social capital building and linking these to models of community development, a cornerstone health promotion strategy. In so doing, the paper contributes to the existing literature by providing a theoretical exposition and critique of various threads in social capital discourse, and linking these threads explicitly to community development practice. Distinctions between communitarian, institutional and critical approaches to social capital are elaborated, and the relationships between these three approaches and three models of community development-social planning, locality development, and social action-are discussed. The existing social capital literature is then critically examined in relation to three key themes common to both literatures: community integration, public participation, and power relations. This examination suggests that social capital cannot be conceived in isolation from economic and political structures, since social connections are contingent on, and structured by, access to material resources. This runs counter to many current policy discourses, which focus on the importance of connection and cohesion without addressing fundamental inequities in access to resources. This paper posits that approaches to community development and social capital should emphasise the importance of a conscious concern with social justice. A construction of social capital which explicitly endorses the importance of transformative social engagement, while at the same time recognising the potential negative consequences of social capital development, could help community organizers build communities in ways that truly promote health.

Approaches to substance use prevention utilizing school curriculum plus social environment change

Hundreds of studies have tested the efficacy or effectiveness of school curriculum-based (CB) substance use prevention programs. Over the years, various researchers have also tested programs that included school curricula, but with the addition of school environment, family, mass media, or community components. The purpose of this review is to determine the extent to which adding any of these components to CB programs improves overall program effectiveness in the prevention of substance use (SU).

Sociopsychological correlates of motivation to quit smoking among low-SES African American women

This article examines correlates of desire and plans to quit smoking among 248 young, low-socioeconomic status African American women, using variables derived from the health belief model (HBM) and the theory of reasoned action. Consistent with these theoretical models, stronger concern about the effect of smoking on one's health and having close others who want the smoker to quit increased motivation to quit smoking. However, motivation was not associated with specific HBM components regarding lung cancer. Heavier smoking and stronger perceptions regarding the functional utility of smoking decreased motivation to quit, but not as much as expected in this study population. Consistent with a process of change approach to smoking cessation, the factors that moved smokers from not planning to planning to ever quit were different from factors associated with further motivation level among the smokers who did plan to ever quit.

A Voluntary Smokers' Registry: Characteristics of joiners and non-joiners in the Community Intervention Trial for Smoking Cessation (COMMIT)

OBJECTIVES

This paper examines differences between joiners and nonjoiners of a voluntary smokers' registry.

METHODS

A baseline prevalence survey was used to identify characteristics of smokers who joined or did not join a smokers' registry.

RESULTS

Communities varied significantly in registry enrollment rates. Heavy-smoking joiners expressed more desire to quit, were more likely to live with nonsmokers, and were older than nonjoiners. Light-to-moderate joiners smoked more, were more addicted to cigarettes, and expressed more desire to quit than nonjoiners.

CONCLUSIONS

Few baseline characteristics differentiated joiners from nonjoiners. Nonjoiners were significantly more likely to achieve cessation than joiners.

Worksite characteristics and changes in worksite tobacco-control initiatives. Results from the COMMIT study

Few studies have prospectively examined the characteristics associated with worksite adoption of tobacco-control initiatives. Data were collected as part of the Community Intervention Trial (COMMIT) for Smoking Cessation, which conducted interventions in 11 communities. This smoking cessation intervention was based on community organization principles and delivered through multiple community channels, including worksites, health care providers, the media, and cessation resources. This article reports results from telephone interviews of intervention community worksites having 50 or more employees, conducted at baseline and the end of the intervention period. Among worksites that responded to both baseline and final surveys, 83% had not adopted a smoke-free policy at baseline, and 61% did not offer any cessation aid or quitting resources at baseline. By the final survey, 34% of those with no smoking ban at baseline had become smoke-free, and 36% of those offering no cessation assistance at baseline were offering cessation resources at the follow-up. The prevalence of policy adoption was higher among worksites employing more female employees and offering other health-promotion activities; manufacturing businesses were significantly less likely than businesses other than service and wholesale/retail businesses to adopt policies. Adoption of cessation programs was significantly more likely among worksites employing 100 to 249 workers, compared with those employing 50 to 99 workers; those predominantly employing men; those offering other types of health-promotion activities; and those with a higher rate of turnover. These results provide important information about the characteristics of worksites likely to engage in tobacco-control efforts. Health educators and others may choose to target those worksites most ready for adoption of tobacco control policies and programs, as indicated by these findings.

Building academic-community linkages for health promotion: a case study in Massachusetts

Using select practice variables from Rothman's typology of models of community organization, this case study of the Massachusetts Community-Based Public Health Consortium analyses potential sources of conflict in collaborations between academic institutions and community coalitions. Based on different socialization experiences and organizational expectations, the goals, assumptions, basic change strategies, salient practitioner roles, conceptions of the client population, and client roles of the respective organizations were found to differ between these two partners and to be a source of chronic, unproductive tensions in consortium deliberations. The article concludes with recommendations for facilitating the development of more mutually trustworthy academic-community linkages to achieve public health promotion goals. These recommendations include (1) developing a greater awareness of the respective kinds of assumptions academic and community partners are likely to bring into new partnerships and (2) developing a more highly integrated model of community-based public health that capitalizes on the strengths of both the social planning and locality development approaches.

Statistical design of the Child and Adolescent Trial for Cardiovascular Health (CATCH): implications of cluster randomization

This paper describes some statistical considerations for the Child and Adolescent Trial for Cardiovascular Health (CATCH), a large-scale community health trial sponsored by the National Heart, Lung, and Blood Institute. The trial involves randomization of entire schools rather than individual students to the experimental arms. The paper discussed the implications of this form of randomization for the design and analysis of the trial. The power calculations and analysis plan for the trial are presented in detail. The handling of outmigrating and immigrating students is also discussed.

Cohort versus cross-sectional design in large field trials: precision, sample size, and a unifying model

In planning large longitudinal field trials, one is often faced with a choice between a cohort design and a cross-sectional design, with attendant issues of precision, sample size, and bias. To provide a practical method for assessing these trade-offs quantitatively, we present a unifying statistical model that embraces both designs as special cases. The model takes account of continuous and discrete endpoints, site differences, and random cluster and subject effects of both a time-invariant and a time-varying nature. We provide a comprehensive design equation, relating sample size to precision for cohort and cross-sectional designs, and show that the follow-up cost and selection bias attending a cohort design may outweigh any theoretical advantage in precision. We provide formulae for the minimum number of clusters and subjects. We relate this model to the recently published prevalence model for COMMIT, a multi-site trial of smoking cessation programmes. Finally, we tabulate parameter estimates for some physiological endpoints from recent community-based heart-disease prevention trials, work an example, and discuss the need for compiling such estimates as a basis for informed design of future field trials.

Smoking cessation factors among African Americans and whites. COMMIT Research Group

OBJECTIVES

This study was undertaken to explore smoking patterns and attitudes that influence smoking cessation and relapse among African Americans.

METHODS

Baseline data from eight Community Intervention Trial for Smoking Cessation (COMMIT) sites were analyzed.

RESULTS

Compared with Whites, African Americans who smoke less than 25 cigarettes per day were 1.6 times more likely to smoke within 10 minutes of awakening (a behavioral indicator of nicotine dependence), adjusting for education, age, and gender (OR = 1.2 for heavier smokers). African Americans reported a stronger desire to quit smoking and reported serious quit attempts in the past year. African Americans favored tobacco restrictions (they were 1.8 times more likely than Whites to view smoking as a serious community problem, 1.7 times more likely to favor restrictions on cigarette vending machines, and 2.1 times more likely to prohibit smoking in their car). African Americans were lighter/moderate, menthol smokers.

CONCLUSIONS

African Americans find smoking socially unacceptable and are strongly motivated to quit, but their "wake-up" smoking may indicate high nicotine dependence, making abstinence difficult even for lighter smokers.

Compliance with worksite nonsmoking policies: baseline results from the COMMIT study of worksites

PURPOSE

Little is known about compliance with worksite nonsmoking policies. This study provides an examination of the relationship of policy compliance to characteristics of the organization and the manner in which the policy was implemented.

DESIGN

Data came from two separate surveys of 1) representatives of worksites that reported having a nonsmoking policy and 2) employed residents from the same communities whose worksites had nonsmoking policies.

SETTING

This study was conducted as part of the Community Intervention Trial for Smoking Cessation (COMMIT), being conducted in 11 diverse intervention communities.

SUBJECTS

Data are presented from surveys of 710 worksites (response rate = 90%) and 3,143 employed residents (response rate = 80%) of the same communities.

MEASURES

Compliance with nonsmoking policies was measured by self-report in both surveys and is compared with worksite and respondent characteristics, type of policy, and methods of policy implementation.

RESULTS

Compliance with nonsmoking policies was high; 55% of worksites with a policy restricting smoking reported that employees always adhered to the policy. Compliance was highest in worksites with more restrictive policies and where labor-management relations were reported to be good. Compliance also was high where the policy was effectively communicated to workers, as through worksite distribution channels, the absence of cigarette vending machines, and the availability of cessation assistance.

CONCLUSIONS

These findings indicate that compliance with worksite nonsmoking policies is generally high, especially in the presence of more stringent policies.

Employee advisory boards as a vehicle for organizing worksite health promotion programs

PURPOSE

The purpose of this article is to describe the "employee advisory board model" applied in the Treatwell program, a worksite nutrition intervention program.

DESIGN

The employee advisory boards of five of the seven intervention worksites participating in the Treatwell program were surveyed. Results were compared with results of employee surveys conducted in these five worksites.

SETTING

The five worksites included in this study are among 16 participating worksites from Massachusetts and Rhode Island.

SUBJECTS

Of the 95 board members represented in the five worksites, 88% responded to the survey. This article also presents results from the 698 respondents of the five intervention worksites where the board surveys were conducted.

INTERVENTION

The boards in each worksite participated in planning, promoting, and implementing this program in each worksite.

MEASURES

Respondents to the board survey were asked about their participation on and satisfaction with the board and factors they thought contributed to its effectiveness. A survey of all employees included information on demographics and program participation.

RESULTS

Board members reported that they were highly satisfied with the board's functioning. Board member hours spent on Treatwell activities were directly related to the proportion of employees aware of the program. (r = .82). The boards' effectiveness was limited by conflicting priorities between the job and board responsibilities.

CONCLUSION

The employee advisory board model provides promise for increasing worker awareness of worksite health promotion programs through enhanced worker ownership.

Aspects of statistical design for the Community Intervention Trial for Smoking Cessation (COMMIT)

We present statistical considerations for the design of the Community Intervention Trial for Smoking Cessation (COMMIT). One outcome measurement, the quit rate in randomly selected cohorts of smokers, is compared with another outcome measurement, the decrease in smoking prevalence, in terms of statistical efficiency and interpretability. The COMMIT study uses both types of outcome measurements. The merits of pair-matching the communities are considered, and sample size calculations take into account heterogeneity among pair-matched communities. In addition to significance tests based on the permutational (randomization) distribution, we also describe approaches for covariate adjustment. The COMMIT design includes 11 pair-matched communities, which should provide good power to detect a 10% or greater difference in quit rates between the intervention and control communities in cohorts of heavy smokers and in cohorts of light or moderate smokers. The power is only moderate to detect intervention effects on the decreases in overall smoking prevalence or in the prevalence of heavy smoking.