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Optimal Monitoring of the Tobacco Epidemic: What Cohort Studies Add
Gary Giovino, PhD Department of Health Behavior SUNY at Buffalo School of Public Health and Health Professions Innovations in Building Consumer Demand for Tobacco Cessation Products and Services May 4, 2007
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Outline Uses of Surveillance and Evaluation Examples of Cohorts Issues
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Uses of Surveillance and Evaluation Studies
To better understand: Trends over time Natural history of initiation and cessation processes Factors influencing use Consequences of use Justify and conduct research initiatives Identify high risk groups Set realistic objectives Justify and evaluate policies and programs Incorporating Pro--tobacco strategies Anti-tobacco strategies Moderators Assess the consequences of various harm reduction strategies
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Uses of Surveillance and Evaluation Studies
To better understand: Trends over time Natural history of initiation and cessation processes Factors influencing use Consequences of use Justify and conduct research initiatives Identify high risk groups Set realistic objectives Justify and evaluate policies and programs Incorporating Pro--tobacco strategies Anti-tobacco strategies Moderators Assess the consequences various harm reduction strategies
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Methods/Strategies Used Individual-level moderators
Conceptual Model Methods/Strategies Used Outcome Quit Attempt Policy Individual-level moderators (e.g., demographics, level of dependence, previous quit history, perceptions about pharmacotherapy and other treatment options, motivation, enjoyment of smoking) Adapts the International Tobacco Control Policy Evaluation Project Conceptual Model
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Optimal Methodology for Assessing Hard Core Smoking
Population-based serial cross sectional surveys AND rolling cohorts – national Measuring Tobacco use behaviors (including cessation strategies) Dependence Motivation, perceptions, attitudes, & intentions Co-Morbidities Efficacy, stress, support, coping skills Saliva/hair for biomarkers
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NATIONAL YOUTH SMOKING CESSATION SURVEY: STUDY DESIGN
24-month telephone study of smokers, ages years At baseline: Smoked 1+ cigarette in past 30 days Smoked 20+ cigarettes in lifetime Resided in the 50 states Four waves: Baseline (2003), 6-month ( ), 12-month (2004), 24-month (2005) Nationally representative-U.S. youth smokers years Weighted to CPS, Tobacco Use Supplement
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NATIONAL YOUTH SMOKING CESSATION SURVEY RR: 65.5% baseline respondents
Baseline Data June 30, 2003 – November 24, 2003 RR: 71.8% youth ages years (n = 2,582) 12-Month Follow-up Data June 30, 2004 – November 30, 2004 RR: 65.5% baseline respondents (n = 1,690)
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Methods/Strategies Used Individual-level moderators
Conceptual Model Outcome Methods/Strategies Used Quit Attempt Smoke-free Individual-level moderators (e.g., demographics, level of dependence, previous quit history, perceptions about pharmacotherapy and other treatment options, motivation, enjoyment of smoking) Adapts the International Tobacco Control Policy Evaluation Project Conceptual Model
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Assessing Hard Core Smoking Survey
National cohort study (telephone survey) of all current smokers aged ≥25 years Baseline survey, 2004 (n=1,000); 48% response rate 14-month follow-up survey, 2005 (n=761, follow-up rate = 76%) Assessed questions on smoking behaviors, indicators of nicotine dependence, experiences with quitting, physical activity, fruit and vegetable consumption, and demographic characteristics
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Methods/Strategies Used Individual-level moderators
Conceptual Model Outcome Methods/Strategies Used Quit Attempt Policy Individual-level moderators (e.g., demographics, level of dependence, perceptions about pharmacotherapy and other treatment options, motivation, enjoyment of smoking, functional utility) Adapts the International Tobacco Control Policy Evaluation Project Conceptual Model
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The International Tobacco Control Policy Evaluation Project
Canada United States Australia United Kingdom Ireland Thailand Malaysia South Korea China Mexico Uruguay France New Zealand Sudan India Netherlands
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ITC Survey Research Team
Canada Geoffrey T. Fong Mary E. Thompson Christian Boudreau K. Stephen Brown Sharon Campbell David Hammond Paul W. McDonald Changbao Wu Mark P. Zanna United States K. Michael Cummings Gary A. Giovino Andrew Hyland Richard J. O’Connor Frank J. Chaloupka Fritz L. Laux Hana Ross Maansi Travers Australia Ron Borland Mohammad Siahpush Melanie Wakefield Hua Yong David Young United Kingdom Gerard Hastings Ann McNeill Louise Hassan Anne Marie Mackintosh Fiona Harris Ireland Shane Allwright Luke Clancy Fenton Howell Maurice Mulcahy Korea Hong Gwan Seo Yoo-Seock Cheong Thailand Buppha Sirirassamee Chanya Sethaput Aree Prohmmo Philip Guest Steve Hamann Prakit Vateesatogkit Malaysia Maizurah Omar Foong Kin Rahmat Awang India* Prakash Gupta Dhirendra Sinha Prabhat Jha France Sylviane Ratte Pierre Arwidson François Beck Mexico James Thrasher Sudan* Asma Elsony China Jiang Yuan Yang Yan Feng Guoze Wei Xiao Shuai Uruguay Marcelo Boado Eduardo Bianco New Zealand Nick Wilson George Thomson Netherlands* Marc Willemsen * ITC Surveys currently in development
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The ITC Surveys Extensive surveys of national representative samples of adult smokers in each country (in most countries, N ≥ 2,000) ITC Methods: as rigorous as the conditions will allow Evaluation of FCTC policies at the individual level Cohort survey: same individuals surveyed every year Identical/similar methods/measures in all countries Measures of each FCTC demand policy
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The ITC Surveys
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(Psychosocial Mediators)
Mediational Model(s) of Policy Effects Proximal Variables (Policy-Specific) Distal Variables (Psychosocial Mediators) Policy Behavior Label Salience Perc Effectiveness Depth of Processing Labels Perceived risk Perceived severity Intentions to Quit Quit Attempt Denorm beliefs Social accept Subjective norms Advertising salience Positive assns Intentions to Quit Quit Attempt Ad Ban Different policies operate differently, but can be described by the same general model
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Smoking Toolkit Study United Kingdom – Robert West Needs:
Accurate and timely information on key markers of progress for smoking cessation Data to guide policy Facilitate achieving goals in prevalence reduction STS = feasibility study Panel study of consumers (similar to tobacco industry panel studies)
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Smoking Toolkit Study - Methods
Baseline data from omnibus household survey (April-May 2005) Identify smokers willing to participate in a follow-up study (901 of 1432) Wave 1 Mail survey (July-August 2005)(329 responded; 93 provided cotinine) Wave 2 Mail Survey (November-December 2005)(271 –responded; 74 provided cotinine) Measured: CPD, dependence, quit attempts/methods/strategies; motivators
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Smoking Toolkit Study - Results
Application of weights to baseline data demographic and smoking data similar to General Household Survey Little missing data and few don’t knows 50% of attempts involved assistance 36% of attempts involved GR 38% of attempts were initiated as soon as the decision to quit was made Forgetting of shorter quit attempts Low follow-up rate (271/1432 – 18.9%)
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Smoking Toolkit Study Future work:
Quarterly and ideally monthly assessments 7,000 respondents for ₤300,000 per year Follow-up rate needs to be addressed Adjustments for forgetting needed (forward telescoping?)
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Issues Representativeness Necessary in XS studies Important in cohorts
Timeliness may be of greater value Multi-level models optimal
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Acknowledgements Funding from: Robert Wood Johnson Foundation
American Legacy Foundation National Cancer Institute Centers for Disease Control and Prevention
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Mean BMI at Baseline (1971-1975) and Follow-up (1982-1984)
Never Smokers Former Smokers Quitters Current Smokers Source: Williamson et al. New England J Medicine 1991;324:
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Multivariate Analysis
Multivariate Analysis* of ≥ 5 Servings of Fruits and Vegetables Per Day by Smoking Status – United States, (BRFSS) Former Smoker *Logistic regression analyses adjusted for age, sex, race/ethnicity, education, and income. Source: Yang J, Giovino G. Smoking Status and Body Mass Index in the United States: Unpublished data. N=429,657.
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Total Fruits & Fruit Juice Total Fruits & Vegetables
Multivariate Analyses of Weekly Consumption of Fruits and Vegetables and 30-Day Abstinence – Current Smokers, ≥ 25 Years Old, United States, 2004/2005 Q1 Q2 Q4 Q3 Q1 Q2 Q4 Q3 Q1 Q2 Q4 Q3 Q1 Q2 Q4 Q3 Green Salad Total Fruits & Fruit Juice Total Vegetables Total Fruits & Vegetables Q1= servings Q2= servings Q3= servings Q4= ≥4.61 servings Q1= servings Q2= servings Q3= servings Q4= ≥12.01 servings Q1= servings Q2= servings Q3= servings Q4= ≥18.61 servings Q1= servings Q2= servings Q3= servings Q4= ≥29.62 servings Assessing Hardcore Smoking Survey. Weighted to the 2004 National Health Interview Survey. Unweighted n=744; weighted n=719.
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