Colorado's State Tobacco Education and Prevention Partnership: Evaluation of Impact,

Transcription

1 Colorado's State Tobacco Education and Prevention Partnership: Evaluation of Impact, Arnold H. Levinson, Ph.D. Theresa Mickiewicz, M.S.P.H. University of Colorado at Denver and Health Sciences Center June 30, 2005

2 Contents Introduction... 1 Overview of the intervention... 2 Results Smoking cessation... 3 Cessation among adults aged Other cessation indicators among adults aged 25+ Quit attempts... 8 Smoking during pregnancy... 8 Nondaily smoking... 9 Cigarette sales... 9 Smoking prevention Adolescents Young adults Other indicators Quit attempts Smoking during pregnancy Nondaily smoking Secondhand smoke Smoke exposure on the job Smoke exposure at home Discussion Smoking cessation Smoking prevention Secondhand smoke Evaluation capacity Conclusions Appendix: Cessation and the Colorado Quitline... 23

3 Introduction This evaluation examines the impact of Colorado's programmatic efforts to prevent and reduce tobacco use, during a period when these efforts were greatly expanded using funds from Colorado's litigation settlement with the tobacco industry. * The central question is: Does available evidence, considered as a whole, support an interpretation that Colorado's expanded tobacco control efforts during the evaluation period led to improved population health in terms of tobacco-related behaviors? The evaluation focuses on three overarching goals that Colorado pursued during this period: o o o increasing cessation among youth and adults; preventing initiation of tobacco use among youth; reducing exposure to environmental tobacco smoke (ETS) or secondhand smoke (SHS). Data used for the evaluation included: o o annual population-level health surveys conducted by the Colorado Department of Public Health and Environment (CDPHE), using questionnaires from the U.S. Centers for Disease Control and Prevention (CDC) that are also used in other states; annual reports and expenditure records from the State Tobacco Education and Prevention Partnership (STEPP) and selected STEPP contractors. Additional information sets were reviewed but not used because of uncertainty about their validity or reliability in the current analytic context. These data limitations are noted in the narrative where they are relevant. An important analytic decision was how to define the "intervention" period when STEPP activities were meaningfully more extensive than before. In the 1990s, Colorado's tobacco-use prevention and reduction program received roughly $1 million per year from the National Cancer Institute or the Centers for Disease Control and Prevention (CDC). Master Settlement Agreement (MSA) funds became available to STEPP as of July 1, 2000, and funding was set at roughly $15 million per year for five years. However, actual funding was considerably lower than originally planned. During Calendar Years (CY) 2000 through 2004, STEPP reported expending the following amounts of MSA funding: CY2000: $200,000 CY2001: $5 million CY2002: $14.7 million CY2003: $9.9 million CY2004: $3.6 million Based on these expenditure levels, the current evaluation defines CY2000 as part of the preintervention period, CY2001 as a transition year, and CY as active intervention. Where data were available for CY2004, we report both CY and CY results to address the possibility that reduced funding in CY2004 might be associated with reduced impact. In addition, since all 50 states received MSA funding during the evaluation period, we compared results between Colorado and other states to determine whether effects were state-specific or reflected elsewhere in the nation. * National Association of Attorneys General. Master Settlement Agreement. Available at: Access verified 1/21/ , Colorado Revised Statutes. 1

4 Introduction, continued Overview of the Intervention The intervention to be evaluated is a comprehensive statewide program that applied CDC best practices * to pursue prevention and cessation of tobacco use and reduction of exposure to secondhand smoke (SHS). The main intervention components included: o local tobacco programs in most counties, housed in county health agencies or nursing offices, pursuing annual program objectives chosen locally within state guidelines; o statewide smoking cessation initiatives, including internet and telephone support services (Colorado Quitline and Colorado QuitNet) promoted through paid advertising; a health provider training and mobilization effort, and the adolescent cessation program "Not on Tobacco" (NOT!); o statewide smoking prevention initiatives, including support for local youth coalitions (Get R!EAL), educational curricula, college education and policy campaigns, and enforcement against cigarette sales to minors. Report Format This report presents results separately for each of the three STEPP target domains cessation, prevention, and protection from secondhand smoke. The discussion section presents the implications and limitations of the main findings. * CDC. Best Practices for Comprehensive Tobacco Control Programs August Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, August

5 Smoking Cessation In theory, smoking cessation programs are needed only if smoking prevention is unsuccessful. However, roughly half of U.S. adults were already smokers when the U.S. Surgeon General first warned in 1965 that smoking is a health hazard, and the biggest gains on the problem have come through adult smokers' quitting. STEPP has implemented a variety of strategies to encourage and support cessation, probably the most visible of which is the Colorado Quitline (see Appendix). The evaluation of STEPP's cessation programming focuses on current smoking rates, rather than cessation rates, because available data are too sparse to evaluate change in the annual percent of smokers who quit. * In the graph below, the years being evaluated are highlighted, and vertical "whiskers" are margins of error, or 95% confidence intervals. The graph shows that Colorado's smoking rate among adults (ages 18+) remained relatively level from 1995 through 2001 except for an unsustained, non-significant decline in The smoking rate declined during , the years of greatest MSA funding, and increased in 2004 but remained lower than pre-2003 levels. The rate increase in 2004 coincides with (but is not necessarily caused by) a substantial reduction in MSA funding for STEPP activities. 27% 26% 25% 24% 23% 22% 21% 20% 19% 18% 17% Current Smoking: Colorado Adults Aged '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 ' * Compared to pre-intervention years, the annual quit rate (not smoking for 6 months or longer) appears to have increased during by about 1.5 percentage points, roughly 9,000 additional ex-smokers per year. However, the apparent improvement may be merely a measurement error due to small sample sizes. Changes in survey question wording during make comparison to the years before 1995 harder to interpret. The 2000 rate is not statistically different from the rates in adjacent years. By treating the 2000 rate as part of the pre-intervention period, the analysis reduces the chance of a "false-positive" intervention success. Unless noted, estimates in this report were computed using data from the Centers for Disease Control and Prevention (CDC), Behavioral Risk Factor Surveillance System (BRFSS). The data are available for download at accessed March

6 Cessation, continued Progress in prevalence Comparing to , Colorado reported the 4 th largest improvement in smoking prevalence among the 50 states. The decline was statistically significant and improved Colorado's rank from 12 th lowest in to 7 th lowest in * Smoking among adults aged 18+ before and during MSA funding of Colorado STEPP '99-'00 '02-'03 '02-'04 Current cigarette smokers (% of total population) 21.3% 19.5%* 19.6% * difference from '99-'00 is significant, p<0.05 Cessation among Adults Aged 25+ Although most adult regular smokers consumed their first cigarette while they were teenagers, nearly half of regular smoking begins during ages (This age group also has the highest smoking rate.) Programs to promote cessation are thus most relevant to smokers older than 24, when experimentation or situational smoking has led to either nonsmoking or regular smoking. 27% 26% 25% 24% 23% 22% 21% 20% 19% 18% 17% 16% Current Smoking: Colorado Adults '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 ' * Smoking data for 2004 are not yet available from other states. Trinidad DR, Gilpin EA, Lee L, Pierce JP. Do the Majority of Asian-American and African-American Smokers Start as Adults? American Journal of Preventive Medicine 2004; 26(2):

7 Cessation among adults aged 25+, continued Progress in prevalence, adults aged 25+ As the previous figures showed, the smoking trend in Colorado was similar among adults aged 25+ to the trend among all adults. Comparing pre-msa and MSA study periods ( vs ), the decline in smoking prevalence among this age group was the 6 th largest improvement among the 50 states. The decline improved Colorado's smoking rate in this age group from 11 th lowest in to 8 th lowest in As with all adults, the rate increased slightly in 2004, coinciding with (but not necessarily caused by) a substantial reduction in MSA funding for STEPP activities. Smoking among adults aged 25+ before and during MSA funding of Colorado STEPP '99-'00 '02-'03 '02-'04 Current cigarette smokers (% of total population) 20.2% 18.7% 18.7% Note: differences are not statistically significant How Colorado Compared As noted in the introduction, all 50 states received MSA funding during the evaluation period. To determine whether improvements were Colorado-specific or reflected elsewhere in the nation, we examined smoking prevalence trends in the United States as well as selected groupings of states, based on the following considerations: Two states California and Massachusetts enacted tobacco-tax measures before 1993 and have devoted substantial revenues to comprehensive tobacco-use prevention and reduction programs. As a result, they generally progressed faster than other states in preventing and reducing tobacco use. Smoking has generally been less common in the western continental United States, and a more appropriate comparison might be between Colorado and the western region (excluding California for the reason cited above). We thus compared Colorado's smoking trend among adults aged 25+ with: the rest of the United States; the rest of the United States excluding California and Massachusetts; the western continental United States excluding California; the two leading states, California and Massachusetts. Graphs and data tables on the next two pages suggest that Colorado's smoking prevalence declined faster during the MSA period than the U.S. rate of decline with or without California and Massachusetts. The gap in smoking prevalence between Colorado and the two leading states appears to have narrowed during the MSA period. Colorado's decline may have been faster than the rate in the western United States, but the difference is not statistically significant. 5

8 Cessation among adults aged 25+, continued 26% 25% 24% Current smoking: Colorado and U.S., adults aged 25+ US w/o CA & MA CO CA & MA 23% 22% 21% 20% 19% 18% 17% 16% 15% '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 US without CA & MA US (not graphed) CO CA & MA

9 Cessation among adults aged 25+, continued 26% 25% Current smoking: Colorado and western U.S., adults aged 25+ west w/o CA CO CA 24% 23% 22% 21% 20% 19% 18% 17% 16% 15% 14% '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 CO western US without CA* western US (not graphed)* CA * Alaska and Hawaii excluded 7

10 Other Cessation Indicators among Adults Aged 25+ Quit Attempts Successful smoking cessation is usually achieved only after repeated failed attempts. An increase in quit attempts thus may predict a future increase in successful cessation. The percentage of smokers aged 25+ reporting a quit attempt in the previous 12 months was significantly higher during the MSA period than immediately before the period. The increase began before substantial MSA funding began in Colorado, however, and may be partly due to other factors. Percent of Colorado smokers aged 25+ who reported a serious quit attempt in the previous 12 months '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 ' * * question was asked differently Comparison of quit attempts, before vs. during MSA-funded period Percent of current smokers '99-'00 '02-'03 '02-'04 who made a "serious" quit attempt (24+ hours) 43.3% 51.5%* 50.7%* *significantly different from rate, p<0.01 Smoking During Pregnancy Since 1996, Colorado has been part of a multi-state monitoring system that examines trends in health risks during pregnancy. * Available data show no detectable change in the rate of smoking during pregnancy between the pre-msa and MSA period in Colorado. The lack of change may be due to a "ceiling effect:" More than 93% of pregnant women in the pre-msa period didn't smoke, so further reduction of smoking in pregnancy was highly unlikely without intensive targeted effort. Colorado Women Aged 25+ Who Smoked During Pregnancy '99-'00 '02-'03 6.6% 6.1% Source: Pregnancy Risk Assessment Monitoring System (PRAMS), Colorado STEPP * Pregnancy Risk Assessment Monitoring System (PRAMS). Data were provided by the Health Statistics Division, Colorado Department of Public Health and Environment. PRAMS documentation is available at and 8

11 Other cessation indicators, adults aged 25+, continued Nondaily Smoking Smokers' average daily cigarette consumption was not measured during MSA funding years. However, a related measure is the proportion of smokers who convert from daily smoking to smoking on some days ("occasional smoking"). The proportion of smokers reporting occasional smoking rather than daily smoking was slightly, non-significantly larger during MSA funding years; no trend is evident across all available years. '96 '97 '98 '99 '00 '01 '02 '03 ' % 23.0% 21.2% 20.0% 26.2% 29.4% 22.7% 24.1% 28.4% Nondaily smoking before vs. during MSA-funded period '99-'00 '02-'03 '02-'04 Percent of current smokers who don't smoke every day 22.9% 23.4% 25.1% Cigarette Sales Another indirect measure of consumption is per capita cigarette sales, which can be estimated in Colorado from wholesale excise tax revenues. * As the graph shows, annual sales per state inhabitant have been declining in Colorado and the nation as a whole. Annual Per Capita Cigarette Sales, Colorado vs. U.S Packs CO packs/capita US packs/capita '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 CO US Sources: Colorado Dept. of Revenue, U.S. Dept. of Agriculture * Wholesale tax revenues reflect business inventory decisions, and are thus a crude measure of retail sales. Colorado is the only state that exempts cigarettes from retail sales tax, which more closely tracks actual consumption. 9

12 Other cessation indicators, adults aged 25+, continued Cigarette Sales, continued Comparing peak MSA funding years with pre-intervention years ( vs ), Colorado's per capita cigarette sales declined more than the national decline (12.1% vs. 8.6%). During 2004, however, the nation's per capita cigarette sales continued to decline but Colorado's sales increased, coinciding with (but not necessarily caused by) a substantial reduction in MSA funding for STEPP activities. For the three-year intervention period being evaluated, the table shows that declines in sales were similar for Colorado and the United States as a whole. Per capita cigarette sales (packs) before and during MSA funding '98-'00 '02-'04 change CO % US % Sources: Colorado Dept. of Revenue, U.S. Dept. of Agriculture 10

13 Smoking Prevention Adolescents Smoking prevention has the obvious potential benefit of avoiding the need later on in life to treat addicted smoking. To paraphrase the old saying, an ounce of smoking prevention might save a pound of treatments for addicted smokers. This rationale underlies the focus on prevention as one of STEPP's three overarching objectives. Information on changes in adolescent smoking for Colorado is limited to years 2000 and 2003, which offers only weak comparison of pre-intervention and intervention periods. Results among high school students * suggest that smoking may have been less common and experimentation may have been delayed during the intervention period compared to the earlier period. The differences are not statistically reliable, possibly because the samples are inadequate to detect small changes. Neither earlier data nor comparable national data are available. Smoking among Colorado High School Students Ever tried cigarettes, even a puff 61.6% 55.6% Currently smoke cigarettes 25.3% 24.1% Smoked on 20+ of last 30 days 11.1% 11.3% Smoked first cigarette before age % 74.8% among students who reported smoking at least one cigarette Source: Youth Tobacco Survey, Colorado STEPP Similarly, smoking during pregnancy among teenaged mothers may have been lower during the intervention period than before. Again, the difference is not statistically reliable, possibly because samples are inadequate to detect small changes. Colorado Adolescents (aged 15-17) Who Smoked During Pregnancy '99-'00 '02-' % 9.0% Source: PRAMS, Colorado STEPP * Middle school data are not shown because relatively few middle school students engage in smoking, and the adolescent health survey samples that are available are big enough only to study widespread behaviors. 11

14 Smoking prevention, continued Young Adults Prevention of smoking focuses on both adolescents and young adults. The latter group is an important audience for prevention efforts because, as previously discussed, nearly half of regular smoking begins during ages (This age group also has the highest smoking rate.) The success of prevention efforts may thus be measured partly in terms of smoking prevalence among young adults. * Colorado's smoking rate among young adults appears to have declined during , the years of greatest MSA funding, and increased in However, none of these apparent changes exceeds the margins of error. 50% 45% 40% 35% 30% 25% 20% 15% 10% Current Smoking: Colorado Young Adults '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 ' * The CDC's annual health surveys make no special effort to include extra numbers of young adults, thus information about this population is based on small samples that reduce the power of comparisons between years. 12

15 Smoking prevention, continued Progress in prevalence, adults aged Comparing to , the decline in smoking prevalence among young adults was the 7 th largest improvement in rates among the 50 states. Although not statistically significant, the change substantially improved Colorado's ranking for young adult smoking, from the 24 th lowest rate in to the 6 th lowest in * Smoking among young adults before and during MSA funding of Colorado STEPP '99-'00 '02-'03 '02-'04 Current cigarette smokers (% of total population) 29.4% 24.3% 25.9% * Smoking data for 2004 are not yet available from other states. 13

16 Smoking prevention among young adults, continued As the graph shows, Colorado's smoking rate among young adults was significantly lower in 2003 than the rate in the rest of the United States, for the first time since data became available. (The next page compares rates in the western United States.) 45% 40% US w/o CA & MA CO CA & MA Young adult current smoking: Colorado and U.S. 35% 30% 25% 20% 15% 10% '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 CO US (not graphed) US without CA & MA CA & MA

17 Smoking prevention among young adults, continued Young adult smoking declined during the MSA-funded period as rapidly in the west as it did in Colorado, except that the rate in California increased in (As noted earlier, smoking has generally been less common in the western continental United States than in the rest of the nation.) 45% 40% CO west w/o CA CA Young adult current smoking: Colorado and western U.S. 35% 30% 25% 20% 15% 10% '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 CO western US without CA* western US (not graphed)* CA * Alaska and Hawaii excluded 15

18 Smoking prevention among young adults, continued Other Indicators Quit Attempts among Young Adults The percentage of young adult smokers reporting a quit attempt in the previous 12 months was slightly lower during the MSA period than immediately before the period. The difference is not statistically significant and is attributable to an unsustained increase in 2000, before the MSA funding period. Percent of Colorado young adult smokers who reported a serious quit attempt in the previous 12 months '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 ' * * question was asked differently Smoking among young adults before and during MSA funding of Colorado STEPP '99-'00 '02-'03 '02-'04 Percent of current smokers who made a "serious" quit attempt (24+ hours) 72.3% 69.1% 67.0% Smoking During Pregnancy Available data show no significant change between the pre-msa and MSA period in the young adult rate of smoking during pregnancy. Colorado Women Aged Who Smoked During Pregnancy '99-'00 '02-' % 12.5% Source: Pregnancy Risk Assessment Monitoring System (PRAMS), Colorado STEPP 16

19 Smoking prevention among young adults, continued Nondaily Smoking Another potential indication that nonsmoking norms are widening or strengthening is the proportion of smokers who convert from daily smoking to smoking on some days ("occasional smoking"). * The proportion of young adult smokers reporting occasional smoking rather than daily smoking rose non-significantly during MSA funding years. '96 '97 '98 '99 '00 '01 '02 '03 ' % 32.2% 46.9% 32.4% 18.9% 35.5% 25.9% 32.5% 41.6% Nondaily smoking among young adults before and during MSA funding of Colorado STEPP '99-'00 '02-'03 '02-'04 Percent of current smokers who don't smoke every day 25.9% 28.9% 33.7% * Another potential indicator, the daily number of cigarettes smoked, was not measured during MSA funding years, preventing comparison to previous years. 17

20 Secondhand Smoke The chemicals that make cigarettes deadly threaten the lungs of not only the user but anyone who inhales the smoke. The risk to bystanders represents one rationale for including protection from secondhand smoke as a major STEPP program objective. The other main rationale is that nonsmoking environments strengthen society's message to adolescents that smoking is not widespread and routinely accepted behavior. Smoke Exposure on the Job Before STEPP expanded its activities, more than four-fifths of Colorado workers reported that their employers required work areas to be smoke-free. This coverage increased slightly but significantly during MSA-funded expansion of STEPP activities. Among other states that surveyed workplace smoking, rates were similar to Colorado's in 1999 and 2003, but significantly lower in 2000 (p<0.0001) and 2002 (p<0.05). Smoking banned in work areas (% of indoor workers) 90% 88% 86% 84% 82% 80% 78% '99 '00 '01 '02 '03 ' % 82.9% n/a 87.2% 85.0% 85.1% Indoor Work Area Smoke-free Rules '99-'00 '02-'03 '02-'04 Percent of indoor workers who report smoking is banned in their employer's work areas 83.5% 87.2%* 86.9%* * difference from '99-'00 is significant, p<

21 Secondhand smoke, continued Smoke Exposure at Home This family policy was first measured in 2002, and no comparison with pre-msa years is possible. During the MSA-funded period, the policy grew slightly but significantly more common each year among Coloradans. Among other states that surveyed in-home smoking bans, rates also increased steadily and significantly, from 65.0% in 2001 to 70.9% in Homes that ban smoking inside 81% 80% 79% 78% 77% 76% 75% 74% '02 '03 ' % 77.8%* 78.9% * different from 2002 percentage, p<0.05 different from 2002 percentage, p<

22 Discussion In 1964, guidelines were drafted for expert review of the link between smoking and lung cancer. * The same guidelines have since been widely used to evaluate evidence that suspected risk factors may increase specific diseases in a population. Although the guidelines are most useful when reviewing a larger body of evidence than was available for the current evaluation, they are presented here as an aid to discussion of STEPP's impact during the MSA-funded period: o o o o o o o temporal sequence: Did program activities precede population behavioral changes? strength of association: How closely linked are program activities and behavioral changes? dose-response relationship: Does the amount of behavioral change vary with the amount/ intensity of related program activities? replication: Have other studies shown the same relationship of program activities and behavioral changes? mechanism plausibility: How coherent are the evaluation findings with logic models that link program activities with behavioral changes? potential alternative explanations: Are the findings explainable in other ways, and how likely are such alternative explanations? cessation of program exposure: Do the behavioral changes decline or disappear when related program activities decline or are withdrawn? Smoking cessation During the peak years of MSA funding for STEPP ( ), smoking prevalence among adults aged 25+ declined in Colorado, as did per capita cigarette sales, more than declines in the rest of the United States. Colorado's ranking on smoking prevalence improved relative to other states. Quit attempts became more widespread. Historically, comprehensive tobacco control programs elsewhere have produced similar results, notably in California, which began comprehensive programming in 1989, and Massachusetts, which began in Furthermore, the advances in Colorado slowed during 2004, when MSA funding of STEPP was reduced threefold from preceding levels. Together, these findings are consistent with guideline criteria for attributing improvements to program activities. A reasonable conclusion is that large-scale STEPP activities played a significant role in reducing Colorado's smoking prevalence and increasing smoking cessation. In addition to cessation, evidence suggests that remaining smokers reduced their consumption, since comparing the three year intervention period ( ) with the pre-intervention period ( ), cigarette sales in Colorado declined by 14.2% (see p. 10) while prevalence declined 10.1% (estimate not previously shown in report). Previous studies suggest that smoking reduction may increase the likelihood of complete cessation, and logic indicates that a reduction in total cigarettes smoked also reduces exposure to secondhand smoke. A potential alternative explanation for the improved prevalence rates is that they came from unknown factors affecting the western United States, where smoking prevalence generally * US Dept. of Health, Education and Welfare. Smoking and Health: Report of the Advisory Committee to the Surgeon General. Washington DC: U.S. Public Health Service, Gordis L. Epidemiology (3 rd ed). Philadelphia: Elsevier Saunders,

23 Discussion, continued declined during This alternative seems unlikely for several reasons. The general western decline was just two-tenths of a percentage point, while it was 1.8 percentage points in Colorado (although the comparison is not statistically different, p=0.11). Also, the baseline measure for Colorado included a pronounced but unexplained one-year dip in smoking prevalence during This fluctuation may reflect random error, in which case it would falsely reduce the amount of improvement that was detected in Colorado. Population migration also may represent an alternative explanation for state-level changes in smoking prevalence, because smoking rates and migration rates both vary by ethnicity, socioeconomic status, and country of origin. Between 2002 and 2003, western states gained a net of nearly half a million new residents, most of them arriving from outside the United States. * However, similar immigration also occurred during the 1990s, when smoking prevalence improvements in Colorado were not noticeably better than national and western improvements generally. The possible impact of migration on improvements in Colorado's smoking prevalence rate deserves further study but exceeds the scope of the current evaluation. A general limitation of using smoking prevalence to evaluate cessation is the overlap with prevention, because smoking prevalence declines not only when adult smokers quit but also when fewer adolescents or young adults become smokers. The fact that prevalence declined thus might reflect increased cessation among confirmed smokers, less initiation of smoking among adolescents and young adults, or a combination of both improvements. Regarding the Colorado Quitline, the available evidence suggests that a) smokers who used Quitline services were more likely than quit-attempters in general to succeed in quitting, at least for one week, and b) advertising generated half or more of Quitline use. Both findings are consistent with previous studies in other states. Smoking prevention Tobacco-use measures among adolescents appeared to improve during the MSA-funded period, but apparent changes weren't larger than the margins of error. Colorado has long relied on school-based health surveys to monitor changes in adolescent smoking, but the survey efforts have struggled with inadequate resources, a neutral to adverse policy climate, and competing pressures on educators to protect academic class time and family privacy. In addition, tobacco use declined steadily among the nation's high school students from 1997 to In the future, Colorado will need more information to determine whether the State's adolescents are keeping pace with, making faster progress than, or falling behind the national trend toward prevent teenaged tobacco use. Among young adults, where half of regular smoking emerges, tobacco use measures in Colorado generally improved during , with the possible exception of quit attempts among young adult smokers. In 2003, smoking prevalence among Colorado young adults fell significantly below the rate in the rest of the United States; reached parity with two leading tobaccoprevention states, and appeared to dip below the rate in the rest of the west for the first time since * U.S. Census Bureau. Geographic Mobility: 2002 to Current Population Reports, 2004; P CDC. Cigarette Use Among High School Students United States, MMWR 2004; 53(23):

24 Discussion, continued at least 1992, although this last difference was not statistically significant. Continued improvement was not evident in Secondhand smoke Workplace smoking bans protected slightly but significantly more Colorado workers during MSA-funded years than in previous years. In-home smoking bans also increased slightly but significantly during MSA-funded years. Both types of improvement were similarly found in other states that assessed the policies. The available evidence is insufficient to evaluate the impact of STEPP activities on protection from secondhand smoke in Colorado. Evaluation capacity The current study could not locate enough relevant data to thoroughly evaluate each STEPP program objective, with the possible exception of smoking cessation. The main problem appears to be a lack of authority and resources to collect relevant data and to commission external evaluation. During the period under study, STEPP had no statutory authority to spend MSA funds on external evaluation, * and the annual budget was substantially less than originally intended in all years but one. Conclusions 1. Smoking among Colorado adults aged 25 and older became less prevalent during a two-year period, , when the State health department conducted its largest effort to prevent and reduce tobacco use. Critical analysis of available evidence strongly suggests that the State's programmatic effort was at least partly responsible for the reduction in smoking. Alternative explanations a general western decline in smoking, or disproportionate in-migration of nonsmokers to Colorado are not well supported but can't be ruled out without further study. 2. Household and workplace exposure to secondhand smoke declined significantly in Colorado during the MSA-funded period of State programming. Similar declines occurred in other states that monitored these exposures. 3. Evidence is insufficient to evaluate State efforts to prevent smoking initiation and promote cessation among adolescents and young adults. Smoking among young adults showed a declining trend during , but the trend may have reversed in In general, the current evaluation was constrained by large gaps in relevant data. Clear authority and adequate resources for evaluation of tobacco program efforts should be established and maintained. * , Colorado Revised Statutes. 22

25 Appendix A Cessation and the Colorado Quitline Smoking cessation more often involves explicit assistance today than it did a quarter-century ago. In the 1980s, more than 90 percent of smokers used the independent "cold turkey" method; * in 2001, more than one-fourth of Colorado quit-attempters used some form of assistance. While lack of insurance or price may limit cessation-medication use, telephone counseling "quitline" services for smoking cessation are free, are effective, are available in more than 30 states, and are nationally accessible under a federal initiative announced last year. ** A recent study found that quitline counseling significantly increased cessation among young adult callers. Quitlines may reduce tobacco disparities, because they bypass barriers to face-to-face counseling. STEPP has funded the Colorado Quitline since fall The American Cancer Society operated the it for a year. Since fall 2002, the provider is National Jewish Medical and Research Center, in Denver. In some years, STEPP promoted the Quitline on TV, radio, billboards, and other media. (STEPP has also sponsored media campaigns to prevent adolescent smoking.) We reviewed the summary Quitline report for , and media expenditure data provided by STEPP, in order to describe Quitline participation. The Colorado Quitline received more than 10,000 calls during , an average of 15 per day. Overall, more than two-thirds (70%) of callers said they learned of the Quitline from media ads (51%) or their doctor (19%). More than half of callers enrolled in the Quitline's telephone counseling program, which is free of charge. Counselors call enrollees for five sessions. Colorado Quitline Volume number % of total Total calls 10, % Requested self-help materials 4, % General information request % Scheduled counseling enrollment, no-show % Enrolled in telephone counseling program 5, % Source: National Jewish Medical and Research Center * Fiore MC, Novotny TE, Pierce JP, et al. Methods used to quit smoking in the United States: do cessation programs help? JAMA 1990; 263: Levinson A. Adult Smoking: Progress and Problems. Colorado Tobacco Attitudes and Behaviors Surveys (TABS), Colorado Tobacco Research Program, [On-Line]. Available: Access verified Sept. 24, Zhu SH. Anderson CM. Tedeschi GJ. Rosbrook B. Johnson CE. Byrd M. Gutierrez-Terrell E. Evidence of realworld effectiveness of a telephone quitline for smokers. New Engl J Med 2002; 347(14): Lichtenstein E. Glasgow RE. Lando HA et al. Telephone counseling for smoking cessation: rationales and review of evidence. Health Ed Res 1996; 11: Fiore MC. Bailey WC. Cohen SJ et al. Treating tobacco use and dependence. Clinical practice guideline. Rockville (MD): US Department of Health and Human Services, Public Health Service, Stead LF. Lancaster T. Telephone counseling for smoking cessation. Cochrane Database Syst Rev 2001; (2):CD Ossip-Klein DJ. McIntosh S. Quitlines in North America: evidence base and applications. Am J Med Sci 2003; 326(4): ** US Department of Health and Human Services. HHS Announces National Smoking Cessation Quitline Network. [On-line.] Available: Accessed 6/8/04. Rabius V, McAlister AL, Geiger A, Huang P, Todd R. Telephone Counseling Increases Cessation Rates Among Young Adult Smokers. Health Psychol 2004; 23(5): Prout MN. Martinez O. Ballas J. Geller AC. Lash TL. Brooks D. Heeren T. Who uses the Smoker's Quitline in Massachusetts? Tob Control 2002; 11(Suppl 2):ii74-ii75. 23

26 Appendix A Cessation and the Colorado Quitline, continued Approximately half of enrollees stopped using the program without completing it. About onethird completed all five counseling sessions, and the remainder exited after having quit, decided not to quit, or moved out of Colorado. Nearly one-third of telephone counseling users reported that they were not smoking at the time of leaving the program. Completion Status, Colorado Quitline Telephone Counseling, number % of total % excluding still active Total enrollment 5, % 100.0% Completed counseling program 1, % 32.6% Actively exited* % 17.2% Counselor unable to reach 2, % 50.1% Still active in program % * quit smoking and "no more help needed," abandoned quit, or moved out of Colorado Source: National Jewish Medical and Research Center Self-Reported Smoking Status at Exit, Colorado Quitline Telephone Counseling, number % of total Total 5, % not smoking 1, % quit but relapsed during program % did not quit during program 2, % Source: National Jewish Medical and Research Center 24