A.7 Prototype Indicator Set: Tobacco and Health

BACKGROUND

Tobacco consumption poses many health risks. Despite a steady decline since 1964 in the proportion of the adult population that smokes, about 20 percent of all deaths in the United States are associated with tobacco use, making its prevention the single most effective way to reduce mortality (CDC, 1993b; McGinnis and Foege, 1993). Some of these deaths are nonsmokers affected by exposure to tobacco smoke and residential fires. In addition, smoking during pregnancy increases risks for prematurity, low birth weight, and infant deaths. Smoking-related illness is estimated to account for 7 percent of total medical care expenditures (CDC, 1994b) and for a disproportionate share of time lost from work and diminished productivity in the workplace.

Over the past 40 years, as evidence has accumulated on the extensive adverse health effects of tobacco use, tobacco products have been sold with little restriction. During this period, death rates for some conditions, such as lung cancer and chronic obstructive pulmonary disease (COPD), have actually risen (Gardner and Hudson, 1996). Continued sale and use of tobacco reflect both the addictive nature of nicotine and the political and economic influence of the tobacco industry. This makes the use of tobacco an excellent indicator of society's capacity to control a



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Improving Health in the Community: A Role for Performance Monitoring A.7 Prototype Indicator Set: Tobacco and Health BACKGROUND Tobacco consumption poses many health risks. Despite a steady decline since 1964 in the proportion of the adult population that smokes, about 20 percent of all deaths in the United States are associated with tobacco use, making its prevention the single most effective way to reduce mortality (CDC, 1993b; McGinnis and Foege, 1993). Some of these deaths are nonsmokers affected by exposure to tobacco smoke and residential fires. In addition, smoking during pregnancy increases risks for prematurity, low birth weight, and infant deaths. Smoking-related illness is estimated to account for 7 percent of total medical care expenditures (CDC, 1994b) and for a disproportionate share of time lost from work and diminished productivity in the workplace. Over the past 40 years, as evidence has accumulated on the extensive adverse health effects of tobacco use, tobacco products have been sold with little restriction. During this period, death rates for some conditions, such as lung cancer and chronic obstructive pulmonary disease (COPD), have actually risen (Gardner and Hudson, 1996). Continued sale and use of tobacco reflect both the addictive nature of nicotine and the political and economic influence of the tobacco industry. This makes the use of tobacco an excellent indicator of society's capacity to control a

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Improving Health in the Community: A Role for Performance Monitoring health problem in the face of strong counterpressures from industry and from those in the population who smoke. Currently, about 25 percent of adults (CDC, 1996c) and 16 percent of adolescents (CDC, 1996a) smoke regularly. Because more than 80 percent of current smokers began as preteens or teenagers (CDC, 1994a), increasing efforts are being made to reduce youth access to tobacco by enforcing restrictions on the sale of tobacco products to minors. State education agencies also require public schools to teach the hazards of tobacco use, even in states that grow and process tobacco. Encouraging current tobacco users to quit is also a priority. Largely in response to the ill effects of environmental tobacco smoke, restrictions on public indoor smoking are increasingly widespread. California and Massachusetts have both increased excise taxes on cigarettes to encourage reduced consumption and to fund a variety of activities (e.g., media campaigns, school-based programs) aimed at reducing levels of tobacco use. Healthy People 2000 (USDHHS, 1991) includes several objectives that target preventing and reducing tobacco use. More recently, both the U.S. Preventive Services Task Force (1996) and the Smoking Cessation Guideline Panel (1996), which was assembled by the Agency for Health Care Policy and Research (AHCPR), have issued recommendations that health care practitioners routinely provide cessation counseling to tobacco users and counseling to children and adolescents aimed at preventing initiation. In addition, the current draft of HEDIS 3.0 (NCQA, 1996) proposes that health plans report on the percentage of adult smokers who received advice to quit. Tobacco use and its health effects can be measured in several ways. Morbidity and mortality from tobacco-related diseases can be measured, but these conditions often occur decades after smoking begins, so they are not immediately sensitive to changes in tobacco use. Data on the association between tobacco use and these diseases, however, make it possible to predict future levels of morbidity and mortality that would result from reduced tobacco use. Therefore, the intermediate measure of tobacco use can serve as a proxy for those health outcomes. Such measures include the numbers of people who currently use tobacco, who quit, and who start using tobacco. It is also possible to measure efforts being made to reduce tobacco use through prevention and cessation. In addition, efforts to increase tobacco use through marketing and blocking tobacco control policies can be assessed. The current competition

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Improving Health in the Community: A Role for Performance Monitoring between these forces within communities will influence future tobacco use and the morbidity and mortality associated with it. ''FIELD" SET OF PERFORMANCE INDICATORS The domains of the field model suggest a variety of indicators that might be used to examine a community's efforts to reduce the level of tobacco use and thereby improve health status. These efforts would include both increasing the cessation rate among current smokers and other users of tobacco products and reducing the number of young people who begin using tobacco products. Disease Tobacco use contributes to illness and death from a variety of causes. Estimates have been made that up to 30 percent of all cancer deaths and 21 percent of cardiovascular disease deaths are tobacco related (McGinnis and Foege, 1993). Specific conditions such as lung cancer and COPD are attributed almost entirely to prolonged smoking (CDC, 1989). Acute bronchitis is aggravated and prolonged in smokers, increasing the time lost from work or school. Use of smokeless tobacco is associated with oral cancers. Nonsmokers who are exposed to environmental tobacco smoke also experience health problems. Approximately 3,000 lung cancer deaths per year among nonsmokers have been attributed to environmental tobacco smoke (EPA, 1992). Young children exposed to tobacco smoke in the home suffer more respiratory illness and otitis media than other children (EPA, 1992). About 10 percent of infant deaths and 20–30 percent of low-weight births are attributable to maternal tobacco use (Kleinman and Madans, 1985). Smoking is also linked to 25 percent of deaths in residential fires (U.S. Consumer Product Safety Commission, 1993). Although the health consequences of tobacco use are indisputable, measures of many types of morbidity and mortality are not optimal indicators for monitoring efforts to reduce the health impact of tobacco use. Many years can be required for changes in tobacco use to be reflected in levels of morbidity and mortality. Communities can, however, use current levels of tobacco-related morbidity and mortality to demonstrate the community-level impact of this major health problem and, therefore, the importance of reducing the levels of tobacco use.

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Improving Health in the Community: A Role for Performance Monitoring Indicators to consider include the following: Number of deaths in the community due to lung cancer, cardiovascular disease, emphysema, chronic bronchitis, and respiratory infections; percentage of these deaths attributable to smoking. In general, these conditions account for the greatest number of deaths attributable to smoking. The Centers for Disease Control and Prevention (CDC) has developed computer software that can be used to estimate smoking-attributable morbidity, mortality, and costs (SAMMEC) (Shultz et al., 1991). Even though these are leading causes of death, the number of cases at the community level may be small in any one year. Percentage of infants born weighing less than 2,500 grams whose mothers report smoking during pregnancy. Low birth weight is associated with increased risks for morbidity and mortality. Reducing the prevalence of smoking during pregnancy is a readily identifiable goal that would contribute to improved pregnancy outcomes and longer-term infant health. Individual Response Tobacco use is a learned behavior that typically begins before adulthood. For example, data show that among adults ages 30–39 who had ever been daily smokers, 82 percent began by 18 years of age (CDC, 1994a). Recent data also show that 25 percent of white high school students have used smokeless tobacco in the previous month (CDC, 1996a). Many different forces encourage young people to initiate and continue tobacco use (IOM, 1994), and it may never be possible to quantify the relative contribution of each. Some of the behavioral and personal influences include academic achievement, personality, and self-image. Other important influences are found in the social environment. Once use is initiated, the chemical addictive effect of nicotine quickly becomes a powerful motivator for continued use and a barrier to efforts to quit. Of adults who are current smokers, 69 percent are interested in quitting (CDC, 1996c), but only 2.5 percent succeed in quitting permanently each year (CDC, 1993a). Smokers with higher levels of education and income appear more successful in stopping. Data on the sociodemographic characteristics of smokers in a community could help guide cessation efforts. Indicators to consider include the following:

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Improving Health in the Community: A Role for Performance Monitoring Percentage of the adult population who smoke regularly. This measure can be followed over time to track trends and can also be examined by age, race, and gender to identify those groups in which smoking behavior is changing. It might be revised to capture all tobacco use, including smokeless tobacco products. More difficult to measure accurately, but potentially important, is the quantity of tobacco used. Self-reports of tobacco use appear to understate consumption when compared to data on tobacco sales, but a consistent level of understatement makes it possible to track trends from such survey data (Hatziandreu et al., 1989). The importance attached to monitoring the prevalence of smoking is reflected in the recent decision by the Council of State and Territorial Epidemiologists to add it to the list of "conditions" reportable by states to the CDC (1996b). Percentage of births for which mothers report smoking during pregnancy. Mothers reported smoking during pregnancy in 15 percent of births in 1994 (Ventura et al., 1996). These data are obtained from birth certificate reports, but not all states report the smoking status of mothers. As with survey reports, birth certificate data may understate true levels of smoking. Percentage of youth ages 11–18 who initiate smoking each year. It is estimated that in the United States as many as 3,000 young people, most less than 18 years of age, begin smoking each day (Pierce et al., 1989). Because most smokers begin using cigarettes by age 18, prevention efforts will be focused on this population. Tracking initiation of smoking will reflect the effectiveness of those efforts. Percentage of smokers who quit for more than six months in each year. Among most smokers who try to quit, relapse is common; only 5.7 percent reported being able to quit for at least one month during the previous year (CDC, 1993a). The longer cessation continues, however, the greater is the long-term benefit to health. Increasing the number of smokers who quit and decreasing the length of their lifetime use of tobacco not only have personal health benefits but also diminish the number of smoking role models.

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Improving Health in the Community: A Role for Performance Monitoring Genetic Endowment There is some evidence from twin studies that genetic factors influence initiation and continuation of tobacco use (IOM, 1994). There may also be genetically influenced susceptibilities to tobacco-related illness. No performance indicators are proposed for this domain. Social Environment The social environment is the most critical piece in the tobacco puzzle. As noted, various social influences encourage the initiation of tobacco use by as many as 3,000 young people each day (Pierce et al., 1989). Some of these factors include friends who smoke, parental smoking, and advertising, which portrays smoking as an attractive adult behavior. These factors help shape perceived social norms regarding smoking. Advertising and marketing also appeal to normal tendencies of adolescents to rebel against authority. In addition, numerous studies have documented the ease with which even young teenagers can purchase cigarettes, despite laws in every state prohibiting sales to minors (see IOM, 1994; CDC, 1996a). Strong forces are also operating to control, prevent initiation of, and encourage cessation of tobacco use. Increasingly, state and local laws restrict smoking in public spaces and workplaces, and more rigorous efforts are being made to enforce laws prohibiting tobacco sales to minors. These steps help create not only a legal but also a social environment that discourages tobacco use. By reducing the opportunity to smoke, public and workplace restrictions can help reinforce individuals' efforts to quit. School and community health education programs and antitobacco media campaigns try to communicate both the ill effects of tobacco use and the benefits of cessation. School-based prevention programs have been shown to at least delay initiation of tobacco use (see U.S. Preventive Services Task Force, 1996). An examination of California's antismoking media campaign indicates that it has contributed to reduced levels of tobacco consumption and might have had a greater impact with higher levels of funding (Hu et al., 1995). Other steps to discourage tobacco use that are being taken, often at the state level, include increased excise taxes, price controls, litigation against the tobacco industry, and additional restrictions on advertising and marketing. In some states, however, preemptive state legislation may prevent local govern-

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Improving Health in the Community: A Role for Performance Monitoring ments from implementing more stringent controls on matters such as placement of cigarette vending machines or enforcement of prohibitions on sales to minors (IOM, 1994). Indicators that might be considered include the following: Effectiveness of local enforcement of laws prohibiting tobacco sales to minors. Enforcement of these laws is a reflection of a community's commitment to preventing tobacco use among youth. Some communities have demonstrated a drop in reported teenage smoking two years after implementing strict enforcement programs (see IOM, 1994). A community might monitor enforcement on the basis of the proportion of adolescents (e.g., ages 11–18) who report being asked for proof of age, the proportion of test purchases that elicit a request for proof of age, or the proportion of test sales that are completed. Extent to which tobacco use prevention is incorporated into school curricula and activities. All states encourage or require health curricula in public schools to address the dangers of tobacco use. Objective 3.10 in Healthy People 2000 (USDHHS, 1991) calls for the inclusion of tobacco use prevention in school health curricula at all grade levels, and CDC (1994d) has issued guidelines for the content and implementation of school programs. The extent to which prevention messages are delivered and the adequacy of training teachers receive to teach tobacco use prevention, particularly to the early adolescent, vary. The best programs not only inform students of the ill effects of tobacco but also equip them to resist social pressures to use tobacco and seek to identify and assist those who use tobacco to quit successfully. In judging whether programs are appropriate, however, competing demands for curriculum time and other school resources should be taken into consideration. Number of tobacco use cessation programs available in the community; their success rate (proportion of participants with at least six months of cessation following completion of the program). Cessation programs are part of a community's resources to assist tobacco users who want to quit and to improve the prospects of successful quitting. Programs range from group efforts to individual counseling and hypnosis, and they vary greatly in their effectiveness, depending not only on the methods used but also

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Improving Health in the Community: A Role for Performance Monitoring on the skills of the program leaders. The need for additional programs might be suggested by a measure such as an increase in average waiting time to participate. Existence of local or state ordinances to control the placement of tobacco advertising; if ordinances exist, the effectiveness with which they are enforced. Federal law currently prohibits state and local regulation of the content of tobacco advertising, but court rulings have upheld regulation of its placement (Garner, 1996). Some states and municipalities have implemented ordinances that prohibit tobacco advertising near schools and playgrounds, at sports arenas, and on public transit systems. Highlighting the opportunity offered by such ordinances, and advocating for them in their absence, may be a way to reduce the impact of tobacco advertising and to express community support for reducing tobacco use. Criteria would have to be established to judge the effectiveness of enforcement. Existence of local tobacco control organizations or coalitions. The many national, state, and community organizations that are dedicated to reducing tobacco use initiate and support efforts at the community level to address issues such as youth tobacco use, environmental tobacco smoke, and public policies. If such organizations are operating, communities might want to assess their effectiveness in local tobacco control efforts. Their presence and effectiveness serve as an indicator of the extent of community support for tobacco control. Measuring the effectiveness of these groups would require specifying what they should be expected to accomplish. Physical Environment Smoking creates hazards in the physical environment in the form of environmental tobacco smoke (ETS) and fires. As noted above, ETS is estimated to cause as many as 3,000 lung cancer deaths per year, as well as to increase the severity of respiratory infections and otitis media in children. Smoking is also associated with residential fires. Estimates for 1990 link smoking to 44,000 fires, 1,200 deaths, and 3,360 injuries (U.S. Consumer Product Safety Commission, 1993). Community efforts to reduce exposure to ETS can include restricting smoking in public places, work sites, and restaurants.

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Improving Health in the Community: A Role for Performance Monitoring Both government and voluntary action are possible. Fire hazards might be reduced by enforcing requirements for installation of smoke detectors, but the benefit will be limited if residents and landlords do not keep installed detectors in working order. Indicators might include the following: Extent to which state or local ordinances control environmental tobacco smoke in the community. Many states, counties, and municipalities have ordinances to control environmental tobacco smoke. Local ordinances will have to be assessed in the context of state laws, which may be sufficiently strict that local measures are not needed or, alternatively, may preempt the authority of local government to enact more stringent controls. Number of residential fires in the community in the past year attributable to smoking; number of deaths and disabilities that resulted from these fires. In any given community, the numbers of fires, deaths, and disabilities will be small, but they can serve as sentinel events that attract public attention to this hazard of tobacco use. Prosperity Direct and indirect costs associated with smoking have been estimated at $68 billion in 1990 (OTA, 1993). Near-term improvements in the efficiency or effectiveness of treatment of tobacco-related disease are likely, so the greatest impact on health care costs will come from reducing the levels of disease by reducing tobacco use. For individuals who use tobacco, consumption of one pack of cigarettes per day costs about $700 per year, and additional costs can be incurred for health care and time lost from work. The disproportionately high smoking rates for lower socioeconomic populations increase the relative impact of the cost of tobacco on financial resources. Tobacco use generates income for growers, manufacturers, and those who advertise, market, and sell tobacco products. In addition, excise taxes on sales of tobacco products generate revenue for federal, state, and local governments. A recent analysis suggests, however, that even complete elimination of tobacco from the economy would not result in a net national loss of jobs, al-

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Improving Health in the Community: A Role for Performance Monitoring though there would be losses in the southeastern states that grow and process tobacco (Warner et al., 1996). Indicators that might be considered include the following: Annual per capita retail cost of tobacco consumption for tobacco users. The per capita cost of tobacco use is a product of the numbers of tobacco users, the quantity of tobacco consumed, and the current pricing of tobacco products, including excise taxes. For some individuals or families, expressing use in economic terms may provide a better incentive to quit or reduce consumption so that the money can be used for other purposes. To employ this measure, communities would need an estimate of the number of tobacco users in the population. State excise tax records might serve as a source of information on consumption. Average annual value of retail sales of tobacco products per retail outlet. This measure would provide an indication of the contribution of tobacco sales to retail income in the community. Where tobacco sales are a major source of income, communities might expect less support for efforts to reduce tobacco use. Data on excise tax receipts might be a basis for estimating the value of retail sales. Health Care The health care system can contribute to preventing tobacco use, promoting cessation of use, and treating tobacco-related illnesses. Most health care resources are used in treating illness, and cure is generally not possible for more serious conditions such as lung cancer and emphysema. Many tobacco-related health risks can be reduced when people stop using tobacco products, and studies have demonstrated that tobacco cessation counseling by health care providers can increase cessation rates (see U.S. Preventive Services Task Force, 1996). In one study, 5 percent of smokers quit as a result of their doctor's spending less than one minute encouraging them to do so (Russell et al., 1979). Cessation rates have been shown to increase as the time devoted to counseling increases (Smoking Cessation Guideline Panel, 1996). On a national basis, even a 5 percent annual cessation rate among smokers who have a health care visit would translate

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Improving Health in the Community: A Role for Performance Monitoring into about 1.6 million fewer smoker each year and, over the long term, a substantial reduction of disease burden. Health care providers can also promote the use of nicotine replacement therapy as an adjunct to counseling. Health plans can be encouraged to support tobacco use cessation programs as well as purchase of the nicotine patch or nicotine gum to assist in cessation. Providers also have the opportunity to counsel children and adolescents against initiating tobacco use, but studies have not yet been done to demonstrate its effectiveness. As noted above, recommendations have been issued that health care providers routinely ask about tobacco use and provide counseling for cessation or prevention (Smoking Cessation Guideline Panel, 1996; U.S. Preventive Services Task Force, 1996). Healthy People 2000 calls for 75 percent of health care providers to routinely advise cessation, but only 37 percent of adult smokers reported receiving such advice in the previous year (CDC, 1993c) and only 25 percent of persons ages 10–22 reported any mention of smoking by a health care provider (CDC, 1995a). A specific effort was made to support the inclusion in HEDIS 3.0 of measures that would encourage providers to offer such counseling (Center for the Advancement of Health, 1996). Indicators for a community might include the following: Percentage of tobacco users whose health care providers ask about tobacco use; percentage whose providers deliver cessation counseling; percentage whose providers assist in the cessation process when interest in quitting is expressed. Provider counseling promotes cessation of tobacco use, yet many physicians do not determine if their patients use tobacco. With the new edition of HEDIS (NCQA, 1996), however, health plans would be asked to report the proportion of their adult members (age 21 and older) who smoke and who received advice to quit. Percentage of nonsmoking youth who are counseled by a health care provider not to begin tobacco use. The impact of physicians counseling nonsmoking youth not to initiate use has not been measured, but such counseling has been recommended (Smoking Cessation Guideline Panel, 1996; U.S. Preventive Services Task Force, 1996). Clinicians are also advised to support the implementation and operation of school-based prevention programs, which have been shown to delay the initiation of tobacco use.

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Improving Health in the Community: A Role for Performance Monitoring causes may be small, so analysis will require aggregation of data over two or more years. Smoking-related fire deaths would be identified separately and would be so rare that no trend analysis would be possible. Because of the long-term nature of the relationship between smoking and most of these health outcomes, numbers of deaths serve more to inform the community of the opportunity for health improvement than to measure current performance. 2. Percentage of the adult population (age 18 and older) who smoke regularly. In most national surveys, ''smoking" refers to the use of cigarettes. For a community health improvement effort, this indicator might be modified to cover all forms of tobacco use. Specific definitions of smoking and other forms of tobacco use will be needed. The National Health Interview Survey, for example, distinguishes those who smoke every day from those who smoke some days (CDC, 1994c). Because this measure provides a near-term indication of the effects of smoking cessation efforts, it is a good proxy for anticipated long-term changes in smoking-related health outcomes. In terms of accountability, it captures the collective effect of actions across the community. Special sampling in a state survey for the Behavioral Risk Factor Surveillance System might be a source of community-level estimates. 3. Extent to which state or local ordinances control environmental tobacco smoke in the community. Using this indicator will require establishing a definition of "control" of ETS. Communities might focus on ordinances for specific settings such as government buildings, private workplaces, and restaurants. The extent of these ordinances, the degree of compliance, and the degree to which they are enforced generally reflect the community's commitment to tobacco use prevention. In some instances, however, a community's desire to     cardiac arrest, other heart disease (420–429); cerebrovascular disease (430–438); atherosclerosis (440); aortic aneurysm (441); other arterial disease (442–448) • Respiratory disease: respiratory tuberculosis (010–012); pneumonia, influenza (480–489); bronchitis, emphysema (490–492); asthma (493); chronic airway obstruction (496) • Pediatric conditions: short gestation, low birth weight (765); respiratory distress syndrome (769); respiratory conditions-newborn (770); sudden infant death syndrome (798.0)

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Improving Health in the Community: A Role for Performance Monitoring restrict smoking may conflict with state laws that limit local authority in this area. Additional indicators proposed for monitoring community action to prevent the health consequences of tobacco use include the following: 4. Number of residential fires per year attributable to smoking. Residential fires are another undesirable outcome of smoking. Unlike deaths from lung cancer and other causes, which are a long-term outcome, fires are a more immediate consequence of smoking. In addition to the small number of deaths and serious injury that occur, fires carry economic costs for individuals and the community. Data should be available from the fire department or a similar public safety agency. 5. Percentage of youth, ages 11-18, who initiate smoking each year. Most smokers begin using cigarettes before age 18, making the adolescent population the focus of efforts to prevent tobacco use. Smoking initiation rates in this population will be an indicator of the success of prevention efforts. Depending on the community, it may be useful to track smoking initiation by gender or race, or among younger and older teens. If the population is large enough, age-specific rates could be used to monitor changes in the average age of smoking initiation. School-based surveys are a prominent candidate for data collection but will miss those teenagers who have dropped out of school. The Youth Risk Behavior Surveillance System (see CDC, 1995b) and other national surveys might be a source of validated questions for a community survey. Smoking initiation is a product of many factors, so specific accountability cannot be established, but school-based prevention programs and enforcement of age restrictions on sales of tobacco products would be important priorities. 6. Effectiveness of local enforcement of laws prohibiting tobacco sales to minors. This indicator could be operationalized more specifically with measures such as Existence of a program by the local health department or other appropriate agency for routine checks on sales to minors.

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Improving Health in the Community: A Role for Performance Monitoring Percentage of test sales in which an underage purchase was completed. These measures target actual sales practices, and data should be available from the agency responsible for enforcement. Survey data on the proportion of adolescents who report being asked for proof of age when purchasing cigarettes might also be sought. The extensive recommendations regarding enforcement of sales restrictions from the report Growing Up Tobacco Free (IOM, 1994) could suggest other measures that communities might want to use (e.g., on vending machine access, merchant licensing, merchant fines). Data could come from agencies charged with enforcing the ordinances. This indicator addresses accountability on the part of both merchants and enforcement agencies. 7. Extent to which tobacco use prevention is incorporated into school curricula and activities. This indicator could be operationalized with measures such as Percentage of schools including tobacco use prevention in the curriculum of every grade level. For each grade level, percentage of health curriculum hours devoted to tobacco use prevention. This indicator specifically addresses the role of schools in contributing to efforts to prevent tobacco use. The commitment of the local school system to this endeavor is also a good indicator of community support for the prevention of tobacco use. The necessary data should be available from school districts. These measures do not address the appropriateness of the curriculum content or the effectiveness with which it is presented. Guidelines issued by CDC (1994d) suggest some basis for making those judgments, but specific measures would have to be developed. 8. Number of tobacco use cessation programs available in the community; their success rate (proportion of participants achieving at least six months of cessation following completion of the program). The number of cessation programs reflects, in a very general manner, capacity available in the community to provide assistance to smokers who want to quit. A specific definition of a cessation "program" would be needed to count how many there are. Measures of participation demonstrate the use of available

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Improving Health in the Community: A Role for Performance Monitoring services but may be hard to interpret. Some smokers may participate repeatedly and without success; others may quit successfully without any program participation. Success rates go beyond capacity and participation to measure program performance. They should be based on recent program attendance—for example, completion of a program 6–18 months previously. Data might come from community surveys or, perhaps, cessation program records if six-month follow-up information can be obtained from most participants. In terms of accountability, success rates target cessation programs directly, but responsibility for the number of programs is less specific. Hospitals, health plans, and organizations in the community such as the American Lung Association might be expected to offer programs, but market forces will influence the number of commercial programs. 9. Percentage of tobacco users whose health care providers ask about tobacco use; percentage whose providers deliver cessation counseling; percentage whose providers assist in the cessation process when interest in quitting is expressed. Counseling from health care providers of all types promotes cessation of tobacco use but is not offered routinely to all patients who use tobacco. HEDIS reporting on cessation counseling for adults would generate data on the performance of providers in health plans but not for the community as a whole. The member survey used to generate HEDIS data might provide a model for a comprehensive community survey. "Assistance" in cessation, which will require a formal definition, could include follow-up counseling, self-help materials, referral to a cessation program or to more intensive individual counseling, or nicotine replacement products. This measure directly addresses the responsibilities of health care providers. 10. Percentage of nonsmoking youth who are counseled by a health care provider not to begin tobacco use. This measure, which addresses prevention and complements the previous one on cessation, also focuses on health care provider responsibilities. A school-based survey, which has been suggested as a source of data for other measures, might be used here as well. Because the effectiveness of provider counseling has not been tested, the use of this indicator should be reassessed as additional evidence becomes available. 11. For the major health care plans serving the community's

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Improving Health in the Community: A Role for Performance Monitoring population, the percentage of covered lives with partial or complete coverage for participation in tobacco cessation programs. Health plan coverage for tobacco cessation programs may encourage participation. Data for this indicator would have to come from health plan records or possibly state records. The kinds of programs for which coverage would be expected would have to be specified. Consideration should be given to including coverage for nicotine replacement products approved by the Food and Drug Administration. As framed, the indicator would not measure the coverage available under indemnity plans. In terms of accountability, the indicator addresses health plans and purchasers of health services, particularly employers and Medicaid programs, whose choice of plans affects the availability of coverage for specific services. The proposed indicator set includes measures of outcomes (smoking related deaths, house fires), risk factors (smoking prevalence, smoking initiation), and community actions aimed at reducing tobacco use and, thus, its long-term health impact. Tobacco use is a habit that is acquired within a couple of years but can take many more years to change. The mix of short- and long-term factors is reflected in the inclusion of risk measures that address both smoking initiation and smoking status. In interpreting trends in the smoking status indicator, it is important to consider whether changes reflect recent smoking cessation among those who began smoking in the past or are due to new cohorts of smokers who have substantially higher or lower rates of smoking than older adults. Similarly, there are both shortand long-term effects of smoking. The indicators on house fires and tobacco-related deaths reflect this range of possible effects. The smoking outcome measures (indicators 1 and 4) and risk factors (indicators 2 and 5) indicate the performance of the community as a whole, in conjunction with regional and national trends in preventing and controlling tobacco use. Other proposed indicators suggest (groups of) responsible entities in the community that might be held accountable for tobacco control measures. The measures relating to laws and regulations (ETS ordinances, tobacco sales to minors) indicate political will in the community to take legal measures to control tobacco use. Responsibility for enacting the appropriate ordinances and regulations, an initial step without which the proposed indicators have no meaning, may however lie at the state rather than the community level.

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Improving Health in the Community: A Role for Performance Monitoring Both of the measures are also written to indicate the ability of the community to enforce these ordinances and regulations, either by official, governmental means or by the actions of those directly responsible such as employers and merchants. Other measures reflect specific actions that entities in the community can take to influence tobacco use. Indicator 7, for instance, measures school-based efforts (curriculum and other efforts) to prevent initiation of tobacco use. It reflects the capacities and actions of school boards, administrators, and teachers, as well as the community's willingness to accept these efforts. Indicator 8 addresses smoking cessation programs in the community. Such programs might be provided by voluntary health agencies such as the American Lung Association (ALA); public health departments; managed care organizations, hospitals, or other health service providers; or some combination of the above (e.g., a hospital might sponsor a program and provide space, the ALA might provide the staff, and the health department might advertise its availability). A small number of smoking cessation programs in the community does not mean that any one of these parties is responsible; rather, it points to an opportunity for the community that can be met only if some of the relevant parties work together. The indicators regarding counseling by health care providers (indicators 9 and 10) and coverage for cessation programs (indicator 11) measure actions that can be taken by the health care delivery system to reduce tobacco use. Indicators 9 and 10 directly measure provider behavior, which is the product not only of an individual's immediate actions but also of other influences such as professional training, expectations of colleagues and patients, and health system policies regarding tobacco counseling. Indicator 11, on health plan coverage for cessation programs, is an important measure in its own right and might provide an incentive for the development of smoking cessation programs in the community. REFERENCES CDC (Centers for Disease Control and Prevention). 1989. Reducing the Health Consequences of Smoking: 25 Years of Progress—A Report of the Surgeon General. DHHS Pub. No. (CDC)89-8411. Washington, D.C.: U.S. Department of Health and Human Services. CDC. 1993a. Smoking Cessation During Previous Year Among Adults—United States, 1990 and 1991. Morbidity and Mortality Weekly Report 42:504–507.

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Improving Health in the Community: A Role for Performance Monitoring CDC. 1993b. Cigarette Smoking-Attributable Mortality and Years of Potential Life Lost—United States, 1990. Morbidity and Mortality Weekly Report 42:645–649. CDC. 1993c. Physician and Other Health-Care Professional Counseling of Smokers to Quit—United States, 1991. Morbidity and Mortality Weekly Report 42:855–857. CDC. 1994a. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. DHHS Pub. No. 94-0111-P. Washington, D.C.: U.S. Department of Health and Human Services. CDC. 1994b. Medical-Care Expenditures Attributable to Cigarette Smoking—United States, 1993. Morbidity and Mortality Weekly Report 43:469–472. CDC. 1994c. Cigarette Smoking Among Adults—United States, 1993. Morbidity and Mortality Weekly Report 43:925–930. CDC. 1994d. Guidelines for School Health Programs to Prevent Tobacco Use and Addiction. Morbidity and Mortality Weekly Report 43(RR-2). CDC. 1995a. Health-Care Provider Advice on Tobacco Use to Persons Aged 10–22 Years—United States, 1993. Morbidity and Mortality Weekly Report 44:826–830. CDC. 1995b. Youth Risk Behavior Surveillance—United States, 1993. Morbidity and Mortality Weekly Report 44(SS-1). CDC. 1996a. Tobacco Use and Usual Source of Cigarettes Among High School Students—United States, 1995. Morbidity and Mortality Weekly Report 45:413–418. CDC. 1996b. Addition of Prevalence of Cigarette Smoking as a Nationally Notifiable Condition—June 1996. Morbidity and Mortality Weekly Report 45:537. CDC. 1996c. Cigarette Smoking Among Adults—United States, 1994. Morbidity and Mortality Weekly Report 45:588–590. Center for the Advancement of Health. 1996. Development of Tobacco-Related Performance Indicators for Managed Care . Washington, D.C. (mimeo) Cummings, S.R., Rubin, S.M., and Oster, G. 1989. The Cost-Effectiveness of Counseling Smokers to Quit. Journal of the American Medical Association 261:75–79. EPA (Environmental Protection Agency). 1992. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. Pub. No. EPA-600/6-90/006F. Washington, D.C.: EPA, Office of Health and Environmental Assessment. Fiscella, K., and Franks, P. 1996. Cost-Effectiveness of the Transdermal Nicotine Patch as an Adjunct to Physicians' Smoking Cessation Counseling. Journal of the American Medical Association 275:1247–1251. Gardner, P., and Hudson, B.L. 1996. Advance Report of Final Mortality Statistics, 1993. Monthly Vital Statistics Report 44 (No. 7, supplement). Hyattsville, Md.: National Center for Health Statistics. Garner, D.W. 1996. Banning Tobacco Billboards: The Case for Municipal Action. Journal of the American Medical Association 275:1263–1269. Hatziandreu, E.J., Pierce, J.P., Fiore, M.C., Grise, V., Novotny, T.E., and Davis, R.M. 1989. The Reliability of Self-Reported Cigarette Consumption in the United States. American Journal of Public Health 79:1020–1023. Hu, T., Sung, H., and Keeler, T.E. 1995. Reducing Cigarette Consumption in California: Tobacco Taxes vs an Anti-Smoking Media Campaign. American Journal of Public Health 85:1218–1222.

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Improving Health in the Community: A Role for Performance Monitoring IOM (Institute of Medicine). 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. B.S. Lynch and R.J. Bonnie, eds. Washington, D.C.: National Academy Press. Kleinman, J., and Madans, J.H. 1985. The Effects of Maternal Smoking, Physical Stature, and Educational Attainment on the Incidence of Low Birth Weight. American Journal of Epidemiology 121:832–855. Marks, J.S., Koplan, J.P., Hogue, C.J.R., and Dalmat, M.E. 1990. A Cost-Benefit/Cost-Effectiveness Analysis of Smoking Cessation for Pregnant Women. American Journal of Preventive Medicine 6:282–289. McGinnis, J.M., and Foege, W.H. 1993. Actual Causes of Death in the United States. Journal of the American Medical Association 270:2207–2212. NCQA (National Committee for Quality Assurance). 1996. HEDIS 3.0 Draft for Public Comment. Washington, D.C.: NCQA. OTA (Office of Technology Assessment). 1993. Smoking-Related Deaths and Financial Costs: Office of Technology Assessment Estimates for 1990. Washington, D.C.: U.S. Congress. Pierce, J.P., Fiore, M.C., Novotny, T.E., Hatziandreu, E.J., and Davis, T.M. 1989. Trends in Cigarette Smoking in the United States: Projections to the Year 2000. Journal of the American Medical Association 261:61–65. Russell, M.A.H., Wilson, C., Taylor, C., and Baker, C.D. 1979. Effect of General Practitioners Advice Against Smoking. British Medical Journal 2(6184):231–235. Shultz, J.M., Novotny, T.E., and Rice, D.P. 1991. Quantifying the Disease Impact of Cigarette Smoking with SAMMEC II Software. Public Health Reports 106:326–333. Smoking Cessation Guideline Panel. 1996. Smoking Cessation: A Guide for Primary Care Clinicians. Clinical Practice Guideline, No. 18. AHCPR Pub. No. 96-0693. Rockville, Md.: U.S. Department of Health and Human Services. U.S. Consumer Product Safety Commission. 1993. Practicality of Developing a Performance Standard to Reduce Cigarette Ignition Propensity. Overview . Washington, D.C.: U.S. Consumer Product Safety Commission. USDHHS (U.S. Department of Health and Human Services). 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives . DHHS Pub. No. (PHS) 91-50212. Washington, D.C.: Office of the Assistant Secretary for Health. U.S. Preventive Services Task Force. 1996. Guide to Clinical Preventive Services. 2nd ed. Baltimore: Williams and Wilkins. Ventura, S.J., Martin, J.A., Mathews, T.J., and Clarke, S.C. 1996. Advance Report of Final Natality Statistics, 1994. Monthly Vital Statistics Report 44 (No. 11, supplement). Hyattsville, Md.: National Center for Health Statistics. Warner, K.E., Fulton, G.A., Nicolas, P., and Grimes, D.R. 1996. Employment Implications of Declining Tobacco Product Sales for the Regional Economies of the United States. Journal of the American Medical Association 275:1241–1246.

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Improving Health in the Community: A Role for Performance Monitoring TABLE A.7-1 Field Model Mapping for Sample Indicator Set: Tobacco and Health Field Model Domain Construct Sample Indicators Data Sources Stakeholders Disease Reduce the impact of tobacco-related mortality Deaths due to lung cancer, cardiovascular disease, respiratory diseases; percentage of these deaths attributable to smoking Death certificates Health care providers Health care plans State health agencies Local health agencies Business, industry Community organizations Special health risk groups General public Individual Response Reduce the prevalence of smoking Percentage of adults who smoke regularly Percentage of youth who initiate smoking each year Community surveys Community or school-based surveys State health agencies Local health agencies Education agencies and institutions Community organizations Special health risk groups General public Social Environment Reduce youth access to tobacco Effectiveness of enforcement of local laws prohibiting tobacco sales to minors Local (or state) government enforcement agencies State health agencies Local health agencies Local government Business, industry General public

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Improving Health in the Community: A Role for Performance Monitoring Field Model Domain Construct Sample Indicators Data Sources Stakeholders Social Environment Promote prevention of initiation of tobacco use Extent to which tobacco use prevention is incorporated into school curricula and activities School systems Local Government Education agencies and institutions General public   Promote cessation of tobacco use Number of cessation programs available; success rate (percentage of participants achieving at least 6 months of cessation) Community surveys; cessation program records Health care providers Health care plans Business, industry Community organizations General public Physical Environment Reduce exposure to environmental tobacco smoke Extent to which ordinances control environmental tobacco smoke Local (or state) government enforcement agencies State health agencies Local health agencies Local government Business, industry General public   Reduce loss of life and property from fires Number of residential fires attributable to smoking Public safety agencies  

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Improving Health in the Community: A Role for Performance Monitoring Health Care Promote health care provider counseling on cessation of tobacco use Percentage of tobacco users whose health care providers ask about tobacco use; provide cessation counseling; assist cessation efforts Community surveys Health care providers Health care plans Local health agencies Business, industry General public     Percentage of nonsmoking youth counseled by a health care provider not to begin tobacco use Community or school-based surveys Health care providers Health care plans Local health agencies General public   Reduce financial barriers to participation in cessation programs Percentage of health plans' covered lives with partial or complete coverage for participation in tobacco cessation programs Health plan records Health care plans State health agencies Local health agencies Business, industry General public