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OffLine Fall 1998

Volume 11 Number 2

Cigarette smoking accounts for the vast majority of lung cancer causes and about one-third of cardiovascular diseases in the U.S., making it the nation's single biggest cause of preventable deaths. Although smoking prevalence in the U.S. is about half what it was in 1965, 25 percent of adult Americans continue to smoke despite overwhelming evidence of cigarettes' harmful effects.

The comparable prevalence figure at Group Health is 15 percent, well below the community and national averages of 22 and 25 percent, respectively. Center for Health Promotion Director Tim McAfee attributed this in part to the Cooperative's commitment to tobacco cessation: "Members are provided full access to the support they need—without the financial barriers of many other health plans—to live tobacco-free". Interestingly, this statement alludes to two important contributions of Group Health Center for Health Studies to Group Health's tobacco cessation effort. First, smokers can obtain "support" through Free & Clear, the behavioral program that grew out of a 1983 Center research grant. Second, enrollees can use Group Health smoking cessation services "without financial barriers" because of a policy change motivated by findings from a CHS study. Briefly, the Cooperative decided to offer full coverage for smoking cessation services after the CHS evaluation found that use of services doubled, with quit rates remaining about the same, when enrollees were offered full coverage. (NEJM 1998;339:673–679).

CHS' impact on Group Health tobacco cessation programs and policy is just one indication of the department's longstanding commitment to this research area. In the 15 years since the award of the Free & Clear grant, the Center has become a national player in the smoking cessation and relapse prevention arena under the direction of Dr. Susan Curry. The unifying theme of much of this research has been minimal self-help interventions consisting of a core set of general written materials complemented by personalized motivational adjuncts such as written feedback or telephone counseling calls. This issue of OffLine discusses some recent studies in the context of two developments in CHS smoking-related research. The first is a shift from targeting the general population of smokers to focusing on specific subpopulations for whom smoking cessation or prevention may be of particular salience. For example, a current cessation study is targeting low income women, a group with smoking rates approximately twice the national average. The second development, brought about by the recent additional of Associate Investigator David Wetter to CHS, is to start to deliver individually tailored smoking cessation or relapse prevention interventions through state-of-the-art technology, namely palm-sized computers.

SUBPOPULATIONS

Steering Clear: Ninety percent of adult smokers take up regular smoking before age 18. The implication is that if people don't start smoking as adolescents, they are unlikely to become addicted to nicotine as adults. Unfortunately, smoking initiation rates among adolescents actually increased between 1992 and 1994. It is estimated that 3,000 adolescents become regular addicted smokers each day; an additional 6,000 try their first cigarette.

In the light of these statistics, Curry and researchers at the Center for Health Research at Kaiser Permanente Northwest are currently collaborating on a study, "Steering Clear", designed to prevent smoking initiation among children aged 10 to 12. The investigators settled on this subpopulation of children because it represents the earliest age at which "susceptibility to smoking" can be reliably measured. Defined as an absence of a firm resolve not to smoke, this concept is a robust predictor of experimentation with tobacco which, in turn, is a strong predictor of regular smoking.

In contrast with most smoking prevention efforts to date that have been school-based, this study delivers interventions through parents and the health care delivery system. Parents receive a prevention kit and a video to watch with their child; medical providers endorse the "Steering Clear" message when participants visit the clinic. This novel design recognizes the influence of parents' attitudes and behaviors on smoking initiation, as well as the unique ability of medical practitioners to link smoking risks with current health problems (e.g., upper respiratory infections).

Fresh Start: "Project Fresh Start" is a smoking cessation effort targeting low income women smokers who bring their children to a pediatric health care clinic (Harborview Medical Center or Odessa Brown). Rates of smoking among low income women of child-bearing age have been reported to be as high as 40 to 60 percent, twice the national average. Further, this population of smokers is traditionally underrepresented in cessation programs. The site of recruitment, a pediatric health care clinic, is an integral part of the study design because it represents a "teachable setting"—an opportunity for health care providers to link both the child's and woman's health to smoking. For example, intervention-sponsored motivational messages from the health care provider and an on-site study nurse might point out that maternal smoking is the primary source of early childhood exposure to secondhand smoke. Given the study's focus on low income women, the specific participating pediatric clinics—Harborview and Odessa Brown—are critical. In contrast to the Group Health population, a large proportion of patients (>70 percent) at these two institutions are Medicaid recipients. CHS Principal Investigator, Sue Curry, is excited to be collaborating with researchers from these community medical centers.

HOPP: The recently completed Project HOPP (Healthy Options for Pregnancy and Parenting) was based on the premise that pregnancy and the post-partum period represent unique opportunities to encourage permanent smoking cessation. Thirty percent of female smokers quit smoking when they become pregnant out of concern for the fetus' well-being. However, 80 to 90 percent return to smoking within 1 year of delivery, with greatest relapse in the 4 to 6 months postpartum. These statistics prompted scientists at CHS and the University of Minnesota to collaborate on a randomized trial with the primary purpose of preventing relapse to smoking among women who quit during pregnancy. This trial was novel in testing a relapse prevention intervention provided both during pregnancy and post-partum—previous relapse prevention interventions had been delivered during the pre-partum period only.

The two sites screened the subpopulation of new prenatal women to identify current and recent smokers (those who had quit smoking upon becoming pregnant). Out of almost 7,500 women surveyed, 1,007 (13 percent) met the smoking criteria. Almost 900 of these pregnant smokers were randomized to one of three interventions: 1)a self-help book with messages about cessation and relapse prevention; 2)#1 plus a relapse prevention kit and 3 telephone counseling calls before delivery; and 3)#2 plus 3 telephone counseling calls up to 4 months after delivery. The study found that the counseling calls delivered post-partum delayed the return to smoking but did not prevent it—smoking relapse rates among the three groups were identical 12 months postpartum. Citing the unique opportunity to encourage permanent smoking cessation among pregnant and post-partum women, co-P.I. Colleen McBride proposes taking the study one step further and incorporating relapse prevention into both prenatal and pediatric care.

SALONS: Smoking rates have remained relatively stable among women in the past 10 to 15 years with the highest rates, up to 30 percent, reported among reproductive age women. "Project SALONS" evaluated a minimal smoking cessation intervention projected to young female smokers as a follow-up to a Pap test. With this design, investigators Colleen McBride, Delia Scholes, and Sue Curry attempted to capitalize on a "teachable moment" when smokers may be especially motivated to consider quitting. Smoking has been linked with an increased risk of cervical cancer and severe cervical abnormalities; the thinking was that this information might be particularly motivational and salient in the context of a recent Pap test.

Unfortunately, quit rates did not differ between the usual care and intervention groups at 6 and 25 months post-randomization. Further, the investigators' hypothesis that the intervention would be more effective among women with abnormal test results was not supported by the data. However, a separate analysis of study data showing that current smoking and passive smoking exposure were associated with low-grade (not just severe) cervical cytological abnormalities provides further impetus to pursue this line of research. That is, this new evidence linking current smoking behavior and early cervical abnormalities could be used to strengthen tobacco cessation interventions delivered in the context of screening for cervical cancer. Indeed, in a fortuitous development, new CHS Research Associate Jennifer McClure (see below) has received an academic career development award to conduct research in this very area. She will evaluate a brief motivational counseling intervention delivered to female smokers who have recently had abnormal Pap tests.

TECHNOLOGY

CHS' foray into "high tech" smoking cessation and relapse prevention interventions is spearheaded by Dr. David Wetter. Wetter, a clinical psychologist who joined the Center in December 1998 as an Associate Investigator, has had extensive experience in the areas of nicotene addiction and smoking cessation. He spent the previous 3 1/2 years before coming to CHS as an Assistant Professor at the MD Anderson Cancer Center at the University of Texas. Center Director Sue Curry regards Wetter's hiring as a real coup, saying: "Dave brings an impressive aray of interests and talents to the Center in the area of health behavior change. His work extends from basic research on the impact of nicotine withdrawal on sleep to evaluating cutting-edge behavior change interventions to participating in the AHCPR Smoking Cessation Guideline". In fact, CHS is triply fortunate. Wetter's colleagues from MD Anderson—clinical psychologist Jennifer McClure and experimental psychologist Ludmilla Cofta-Gunn—also decided to make the move to CHS and will spend part of their time collaborating with Wetter on two smoking-related grants he brought with him.

One trial is evaluating a relapse prevention intervention specifically tailored for women; the second is testing a self-help smoking cessation intervention in the general population of smokers. Both trials feature individually tailored interventions delivered via palm-sized computers. The content of the tailored interventions is based on a one-week of assessment data also collected via the hand-held computers. For example, if a subject feels an urge to smoke during this pre-intervention assessment period, s/he turns on the computer and answers questions that identify the source of the urge and the most useful means of dealing with it. These real-time, real-world responses are used to customize interventions that are then programmed into the computer. The interventions accessible via the hand-held computer are of 3 types: 1)non-tailored self-help materials; 2)individualized coping strategies addressing specific real-time situations (e.g., cigarettes are available); and 3)pre-programmed motivational messages.

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