While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
From 2002 to 2007, Michael Cummings, Ph.D., M.P.H. at the at the Roswell Park Cancer Institute, a cancer research center located in Buffalo, N.Y., and colleagues at Health Research, Inc., Rensselaer, N.Y., conducted surveys that compared tobacco policies in four demographically similar countries—Australia, Canada, the United Kingdom and the United States—to understand the impact of national-level policies on smoking behavior.
An introductory article in the supplement summarized the findings from the research papers—most of them published in the supplement—according to each policy examined. Among the findings:
The Robert Wood Johnson Foundation (RWJF) supported the project with a grant of $1,499,633 to Health Research, Inc. between August 2002 and July 2007.
State-level tobacco control policies, such as raising the excise tax on cigarettes, have been proven to be effective in lowering tobacco consumption. Evidence of this has been widely published, including articles in:
Certain other tobacco control policies—such as graphic warning labels, restrictions on tobacco advertising and marketing and limits on the use of such terms as "light" and "mild"—must be enacted at the national level.
In 2002, when this grant began, other countries had enacted national legislation mandating graphic warning labels (Canada) and banning advertising and promotion (Thailand and Poland), but such policies had not yet been evaluated for their impact on tobacco use.
According to K. Michael Cummings, Ph.D., M.P.H, study principal investigator, the lack of scientific studies examining the impact of national-level policy changes made it difficult to enact such policies in the United States.
One impetus for new, stricter tobacco policies in other countries was the Framework Convention for Tobacco Control, a treaty the World Health Organization's members had begun to formulate in 1999 as a way of regulating tobacco use internationally.
Among its measures, the treaty required countries to impose restrictions on tobacco advertising, sponsorship and promotion; establish new packaging and labeling of tobacco products; establish clean indoor air controls; and strengthen legislation to clamp down on tobacco smuggling.
In 2002, the World Health Organization's members looked likely to ratify the treaty, at which point countries could begin signing it. Countries signing the treaty agreed to implement the tobacco control measures the treaty mandated.
The timing of this RWJF grant resulted from a special opportunity: within an estimated two years after treaty ratification, three English-speaking countries with socioeconomic and demographic profiles similar to those of the United States—Australia, Canada and the United Kingdom—expected to implement major national-level tobacco policy changes. Cummings recognized these imminent policy changes offered an opportunity to study the effects on smoking of national tobacco policy change in countries similar to the United States.
Cummings and a team of international researchers wanted to collect baseline information about smokers' attitudes and behavior before the countries began implementing the new policies so they could monitor subsequent changes.
The tobacco control treaty entered into force in February 2005. The United States ratified the treaty in 2004 but as of April 2008, President Bush had not brought it forward to the U.S. Congress for approval.
Smoking remains among the most pressing threats to America's health. RWJF has been committed to reducing the use of tobacco, with an emphasis on advancing and sustaining policy changes that have been shown to prevent and reduce tobacco use and exposure to secondhand smoke and to help addicted smokers quit. Many Grant Results reports have been written on RWJF's tobacco control efforts.
At the time this grant was made, RWJF had a program management team focused exclusively on tobacco. Since that time, the Public Health program management team and Tobacco program management team have merged to ensure that the lessons on advancing public health policies and strengthening the public health infrastructure are more aligned.
The team now focuses on ensuring that all Americans have quality public health services and policies that protect, promote and preserve their health, regardless of who they are or where they live.
In August 2002, RWJF made a one-year grant of $1.5 million to Health Research, Inc., in Rensselaer, N.Y., to support the design and initial implementation of a longitudinal survey of the psychosocial and behavioral impacts of national-level policies on cigarette smokers in Australia, Canada, the United Kingdom and the United States. Health Research is a not-for-profit corporation affiliated with the New York State Department of Health and the Roswell Park Cancer Institute, a cancer research center in Buffalo, N.Y.
The research collaborative also included scientists at:
Funding was to support data collection, analysis and dissemination of findings—especially to policy-makers in the United States. Cummings and his colleagues hoped to secure other funding to continue the project for an additional two years but had not yet done so.
During the grant period, Cummings and his colleagues secured substantial additional funding (see Other Funding). RWJF permitted the researchers to conduct certain additional activities with grant funds and eventually extended the grant at its original funding level through July 2007.
Also with these additional funds, Cummings and his colleagues added other countries to the survey. By July 2007, the project was tracking the impact of tobacco policies on smokers in 15 countries.
The project surveyed by telephone over 8,000 smokers in the four countries, with over 2,000 smokers from each country. (The researchers used statistical sampling methods to ensure a representative sample of smokers from each country. All smokers were age 18 and older.)
The survey asked questions to probe smokers' responses to such policies as:
The survey interview was 40 minutes long. Researchers interviewed the same smokers every eight months. They replaced smokers lost to attrition with new subjects that smoked.
Key behaviors against which the researchers measured change were:
Pilot Testing for a Study about a New Law in the United Kingdom
The research team also conducted a pilot test on the feasibility of collecting saliva and spent cigarette butts so they could chart the differences in smoking patterns after the implementation of a law in the United Kingdom mandating lower tar, nicotine and carbon monoxide in cigarettes.
The researchers mailed separate specimen containers to 600 new recruits taking the survey in the four countries, asking them to mail their specimens (both saliva and cigarette butts) back in separate containers. Other researchers collected specimens face to face from 175 survey respondents from study sites in Mexico and Uruguay, countries added to the original study.
The researchers raised over $35 million, most of it from funders outside the United States to continue and expand the study during the grant period. They reported receiving 54 additional grants or in-kind contributions. Among the major funders were the National Cancer Institute, Canadian Institutes of Health Research, Cancer Research UK and the Health Research Council of New Zealand.
The research team worked with the Campaign for Tobacco-Free Kids and the Framework Convention Alliance to disseminate the findings to policy-makers. The campaign is a non-governmental organization in Washington working to prevent kids from starting to smoke, help smokers quit and protect everyone from secondhand smoke. Among its strategies is providing information to policy-makers and the public. RWJF created the campaign and has supported its activities for many years. See Grant Results about its creation.
The Framework Convention Alliance is a Geneva-based organization of 200 nonprofit organizations in 90 countries working to ensure proper implementation of the tobacco control treaty.
This effort was also partly funded by a $60,000 grant from GlaxoSmithKline.
Cummings and two researchers wrote an introductory article (Fong GT, Cummings KM and Shopland DR) in the June 2006 supplement to Tobacco Control that described the research model and summarized the findings from the research papers-most of them published in the supplement—according to each policy examined. (See the Bibliography for more information about the articles in the supplement as well as those published elsewhere.)
The summary findings were:
The supplement contained an article on the conceptual model of the survey, pointing out certain limitations to the study. Among them were:
The research team completed the sixth wave of the four-country survey in February 2008.
Do National-Level Tobacco Policies Decrease Smoking: A Four-Country Tobacco Policy Study
Health Research, Inc. (Rensselaer, NY)
K. Michael Cummings, Ph.D., M.P.H.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Chaloupka FJ, Fong GT, Yurekii A and van Walbeek C (eds). The Economics of Tobacco and Tobacco Control. U.S. National Cancer Institute Smoking and Tobacco Control Monograph 21. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health. In press. (Note: This volume will be an update of the 2002 World Bank publication Tobacco Control in Developing Countries and its companion piece, Curbing the Epidemic, which was a seminal review/analysis of the economics of tobacco control. This monograph is supported by the U.S. National Cancer Institute and the World Health Organization.)
Hastings G. Social Marketing: Why Should the Devil Have all the Best Tunes? Oxford, U.K.: Butterworth Heinemann, 2007.
Royal College of Physicians Tobacco Advisory Group. Harm Reduction in Nicotine Addiction. London: Royal College of Physicians, 2007. Summary available online.
Szilágyi T. Hungry for Hungary: Examples of the Tobacco Industry's Expansionism. (A resource for tobacco control advocates in developing countries). Available online.
Borland R, Cummings KM, Leon M et al. "Methods for Evaluating Tobacco Control Policies." In IARC Handbooks of Cancer Prevention (1st ed.). Geneva, Switzerland: World Health Organization, June 2009.
da Costa e Silva VL and Fong GT. "Tobacco Control Policies of the Framework Convention on Tobacco Control" In The Economics of Tobacco and Tobacco Control: U.S. National Cancer Institute Smoking and Tobacco Control Monograph 21, Chaloupka FJ. Fong GT, van Walbeek C and Yurekii A (eds). Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health. In press.
Ferrence R, Hammond D and Fong GT. "Warning Labels and Packaging" In Ending the Tobacco Problem: A Blueprint for the Nation, Bonnie RJ, Stratton K and Wallace RB (eds), Committee on Reducing Tobacco Use: Strategies, Barriers, and Consequences. Washington: National Academies Press. 2007. Additional information online.
Fong GT, Hammond D and Zanna MP. "Bridging to Evidence-Based Public Health Policy." In Bridging Social Psychology, Van Lange PAM (ed). Mahwah, NJ: Lawrence Erlbaum Associates, 2006.
Hyland A, Fong GT and van Walbeek C. "Smoke-Free Air Policies." In The Economics of Tobacco and Tobacco Control: U.S. National Cancer Institute Smoking and Tobacco Control Monograph 21, Chaloupka FJ. Fong GT, van Walbeek C and Yurekii A (eds). Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health. In press.
McNeill A. "Tobacco Product Regulation." In Civil Society Monitoring of the Framework Convention on Tobacco Control: 2007 Status Report of the Framework Convention Alliance, Jategaonkar N (ed). Geneva, Switzerland: Framework Convention Alliance, 2007.
Saffer H, Omar M and Fong GT. "Information Interventions to Reduce Demand." In The Economics of Tobacco and Tobacco Control: U.S. National Cancer Institute Smoking and Tobacco Control Monograph 21, Chaloupka FJ. Fong GT, van Walbeek C and Yurekii A (eds). Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health. In press.
The following articles appear in Tobacco Control, 15(Suppl. 3): 2006, and are available online:
Alpert HR, Carpentier CM Travers MJ and Connolly GN, "Environmental and Economic Evaluation of the Massachusetts Smoke-Free Workplace Law." Journal of Community Health, 32(4): 269281, 2007.
Barker, DG, Giovino GA, Bable J, Tworek C, Orleans CT and Malarcher A. "Use of Cessation Methods Among Smokers Aged 1624 Years—United States 2003." Morbidity and Mortality Weekly Report, 55(5): 13511354, 2006.
Borland R, Yong H-H, King B, Cummings KM, Fong GT et al. "Use of and Beliefs about Light Cigarettes in Four Countries: Findings from the International Tobacco Control Policy Evaluation Survey." Nicotine & Tobacco Research, 6(Suppl. 6): S311S321, 2004.
Brown AK, Hastings G, Hassan L and MacKintosh AM. "Tobacco Policy Influence on Denormalisation of Smoking." Taiwan Journal of Public Health. In press, 2007.
Carpentier CM, Connolly GN, Travers M, Hyland A and Cummings KM. "Health Meetings do not Belong in Smoky Cities" (Letter). Tobacco Control, 15(1): 6970, 2006.
Cheong YS, Yong HH and Borland R. "Does How you Quit Affect Success? A Comparison between Abrupt and Gradual Methods Using Data from the International Tobacco Control (ITC) Policy Evaluation Survey." Nicotine & Tobacco Research, 9(8): 801810, 2007.
Fong GT, Hammond D, Laux FL, Zanna MP, Cummings KM et al. "The Near-Universal Experience of Regret among Smokers in Four Countries: Findings from the International Tobacco Control Policy Evaluation Survey." Nicotine & Tobacco Research, 6(Suppl. 3): S341S351, 2004.
Gower SK and Hammond D. "CSP Deposition to the Alveolar Region of the Lung: Implications of Cigarette Design." Risk Analysis, 6: 15191533, 2007.
Hall PA and Fong GT. "Temporal Self-Regulation Theory: A Model for Individual Health Behavior." Health Psychology Review, 1: 652, 2007.
Hamann S. "Thailand: Mass Exercise, Petition, and Lure-Free Points of Sale" (Letter). Tobacco Control, 15: 5, 2006.
Hammond D, Collishaw N and Callard C. "Secret Science: Tobacco Industry and Cigarette Toxicity." Lancet, 367: 781787, 2006.
Hammond D, Costello MJ, Fong GT and Topham J. "Exposure to Tobacco Marketing and Support for Tobacco Control Policies among University Students." American Journal of Health Behavior, 30: 700709, 2006.
Hammond D, Fong GT, Borland R, Cummings KM, McNeill A and Driezen P. "Text and Graphic Warnings on Cigarette Packages: Findings from the ITC Four Country Survey." American Journal of Preventive Medicine, 32(3): 202209, 2007.
Hammond D, Fong GT, Cummings KM and Hyland A. "Smoking Topography, Brand Switching and Nicotine Delivery." Cancer, Epidemiology, Biomarkers & Prevention, 14(5): 13701375, 2005. Abstract available online.
Hammond D, Fong GT, Cummings KM, O'Connor RJ, Giovino G and McNeill A. "Cigarette Yields and Human Exposure: A Comparison of Alternative Smoking Regimes." Cancer Epidemiology, Biomarkers & Prevention, 15(8): 14951501, 2006. Abstract available online.
Hammond D, Fong GT, McDonald PW. Cameron R and Brown KS. "Showing Leads to Doing: Graphic Cigarette Warning Labels are an Effective Public Health Policy." European Journal of Public Health, 16(2): 223224, 2006.
Hammond D, Fong GT, McDonald PW, Cameron R and Brown KS. "The Impact of the Graphic Canadian Warning Labels on Adult Smoking Behaviour." Tobacco Control, 13: 391395, 2003.
Hammond D, Fong GT, McDonald PW, Cameron R and Brown KS. "Graphic Canadian Warning Labels and Adverse Outcomes: Evidence from Canadian Smokers." American Journal of Public Health, 94: 14421445, 2004.
Hammond D, Fong GT, Zanna MP, Thrasher JF and Borland R. "Tobacco Denormalization and Industry Beliefs among Smokers from Four Countries." American Journal of Prevention Medicine, 31(3): 225232, 2006.
Hammond D, Kin F, Prohimmo A, Kungeskulniti N, Lian TY et al. "Patterns of Smoking Among Adolescents in Malaysia and Thailand: Findings from the International Tobacco Control Southeast Asia Survey." Asia-Pacific Journal of Public Health, 20(3): 193203, 2008. Abstract available online.
Hammond D, McDonald PW, Fong GT and Borland R. "Do Smokers Know How to Quit? Knowledge and Perceived Effectiveness of Cessation Assistance as Predictors of Cessation Behaviour." Addiction, 99: 10421048, 2004.
Hammond D, McDonald PW, Fong GT, Brown KS and Cameron R. "The Impact of Cigarette Warning Labels and Smoke-Free By-Laws on Smoking Cessation: Evidence from Former Smokers." Canadian Journal of Public Health, 95: 201204, 2004.
Hammond D, Wiebel F, Kozlowski LT, Borland R, Cummings KM et al. "Revising the Machine Smoking Regime for Cigarette Emissions: Implications for Tobacco Control Policy." Tobacco Control, 16: 814, 2007.
Hassan LM, Shiu E, Thrasher JF, Fong GT and Hastings G. "Exploring the Effectiveness of Cigarette Warning Labels: Findings from the United States and United Kingdom Arms of the International Tobacco Control (ITC) Four Country Survey." International Journal of Nonprofit and Voluntary Sector Marketing, September 11, 2007 (published online by John Wiley & Sons, Ltd.). Abstract available online.
Haw SJ, Gruer L, Amos A, Currie C, Fischbacher C, Fong GT et al. "Legislation on Smoking in Enclosed Public Places in Scotland: How Will We Evaluate the Impact?" Journal of Public Health, 28(1): 2430, 2006.
Jones SC, Travers MJ, Hahn EJ, Robertson H, Lee K et al. "Secondhand Smoke and Indoor Public Spaces in Paducah, Kentucky." Journal of the Kentucky Medical Association, 104: 281288, 2006.
Kozlowski LT, O'Connor RJ, Giovino GA, Whetzel CA, Pauly J et al. "Maximum Yields Might Improve Public Health-If Filter Vents were Banned: A Lesson from the History of Vented Filters." Tobacco Control, 15(3): 262266, 2006.
O'Connor R, Cummings KM, McNeill A and Kozlowski L. "How Did UK Cigarette Makers Reduce Tar to 10 mg or Less?" (Letter). British Medical Journal, 332: 302, 2006.
O'Connor RJ, Bauer JE, Giovino GA, Hammond D, Hyland A et al. "Prevalence of Behaviors Related to Cigarette-Caused Fires: A Survey of Ontario Smokers." Injury Prevention, 13: 237242, 2007. Abstract available online.
O'Connor RJ, Giovino GA, Fix BV, Lyland A, Hammond D et al. "Smokers' Reactions to Reduced Ignition Propensity Cigarettes: Findings from the U.S. Arm of the ITC Four Country Survey." Tobacco Control, 15: 4549, 2007.
O'Connor RJ, Hyland A, Cummings KM, Giovino GA and Fong GT. "Smoker Awareness of and Beliefs about Supposedly Less-Harmful Tobacco Products." American Journal of Preventive Medicine, 29: 8590, 2005.
O'Connor RJ, Kozlowski LT, Borland R, Hammond D and McNeill A. "Relationship Between Constituent Labelling and Reporting of Tar Yields among Smokers in Four Countries." Journal of Public Health, 28(4): 324329, 2006. Abstract and full article available online.
O'Connor RJ, McNeill A, Borland R, Hammond D, King D et al. "Smokers' Beliefs about Relative Safety of Other Tobacco Products: Findings from the ITC Collaboration." Nicotine & Tobacco Research, 9(10): 10331042, 2007.
Pauly J, Li Q and Barry MB. "Tobacco-Free Electronic Cigarettes and Cigars Deliver Nicotine and Generate Concern" (Letter). Tobacco Control, 16: 357, 2007.
Shahab L, Hammond D, O'Connor R, Cummings KM, Borland R et al. "The Reliability and Validity of Self-Reported Puffing Behaviour: Evidence from a Cross-National Study." Nicotine & Tobacco Research, 10(5): 867874, 2008.
Shahab L, West R and McNeill A. "The Feasibility of Measuring Puffing Behaviour in Roll-Your-Own Smokers." Tobacco Control, 17(Suppl. 1): i17i23, 2008. Abstract available online.
Siahpush M, Borland R and Scollo M. "Factors Associated with Cessation in a National Sample of Australians." Nicotine & Tobacco Research, 5: 597602, 2003.
Siahpush M, Borland R and Yong H-H. "Sociodemographic and Psychosocial Correlates of Smoking-Induced Deprivation and its Effect on Quitting: Findings from the International Tobacco Control Policy Evaluation Survey." Tobacco Control, 16(2): e2, 2007.
Strahan EJ, White K, Fong GT, Fabriger LR, Zanna MP et al. "Enhancing the Effectiveness of Message Labels on Tobacco Packaging: A Social Psychological Perspective." Tobacco Control, 11: 183190, 2002.
Thompson ME, Boudreau C and Driezen P "Incorporating Time-in-Sample in Longitudinal Survey Models." Proceedings of Statistics Canada 2005 International Methodology Symposium, 2005. Abstract available online.
Thompson ME and Wu C. "Simulation-Based Randomized Systematic PPS Sampling Under Substitution of Units." Survey Methodology, 34(1): 310, 2008. Available online.
Thrasher JF, Chaloupka FJ, Hammond D, Fong G, Borland R et al. "Evaluacion de las politicas contra el tabaquismo en paises latinoamericanos en la era del Convenio Marco para el Control del Tobaco." Revista de Salud Publica de México, 8(Suppl. II): S155S166, 2006. (Evaluation of Tobacco Control Policies in Latin American Countries During the Era of the Framework Convention on Tobacco Control.)
Thrasher JF, Hammond D, Fong GT and Arillo-Santilan E. "Smokers' Reactions to Cigarette Package Warnings with Graphic Imagery and with Only Text: A Comparison between Mexico and Canada." Salud Pública de México, 49(Suppl. 2): s233s240, 2007. Abstract available in English and Spanish online. Text also available.
Wilson N, Edwards R, Maher A, Nathe J and Jalali R. "National Smokefree Law in New Zealand Improves Air Quality Inside Bars, Pubs and Restaurants." Biomed Central Public Health, 7: 85, 2007. Abstract available online.
Wilson N, Peace J, Thomson G and Edwards R. "The Prevalence of Misleading Tobacco Descriptors in the new England Tobacco Market" (Letter). New Zealand Medical Journal, 120(1252): 13, 2007.
Yong H-H, Borland R, Hammond D, Sirirassamee B, Ritthiphakdee B et al. "Levels and Correlates of Awareness of Tobacco Promotional Activities Among Adult Smokers in Malaysia and Thailand. Findings from the International Tobacco Control Southeast Asia (ITC-SEA) Survey." Tobacco Control, 17: 4652, 2008. Abstract and article available online.
Yong H-H, Borland R and Siahpush M. "Quitting-Related Beliefs, Intentions, and Motivations of Older Smokers in Four Countries. Findings from the International Tobacco Control Policy Survey." Addictive Behaviors, 30: 777788, 2005.
Young D, Borland R, Siahpush M, Hastings G, Fong GT and Cummings for the ITC Collaboration. "Australian Smokers Support for Stronger Regulatory Control on Tobacco: Findings from the ITC Four-Country Survey." Australian and New Zealand Journal of Public Health, 31(2): 164169, 2007. Abstract available online.
Young D, Yong HH, Borland R, Ross H, Sirirassamee B et al. "Prevalence and Attributes of Roll-Your-Own Smokers in Thailand and Malaysia: Findings of the ITC-SEA Survey." Nicotine & Tobacco Research, 10(5): 907915, 2008 Abstract available online.
Report prepared by: Susan G. Parker
Reviewed by: Janet Heroux
Reviewed by: Molly McKaughan
Program Officer: Nancy Kaufman
Program Officer: Karen Gerlach
Program Officer: Marjorie Paloma
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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