the Minnesota Heart Health Program - NCBI

Changes in Adult Cigarette Smoking in the Minnesota Heart Health Program

HarnyA. Lando, PhD, Teny F. Pechacek PhD, Phyllis L. Pine, PhD, David M. Murray, PhD, Maunrce B. Mittelmark; PhD, Edward Lichtenstein, PhD, Fatyle Nothwehr, MPH, and Clifton Gray, PhD

Introduction Cigarette smoking is recognized as the leading preventable cause of death in the United States."l2 Approximately 434 000 deaths each year in this country are attributable to smoking.' As many as one third of 35-year-old heavy smokers will die before age 85 of diseases caused by their smoking.3 Despite these health consequences, almost 50 million Americans continue to smoke.4 Cardiovascular diseases are the leading causes of death and disability in industrialized countries, and smoking is a major risk factor for

these diseases.5-8 Hundreds of studies have addressed smoking cessation methods, primarily at the level of the individual smoker.9""( Despite their strengths, these methods have little hope of producing major prevalence reductions in the general population.9"' Population risk should be amenable to change through communitywide strategies,' 2 and a number of community intervention research and demonstration projects are under way or have been completed in the United States and Europe.'l-"8 One of the largest of these studies in the United States is the Minnesota Heart Health Program.' 3"4 Initiated in 1980, the Minnesota Heart Health Program involved six communities in the upper Midwest with a combined population of approximately 500 000. It was hypothesized that an intensive 5-year intervention program would (1) improve health behaviors, including cigarette smoking and physical activity levels; (2) lower population levels of blood cholesterol and blood pressure; and (3) result in reductions in cardiovascular disease morbidity and mortality. Descriptions of Heart Health Program interventions and over-

all risk factor outcomes are presented

elsewhere.7' 4 9 The current paper focuses on specific interventions and outcomes related to tobacco use.

Methods Study Design The design and methods of the Minnesota Heart Health Program have been presented elsewhere'° and are only summarized here. Three pairs of communities were selected for the study, each pair with one education and one comparison site. Communities were matched on size, community type, and distance from the Minneapolis-St. Paul metropolitan area. Assignment of communities to conditions from within the matched pairs was nonrandom, based on logistical and budgetary considerations, and was completed before collection of any data.7

Harry A. Lando, Phyllis L. Pirie, David M. Murray, and Clifton Gray are with the Division of Epidemiology, School of Public Health, University of Minnesota. Minneapolis. Terry F. Pechacek is with the Department of Social and Preventive Medicine, State University of New York at Buffalo, NY. Maurice B. Mittelmark is with the Bowman Gray School of Medicine, Wake Forest University, Winston Salem, NC. Edward Lichtenstein is with the Oregon Research Institute, Eugene. Faryle Nothwehr is with the School of Public Health, University of Michigan, Ann Arbor. Requests for reprints should be sent to Harry A. Lando, PhD, Division of Epidemiology, School of Public Health, University of Minnesota, 1300 S Second St, Suite 300, Minneapolis, MN 55454-1015. This paper was accepted October 11, 1994.

American Journal of Public Health 201

Lando et al.

TABLE 1-Summary of Smoking Intervention Studies, Minnesota Heart Health Program Study Design

Intervention

Reference

Total No.

Outcome 17% abstinence, 3-4 months, self-report 21%-24% abstinence, 6-7 months, self-report 5.5% abstinence in intervention group, 2.5% abstinence in comparison group, 6 months, cotinine validation, P = .005; effects no longer significant at 18 months 12% abstinence at intervention sites; 9% abstinence at control sites, 6 months, self-report, P < .05 10% abstinence, 7 months, selfreport, no dffference between conditions

Lando et al.28

Extended Quit and Win contest

Nonrandom

918

Pechacek et al.29

Quit and Win contests

Nonrandom

4358

Lando et al.30

Two brief supportive telephone calls

Randomized trial

1827

Sorensen et al.31

Work-site consultation, work-site quit classes

Randomized trial

8 work sites

Lando et al.32

Telephone call inviting participation in study, two types of selfhelp materials vs no-materials control Home correspondence course; nonrefundable $5 fee vs $60 refundable deposit Work-site policy consuftation

Randomized trial

570

Randomized trial

142

Enriched vs standard staff training in health promotion

Randomized trial

Jeffery et al.33

Gleason-Comstock et al.34

Lando et al.35

49 work sites in Mankato, 28 work sites in Bloomington 6 churches, 6 work sites

Nonrandom

TABLE 2-Exposure Reported by Smokers to Smoking-Cessation Messages and Programs

Exposure Question

Comparison Education Communities Communities No. Percentage No. Percentage

In the past 12 months, has your doctor given 117 you literature, pamphlets, or other written material about cigarette smoking? In the past 12 months, has your doctor talked 135 with you about cigarette smoking? Have you taken part in any classes, programs, 45 or contests designed to help people quit

10.3

84

6.7

11.0

157

12.5

4.0

39

3.1

87.3

1081

86.3

smoking? In the past year, have you noticed any informa- 988 tion in newspapers, radio, or TV about how to quit smoking?

Note. Table values are the percentages of respondents at the height of the intervention program (E3) who answered yes to the question.

Smoking Intervention Methods The Minnesota Heart Health Program smoking intervention program operated at the individual, group, and community levels and encompassed a wide range of strategies stimulated by social learning theory,21 persuasive-communications 202 American Journal of Public Health

theory,2= and

models for the involvement of community leaders and institutions.24 There were six key elements of the

smoking intervention program: 1. Community analysisladvisory board. The overall intervention activities in the communities were guided by a community

Far greater enrollment with $5 fee, 10% abstinence, 6 months, cotinine validation Greater proportion of work-site areas smoke free; greater number of totally smoke-free work sites No difference between conditions; minimal participation in quit classes

advisory board made up of influential political, business, health, and other leaders in the community. A citizen task force was established, supported by Heart Health Program staff and materials, to lead smoking intervention efforts. 2. Mass media. Mass media were used to promote community awareness of the program and to reinforce the other education components.25 3. Health professionals. More than 1840 health professionals, almost all of whom were physicians, were trained on the major risk factors for coronary heart disease after the Heart Health Program began. All received training in the relationship between smoking and coronary heart disease and advice on how to guide their patients to quit smoking. However, smoking was only one of a number of topics covered in the training sessions. Virtually every primary care physician in the three education communities participated in at least one training session.26 4. Risk factor screening. Systematic risk factor screening and education were conducted during the first 3 years of the intervention program.19 Risk measurement included blood pressure, choles-

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Changes in Adult Smoking

terol, physical activity, and body weight in addition to smoking. 5. Adult education. The adult education component consisted of multiple types of smoking cessation programs including Quit and Win contests held in each of the intervention communities,27-29 telephone support,30 classes in both community settings and work sites,31 self-help materials,32 and home correspondence

programs.33 6 Environmental programs. SmokeFree Week was a communitywide effort to effect policy change in the workplace and was first implemented in Mankato in February 1986. Similar programs were employed in Fargo-Moorhead and Bloomington.34 Staff training was implemented in work sites and churches to facilitate offering of health promotion programs including programs in smoking.35 The Quit and Win contests also were intended to provide environmental support for quitting. Individual smoking intervention studies are summarized in Table 1.

50 -

Exposure questionnaire. Respondents were asked about exposure to information and programs relevant to cardiovascular disease prevention. Four exposure questions pertained to smoking. Annual risk factor survey. Both crosssectional and cohort surveys were included. Cross-sectional samples consisted of approximately 23 000 randomly selected adults, 25 to 74 years of age, chosen by the two-stage sampling method of Kish.36 Data were obtained in each of the 4 years before the interventions and for 6 years after intervention. Approximately 7000 randomly selected participants from the baseline surveys were followed as a cohort after 2, 4, and 7 years of intervention. The number of participants in the education community and in the comparison community in each pair of cities was approximately equal for all years.7 Survey data were collected in home interviews and during subsequent visits to an assessment center, at which physical measurements were taken. Measurements included height and weight, blood pressure, and cholesterol. Participants were asked about physical activity and smoking behavior. Participants were classified as current smokers if they reported smoking at least 100 cigarettes in their lifetime and smoked at present. Serum thiocyanate was also measured as a check on self-reported smoking.37


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FIGURE 1-CIgarette smoking In men: cross-section (clinic self-report).

Analysis Methods Smoking prevalence was the key outcome measure. Both self-reported and thiocyanate-adjusted prevalence rates were computed from the annual risk factor survey data. By design, the community was the unit of assignment, and the individual was the unit of observation.

Consequently, variation caused by the treatment is confounded with variation caused by the cities. Unless this extra

variation is accounted for in analysis, the evaluation of treatment effects will be positively and often substantially biased.38'39 The analysis method, which approximated a stratified analysis of covariance, is reported in detail elsewhere.40 The unit of analysis was city-year means. Nested communities were treated as random effects, and time, condition (intervention vs comparison), and stratification

factors were treated as fixed effects. A common linear secular trend was estimated from all years in comparison communities and from years before intervention in education communities. The null hypothesis was tested that effects of the Minnesota Heart Health Program after intervention did not differ from the secular trend. The incidence of quitting also was examined by using methods of survival analysis. Smokers were defined by their self-report. Quitters were defined as those who met all of the following criteria: reported having smoked at least 100 cigarettes in their lifetime, reported that they did not currently smoke, reported a quit date later than the start of the education program in their city, and had a measured thiocyanate level below the cutoff of 85 ng/ml. Approximately 5% of American Journal of Public Health 203

Lando et aL

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30/' .20), as they did with nonvalidated smoking rates. Among women, the cross-section treatment effect was slightly reduced (revised P = .051); the treatment effect in the cohort remained at chance (P > .10).

Discussion The findings for smoking intervention in the Minnesota Heart Health Program were mixed, but primarily negative. The program had no effect on smoking prevalence in men. In women there were positive effects only in the cross-section. The secular declines of almost 1.5% per year (evidenced in the cohort in both men and women and in the cross-section in men) greatly exceeded the overall secular trend in the United States in the same time period of approximately 0.5% per year.42'43 Given these unexpectedly large secular changes, it may have been unrealistic to expect additional effects due to the Heart Health Program.


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FIGURE 3-Cigarette smoking In women: cross-section (clinic self-report).

Despite differential disconfirmation among women in the education communities, the thiocyanate-adjusted data remained supportive of the education effect for women in the cross-section. In evaluating the outcomes for women, consideration should be given to the differences in the cross-sectional and cohort data. The differences in these data were not anticipated, and there is not an obvious explanation for these results. Intrasubject comparisons are more sensitive than intersubject comparisons when other factors are equivalent. Furthermore, the cohort case subjects were more thoroughly exposed to intervention. These two factors should have resulted in a greater effect in the cohort-the opposite of the observed results. On the other hand, the cohort consisted of

a more

stable and

permanent population than the

cross-

section. These individuals tended to be healthier and to be more likely to quit on their own. Cohort cases lost to follow-up had higher smoking rates than those retained.7 There was no evidence of differential attrition between the education and comparison communities, but such attrition could account for differences between cohort and cross-sectional data. A number of studies have been published that appear to have found positive effects of communitywide intervention on smoking. Notable among these are the North Karelia Project in Finland,18 the North Coast "Quit for Life" program in Australia,44and the Stanford Five-Community study.5 It should be noted, however, that these other projects American Journal of Public Health 205

Lando et al.

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FIGURE 5-VerIfied cigarette smoking: women.

did not demonstrate consistently significant effects when the analyses were conducted at the city-year level, as was

206 American Journal of Public Health

done for the Minnesota Heart Health Program. Furthermore, it should be noted that in the Stanford Five-Community

Project, initiated before the Minnesota Heart Health Program, the risk-factor changes were larger, but the secular trends were not as strong as those observed in the Heart Health Program.5"16 Although overall community comparisons were largely disappointing, individual Minnesota Heart Health Program interventions often were successful. The Quit and Win contests were especially noteworthy. These contests have been applied in multiple locations both in the United States and abroad.45A46 The impact of the Quit and Win contests may have extended considerably beyond the contest enrollees. Publicity surrounding the contests appeared to create a more positive and supportive populationwide attitude toward smoking cessation. Furthermore, many smokers who did not enroll in contests attempted to quit on their own during the same time period. Thus, in the first Mankato contest, although only approximately 5% of smokers participated, over 45% of all smokers in the community reported a quit attempt during the contest promotion.29 Quit classes enrolled relatively few smokers (those having the most difficulty in quitting). Many of the Minnesota Heart Health Program smoking interventions were targeted to harder-core smokers who may have been ready to quit but who were less likely to quit on their own. Influencing quit rates among these harder-core smokers might be expected to have relatively little impact on the overall population prevalence. Interventions that could reach less-addicted smokers and those who are in precontemplation or contemplation47 and thereby more significantly affect overall smoking prevalence (e.g., media messages, self-help materials) may have been distributed more evenly across education and comparison communities. Smokers reported far greater exposure to smokingcessation information, advice, and materials than to formal programs. However, no differences in self-reported exposure to any type of smoking-cessation messages or programs were found between the education and comparison communities. Efforts were made to minimize media sharing of Minnesota Heart Health Program messages in the education and comparison communities. This sharing was a potential problem largely for Bloomington and Roseville, given their close physical proximity and their status as Twin Cities suburbs. However, no shared media were used in Bloomington. Instead messages were delivered through localaccess cable television and local commuFebruary 1995, Vol. 85, No. 2

Changes in Adult Smoking

nity newspapers. It is possible that continuing-education programs were attended by a few health care professionals who provided care to individuals from both Bloomington and Roseville. However, especially given that these communities are on opposite sides of the Twin Cities, such contamination is likely to have been minimal. Even so, health promotion activities such as those developed and implemented in the education communities appeared to spread rapidly in the region and may have "contaminated" the comparison communities.7 The comparison communities may have been unusually ready for change. This supposition is consistent with the rather dramatic secular trends toward reduced smoking prevalence, trends that not only substantially exceeded national smoking reductions but also exceeded smoking reductions in Minnesota and the upper midwest as a whole. It should be noted that these communities were not volunteers willing to be randomized. Rather, they were selected by researchers at the University of Minnesota and were matched within the three pairs. Education communities then were selected for administrative convenience. Even so, these comparison communities (and Minnesota more generally) might be seen as earlyadopter populations. Future Heart Health Program-type interventions may be more effective in communities in which smoking prevalence is static and in which multiple existing smoking-cessation messages and activities do not already exist. In addition to developing and testing several promising interventions, the Minnesota Heart Health Program succeeded in influencing the three education communities to incorporate a number of smokingintervention activities and to continue these activities on their own.29 Incorporation of the Quit and Win contests has been especially noteworthy. Furthermore, the Heart Health Program appears to have activated political constituencies around health-related issues. In Bloomington, for example, former members of Heart Health Program task forces were instrumental in influencing the Bloomington City Council to adopt a ban on cigarette vending machines and to maintain the ban in the face of considerable industry pressure for repeal.48 In future interventions, a combination of education and political advocacy for health issues may be more effective than education alone. The Minnesota Heart Health Program was implemented in only three


education communities. In contrast, the National Cancer Institute (NCI) Community Intervention Trial for Smoking Cessation included a total of 22 communities (i.e., 11 matched pairs). This substantially larger sampling of communities provides more power than was available in the Heart Health Program. Because intervention in the NCI trial focused exclusively on smoking, more resources could be brought to bear on this single key health issue. Perhaps the Minnesota Heart Health Program, with its attention to multiple risk factors, sufficiently diluted smoking-cessation efforts and activities to minimize the likelihood of achieving significant overall community effects for smoking prevalence. A goal of future research and application will be to establish cost-effective interventions that can influence smoking prevalence in substantially larger populations. Efforts are currently under way in the American Stop Smoking Intervention Study for Cancer Prevention (ASSIST) trial (also funded by the NCI) to demonstrate an impact on smoking prevalence in entire states through coalitions led by state health departments and the American Cancer Society. This work may contribute to accelerating changes in the larger social environment that will in turn influence smoking prevalence. Noteworthy in ASSIST is an emphasis on coalition building and political advocacy. Perhaps statewide, regional, or national initiatives that emphasize policy change as well as education can be successful, whereas programs limited to single communities and to education alone may have minimal impact. O

Acknowledgment This research was supported by grant R01HL25523 from the National Heart, Lung, and Blood Institute.

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