Improve the health of the people of Wisconsin by supporting and strengthening physicians' ability to practice high-quality patient care in a changing environment.

Volume 104, Issue 4 (May 2005)

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Thomas C. Meyer, MD, Medical Editor, Wisconsin Medical Journal
Good news, bad news, just news, and a plea
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It is just over 4 years since we last published an issue in which the theme was Tobacco, so it seemed appropriate to look at what changes, if any, had occurred in that time. Interestingly enough, there is comparatively little overlap between the reports in the spring of 2001 and those in this issue. The Tobacco Quit Line was in its developmental stages, teen-age smoking and smoking during pregnancy, smoking by the American Indian/Alaska natives, the under-use of Medicaid support for the reduction of smoking in that population and lung cancer were uppermost in authors’ minds in 2001. So what are the concerns of the authors in 2005?

Representative J.A. “Doc” Hines
Health care, politics, and the cigarette tax
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Say “Cigarette Tax Increase” around a group of medical professionals and you get a room full of cheers. It is an idea that you have been touting for years. You’ve seen firsthand the devastating effects smoking has on people. Every day you do your part to inform the public of the dangers of smoking and what is out there to help them quit. However, you can only do so much to have an impact. You know raising the cigarette tax is a commonsense solution to a problem that has a huge impact on the health and the pocketbook of the state of Wisconsin.

Patrick Remington, MD, MPH
Recognizing progress in tobacco control
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My daughter asked for help on her math homework a few weeks ago. She said, “Five birds were sitting on a telephone pole. Three decided to fly away. How many were left?” I knew that there must be a trick, but went along and answered, “Two?” “Nope,” she replied. “The answer is five. Deciding to do something is not the same as doing it!” In 1999, the Centers for Disease Control and Prevention (CDC) published a report describing the 10 greatest public health accomplishments of the 20th century.1 Improvements in vaccination rates, motor-vehicle safety, workplace safety, infectious disease control, and food safety contributed to a 25 year life expectancy increase between 1900 and 2000.

Original Research

Marion Ceraso, MHS; David Ahrens, MS; Patrick Remington, MD
Increasing tobacco taxes: An evidence-based measure to reduce tobacco use
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Tobacco use is Wisconsin’s single most important preventable cause of premature death and disease, killing almost 8000 state citizens every year, and costing the state more than $3 billion annually in health care and lost productivity.1 Wisconsin’s high tobacco-related disease rates and escalating health care costs make it critical that any program to improve the public health and economy of the state include an aggressive tobacco prevention and control program.

David Ahrens, MS; Priti Bandi, MS; Jennifer Ullsvik, MS; D. Paul Moberg, PhD
Who Smokes? A Demographic Analysis of Wisconsin Smokers
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Context: Despite the general decline in prevalence of smoking and actual consumption of cigarettes, there is a heightened concern that this decline has not been uniform throughout the population and that specific sub-populations are adversely affected by tobacco use.

Objective: To estimate smoking prevalence and cigarette consumption among Wisconsin subpopulations by demographic identifiers, gender, race, age, educational attainment, and income.

Design, Setting and Participants: We estimated tobacco use among primary sub-populations in Wisconsin in 2003 from the Wisconsin Tobacco Survey. Approximately 8000 interviews were completed via a telephone survey. Main Outcome

Measure: Smoking prevalence and tobacco consumption among sub-populations and related policy recommendations.

Results: Approximately 20% of the Wisconsin adult population smokes cigarettes. However, the prevalence of smoking is not the same among all population groups. There are also substantial group differences in how many cigarettes people smoke per day. The number of cigarettes smoked is closely tied to the risk of smoking-related illness. The greatest disparities are associated with income and education. People with incomes between $10,000-$15,000 per year are more than twice as likely to smoke as people with incomes of more than $75,000. Also, smokers in the lower-income group smoke more cigarettes per day than those in the higher income group. There is also a consistent and major disparity in smoking behavior between genders. Within every income, racial, or educational group, men are more likely to smoke and, when they do, they smoke more cigarettes per day. There are significant but smaller differences in smoking behavior between rural and urban residents.

Conclusion: The pronounced differences in smoking rates and the number of cigarettes smoked among different population groups underline the need to focus prevention and treatment interventions on lower socioeconomic smokers with a specific emphasis on male smokers.

Karen A. Palmersheim, PhD, MS
Trends in Cigarette Smoking Among High School Youth in Wisconsin and the United States, 1993-2004
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Trends in current cigarette smoking among high school students in Wisconsin and the United States were examined using data from the Youth Risk Behavior Surveillance System and the Youth Tobacco Survey. Data were analyzed for years 1993 through 2004. Results of the analyses reveal an increasing prevalence in current smoking among high school youth in both Wisconsin and the United states during most of the 1990’s, followed by a downward trend. During the period under consideration, peak prevalence is observed for the United States in 1997 (36.4%), with rates decreasing to 22.3% in 2004. In Wisconsin, rates peaked during 1999 (38.1%) and decreased to 20.9% in 2004. Subgroup analyses of Wisconsin data show similar rates of smoking among females (21.9%) and males (19.8%) in 2004. Analysis by grade demonstrate a narrowing of the gap between the oldest and the youngest grades over time, with all 4 grades displaying decreasing rates in current smoking. Overall, the findings are very positive, and suggest that efforts aimed at reducing tobacco use among our youth have been effective at both the state and national level. However, recent cuts in state and federal funding have led to reductions in tobacco control program initiatives. Thus, vigilant monitoring is crucial as we continue to work towards the “Healthy People 2010” goal that states that no more than 16% of high school students will report current cigarette use.

Stevens S. Smith, PhD; Tyler Beckley; Michael C. Fiore, MD, MPH
Health Care Provider Use of Guideline-Based Smoking Cessation Interventions: Results from the 2003 Wisconsin Tobacco Survey
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Tobacco use is the chief preventable cause of morbidity and mortality in the United States. In Wisconsin, approximately 7300 deaths—representing about 20% of all deaths within our state each year—are attributable to smoking. Nearly half of the estimated 815,000 adult smokers in Wisconsin make a quit attempt each year, but most smokers make unaided quit attempts that have a very low probability of success (< 5%). The 2000 Public Health Service Clinical Practice Guideline, “Treating Tobacco Use and Dependence,” provides recommendations for evidence-based treatments (e.g., counseling, FDA-approved cessation medications) for smoking cessation that can result in long-term abstinence rates of up to 25% or more. The current study provides results from the 2003 Wisconsin Tobacco Survey on the extent to which Wisconsin health care professionals are using Guideline-based interventions to identify smokers and assist them to quit smoking. Results show that in 2003 about 77% of current smokers were asked about tobacco use and about 61% were advised to quit. Rates of cessation assistance ranged from 6% to 22%. Increases in smoking cessation interventions by health care professionals have enormous potential to decrease the smoking prevalence rate and improve the health of Wisconsin smokers. Robert Adsit, MEd; David Fraser, MS; Lezli Redmond, MPH; Stevens Smith, PhD; Michael Fiore, MD, MPH
Changing Clinical Practice, Helping People Quit: The Wisconsin Cessation Outreach Model
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Six University of Wisconsin-Center for Tobacco Research and Intervention (UW-CTRI) Regional Outreach Specialists, based in 5 regions across the state, provide training and technical assistance on evidence-based tobacco cessation interventions to clinics, hospitals, health systems, insurers, community organizations and worksites through academic detailing methods. The core of this approach involves individualized training on the US Public Health Service Clinical Practice Guideline, “Treating Tobacco Use and Dependence” as well as follow-up technical assistance to achieve sustainable system changes and a reduction in barriers to tobacco cessation services. The program’s scope includes health systems, managed care organizations, hospitals, worksites, and community organizations. The program also links organizations and the communities they serve to the Wisconsin Tobacco Quit Line and related cessation services. Since 2001, over 10,000 health care providers in over 500 clinics and 26 health systems and managed care organizations have received Guideline-based cessation training through the Outreach program. This paper examines research supporting this Cessation Outreach Model, describes its operation, discusses key outcomes, and reviews future directions and applications.

Robin J. Perry, BS, CHES; Paula A. Keller, MPH; Dave Fraser, MS; Michael C. Fiore, MD, MPH
Fax to Quit: A Model for Delivery of Tobacco Cessation Services to Wisconsin Residents
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Research has shown that proactive tobacco cessation quitlines are effective in increasing quit rates 4-fold, compared to quitting with no counseling support. In Wisconsin, the state-funded Wisconsin Tobacco Quit Line has documented a quit rate of 22%, with an estimated 6700 individuals quitting as a result of receiving Quit Line services. Since its launch in 2001, the Wisconsin Tobacco Quit Line has assisted more than 36,000 callers. Until recently, quitline call volume has been highly dependent on paid media campaigns—an expensive, episodic, and often politically difficult strategy to fund at the state level. To foster and sustain quitline use and assist health care professionals in helping their patients successfully quit, the University of Wisconsin Center for Tobacco Research and Intervention (UW-CTRI) developed the “Fax to Quit” program in March 2003. The model involves close collaboration between UW-CTRI and health care delivery systems who train their staff and integrate a quitline referral system into their regular delivery of health care for smokers who are interested in having the quitline contact them. This paper examines the extent to which this approach has been adopted by health care providers in Wisconsin. The potential is for this to become a key component of an integrated tobacco dependence treatment.

Jessica Thieleke, CHES; Janet McMahon, MPH; Gary Meyer, PhD; Kimo AhYun, PhD
An Evaluation of the Freedom From Smoking® Online Cessation Program Among Wisconsin Residents
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Objective: To study the effectiveness of the American Lung Association’s Freedom From Smoking® Online cessation program in assisting Wisconsin residents to quit smoking. Methods: Five hundred fifty-three Wisconsin residents who signed up for the American Lung Association’s Freedom From Smoking® Online cessation program over a 10-month period were solicited for participation. Of these, 80 individuals completed the initial survey (response rate 14.41%). Follow-up surveys were conducted 3, 6, 9, and 12 months after participants completed the program. Fifty-two participants completed the 3-month follow-up, 43 completed the 6-month follow-up, 38 completed the 9-month follow-up, and 36 completed the 12-month follow-up. Results: Initial point prevalence rates or whether participants reported that they had smoked in the previous 24-hour period revealed a quit rate of 55%. Sustained abstinence or whether they reported that they had smoked in the previous 3-month period ranged between 28.8% (3 months after program completion) and 16.3% (1 year after program completion). Conclusion: Quit rates compare favorably to current clinic-based smoking cessation programs. Given the low cost nature of an on-line cessation program and the ability to reach a wide audience, the evaluation undertaken of the American Lung Association’s Freedom From Smoking® Online cessation program revealed promising results.

Brenda L. Rooney, PhD, MPH; Paula Silha, BS; Jeff Gloyd, BS; Rose Kreutz, BS, BSN, MSEd
Quit and Win Smoking Cessation Contest for Wisconsin College Students
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Objective: To determine effectiveness of smoking cessation contests at 3 Wisconsin colleges.

Design: Pre-post program evaluation, with 6-month follow-up.

Setting: Two-year technical college, private 4-year college, and state university in spring and fall of 2000.

Subjects: One hundred fifty-two college smokers.

Interventions: Students participated in 7-week stop-smoking contests. Successful quitters were eligible for prizes. Smoking status was assessed at 6-month follow-up by telephone survey.

Results: The cessation rate for 18- to 24-year-olds was 30% at the end of the contests. At the 6-month follow-up, 12% of participants were not smoking. Participants who smoked fewer cigarettes per month were more likely to quit smoking at the end of the contests. Although no difference was found between 2- and 4-year college participants, heavier smokers from 4-year colleges were more likely to quit.

Conclusions: Because of their similarity to effective smoking promotions, contests should be considered a cost-effective strategy for this age group.

Nicholas M. Edwards, MD; Melissa Umland, BS; David Ahrens, MA; Patrick Remington, MD, MPH
The Silent Epidemic Among Wisconsin Women: Chronic Obstructive Pulmonary Disease Trends, 1980-2000
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Purpose: To investigate trends in mortality from chronic obstructive pulmonary disease (COPD) in Wisconsin. Methods: COPD mortality data for those 45 years of age and older were extracted from the Centers for Disease Control and Prevention WONDER database and analyzed. Rates were adjusted to the 2000 US Census.

Results: In Wisconsin, the mortality rate from COPD increased by 88% between 1980 and 2000. A similar increase in COPD mortality occurred in the United States during this same period. Among Wisconsin males, the 33% increase from 1980-2000 was higher than the increase for US males. Likewise, the rate among Wisconsin females increased 3.9 times compared to an increase of 2.8 among US females. Unlike men, mortality increased in all age groups of women from 1980 to 2000.

Conclusions: COPD mortality rates are increasing dramatically in Wisconsin, especially among women. Long-term trends in smoking do not explain the increases in COPD death rates among women. Other possible reasons include changes in the pattern of smoking or in the type of cigarette smoked, or women may be more susceptible to lung disease. Wisconsin physicians should target women for diagnosis and treatment of COPD and for smoking cessation and prevention.

Your Practice

David Meyers, MD; David A. Feldstein, MD
Clinical Questions #2
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Initial treatment of biliary colic: Are NSAIDs better than opiates?

Jonathan W. Hill, RPA
Deciding between your old 401(k) or a new IRA
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As workers retire or change jobs, they often struggle with what to do with their old employer’s 401(k) or similar defined-contribution retirement plan. Cashing in the account is never the best option—the income taxes, potential penalties, and loss of tax-deferred growth are all significant reasons why this is no financial answer. But what is the best option? Should investors keep their money in the old plan, roll it into a new employer’s defined-contribution plan if available, or roll it over into an individual retirement account? The answer to this question is as varied as the investors themselves and depends completely on each investor’s unique financial situation.

Jay A. Gold, MD, JD, MPH
Smoking cessation counseling in the acute care setting
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At any given time, relatively few people who smoke are inpatients. Hence, most efforts at counseling people to end smoking take place outside the hospital. However, it behooves us to remember the importance of taking advantage of the opportunity afforded by hospitalization to counsel our patients to stop smoking. This is especially important when patients are admitted for illnesses that may be smoking-related, like acute myocardial infarction or community-acquired pneumonia.

Your Profession

Philip J. Farrell, MD
Time to become a smoke-free state
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I’m very pleased that the Wisconsin Medical Journal is featuring smoking cessation and tobacco addiction again. This is a topic I care deeply about. The point was driven home yet again on St. Patrick’s Day a few months back, when my wife and I visited the new Irish pub in downtown Madison. The place was packed and the atmosphere was great, but the air was polluted because so many people were smoking.

Your Society

House of Delegates
2005 House of Delegates Action on Resolutions and Board Reports
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