The Health Impact of Smoking and Obesity and What to Do About It 9781442684935

Table of contents :
Contents
PART ONE. Taking Steps towards Health
Introduction to Part One
1. Introduction: Planning to Reduce the Risks of Chronic Disease
2. Risk Factors and the Burden of Disease
3. The Economic Cost of Risk Factors
4. Risk Factor Targets around the World
5. The Benefits of Reducing Risk Factors
PART TWO. From Setting to Achieving Targets
Introduction to Part Two
6. Tobacco Control Evidence (1): Preventing Uptake
7. Tobacco Control Evidence (2): Smoking Cessation
8. Tobacco Control Evidence (3): Second-Hand Smoke, Specific Populations, and a Summary
9. Tobacco Control Evidence (4): Cost-Effectiveness
10. Lessons from the Tobacco Wars
PART THREE. One Risk to Rule Them All
Introduction to Part Three
11. Obesity and Tobacco Control: New Territory and Established Pathways
12. Obesity Control Evidence (1): Reducing Energy Intake
13. Obesity Control Evidence (2): Increasing Energy Expenditure
14. Obesity Control Evidence (3): Combined Approaches, Cost-Effectiveness, and a Compendium
15. Important Issues in Obesity Control
16. Collaborating for Health
17. Conclusion: Four Fundamentals for Reducing Risk Factors
Notes
Index

Citation preview

TH E H EA LT H I M PA CT O F S M O KI NG A N D O BES I TY A ND W H AT TO D O A B O U T IT

Despite significant progress due to public health campaigns and other policy efforts, smoking continues to be a serious health threat throughout the world. In addition, sedentary lifestyles, poor diet, and obesity continue to be major causes of chronic disease. The Health Impact of Smoking and Obesity and What to Do about It synthesizes a vast quantity of recent data on the benefits and cost-effectiveness of both clinical and public health interventions in addressing the risk factors of smoking and obesity. A large proportion of chronic disease is preventable. The Health Impact of Smoking and Obesity and What to Do about It provides solid evidence and practical advice to health care planners, decision-makers, and frontline providers alike. The volume discusses various approaches to measuring disease burden and setting health care targets, and provides a summary of interventions of proven effectiveness. Taking into account the vital lessons learned from the experience of tobacco control over forty years, and focusing on the current state of the evidence for obesity control, the study stresses the importance of comprehensive strategies that deal with both individual behaviour changes and the need to encourage social contexts that enhance healthy choices and lifestyles. hans krueger is the president of H. Krueger & Associates Inc., a health care consulting company in Vancouver. He holds a PhD in health policy and research from the University of British Columbia. dan williams is head of research and writing for H. Krueger & Associates Inc. barbara kaminsky is an adjunct professor in the Department of Medicine at the University of British Columbia and CEO of the Canadian Cancer Society, British Columbia and Yukon Division. david mclean is a professor in the Department of Medicine at the University of British Columbia and head of cancer prevention at the British Columbia Cancer Agency.

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The Health Impact of Smoking and Obesity and What To Do about It

Hans Krueger, Dan Williams, Barbara Kaminsky, and David McLean

UNIVERSITY OF TORONTO PRESS Toronto Buffalo London

www.utppublishing.com © University of Toronto Press Incorporated 2007 Toronto Buffalo London Printed in Canada ISBN-13: ISBN-10: ISBN-13: ISBN-10:

978-0-8020-9200-7 (cloth) 0-8020-9200-4 (cloth) 978-0-8020-9441-4 (paper) 0-8020-9441-4 (paper)

Printed on acid-free paper

Library and Archives Canada Cataloguing in Publication The health impact of smoking and obesity and what to do about it / Hans Krueger ... [et al.]. Includes bibliographical references and index. ISBN-13: 978-0-8020-9200-7 (bound) ISBN-13: 978-0-8020-9441-4 (pbk.) ISBN-10: 0-8020-9200-4 (bound) ISBN-10: 0-8020-9441-4 (pbk.) 1. Chronic diseases – British Columbia – Prevention. 2. Chronic diseases – Risk factors. 3. Smoking – Health aspects. 4. Obestity – Health aspects. I. Krueger, Hans RA644.5.H42 2006

614.09711

C2006-904367-1

University of Toronto Press acknowledges the financial assistance to its publishing program of the Canada Council for the Arts and the Ontario Arts Council. University of Toronto Press acknowledges the financial support for its publishing activities of the Government of Canada through the Book Publishing Industry Development Program (BPIDP).

The function of protecting and developing health must rank even above that of restoring it when impaired. Hippocrates

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Contents

PART ONE: TAKING STEPS TOWARDS HEALTH

1

1 Introduction: Planning to Reduce the Risks of Chronic Disease 2 Risk Factors and the Burden of Disease

14

3 The Economic Cost of Risk Factors 32 B.C. Risk Factor Plan (1) 39 4 Risk Factor Targets around the World B.C. Risk Factor Plan (2) 49

41

5 The Benefits of Reducing Risk Factors 57 B.C. Risk Factor Plan (3) 68

PART TWO: FROM SETTING TO ACHIEVING TARGETS 75 6 Tobacco Control Evidence (1): Preventing Uptake

81

7 Tobacco Control Evidence (2): Smoking Cessation 96 8 Tobacco Control Evidence (3): Second-Hand Smoke, Specific Populations, and a Summary 117 9 Tobacco Control Evidence (4): Cost-Effectiveness

134

10 Lessons from the Tobacco Wars 152

PART THREE: ONE RISK TO RULE THEM ALL

159

11 Obesity and Tobacco Control: New Territory and Established Pathways 165

5

viii Contents

12 Obesity Control Evidence (1): Reducing Energy Intake

176

13 Obesity Control Evidence (2): Increasing Energy Expenditure

207

14 Obesity Control Evidence (3): Combined Approaches, Cost-Effectiveness, and a Compendium 228 15 Important Issues in Obesity Control 248 B.C. Risk Factor Plan (4) 258 16 Collaborating for Health 265 17 Conclusion: Four Fundamentals for Reducing Risk Factors

Notes

287

Index

367

275

PART ONE Taking Steps towards Health

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if hippocrates were alive today he would probably have some pointed questions for us. What would happen if we really began to tackle the modifiable risk factors that lead to chronic disease? If you were aware of affordable steps that could be taken as part of a public and primary health care plan that would prevent 50% of the premature deaths in your community, how would you respond? What if the interventions proposed in the plan were 100 times more cost-effective than most routine medical procedures? What if it could be demonstrated that, in addition to reducing human discomfort and disability, the plan would actually save a national health care system and the general economy billions of dollars? To establish that such a plan is feasible is one objective of this book. The other point is to ask what has already been asked: what will you and your community do about it? Part 1 of this book begins to address these and other questions, first by introducing the key risk factors addressed in our review and then by examining in detail their health burden and consequent economic impact. To this compelling evidence is added the story of target-setting to reduce the risk factors in various jurisdictions of the world. Finally, the potential value of tackling risk factors at a societal level is estimated, with the general picture filled in with details specific to one Canadian province.

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1 Introduction: Planning to Reduce the Risks of Chronic Disease

Think Globally, Act Locally The Health Impact of Smoking and Obesity and What to Do About It represents a distillation of multiple reports that emerged from a risk factor project initiated in 2004 by the British Columbia Healthy Living Alliance (BCHLA). The objective of the project was to create a plan to aggressively tackle risk factors and reduce chronic disease rates in the province of British Columbia over the long term. British Columbia is the most western of Canada’s ten provinces and three territories; situated adjacent to the Pacific Ocean, and known for its spectacular mountains, rivers, and forests, British Columbia prides itself on being a health-friendly mecca of outdoor recreation. ‘Public relations momentum’ has been created by the province’s winning the bid to host the 2010 Winter Olympic and Paralympic Games. As part of the province’s ‘golden decade,’ the premier has declared the intent that British Columbia will be the healthiest Olympics host ever. This sentiment informed the title of the final report prepared for the BCHLA to describe the plan, The Winning Legacy. The B.C. context and the BCHLA process will help to put some meat on the bones of the concepts outlined in this book, providing a localized case study of how research evidence drawn from around the world was incorporated into a potent plan for one jurisdiction. The Disease/Resource Dilemma One of the hot issues in health care is the management of chronic disease. Chronic diseases are prolonged conditions that are rarely cured

6 Part One: Taking Steps Towards Health

completely. They usually have a debilitating effect on physical, emotional, and mental well-being. When people are afflicted with a chronic condition, it is often profoundly difficult for them to maintain normal routines and relationships. Fortunately, good disease management is sometimes able to minimize physical and mental deterioration and allow for better functioning in daily life. Significant chronic conditions include many cancers, diabetes, ischemic heart disease, depression, hypertension, degenerative joint disease, asthma, cardiac arrhythmias, chronic obstructive pulmonary, disease, and cerebrovascular disease.1 These conditions are very prevalent, especially in developed countries. This book focuses on a cancer and chronic disease prevention plan for one North American jurisdiction, the province of British Columbia in Canada. This province has a population of 4.3 million, approximately 1.2 million (or 36% of the adult population) of whom suffer from one or more chronic diseases.2 Such data are representative of the impact of chronic disease in North America. The burden in terms of personal suffering and societal costs associated with chronic diseases is significant, and the situation is not static. Health care planners need to take into account the increasing burden, as the population ages and as the prevalence of certain risk factors, such as obesity, continues to escalate. A true dilemma is to be faced: how to deal with the huge problem of chronic disease with a limited set of resources, including those related to finance, personnel, and facilities and other infrastructure. This situation is stressing the system of disease management; something needs to give. The challenges have become clear: A way has to be found to reduce the burden of illness before it crushes health care budgets, and the focus needs to shift from chronic disease management to reduction of the risk of chronic disease. Risky Business Risk factors play an enormous role in chronic disease. In a population of 4.3 million, in any given year 5,600 people will die of smokingrelated cancer and other chronic diseases related to smoking. Moreover, 20% or more of the cases of chronic disease such as type 2 diabetes, stroke, coronary heart disease, and colon cancer result simply from sedentary lifestyles. Obesity rests heavily on the health of many people, contributing, for example, to the diabetes crisis. Being overweight is, in turn, mainly due to an increase in energy intake (excessive

Introduction 7

and/or unhealthy eating) and – once again – a reduction in energy expenditure (a sedentary lifestyle). This book, which provides a plan that emerged out of a specific context, synthesizes data that are applicable in different jurisdictions. Indeed, most developed countries are facing a similar crisis in relation to chronic disease and risk factors. The data from British Columbia could be repeated for other settings in Canada and around the world. This book provides raw material designed to help create building blocks for a plan that can make a difference to the health of all populations in the developed world, and parts of it are applicable in the developing world. It identifies effective, and often cost-effective, approaches to reduce risk factors for major chronic diseases, with the ultimate aim of reducing the personal and economic burden of disease within any given society. Based on mortality data, the risk factors that should demand serious attention are obvious: they are tobacco use and obesity. Together, they account for up to one-third of deaths from all causes.3 The factors that play a significant role in the onset of obesity and overweight – unhealthy eating and physical inactivity – may be added to the high priority list. Crossing Epidemics We live in an era of crisis where two different epidemics are about to cross. The epidemic of tobacco use is currently declining in developed countries, but the epidemic of obesity is on the rise. Although the epidemiological data are debated, it appears that in the developed world mortality attributable to obesity is about to overtake deaths from smoking. Another crossing phenomenon is that, globally, the number of people who eat too little has recently been matched by the number who eat too much. Sometimes these two populations exist within the same developing country, especially in settings marked by the sort of economic growth that leads to a nutritional transition. With respect to risk factors, and especially obesity, both the present reality and the trend lines are alarming. Data show that there is little room for relaxation on any front, and that includes smoking. Smoking Gun Premature death due to tobacco use is still the most prominent public health problem facing almost all global populations. In Canada, with a

8 Part One: Taking Steps Towards Health

population of 32.6 million, each year there are at least 45,000 deaths caused by smoking.4 While it is true that dramatic progress has been made over the past 20 years in terms of tobacco use, there is general acknowledgment that with regard to smoking prevention much more work remains.5 The improvements over recent decades in many European settings have been of a similar order, but Europeans, too, do not feel it is prudent to be resting on their laurels.6 The 2004 U.S. Surgeon General’s report,7 while celebrating the enormous improvement in the public perception and practice concerning tobacco use over the past four decades,8 noted that in the United States smoking remains the leading preventable cause of disease and death: More than 440,000 premature deaths each year can be connected to smoking,9 and for the period 1995–9, the costs attributed to misuse of tobacco were estimated to be U.S.$157 billion annually.10 Equivalent Canadian data will be discussed later in this book, adding to the evidence that the health and financial costs of tobacco use are compelling issues in the developed and developing world. In the face of such a burden, programs to promote smoking cessation make enormous sense from a public health perspective. With regard to established smokers, one of the main motivations to focus on tobacco use is that quitting can reverse many health impacts, often yielding immediate benefits.11 An alarming statistic is that at least one-quarter of North American teens currently smoke. Given that most lifelong smokers start smoking in their teen years, obviously there is more progress to be made in reducing this risk factor.12 Furthermore, there is some evidence that the prolonged decline in smoking prevalence has now levelled off.13,14 The Fat of the Land Excess weight, and especially excess body fat – the true definition of being obese – is a risk factor that is likely here to stay. In stark contrast to the more than three million children who die annually of undernutrition, there are more than one billion adults worldwide who are overweight, of whom 300 million are clinically obese.15 Reflecting these totals, as many as 500,000 people in North America and western Europe die from obesity-related diseases every year.16 These statistics have led researchers and planners to apply the term epidemic, classically used with infectious diseases, to the reality of obesity around the world.17–19 The increase in the number of overweight

Introduction 9

individuals cannot be overstated. One estimate suggests that obesity rates have risen by 400% in the western world in the past 50 years. Canada provides an example over a shorter time frame, with rates of overweight more than doubling between 1985 and 1997. British Columbia mirrors the national pattern.20 Likewise, the prevalence of serious obesity in Great Britain doubled between 1980 and 1991,21 and the percentage of obese adults in the United States more than doubled between 1980 and 2000.22 Children are being especially hard hit: one in five American children are either overweight or obese, an increase of 50% since 1980.23 This trend is particularly alarming considering the serious health implications for the young and that childhood obesity itself is a risk factor for adult obesity and other adult morbidities. Obesity is a major problem, and one that is going in the wrong direction. Indeed, because smoking is gradually declining, obesity-related economic costs are predicted to eventually exceed those connected with tobacco.24–26 Balancing Act The factors behind obesity and overweight are a concern. An imbalance between energy intake (i.e., diet) and energy expenditure (i.e., physical activity) has been firmly implicated in the production of excess weight and, especially, excess fat storage.27,28 Although physical activity offers significant improvements in health and well-being, and substantial protection against disease and mortality, the majority of people in the developed world are not participating in high enough levels of physical activity. The Canadian Fitness and Lifestyle Research Institute (CFLRI) reported that in 1999 61% of the population was too sedentary to gain any activity-related health benefits.29 In 1996, the U.S. Surgeon General reported that 60% of American adults were not regularly active, and 25% were not active at all.30 The conclusion at that time was that as little as 30 minutes of moderate activity on most days of the week would allow some benefits to be achieved; most people were not reaching even that level. The good news is that there has been recent progress with respect to physical inactivity. National data sets obtained since the first Canada Fitness Survey in 1981 allow for analysis of trend lines in Canada. Physical inactivity rates decreased from 79% in 1981 to 63% in 1995.31 A similar decrease in inactivity rates was identified for 1995–2000.32

10

Part One: Taking Steps Towards Health

Unfortunately, there is some evidence that progress has now been stalled (including in British Columbia). Whatever the case, it is evident that even larger health benefits can be mined by further improving the risk factor of physical inactivity at the population level. The risks associated with unhealthy eating are largely different in the developed world compared with developing countries. In the latter case, deficiency in key nutrients such as iron, vitamin A, and iodine is a more significant issue, as well as undernutrition (especially with children). In developed countries, “overnutrition” or inappropriate nutrition is the focus of concern, and especially the excessive consumption of fatty and sugary products. The dietary dilemma in developed countries includes overindulgence in the many processed foods and what is commonly known as junk food, and relatively low consumption of vegetables and fruit.33 The impact of these polarized nutritional conditions – too little good food in some cases and too much unhealthy food in others – represents a global challenge. Seizing the Day There are genuine opportunities associated with tackling modifiable risk factors. First, a large proportion of disease is preventable. There is growing understanding that chronic disease and its consequences can be mitigated, including the disability related to old age. Preventable illness makes up approximately 70% of the burden of illness and its associated costs.34 The estimate for cancer is more conservative, but it still indicates that at least half of cancers are attributable to the modifiable risk factors of tobacco use, poor diet, and sedentary lifestyle.35 Second, coalitions are emerging to target risk factors and related disease. Prompted by the desire to alleviate suffering and conserve health care resources, many different groups have been forming to spearhead efforts directed at disease prevention. While non-governmental groups are often at the forefront of such coalitions, it is encouraging to see the diversity of stakeholders that are forming partnerships today, with memberships ranging from advocacy organizations to health authorities and from government departments to industry. Other aspects of the contemporary situation with risk factors could be added to this positive list, including a growing appreciation of the socioenvironmental context of disease, as well as the general desire, if not outright momentum, for health care reform. An important species of the reform movement is the more robust incorporation of preven-

Introduction 11

tion in primary care settings. However, the opportunity that perhaps exceeds all others is that found in the intense basic research and evaluation of many implementation programs over the past several decades. Vital lessons have been learned, especially through successful tobacco control initiatives. The challenge is to commit to full exploration and exploitation of these lessons as new crises in population health develop. The Next Chapter of a (Relative) Success Story In many ways, Canada has led the world in reducing the consumption of tobacco products and the adverse health impacts related to smoking. A case study of Canada’s success in tobacco control was prepared in 2003 for the World Bank.36 It describes the coordinated efforts, over more than 25 years, that were led by health advocates both from inside the government and from a number of important organizations such as the Canadian Cancer Society and the Heart and Stroke Foundation. Political and/or legislative actions, as well as key initiatives in prevention, protection, and cessation, have yielded dramatic results. One compelling measure of the concerted efforts can be seen in the following statistic: The adult smoking rate in Canada dropped from 50% to 22% between 1965 and 2001.37 Some of the most impressive interventions described in the World Bank report are: • Increased taxation on tobacco products: According to the World Bank, the affordability of tobacco products has always proven to be the single biggest factor in predicting per capita consumption. • Extensive protection in the workplace from passive smoke (also known as secondhand smoke or environmental tobacco smoke):38 This was accompanied by a gradual expansion of such policies into other public areas (e.g., Canada was the first country to ban smoking on international passenger flights). • Restrictions on advertising and on sales to minors, as well as ground-breaking changes in package labelling, which now includes the famous large – and dramatic – pictorial warnings. Perhaps the most significant advances in Canada, and those hardest to measure, have been in the arena of public opinion and social norms, that is, the growing negative attitudes towards tobacco companies,

12

Part One: Taking Steps Towards Health

smoking in public, and exposing children to tobacco smoke. This process – usually called denormalization, especially in reference to the tobacco industry39 – is an explicit part of Canada’s national tobacco control strategy that was established in 1999.40 Major work remains to be done on the smoking front: tobaccorelated death rates are still high, smoking is very prevalent among atrisk populations such as Aboriginal peoples, and too little attention is being given to helping smokers quit. In a letter released on 1 November, 2004, 50 of Canada’s most influential health care leaders urged the federal government to take more aggressive action in fulfilling the national plan to denormalize ‘Big Tobacco.’41 There is no doubt, however, that impressive progress on tobacco use has been made in Canada and many other jurisdictions over several decades. The lessons learned from the various campaigns to tackle the tobacco epidemic are providing invaluable guidance to new battlefronts, particularly with respect to obesity. In this book, we pay particular attention to the insights from the tobacco wars applicable to other risk factors. The Organization of This Book This book has three main parts: • Tracking health care. Part 1 identifies the importance of, and various approaches to, measuring the burden of disease and progress in health care. • Setting targets is one thing, achieving them is another. Part 2 looks at the importance of having clear and effective interventions available to actually make progress on health goals, beginning with an ongoing effort regarding tobacco control. • Identifying overweight as the lead risk factor, over simply unhealthy eating or physical inactivity. Part 3 examines the state of the currently available evidence related to promising directions in obesity control. The case study describing the B.C. context and plan will be interspersed throughout these three comprehensive discussions in an effort to provide both illustration and inspiration to inform the application of this material in other jurisdictions.

Introduction

13

What the Reader Will Take Away The hope and aim of this book are to provide both a foundation for action on risk factors, as well as a practical manual of proven and promising interventions. The desire is for the reader, whether an advocacy organization executive, public health policymaker, academic, graduate student, politician, health ministry staff person, or volunteer, to be both informed and empowered. In sum, this book offers: • The rationale for redoubled attacks on the risk factors for chronic disease • A set of public health priorities urgent enough to be tackled right now • An inventory of approaches to consider in assembling a comprehensive risk factor intervention plan • An example from one jurisdiction suggesting how to formulate such a plan • An invitation to join British Columbia in the quest to maximize population health. Why this book? This book is needed because nowhere else has such a full range of current data been pulled together in this fashion. Why now? This book is needed now because there is no time to lose. People are suffering needless disability and premature death, and billions of dollars are being unnecessarily spent that could be invested in other aspects of health care or other public goods. We need to seize the day!

2 Risk Factors and the Burden of Disease

The main motivation for selecting risk factors and then setting targets must be to reduce the associated burden of disease. To evaluate the potential impact of any risk factor reduction, it is important to know how much that factor contributes to the onset of disease. How to quantify this disease burden is the subject of the first section of this chapter. Then the impact of our two focal risk factors will be itemized. Finally, the factors that can contribute to obesity, that is, physical inactivity and unhealthy eating, are examined in terms of their independent health consequences. This chapter should be read closely with the next one, which details the economic costs related to risk factors. What Is a Population Attributable Fraction? To quantify the baseline health impact of a risk factor and identify its priority in health care, a statistic known as the population attributable fraction (PAF) is sometimes used. As a reflection of disease prevalence due to a risk, it has advantages over other measures, such as cumulative risk.1 Simply put, the PAF is the proportion of disease Y in the population that can be attributed to factor X.2 As with all areas of epidemiology, however, there is actually more complexity within the concept than this basic definition reflects.3 The PAF for our selected risk factors and key diseases will be presented later in this chapter. The main policy application of attributable burden estimates is to help assess avoidable burden in the future. Avoidable burden is defined as ‘the fraction of total disease burden in a particular year that could be avoided with a specific reduction in current and future exposure.’4 Estimates of the impact of risk factor reduction on mortality,

Risk Factors and the Burden of Disease

15

morbidity, and costs can be very powerful tools for policy-planning in countries, regions, and local areas. The effect of ‘drift’ also needs to be taken into consideration, that is, identifying what will happen to the attributable burden in the future if there is no intervention. For example, without further action, it was predicted that, while tobacco use is decreasing in the developed world, the global disease burden attributable to tobacco in 2000 would double by 2020.5 This ‘opportunity cost’ of not acting must be figured into any analysis of the cost-effectiveness of potential interventions. The Burden of Tobacco Use The negative health consequences caused by tobacco use are indisputable.6 One Canadian analysis suggested that people who started smoking before age 15 experience double the risk of premature death.7 This conclusion may be conservative. Current research suggests that the ‘risks for persistent smoking are substantially larger than previously suspected.’8 Doll, Peto, and colleagues followed a cohort of British male doctors since 1951. Their latest analysis9 indicated that between one-half and two-thirds of persistent smokers will eventually be killed by their habit. Their data also confirmed that death rates climb dramatically with earlier ages of smoking initiation. This result is particularly ominous given current patterns. Many smokers in the 1950s and 1960s took up smoking in adulthood or even middle age, while the usual age of initiation now is the early teens. The health burden of smoking largely flows from the association between smoking and serious chronic diseases that manifest themselves in high mortality and morbidity. One of the contributions of the 2004 report on tobacco use from the U.S. Surgeon General was the review of more than 1,600 scientific studies that confirmed a causal relationship between smoking and many diseases. No organ in the body appears to be immune.10 Smoking has been implicated in the following diseases and conditions:11 • Respiratory system. Smoking confers a higher risk of developing major lung diseases, including chronic bronchitis, emphysema, pneumonia, and influenza; cigarette smoking is the major cause of all histological types of lung cancer (the risk of lung cancer is 20 times higher in smokers than in non-smokers). • Cardiovascular system. Smoking is an independent risk factor for cor-

16

Part One: Taking Steps Towards Health

onary heart disease and stroke; the risk of stroke is three times greater in smokers, and the degree of risk is dose-dependent; smoking is also a risk factor for peripheral vascular disease. • Gastrointestinal system. Smoking is a risk factor for esophageal, pancreatic, liver, and colorectal cancers. • Reproductive system and neonates. Adverse consequences that are associated with smoking during pregnancy include higher risk for miscarriage, stillbirth, low birthweight, and impaired development. • Other systems. Smoking has been associated with cataracts and macular degeneration; premature wrinkling; psoriasis; osteoporosis; renal, oral, and bladder cancers; and at least a dozen other disorders. An ongoing area of interest is the association between smoking and breast cancer. Although there is biological plausibility for a positive association, the epidemiological data have been mixed.12–14 One major review declared a null association,15 despite significant contrary evidence from Canada and elsewhere.16,17 The second generation of studies on smoking and breast cancer have taken into consideration the confounding effect of passive smoking18 and modifiers such as genetic markers19 or hormone receptors.20 The most recent reports have suggested a statistically significant association between active smoking and breast cancer, which increases with both the intensity and duration of smoking.21,22 The population attributable fraction of disease burden due to smoking has been calculated by the U.S. Centers for Disease Control and Prevention23 and is summarized in table 2.1 (note that breast cancer has not yet been included in these calculations, reflecting the still inconclusive stage to which research has progressed). Reviewing this list, it is not surprising that death rates in smokers are so high. As one example of the impact, premature death due to tobacco use is still the most important public health problem facing the Canadian population today. The estimated annual deaths in Canada, a country of 32.6 million people, caused by smoking range from 45,000 to 48,000.24,25 Single et al.26 estimated that 16.5% of all deaths in Canada in 1995 were directly attributable to tobacco use. Illing and Kaiserman27 raised this estimate to 21.8% as of 1998; based on their work, the estimated number of deaths attributable to tobacco use in Canada and in one provincial case, British Columbia, can be seen on table 2.2. According to these data, 47,585 deaths in Canada, and of these 5,732 deaths in British Columbia, were attributable to tobacco use in 1998. The diseases

Risk Factors and the Burden of Disease

17

Table 2.1 The Population Attributable Fraction (PAF) of Disease Burden Due to Smoking Category

Disease

Cancers

Lip, oral cavity, pharynx Esophagus Pancreas Larynx Trachea, lung, bronchus Cervix uteri Urinary bladder Kidney, other urinary Hypertension Ischemic heart disease Other heart diseases Cerebrovascular disease Arteriosclerosis Aortic aneurysm Other arterial diseases Pneumonia, influenza Chronic bronchitis, emphysema Chronic airway obstruction Short gestation, low birth weight Respiratory distress syndrome Other respiratory conditions of newborn Sudden infant death syndrome

Circulatory diseases

Respiratory disease

Perinatal conditions (< 1 year old)

Female PAF (%)

Male PAF (%)

47.8 58.1 23.8 73.8 71.8 13.3 27.9 5.2 10.8 12.9 9.0 9.2 8.8 50.6 15.2 14.3 80.9 75.1 9.9

74.8 72.8 22.8 83.3 88.3 – 47.6 39.6 18.9 21.0 19.2 14.1 27.4 65.1 14.1 23.0 90.9 81.7 10.3

3.8 5.1

9.1 9.2

14.6

11.4

Source: Calculated from data in CDCP. Morbid Mortal Weekly Rep (2002).

accounting for almost 40% of deaths attributable to tobacco use were cancers, predominantly lung cancers. Another 37% of deaths resulted from circulatory diseases, and a further 22% were the result of respiratory ailments. Included in the total Canadian deaths are an estimated 96 infants who died as a result of smoking-related causes, and 1,110 individuals whose deaths were attributable to exposure to secondhand smoke. As a comparison, the 2004 U.S. Surgeon General’s report28 estimated that 440,000 people died in the United States annually from exposure to first- and second-hand smoke between 1995 and 1999. The summary presented in Table 2.3, taken from that report, is comparable to the Illing and Kaiserman data; it also includes information on total deaths attributable to a given disease, the proportion of total deaths that are

18

Part One: Taking Steps Towards Health

Table 2.2 Smoking Attributable Mortality, Canada and British Columbia, 1998 Canada

% of total

B.C.

% of total

Cancers Lip, oral cavity, pharynx Esophagus Pancreas Larynx Trachea, lung, bronchus Cervix uteri Urinary bladder Kidney, other urinary

817 1,005 955 382 13,951 136 628 475

1.7 2.1 2.0 0.8 29.3 0.3 1.3 1.0

94 153 118 36 1,714 14 73 57

1.6 2.7 2.1 0.6 29.9 0.2 1.3 1.0

Total cancers

18,349

38.5

2,259

39.4

96 298 9,289 200 2,779 2,452 630 1,075 595

0.2 0.6 19.5 0.4 5.8 5.2 1.3 2.3 1.3

15 37 944 27 387 301 60 139 75

0.3 0.6 16.5 0.5 6.8 5.3 1.0 2.4 1.3

17,414

36.6

1,985

34.6

26 2,782 1,224 130 6,457

0.1 5.8 2.6 0.3 13.6

3 425 144 22 779

0.1 7.4 2.5 0.4 13.6

Circulatory diseases Rheumatic heart disease Hypertension Ischemic heart disease Pulmonary heart disease Other heart diseases Cerebrovascular disease Atherosclerosis Aortic aneurysm Other arterial diseases Total circulatory diseases Respiratory disease Respiratory tuberculosis Pneumonia, influenza Chronic bronchitis, emphysema Asthma Chronic airway obstruction Total respiratory diseases

10,619

22.3

1,373

24.0

Perinatal conditions (< 1 year old) Low birth weight Respiratory distress syndrome Other respiratory conditions of newborn Sudden infant death syndrome

31 14 21 30

0.1 0.0 0.0 0.1

2 1 2 2

0.0 0.0 0.0 0.0

Total perinatal conditions

96

0.2

7

0.1

361 746 1,107

0.8 1.6 2.3

38 70 108

0.7 1.2 1.9

47,585

100.0

5,732

100.0

Secondhand smoke deaths Lung cancer Ischemic heart disease Total second-hand smoke deaths Total

Source: Illing and Kaiserman, Can J Public Health (2004). Note: Percentages may not add to totals shown because of rounding.

Risk Factors and the Burden of Disease

19

attributable to tobacco use, and the years of potential life lost (YPLL) as a result of smoking-attributable mortality. For example, in the United States, 7,800 people die annually from cancers of the lip, oral cavity, and pharynx; 5,200 or 67% of these deaths are directly attributable to smoking. The 5,200 smoking-attributable deaths resulted in an estimated 84,600 YPLL.29 In the United States, an estimated 64% of the identified cancers, 16% of the identified circulatory diseases, and 52% of the identified respiratory diseases are directly attributable to smoking (see table 2.3). The Burden of Overweight/Obesity Obesity is a well-established risk factor for many significant diseases, including cardiovascular disease, stroke, and diabetes.30–35 This is because, among other things, obesity leads to adverse metabolic changes such as elevated blood pressure and cholesterol, as well as resistance to insulin (this collection of symptoms has been labelled as the ‘metabolic syndrome’).36–39 In addition to an obvious connection with accidental falls, being overweight also increases the prevalence of certain cancers, kidney failure, asthma, arthritis and other musculoskeletal disorders, gallbladder disease, hormonal and reproductive problems, sleep apnea, impaired immune function, and blindness.40–42 There is also a well-known connection between obesity and depression,43,44 and a growing awareness of the risk of dementia.45–47 Some recent work by Canadian researchers summarized the best current understanding of obesity and serious diseases in one national population.48 As seen in table 2.4, Katzmarzyk and Janssen itemized the types of diseases most often associated with obesity (body mass 30.0), as well as the relative risk of disease, 95% confiindex or BMI dence interval, and PAF. As already noted, the PAF is the proportion of the disease prevalence attributable to the risk exposure. In determining the prevalence of obesity in Canada, the authors used the 2001 Canadian Community Health Survey results. Based on their analysis, Katzmarzyk and Janssen found that 34% of hypertension, 28.6% of diabetes, 25.5% of gallbladder disease, and so on, were directly attributable to obesity in 2001 in Canada. Other chronic conditions can also be of serious concern for those who are overweight. For example, there is at least a 60% increase in risk of arthritis for obese men and women.49 Consistent with this fact is the higher risk of disability in the obese.50 In general, a recent study

>

Table 2.3 Annual Smoking Attributable Mortality (SAM), and Years of Potential Life Lost (YPLL), United States: 1995–1999, and by Sex Males Total deaths Cancers Lip, oral cavity, pharynx Esophagus Stomach Pancreas Larynx Trachea, lung, bronchus Cervix uteri Urinary bladder Kidney, other urinary Acute myeloid leukemia Total cancers Circulatory diseases Ischemic heart disease Other heart diseases Cerebrovascular disease Atherosclerosis Aortic aneurysm Other arterial diseases Total circulatory diseases

SAM

SAM % YPLL

5,200 8,600 7,600 13,400 3,000 91,300

3,900 6,300 2,200 3,100 2,500 80,600

75 73 29 23 83 88

1,464,000 1,494,400 1,430,000 1,446,100 1,437,800 1,106,100

7,800 7,100 3,200

3,700 2,800 800

47 39 25

105,900

147,200

244,200 98,100 61,100 9,000 10,000 4,700 427,100

Females Total deaths

SAM

SAM % YPLL

Total Total deaths

SAM

SAM % YPLL

YPLL % of Total

1,440,200 1,441,900 1,411,000

2,600 2,800 5,300 14,300 14,800 61,600 4,100 3,800 4,500 2,700

1,300 1,600 14,600 3,400 14,600 44,200 14,500 1,100 14,200 14,300

50 57 11 24 75 72 12 29 4 11

20,600 24,300 9,200 49,800 10,300 719,900 13,400 12,500 4,000 4,600

7,800 11,400 12,900 27,700 3,800 152,900 4,100 11,600 11,600 5,900

5,200 7,900 2,800 6,500 3,100 124,800 14,500 4,800 3,000 1,100

67 69 22 23 82 82 12 41 26 19

2, 84,600 118,700 2, 39,200 2, 95,900 2,48,100 1,826,000 2, 13,400 2, 52,700 2, 45,900 2, 15,600

1.6 2.2 0.7 1.8 0.9 33.5 0.2 1.0 0.8 0.3

72

1,471,500

102,500

53,800

52

868,600

249,700

159,700

64

2,340,100

43.0

51,400 18,800 8,600 1,600 6,500 700

21 19 14 18 65 15

767,300 243,300 131,700 1,414,900 1,476,600 1,4 8,500

237,400 117,600 96,600 10,100 6,200 6,200

30,600 10,500 8,900 14,900 3,100 14,900

13 9 9 9 50 15

392,800 122,900 146,500 7,700 37,200 11,800

481,600 215,700 157,700 19,100 16,200 10,900

82,000 29,300 17,500 2,500 9,600 1,600

17 14 11 13 59 15

1,160,100 1,366,200 1,278,200 1, 22,600 1,113,800 1, 20,300

21.3 6.7 5.1 0.4 2.1 0.4

87,600

21

1,242,300

474,100

54,900

12

718,900

901,200

142,500

16

1,961,200

36.0

Respiratory disease Pneumonia, influenza Chronic bronchitis, emphysema Chronic airway obstruction

38,300 10,900 42,800

8,800 9,900 34,900

23 91 82

1,484,900 109,000 353,100

47,400 9,600 39,700

6,800 7,800 29,800

14 81 75

2,169,100 2,199,800 2,353,300

92,000

53,600

58

547,000

96,700

44,400

46

522,200

2,200 930 910

53,220 53, 40 53, 50

10 4 5

1,415,970 1,4 2,600 1,4 3,460

1,770 14,640 14,650

14,180 14, 20 14, 30

10 3 5

2,113,870 2,1 1,930 2,1 2,650

2,1 3,970 2,1 1,570 2,1 1,560

1, 1, 1,

1,770

53,260

15

1,418,940

1,200

14,180

15

2,113,870

2,1 2,970

5,810

53,570

10

1,440,970

4,260

14,410

10

2,132,320

2,110,070

Total (excluding burns and second-hand smoke)

672,110

247,670

37

3,301,770

677,560

153,510

23

2,142,020

1,349,670

Burn deaths

NA

53,590

1,417,300

NA

14,380

2,110,500

NA

1, 970

1, 10,500

Second-hand smoke deaths Lung cancer Ischemic heart disease

NA NA

1,100 14,400

NA NA

NA NA

1,900 20,600

NA NA

NA NA

3,000 35,000

NA NA

Total respiratory diseases Perinatal conditions (

24

Part One: Taking Steps Towards Health

Figure 2.1 Body-Mass Index and Relative Risk of Death from All Causes, Women 3.4 3.2 3.0 2.8

Overweight

Obese

Relative Risk

2.6 2.4 2.2 2.0 1.8 1.6 1.4 1.2 1.0 0.8

< 21.0

21.0–22.9 23.0–24.9 25.0–26.9

27.0–29.9 30.0–32.9 33.0–34.9 35.0–39.9

≥40

Body Mass Index Note: The vertical bars represent the 95% CI. Source: Hu et al. N Engl J Med (2004)

at the highest BMI levels; Flegal and colleagues reported that 73% of the 111,909 excess deaths were in individuals with a BMI of 35 or greater. The recent understanding that obesity is an independent risk factor for diseases such as heart failure is also important. In other words, the increased risk of accumulating extra weight through body fat cannot be accounted for entirely by co-morbidities such as high blood pressure and high cholesterol.65 In fact, Hu et al. established that both increased weight and reduced physical activity are ‘strong and independent predictors of death.’ This means that an individual who is overweight and physically active still has a significantly higher risk of death from all causes compared with an individual of healthy weight who is physically active. This relationship holds for the risk of death specifically from cardiovascular diseases, as well as for death from cancers and death from all causes. The concept of activity or fitness

Risk Factors and the Burden of Disease

25

Table 2.5 Relative Risk of Death by BMI and Physical Activity Physical activity (hr/wk)

$ 3.5

1.0–3.4

< 1.0

All Causes BMI < 25.0 BMI 25.0–29.9 BMI 30

1.00 1.28 1.91

1.18 1.33 2.05

1.55 1.64 2.42

Cardiovascular diseases BMI < 25.0 BMI 25.0–29.9 BMI 30

$

1.00 1.58 2.87

1.51 2.06 4.26

1.89 2.52 4.73

Cancers BMI < 25.0 BMI 25.0–29.9 BMI 30

1.00 1.22 1.57

1.09* 1.20 1.44

1.32 1.39 1.68

$

$

Source: Calculated from Hu et al., N Engl J Med (2004). *Not significant, confidence interval includes 1.0.

mitigating the effects of obesity has thus been seriously called into question. Being overweight is manifestly risky, no matter how fit you are. The relationship between obesity and physical fitness as identified by Hu et al., is noted on table 2.5 (data generated from their results). Based on their large prospective study, Hu et al. found that women with a (healthy) BMI < 25.0 but who were inactive had a 55% increase in all-cause mortality compared with women with a BMI < 25.0 who engaged in moderate to vigorous physical activity at least 3.5 hours per week. For cardiovascular disease and cancers, premature mortality increased by 89% and 32%, respectively. While the study by Hu et al. is based on results for women, similar relationships exist for men.66,67 In fact, their work confirms the results found in numerous smaller studies. Katzmarzyk and co-authors reviewed approximately 170 articles published prior to February of 2003 and, based on their meta-analysis, determined that ‘both physical activity and adiposity68 are important determinants of mortality risk.’69 Furthermore, ‘physically active individuals have a lower risk of mortality by comparison to physically inactive peers, independent of level of adiposity.’ While obesity properly defined (BMI 30.0) remains strongly impli-

>

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Part One: Taking Steps Towards Health

cated in disease onset, the measurement of the broader category of overweight and an assessment of its disease impact remains an evolving area of study. Some researchers are trying to decipher the ‘obesity paradox’ seen in some studies, that is, the protective effect that modest excess weight may have in patients who already have certain chronic diseases; recently, this effect has been confirmed in a cohort of people with heart failure70 and another cohort with myocardial infarction.71 A further noteworthy result from current research is the declining prevalence of cardiovascular disease risk factors over the past 40 years in all BMI groups.72 This is seen as an encouraging trend, even though won at a cost, that is, increased use of lipid-lowering and antihypertensive drugs, especially in obese people.73 Such health improvements, which include reduced smoking rates in the overweight and obese, may account for the declining impact of obesity on mortality over time.74 This trend parallels the general declines in mortality due to ischemic heart disease over the past 30 years in the U.S. population.75 A notable exception to the improving trends for some biological risk factors and chronic diseases is diabetes. Alarmingly, diabetes has increased in the United States by more than 50% in the past 30 years; the presumption is that this development is due to increasing obesity prevalence in the population.76 A final intriguing time-trend is the fact that optimal BMI seems to be historically dynamic. It has shifted in the United States over the past 100 years, from 20.3 to 23.6 in the late nineteenth century to 22.7 to 27.3 in the early 1970s (compare this result with the ‘mortality advantage’ for those modestly overweight, as described earlier). For reasons that are not entirely clear, as the average BMI in a population changes, the optimal BMI also changes.77 This result may add fuel to the fire of those who believe that ‘normal weight’ BMI cut-offs need to be set higher for western populations,78 and especially within certain cohorts.79 This debate is part of an international discussion concerning the universal application of BMI cut-offs.80 Given the ongoing flux in research and data, it is good to treat aggregate statistics and trends concerning obesity-related mortality with some caution; however, whatever the shifts in opinion, we need to hold on to one important fact: at a population level, obesity definitely exerts a toll on health. We also need to follow the advice from an editorial that accompanied the latest U.S. mortality figures: ‘It may be possible to gain a better and more realistic understanding of the preventable disease burden caused by obesity by evaluating public health and indi-

Risk Factors and the Burden of Disease

27

vidual programs designed to both prevent and treat obesity, such as diet and exercise programs.’81 Part 3 of this book explores just such phenomena. The Burden of Physical Inactivity In addition to its contributing role in obesity onset, physical inactivity generates its own independent health burden. Many studies have revealed that people with moderate to high levels of physical activity or cardiorespiratory fitness have a lower mortality rate than do people with a more sedentary lifestyle. Physical inactivity can increase the risk of premature death up to two-fold.82 A variety of theories concerning the biological plausibility of connecting disease with idleness have been put forward, including likely associations between physical activity, carbohydrate metabolism, and diabetes.83 It is important to stress that, in relation to all-cause mortality and especially cardiovascular disease, physical inactivity has been found to be an independent risk factor, not just an influence on health through biological agencies such as adiposity (see the earlier discussion under obesity and/or overweight).84 In particular, as summarized by the U.S. Surgeon General, physical inactivity has been implicated directly in coronary heart disease (CHD) and stroke, diabetes, colorectal cancer, breast cancer, and prostate cancer.85 Since the Surgeon General’s report published in 1996, many studies have confirmed these results.86–93 Table 2.6, based on work by Katzmarzyk and Janssen,94 summarizes the Canadian data for the types of diseases most often associated with physical inactivity. Included in the table are the relative risk of disease, 95% confidence interval, and PAF. In determining the prevalence of physical inactivity in Canada, the authors used the 2001 Canadian Community Health Survey results. Based on their analysis, Katzmarzyk and Janssen found that 24.3% of strokes, 24.0% of osteoarthritis, 21.1% of type 2 diabetes, and so on, were directly attributable to physical inactivity in 2001 in Canada. In developing their results, Katzmarzyk and Janssen surveyed the available literature. They noted that since studies on physical inactivity usually adjust for obesity as a confounding variable, the ‘disease risk and health care costs [of physical inactivity] can be considered to be independent of the effects of obesity.’ (The topic of how risk factors overlap is discussed more fully in chapter 5.)

28

Part One: Taking Steps Towards Health

Table 2.6 Relative Risk Estimates and Population Attributable Fraction (PAF) for Physical Inactivity Canada, 2001 Disease

Summary relative risk

95% CI

PAF (%)

Stroke Osteoarthritis Type 2 diabetes Coronary heart disease Colon cancer Breast cancer Hypertension

1.60 1.59 1.50 1.45 1.41 1.31 1.30

1.42–1.80 1.40–1.80 1.37–1.63 1.38–1.54 1.31–1.53 1.23–1.38 1.16–1.46

24.3 24.0 21.1 19.4 18.0 14.2 13.8

Source: Based on Katzmarzyk and Janssen. Can J Appl Physiol (2004).

The Burden of Unhealthy Eating In addition to its apparent contribution to obesity onset, unhealthy eating affects health directly in a variety of ways. The consequences of a poor diet have been reported to some degree in the literature, although it remains an evolving area of research. For example, correlations have been found between diet and/or nutritional deficiencies and several different cancers; the list includes cancer of the breast, colon, rectum, prostate, small intestine, stomach, mouth, pharynx, esophagus, pancreas, liver, ovary, uterus, endometrium, thyroid, kidney, and bladder. High-fat, low-fibre diets have particularly been implicated in disease, as well as low consumption of vegetables and fruit.95 In the early 1980s, Doll and Peto estimated that approximately 35% of cancers were attributable to diet (excluding alcohol usage).96 A major report endorsed by the American Cancer Society concurred with this result, concluding that 30% to 40% of cancers are directly related to dietary choices.97 Other studies have pointed to even higher percentages for cancer in women. However, some authorities have been more cautious concerning the relationship between diet and cancer, suggesting that reduction in cancer rates of about 30% might be possible over 20 years, but only through a combination of primary prevention factors (including diet, obesity, and physical activity).98 The most recent research has endorsed the more conservative conclusion, especially in reference to vegetables and fruit. During the past decade, researchers had estimated that approximately 2.8% to

Risk Factors and the Burden of Disease

29

4.4% of the burden of disease in developed countries can be attributed to low vegetable and fruit intake, primarily through a reduced protective function for cardiovascular diseases and cancers.99 In the latest studies, however, the protective role of vegetable and fruit consumption has been called into question, particularly for cancers. Riboli and Norat100 provided a meta-analysis of the available literature on the protective effect of vegetables and fruit on cancer risk. They found an important difference in results depending on the methodology used. Retrospective case-control studies indicated that vegetable consumption was protective against cancers of the esophagus, breast, lung, stomach, and colorectum, while fruit consumption was protective against cancers of the mouth, pharynx, larynx, esophagus, lung, stomach, and colorectum. A meta-analysis of prospective cohort studies, on the other hand, indicated that the only protective function was against lung and bladder cancers, and then only with respect to fruit consumption. In November of 2004, Hung and colleagues101 published the results of a major prospective cohort study assessing the protective role of vegetable and fruit consumption on cancers and cardiovascular diseases. This study was based on over 110,000 individuals followed for up to 22 years. After adjusting for total caloric intake, age, smoking status, alcohol use, personal history of hypertension, hypercholesterolemia, diabetes, and (for women only) family history of breast cancer, menopausal status, and use of hormone replacement therapy, they found no protective effect associated with either vegetable or fruit consumption. Another large prospective study in Europe published in 2005 found, more specifically, that vegetable and fruit consumption is not associated with the risk of breast cancer.102 Why this discrepancy between retrospective case-control and prospective cohort studies? Riboli and Norat103 suggested that the differences may be due to recall bias or the difficulties associated with accurately measuring food intake. In case-control studies, individuals are asked to recall their dietary patterns in the past, with this recall potentially biased by the diagnosis of cancer itself. A further source of bias may be the difficulty of finding volunteers for the control group in case-control studies. Individuals who do volunteer may be more health conscious and thus consume more vegetables and fruit than those who do not volunteer.104 The issue of accurately measuring food intake was also raised by

30

Part One: Taking Steps Towards Health

Schatzkin and Kipnis in an editorial published in the same journal issue containing the study by Hung et al.105 They noted that ‘the exposure assessment tool – food frequency questionnaire (FFQ) – used to measure diet, including fruit and vegetable intake, is subject to substantial error, both random and systematic.’ Their final pertinent question was: ‘Is this error sufficient to obscure an existing fruit and vegetable–cancer association?’ Although the debate continues concerning cancer and dietary patterns, unhealthy eating has definitely been associated with increased risk of other chronic diseases such as heart disease, stroke, and diabetes. In developed countries, the World Health Organization (WHO) reported that an estimated 28% of ischemic heart disease and 18% of ischemic strokes can be attributable to low vegetable and fruit intake.106 The most recent research confirms these results. While the Hung et al. study found no association between increased consumption of vegetables and fruit and a reduced risk of cancers, they did find that vegetable and fruit intake was inversely associated with the risk of cardiovascular disease. Participants eating at least 5 or more servings of vegetables and fruit per day had a 28% lower risk of cardiovascular disease than those who consumed fewer than 1.5 servings daily. The authors also noted that ‘the clear inverse relation between fruit and vegetable consumption and risk of cardiovascular disease indicates that exposure misclassification cannot account for the lack of an overall association with cancer incidence.’ The results in Hung et al. for cardiovascular disease are similar to those in the prospective cohort study by Bazzano and colleagues,107 who reported on 9,608 adults followed for an average of 19 years. They found that consuming vegetables and fruit 3 or more times per day was associated with a 42% lower stroke mortality rate, a 24% lower ischemic heart disease mortality rate, and a 27% lower cardiovascular disease mortality rate. Thus, despite some recent contrary evidence, unhealthy eating evidently can join tobacco use, obesity, and physical inactivity as a risk factor connected with a significant burden of disease, one that is crying out for concerted action by health care providers. As we will see in the next chapter, however, the economic picture with respect to unhealthy eating in general, and vegetables and fruit in particular, is not as clear as that seen for the other risk factors.

Risk Factors and the Burden of Disease

Key Points • The burden of a risk factor is often reported in terms of the fraction of disease prevalence in a population that can be attributed to that factor. • No organ in the body seems to be immune from the severe health consequences of smoking; that is why more than 20% of deaths in Canada are directly attributable to tobacco use. • Obesity is an independent risk factor for conditions such as heart failure and diabetes, a reality that cannot be mitigated completely by increasing physical activity or fitness levels. • Physical inactivity, through its impact on the incidence of stroke and other diseases, can increase the risk of premature death by up to two-fold. • Although nutrition is an evolving area of research, a constitutionally poor diet has been strongly linked to cardiovascular disease. Low vegetable and fruit consumption, in particular, may account for more than 25% of the incidence of ischemic heart disease.

31

3 The Economic Cost of Risk Factors B.C. Risk Factor Plan (1)

Although the health burden of risk factors and related diseases presented in the previous chapter is the most important motivator in terms of human values and policy priorities, cost avoidance is also a worthy incentive. After all, preventing unnecessary spending in the health care system allows funds to be redirected to different health needs or other public goods. The benefits can become cyclical and cumulative as resources are freed up. This positive picture does not even take into account the improved productivity and reduction in out-of-pocket expenses for individual sufferers and their families and the consequent economic boost to society as a whole. This chapter briefly outlines the economic costs of smoking, as well as those of obesity and its related risk factors. The aim is to provide a model for how to approach this topic and a high-level impression of the costs involved. The particular details for each jurisdiction vary. An example for one such jurisdiction is provided at the end of the chapter, in the first installment of our B.C. case study. Tobacco Use Costs Due to the wide variety of diseases caused by smoking, the cost of medical care attributable to tobacco has been estimated to be as high as 6% to 14% of total medical care expenditures in developed countries.1 Looking at U.S. national estimates for 1995–9, the total costs related to smoking were U.S.$157 billion annually, or about U.S.$3,400 in direct and productivity costs per smoker. The medical cost portion represents

Economic Cost of Risk Factors

33

Table 3.1 Annual Economic Cost per Smoker (U.S. $) Direct costs Hospital Ambulatory Nursing home care Prescriptions Home health

3,849 3,435 3,268 3,240 03,18

Indirect costs (lost productivity) Illness Premature death

3,320 1,201

Total

3,331

Source: Max et al. Tobacco Control (2004).

about 8% of health care expenditures in the United States.2 As a comparison, a study in California3 estimated the annual economic cost per smoker in 1999 to be U.S.$3,331. The types of costs and their contribution to this total are found in table 3.1. In Canada, the most recent published estimates of direct medical spending plus indirect costs (i.e., the value of economic output lost because of illness, injury-related work disability, or premature death) range from Can.$9.6 to $15.0 billion annually, depending on the type of costs included. 4,5 A study by Kaiserman identified $2.5 billion in direct medical costs, $10.5 billion in lost future earnings, $2.0 billion for worker absenteeism, and $1.5 billion in residential care costs, for a total of $16.5 billion annually. In addition to broader direct (e.g., residential care) and indirect (e.g., worker absenteeism) costs, Kaiserman also estimated the ‘avoided’ health care costs, due to the earlier death of smokers, at $1.5 billion. Net annual costs thus become $16.5 less $1.5, or $15.0 billion. Studies in British Columbia6 and Nova Scotia7 have suggested that the annual cost per smoker is in the range of $3,600 to $4,000, which again is consistent with results in the United States. The reader is directed to table 3.2 for details. Obviously, the economic impact of smoking on society continues to be massive, adding further motivation to tackle this risk factor aggressively. An immediate question which follows: Is obesity as damaging a condition from a financial point of view as smoking?

34

Part One: Taking Steps Towards Health

Table 3.2 Smoking in British Columbia and New Brunswick, Estimated Costs in 2001–2

A. Total costs (millions of $) Direct costs Indirect costs Losses in productivity Increased life insurance premiums Designated smoking areas Absenteeism Unscheduled smoking breaks Subtotal losses in productivity Premature Mortality Subtotal Indirect Total Costs

B.C.

N.B.

3,525.00

3,120.00

3,027.28 3,030.90 3,089.00 3,514.00 3,661.18 3,904.00 1,565.18 2,090.18

3,007.20 3,008.00 3,018.20 3,174.90 3,208.30 3,218.00 3,426.30 3,546.30

B. Costs per smoker Number of smokers 3,542,240 Estimated cost per smoker Direct Cost 3,968.21 Indirect costs, productivity 1,219.35 1,667.16 Indirect costs, premature mortality Total 3,854.71 Adjusting costs to 2004$ (use 'Health and Personal Care' component of the Canadian CPI) Direct costs 3,995.21 Indirect costs, productivity 1,253.36 Indirect costs, premature mortality 1,713.66 Total 3,962.23

3,153,500 3,781.76 1,357.00 1,420.20 3,558.96

3,794.55 1,379.21 1,443.44 3,617.20

Source: B.C. estimates are based on Bridge J. and Turpin B. The cost of smoking in British Columbia and the economics of tobacco control. Health Canada, February 2004. N.B. estimates are based on Coleman R., Rainer R. and Wilson J. The cost of smoking in New Brunswick and the economics of tobacco control. GPI Atlantic, April 2003.

Obesity Costs The increased use of health care services and costs by overweight individuals is well documented.8–11 In addition, being seriously overweight increases the risk of early mortality and disability, resulting in a significant impact on indirect costs, that is, the value of economic output lost because of illness, disability, or premature death. In their analysis, Katzmarzyk and Janssen12 provided estimates of 30.0) in Canada; these the direct and indirect costs of obesity (BMI are summarized in table 3.3. In total, obesity was estimated to have

>

Table 3.3 Estimated Cost for Obesity Canada, 2001 (in millions$) Total Costs

Attributable Costs

Direct

Total

Direct

Obesity (BMI 30) Coronary heart disease Stroke Hypertension Colon cancer Postmenopausal breast cancer Type 2 diabetes Gall bladder disease Osteoarthritis

Indirect

Total

15.4 6.8 34.0 6.2 6.5 28.6 25.5 12.7

2,429.6 1,691.5 1,530.2 1,278.9 1,350.1 1,800.8 1,691.4 1,121.3

6,296.0 1,458.4 1,352.9 1,331.9 1,671.5 1,588.7 1,452.0 5,814.4

1, 1, 1, 1, 1, 1, 1, 1,

8,725.6 3,149.9 2,883.1 1,610.8 2,021.6 1,389.5 1,143.4 6,935.7

1,374.6 1,115.8 1,519.8 1, 17.3 1, 22.6 1,229.3 1,176.4 1,142.5

1,970.7 1, 99.9 1,459.6 1, 82.6 1,108.0 1,168.6 1,115.3 1,738.7

1,345.3 1,215.7 1,979.4 1, 99.9 1,130.6 1,397.9 1,291.7 1,881.2

Total

15.6

8,893.8

18,965.8

1,27,859.6

1,598.3

2,743.4

4,341.7

Estimated Cost per Individual with the Risk Factor in Canadaa Direct

Indirect

Total

2001$ 2004$

1,984.21 1,026.44

1,557.61 1,624.45

$

PAF (%)

1,573.40 1,598.00

Indirect

(increase based on the ‘Health and Personal Care’ component of the Canadian CPI)

$

Source: Katzmarzyk P.T. and I. Janssen. The economic cost associated with physical inactivity and obesity in Canada: An update, Can J Appl Physiol. 2004, 29(1): 90–115. a 2,787,406 2000/01 CCHS number of people in Canada who are obese (BMI 30)

36

Part One: Taking Steps Towards Health

cost the Canadian economy $4.3 billion in 2001. We have used this information and calculated the annual cost per obese individual in 2004 Canadian dollars. Based on this analysis, the annual cost directly attributable to obesity is $1,624 per obese individual. By focusing 30.0), Katzmarzyk and Janssen recognized strictly on obesity (BMI that they ‘underestimate the economic impact of excess body weight in Canada.’ Assessing the impact of overweight as a whole would increase the total costs. There was a rationale behind the approach taken by Katzmarzyk and Janssen. In a survey of the available literature, they noted that since studies on obesity did not usually include physical inactivity as a co-variable, the obesity results are partially influenced by physical inactivity. Focusing on the health care costs and consequences of people with a BMI 30.0 reduces this potential to ‘double-count’ costs.13 Research equivalent to that conducted by Hu et al.14 (described in chapter 2) is required to begin to fully untangle the independent economic effects of overweight/obesity and physical inactivity.

>

>

Physical Inactivity Costs Physical inactivity is associated with an increased use of health care services and costs.15 In addition, physical inactivity increases the risk of early mortality and disability, resulting in a significant impact on indirect costs. In their analysis, Katzmarzyk and Janssen16 provided estimates of the direct and indirect costs of physical inactivity in Canada; these are summarized in table 3.4. In total, physical inactivity was estimated to cost the Canadian economy $5.3 billion in 2001. We have used this information to calculate the annual cost per physically inactive individual in 2004 Canadian dollars. Based on this analysis, the annual cost directly attributable to physical inactivity is $437 per sedentary individual. This figure can be added to the equivalent results for smoking and obesity to generate a picture of the economic costs of combined risk factors (see the B.C. case study at the end of this chapter). The Evolving Picture for Unhealthy Eating Although the whole issue of diet and disease remains a fluid area of study, it is certainly possible to conclude that there are some economic costs related to how we eat. Quantifying the impacts becomes the prob-

Table 3.4 Estimated Cost for Physical Inactivity Canada, 2001 (in millions$) Total Costs

Attributable Costs

PAF (%)

Direct

Indirect

Physical Inactivity Coronary heart disease Stroke Hypertension Colon cancer Breast cancer Type 2 diabetes Osteoporosis

19.4 24.3 13.8 18.0 14.2 21.1 24.0

2,429.6 1,691.5 1,530.2 1,278.9 1,448.8 1,800.8 1,012.0

6,296.0 1,458.4 1,352.9 1,331.9 2,143.0 1,588.7 5,247.7

Total

20.0

8,191.8

Total

Direct

Indirect

Total

8,725.6 3,149.9 2,883.1 1,610.8 2,591.8 1,389.5 6,259.7

1,471.4 1,411.0 1,211.6 1, 50.2 1, 63.8 1,169.0 1,242.8

1,221.7 1,354.4 1,187.1 1,239.6 1,304.5 1,124.2 1,259.0

1,693.1 1,765.4 1,398.7 1,289.8 1,368.3 1,293.2 1,501.8

18,418.6

26,610.4

1,619.8

3,690.5

5,310.3

Direct

Indirect

Total

127.93 133.42

291.47 303.97

419.40 437.39

Estimated Cost per Individual with the Risk Factor in Canadaa

2001$ 2004$

(increase based on the ‘Health and Personal Care’ component of the Canadian CPI)

Source: Katzmarzyk P.T. and I. Janssen. The economic cost associated with physical inactivity and obesity in Canada: An update, Can J Appl Physiol. 2004, 29(1): 90–115. a 12,661,729 2000/01 CCHS number of people in Canada who are physically inactive.

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lem. It was once estimated that healthier diets could save U.S.$71 billion annually in medical costs and lost productivity in the United States.17 However, recent results calling into question the effect of diet (see the previous chapter) mean that such figures are highly suspect. Given the current stage and results of research, it is not yet possible to fully quantify either the health outcomes or economic effect of an unhealthy diet, especially in reference to consumption of vegetables and fruit. Thus, no attempts have been made in this book to estimate the attributable risks associated with lower-than-recommended consumption of vegetables and fruits or to estimate the potential costs associated with these risks . Key Points Key Points • The cost of medical care attributable to smoking ranges from • The cost of of medical care attributable to smoking ranges from 6% to 14% total medical care expenditures in developed 6% to 14% of total medical care expenditures in developed countries. • countries. National estimates for 1995–9 indicate that in the United • National 1995–9 indicate that in the United States theestimates total costsfor associated with smoking were States the total costs associated with smoking were U.S.$157 billion annually, or about U.S.$3,400 in direct and U.S.$157 billion annually, or about U.S.$3,400 in direct and productivity costs per smoker. productivity costs per smoker. • The annual economic burden per obese individual in Canada • The economic burdenin per obese individual in Canada was annual estimated at Can.$1,624 2004. was estimated at Can. $1,624 in 2004. • The annual economic burden per sedentary individual in • The annual per sedentary Canada waseconomic estimatedburden at Can.$437 in 2004. individual in Canada was estimated at Can. $437 in 2004. • Quantifying the costs of an unhealthy diet remains an evolv• Quantifying the costs of an unhealthy diet remains an evolving area of research. area ofColumbia, research. with a population of 4.3 million, the • ing In British • In British Columbia, with a population of 4.3 million, the is estimated annual cost of these risk factors to the economy estimated annual cost of these risk factors to the economy is Can.$3.8 billion. Can. $3.8 billion.

DEVELOPING A RISK FACTOR PLAN (1): RISK FACTORS AND ECONOMIC COSTS IN BRITISH COLUMBIA Our study of one jurisdiction seeking to work on risk factors and chronic disease begins with an assessment of baseline costs. Finding out what the problem costs us always serves as a good motivation to make improvements. British Columbia is the western-most province in

Economic Cost of Risk Factors

39

Table 3.5 Estimated Cost of Risk Factors In British Columbia, 2004 Est. annual $ per individual

Est. total $ in 2004 ($ million)

Smoking Direct costs Indirect costs, productivity Indirect costs, premature mortality Total smoking

1,995 1,253 1,714 3,962

1,679 1,856 1,170 2,705

Physical Inactivity Direct costs Indirect costs Total physical inactivity

1,133 1,304 1,437

1,189 1,432 1,621

1,598 1,026 1,624

1,180 1,309 1,489

$

Obesity (BMI 30 Direct costs Indirect costs Total obesity Total

3,816

Source: author calculations. a Does not include overweight with BMI of 25.0 to 29.9.

Canada, with a population of 4.3 million and a government medical plan that is uniform for the entire population. To estimate the annual economic cost of smoking, physical inactivity, and obesity in British Columbia, we used information on the estimated number of B.C. individuals with that risk factor and multiplied it by the estimated excess cost per individual with that risk factor; the results are summarized on table 3.5. In 2004 smoking cost the B.C. economy an estimated 2.7 billion Canadian dollars, physical inactivity cost an estimated $621 million, and obesity cost an estimated $489 million, for a total of $3.8 billion. To put this number in context, in 2003–4, the provincial government budgeted $4.9 billion for all of primary and secondary education in the province.18 It is evident that reducing the burden related to risk factors could significantly improve the investment available for other public priorities. In simply adding these costs together, it is recognized that there are

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numerous individuals in British Columbia who have more than one risk factor. The manner in which the costs for physical inactivity were calculated reflects the fact that they can be considered to be independent of the effects of obesity. Although the interaction between them is not yet fully clarified, we know that both physical inactivity and obesity are independent risk factors for chronic diseases. For the costs of obesity, 30.0 in order to eliminate the possibility of we only focused on BMI double-counting the costs of being both overweight (BMI, 25.0 to 29.9) and physically inactive. This represents a conservative assumption that may, in fact, underestimate the total economic impact of the three risk factors. Smoking is also an independent risk factor for chronic diseases. In studies of physical inactivity and obesity, smoking status is invariably controlled for in the analysis. Thus, we can assume that the risks identified for physical inactivity and obesity are independent of smoking status. What is not fully understood is the potential interaction of obesity and/or physical inactivity with smoking in any one individual. In totaling the costs, we have made the assumption that the costs are additive, that is, a smoker who is also physically inactive and/or obese has a higher risk than a smoker who is active and of healthy weight.

>

4 Risk Factor Targets around the World B.C. Risk Factor Plan (2)

Many jurisdictions are actively engaged in indicator target-setting to encourage improvements in the prevalence of risk factors and consequent chronic disease within their populations. It is evident that there is significant international momentum around this form of health care planning. This chapter provides a sampling of risk indicator targets from Canada and other countries, first for our main factors – tobacco use and obesity – and then for the contributing factors of physical inactivity and unhealthy eating. Tobacco Use The public health initiatives that have produced such positive results in recent decades around tobacco use continue to inspire more ambitious target-setting in jurisdictions around the world. The formats and details related to recent targets demonstrate a lot of variety. The range of formulations possible with a ‘smoking prevalence’ indicator, for example, can be seen in two Canadian cases: • Alberta. By 2012, reduce from 28% to 18% the proportion of the population who smoke. By 2012, reduce from 25% to 12% the proportion of pregnant women who smoke.1 • Ontario: By 2005, reduce to 10% the proportion of 12- to 19-year-olds who smoke daily. By 2005, reduce to 15% the proportion of adults who smoke daily.2 To illustrate the application of targets at more local levels, the following sample is taken from an initiative by Toronto Public Health.3

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• Daily or occasional smoking among youth in Grades 7 to 12: baseline (2003), 15.5%; target (2007); 12%. • Daily or occasional smoking among adults aged 18 and over: baseline (2003), 20% to 25%; target (2006), 15%. A new initiative in Ontario called Cancer 2020 produced the following targets for smoking:4 By 2020, reduce the prevalence of smoking among teens to 2% or less. By 2020, reduce the prevalence of smoking among those aged 18 and over to 5% or less. International Comparison The United Kingdom is one country that is setting the pace for performance indicators in many sectors of public service, including health care. Recent targets for tobacco use comprise the following:5 • By 2010, reduce smoking among children from 13% (baseline in 1996) to, at most, 9% (11% by 2005). Children smoking means those age 11 to 15 who smoke at least one cigarette a week. • By 2010, reduce adult smoking in all social classes so that the overall rate falls from 28% (baseline in 1996) to, at most, 24% (26% by 2005). Adult smoking means anyone age 16 and over who smokes at least one cigarette a day. To achieve this, the rate of reduction in lower socioeconomic classes would have to be greater than the average across the whole population. • By 2010, reduce the percentage of women who smoke during pregnancy from 23% (baseline in 1995) to 15% (18% by 2005). The Healthy People initiative in the United States is also creating a standard for careful, comprehensive target-setting over a wide range of risk factors and indicators. There has been modest progress on the overall adult smoking indicator (see table 4.1).6 The somewhat refocused and age-adjusted targets for Healthy People 2010 are as follows:7 • Reduce current cigarette smoking by adults (age 18+): Baseline, 24%; target, 12%. • Reduce past 30 days cigarette smoking by adolescents (Grades 9 to 12): baseline, 35%; target, 16%. Overweight / Obesity The vital risk factor of obesity is beginning to receive more interest

Risk Factor Targets around the World

43

Table 4.1 Smoking Prevalence and Targets in the United States (%)

Indicator Cigarette smoking prevalence, age 18+

1987 baseline

1990

1994

1998

2000 target

29

25

26

24

15

Source: Healthy People 2000: Final Review.

across Canada. Again, a wide variety of approaches to framing and timing targets is evident, as well as the characteristic Canadian tendency to emphasize ‘healthy weight’ rather than ‘obesity’ (a ‘positive language’ approach that can be traced back to the 1988 Canadian national guidelines on overweight). Samples of the proposed targets, with the original format edited to facilitate comparisons, include: 8,9 • Alberta. By 2012, increase from 47% to 55% the proportion of people with a healthy BMI. • Ontario. To slow the decrease in the proportion of adults ages 20 to 64 with a healthy weight status (BMI, 20 to 27). • Newfoundland and Labrador. By 2007, decrease from 60% to 55% the proportion of people who are overweight. • Nova Scotia. By 2007, to increase to at least 50% the proportion of the population with a healthy weight (BMI, 20 to 27). Maintenance targeting for this risk factor essentially aims at halting the trend of increasing overweight. Such targets (e.g., see the year 2000 adolescent targets in the United States, below) represent a conservative approach in the face of a problem of epidemic proportions, although not as pessimistic a scenario as in Ontario, where the current goal is only to slow the downward spiral! The Ontario Cancer 2020 initiative provides a final Canadian comparison and a more optimistic picture for the province:10 By 2020, to reduce to less than 10% the proportion of the population that is obese (BMI > 30). International Comparison Many countries, motivated by the enormous stakes in terms of suffering and resources, have been setting and pursuing targets related to obesity. The results to date have not been encouraging.

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Part One: Taking Steps Towards Health

Table 4.2 Overweight Prevalence and Targets in the United States (%)

Overweight prevalence

1976–80 baseline

1994

2000 target

Adults (20–74 years) Males (BMI 27.8) Females (BMI $ 27.3) Adolescents (12–19 years)

26 24 27 15

35 34 37 24

20 20 20 15

$

Source: Healthy People 2000: Final Review.

New Zealand, although admitting that countries normally set targets to reduce obesity prevalence, made a realistic evaluation of the growing epidemic and decided to set its sights lower in 1995. As such, it decided to only prevent any further increase in the current rates of obesity (BMI > 30.0) for males (10%) and females (13%) by the year 2000.11 Unfortunately, a national nutrition survey in 1997 showed that rates had, in fact, increased to 15% of males and 19% of females.12 Provisional results from the 2002–3 national health survey showed that the overall obesity rate for adults had increased to about 20%, with the prediction that the proportion would be approaching 30% by 2011.13 Given such negative statistics in a country that is actively working on the problem, the worldwide alarm concerning obesity becomes more understandable. Progress has also not occurred with the obesity risk factor in the U.S. Healthy People program. The discouraging results in the previous decade are indicated in table 4.2.14 Note that midpoint figures show all indicators significantly moving away from their targets. The objectives for Healthy People 2010 (somewhat refocused compared with the year 2000 targets) are:15 • Increase the proportion of adults who are at a healthy weight (BMI, 18.50 to 24.99) – baseline, 42%; target, 60%. • Reduce the proportion of adults who are obese (BMI 30) – baseline, 23%; target, 15%. • Reduce the proportion of children and adolescents who are overweight or obese16 – baseline, 11%; target, 5%.

>

Physical Inactivity As with the other risk factors discussed in this book, several Canadian

Risk Factor Targets around the World

45

provinces have set targets to increase physical activity levels in their populations. Again, the work does not show the same degree of completeness and precision in each case; there are a variety of approaches to physical activity and its assumed benefits. Note that, in the samples below, the wording has been edited to facilitate comparisons:17,18 • Alberta. By 2012, increase from 52% to 62% the proportion of people who are physically active. • Ontario. By 2010, increase to 40% the proportion of adults who include at least 30 minutes of accumulated, moderate physical activity on most days of the week. By 2010, increase to 60% the proportion of youth who include at least 30 minutes of accumulated, moderate physical activity on most days of the week. Increase the proportion of children who are active. • Newfoundland and Labrador. By 2007, decrease from 33% to 23% the proportion of youth who are inactive. By 2010, to decrease by 10 percentage points the proportion of seniors who are inactive. Increase the proportion of the population intending to make positive changes in physical activity. Only the last jurisdiction employs the negative indicator of physical inactivity rather than expressing the target in positive terms, that is, as activity rates. Such framing decisions involve more than psychological considerations. Research shows, somewhat surprisingly, that interventions aimed at reducing sedentariness in children may be more effective than those geared to increasing activity. Intuitively, one may think these would be equivalent concepts, but it turns out not to be so.19 Finally, referring again to the Cancer 2020 Background Report in Ontario, the relevant target is:20 By 2020, at least 90% of the population will participate in appropriate levels of physical activity as defined by Canada’s Physical Activity Guide.21 International Comparisons Many countries in addition to Canada are setting targets for the risk factor of physical inactivity. The state of the art is again the Healthy People project in the United States, with no fewer than 10 targets related to physical activity and fitness;22 some key ones are laid out in table 4.3. Unlike vegetable and fruit consumption (see below), progress has not occurred with the most relevant indicators: inactivity and optimum

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Part One: Taking Steps Towards Health

Table 4.3 Physical Activity Prevalance and Targets in the United States (%)

Activity level (Age 18+)

Baseline

1991

1995

1998

2000 target

Light-to-moderate 5+ times/week Light-to-moderate 7+ times/week Vigorous Sedentary

22

24

23

30

30

16

17

16

20

30

12 24

16 24

16 23

14 24

20 15

Source: Healthy People 2000: Final Review.

activity. This mirrors the flattening out of advances with respect to physical activity in Canada as a whole, and British Columbia in particular. The somewhat refocused and, in some cases, more modest objectives for Healthy People 2010 are:23 • Reduce the proportion of adults who engage in no leisure-time physical activity – baseline, 40%; target, 20%. • Increase the proportion of adults who engage regularly, preferably daily, in moderate physical activity for at least 30 minutes per day – baseline, 15%; target, 30%. • Increase the proportion of adults who engage in vigorous physical activity that promotes the development and maintenance of cardiorespiratory fitness at least three days per week for at least 20 minutes per occasion – baseline, 23%; target, 30%. Another international example is provided by Northern Ireland, where the target of reducing the proportion of sedentary adults over age 16 years from 20% to 15% is projected to save an estimated 121 lives per year, as well as considerable health care costs.24 Unhealthy Eating Although there are limited baseline data to inform nutrition-related indicators, the majority of Canadian provinces have begun to establish targets. In particular, vegetable and fruit consumption is being addressed in several provincial jurisdictions. Samples of the proposed indicator targets, demonstrating a variety of degrees of precision and finalization (again, the wording has been edited to facilitate comparison) include: 25,26

Risk Factor Targets around the World

47

• Alberta. By 2012, increase from 34% to 50% the proportion of people eating at least five to ten servings of vegetables and fruits per day. • Ontario. By 2010, increase to 75% the proportion of the population age 4 and older consuming five or more servings of vegetables and fruits per day. • Newfoundland and Labrador. By 2008, increase from 30% to 40% the proportion of people eating adequate amounts of vegetables and fruits. As a final comparison, the Ontario Cancer 2020 initiative put forward the following target:27 By 2020, at least 90% of the population will consume at least five servings of vegetables and fruits per day. One way in which the various vegetable and fruit intake targets might be improved is to specify what an adequate amount of vegetable and fruit consumption actually is (compare the Healthy People 2010 wording, below), as well as acknowledging in some way just how close most people are to achieving the recommended level. Although it is not clear whether it would increase motivation or, instead, produce a sense of complacency, a statistic such as average number of servings consumed in a population makes the real situation more transparent (again, see the U.S. example, below). Further refinement of the health benefits can also sometimes change a campaign; note this moving- target phenomenon in the United States, which now specifies the importance of dark green and orange vegetables. International Comparison Several jurisdictions similar to Canada have established targets related to vegetable and fruit consumption, including the United Kingdom and New Zealand. The wording in the latter case was: to increase the consumption of vegetables and fruit so that 75% of New Zealanders eat at least six servings each day by the year 2000. Such international initiatives around vegetables and fruit are consistent with the WHO ‘Global Strategy on Diet, Physical Activity and Health.’ Increasing dietary vegetables and fruit also features in the U.S. Healthy People program. This initiative has been given a boost by the progress made towards the year 2000 target, even though the momentum stalled part-way through the decade (see table 4.4).28 The somewhat refocused targets for Healthy People 2010 are:29

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Part One: Taking Steps Towards Health

Table 4.4 Vegetable and Fruit Consumption Prevalance and Targets in the United States (%)

Indicator

1989–91 Baseline

1994

1995

1996

2000 target

Average no. of servings % Meeting Guidelines (5/day)

4.1 29

4.6 36

4.6 37

4.7 35

5.0 50

Source: Healthy People 2000: Final Review.

• Increase the proportion of persons aged 2 years and older who consume at least two daily servings of fruit – baseline, 28%; target, 75%. • Increase the proportion of persons aged 2 years and older who consume at least three daily servings of vegetables, with at least one-third of them being dark green or orange vegetables – baseline, 3%; target, 50%. (Note that the baseline for the second target is low because of the modest national consumption of dark green or orange vegetables; if the indicator was three or more daily servings of vegetables of any type, then the stated target would already have been achieved.)

Key Points • There is significant worldwide momentum for setting risk factor targets, although the format and details vary considerably from setting to setting. • The U.S. Healthy People 2010 project is aiming to reduce adult smoking prevalence by an average of 1% per year. • The rate of obesity is increasing so rapidly that some jurisdictions are only hoping in the near term to slow down or stop the alarming acceleration. • There has been progress in the past towards physical activity targets, but recent results for reducing the proportion of the sedentary cohort in the population have not been as encouraging. • Although healthy eating targets continue to be refined, it is already encouraging to note that a large proportion of people are not far away from meeting recommended levels of vegetable and fruit consumption.

Risk Factor Targets around the World

49

DEVELOPING A RISK FACTOR PLAN (2): BRITISH COLUMBIA TARGET-SETTING In the spring of 2004 the British Columbia Healthy Living Alliance (BCHLA) took on the task of developing provincial advocacy targets for the reduction of four major risk factors by the year 2010. This is consistent with the mandate of the alliance, namely, ‘to improve the health of British Columbians through leadership that enhances collaborative action to promote physical activity, healthy eating and living smoke-free.’ Formed in February, 2003, the BCHLA is a coalition of organizations that comprise over 40,000 volunteers, 4,300 health and recreation professionals, and 184 local governments across British Columbia. The membership includes the Canadian Cancer Society – B.C./Yukon Division, the Heart and Stroke Foundation of B.C. and Yukon, the B.C. Lung Association, the Union of B.C. Municipalities, the B.C. Recreation and Parks Association, the Public Health Association of B.C., Dietitians of Canada – B.C. Region, Canadian Diabetes Association – Pacific Division, the B.C. Pediatric Society, and Public Health Agency – Yukon Region, as well as non-voting participation from the B.C. Ministry of Health Services, Provincial Health Services Authority, and all regional health authorities in the province (Fraser Health, Interior Health, Northern Health, Vancouver Coastal Health, and Vancouver Island Health). The overall goal of the BCHLA is to reduce the burden of chronic disease in British Columbia by: • Enhancing collaboration among government, non-government, and private sector organizations • Advocating for health-promoting policies, environments, programs, and services • Increasing the capacity of communities to create and sustain healthpromoting policies, environments, programs, and services. The BCHLA and its activities are guided by a commitment to: • A population health approach, recognizing that many factors influence health, including: income, social status, education, social support networks, employment and working conditions, physical environments, personal health practices, biology and genetic endowment, health services, and healthy child development • Fostering vertical and horizontal integration across risk factors, the prevention-management continuum, and jurisdictions

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Part One: Taking Steps Towards Health

• Building on existing programs and experiences, where possible • Basing decisions and actions on the best available evidence • Respecting the unique strengths, experience, and expertise of all organizations and individuals that participate in the Alliance • Participation of member organizations and individuals, recognizing that each will contribute various resources to the Alliance, depending on its capacity to do so. BCHLA Risk Factor Target-Setting Process The goal of this part of the project in British Columbia was to develop consensus on provincial targets for the four risk factors for 2010 – targets that take into account the variation in risk behaviour in communities across the province. The targets were set through a 6-month process. During that time, the BCHLA (with the support of a consulting team): • Reviewed the literature to demonstrate clearly the link between the 4 risk factors and chronic disease • Chose indicators that would allow it to assess how British Columbia was doing in comparison with others, and to track progress over time • Collected and presented information on risk behaviour in B.C. at the provincial, health authority, and health service delivery area level • Compared British Columbia with other provinces and other jurisdictions in terms of risk behaviour • Involved regional health authority representatives and members of regional healthy living alliances in a consultation process aimed at increasing awareness around regional specific risk behaviour and appropriate targets • Held a consensus workshop with the Coordinating Committee of the Alliance and the regional representatives to finalize the targets. A number of documents were developed to support this process. These included a reference document and power point presentation that demonstrated data on risk factors and their link to chronic disease, along with risk behaviour prevalence at the provincial, health authority, and health service delivery area levels. Regional Consultation During the regional consultation process, 11 meetings/workshops, involving more than 200 participants, were held across the province. The

Risk Factor Targets around the World

51

groups discussed the risk factors in their health region, their link with chronic diseases, and potential regional targets. Most participants felt that the targets should be set high, as they would be used for advocacy purposes. The groups also proposed that the targets be set as positive goals, for example, increasing healthy activity rather than reducing the number of people who are inactive. The summary notes from these sessions, with detailed comments on the process and the proposed targets, were used to inform the discussion and final target setting at a consensus workshop with the Coordinating Committee of the Alliance and the regional representatives. The regional representatives who were present at the consensus workshop reported that the process had provided an excellent opportunity to bring this broad stakeholder group together to engage in serious dialogue about how to work together to advance the cause. Most groups wanted to know what the next step was and how they would be involved. BCHLA Targets for 2010 The targets are presented below, along with charts showing where the BCHLA plan fits in relation to various benchmarks. The BCHLA targets are aggressive – purposefully – but in most cases fall within the range proposed through the consultation process. In response to the feedback received during the consultation, the targets are phrased in a positive way. NOT SMOKING

The target (see figure 4.1) is that nine out of ten British Columbians (aged 12 and over) will not smoke by 2010. This represents a change in the proportion of the population who are non-smokers from the current 81% to 87%, an increase of 7%. Included in figure 4.1 are bars indicating the current (2003 calendar year) proportion of non-smokers in British Columbia, the BCHLA target established as part of this process, and best results within the province. For health planning purposes, the province of British Columbia is geographically subdivided into five Health Authorities (HA). Each Health Authority is then further subdivided into three or four Health Services Delivery Areas (HSDA). The ‘best HSDA in BC’ thus represents the 2003 actual results for the best Health Services Delivery Area in the province. For smoking, for example, the best HSDA result for nonsmokers was 86.5% based on a combination of 89.1% of women nonsmokers in the HSDA of Richmond and 83.9% of men non-smokers in the HSDA of North Shore/Coast Garibaldi. The ‘best HSDA in HA’ rep-

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Part One: Taking Steps Towards Health

Figure 4.1 British Columbia: potential targets, non-smokers. 100

% of the population

90

80

70

60

50

Current

BCHLA target

Best HSDA in BC

Best HSDA in HA

Best HA in BC

Potential Targets

resents a combination of the best results from the three or four HSDAs in each Health Authority. The ‘best HA in BC’ represents the results of the best Health Authority in the province. Healthy Eating The target (see figure 4.2) is that seven out of ten British Columbians (aged 12 and over) will be eating at least five servings of vegetables and fruit a day by 2010. This represents a change in the proportion of the population who eat at least five servings of vegetables and fruit a day from 40% to 70%, an increase of 74%. HEALTHY ACTIVITY LEVEL

Another target (see figure 4.3) is that seven out of ten British Columbians (aged 12 and over) will be physically active by 2010. This represents a change in the proportion of the population who are physically active from 58% to 70%, an increase of 20%.

Risk Factor Targets around the World Figure 4.2 British Columbia: potential targets, healthy diet. 100 90

% of the population

80 70 60 50 40 30 20 10 0 Current

BCHLA target

Best HSDA in BC

Best HSDA in HA

Best HA in BC

Potential Targets

Figure 4.3 British Columbia: potential targets, physically active. 100 90

% of the population

80 70 60 50 40 30 20 10 0 Current

BCHLA target

Best HSDA in BC

Best HSDA in HA

Potential Targets Includes both physically active and moderately active individuals.

Best HA in BC

53

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Part One: Taking Steps Towards Health

Figure 4.4 British Columbia: potential targets, healthy weight. 100 90

% of the population

80 70 60 50 40 30 20 10 0

Current

BCHLA target

Best HSDA in BC

Best HSDA in HA

Best HA in BC

Potential Targets

HEALTHY WEIGHT

A fourth target (see figure 4.4) is that seven out ten British Columbians (aged 20 to 64, excluding pregnant women) will have a healthy weight by 2010.This is a change in the proportion of the population with a selfreported healthy body weight from 52% to 70%, an increase of 34%. The absolute numbers of individuals who would need to either eliminate or not develop a risk factor in each case to achieve the targets by 2010 are indicated in figures 4.5 to 4.8.

Risk Factor Targets around the World

55

Figure 4.5 British Columbia population: number of smokers and former smokers / non-initiators if BCHLA targets achieved. 225,000 800,000

No. of Individuals

700,000 600,000 500,000 400,000 300,000 200,000 100,000 –

2003

2004

2005

2006

2007

2008

2009

2010

Year Current smokers

Former smokers / non-initiators

Figure 4.6 British Columbia population: number of individuals who eat fewer than five vegetables or fruits per day, if BCHLA targets achieved. 2,500,000

948,000

No. of Individuals

2,000,000

1,500,000

1,000,000

500,000

–

2003

2004

2005

2006

2007

Year Current

Former

2008

2009

2010

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Part One: Taking Steps Towards Health

Figure 4.7 British Columbia population: number of physically inactive individuals, if BCHLA targets achieved. 1,800,000

351,000

No. of individuals

1,600,000 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 –

2003

2004

2005

2006

2007

2008

2009

2010

Year Current

Former

Figure 4.8 British Columbia population: individuals who are overweight or obese, if BCHLA targets achieved. 1,400,000

254,000

95,000

No. of individuals

1,200,000 1,000,000 800,000 600,000 400,000 200,000 –

2003

2004

2005

2006

2007

2008

2009

2010

Year Currently obese

Currently overweight

Formerly obese

Formerly overweight

5 The Benefits of Reducing Risk Factors B.C. Risk Factor Plan (3)

One of the powerful benefits of addressing risk factors is cost avoidance, in terms of both direct health care spending and indirect productivity losses. These costs are estimated using different assumptions and algorithms. Of course, the absolute totals, whatever the methodology, are unique to each jurisdiction. In the case study following this chapter, key economic principles are applied to British Columbia to come up with a picture of cost avoidance for that province. The numbers are as compelling there as they are for many other settings. Before concerning oneself with financial benefits, however, it is important to examine the health benefits of risk factor reduction. Not only are health effects directly related to relieving human suffering, but reduced disease and disability are the ultimate source of economic savings. As well, the health benefits tend to be universal, similar from country to country, so it is very appropriate to summarize them in general terms. With regard to smoking, principles and issues related to health care costs are detailed in this chapter as a model for analysts who are working with that particular risk factor. As will be seen, these principles and issues are not without controversy. Reduced Tobacco Use A 1990 U.S. Surgeon General’s report focused on the health benefits of smoking cessation. The major conclusions of the report were:1 • Smoking cessation has major and immediate health benefits for men and women of all ages. Benefits apply to persons with and without smoking-related disease.

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• Former smokers live longer than continuing smokers. • Smoking cessation decreases the risk of lung cancer and other cancers, heart attack, stroke, and chronic lung disease. • Women who stop smoking before pregnancy, or during the first three to four months of pregnancy, reduce the risk of having a low birth weight baby to the level experienced by women who have never smoked. • The health benefits of smoking cessation far exceed any risks from the average 3 to 4 kg weight gain experienced by quitters, as well as from any adverse psychological effects that may follow quitting. The Surgeon General’s report noted that the risk of lung cancer is approximately 22 times higher in male smokers and 12 times higher in female smokers compared with people who have never smoked. Furthermore, ‘the risk of lung cancer declines steadily in people who quit smoking; after 10 years of abstinence, the risk of lung cancer is about 30 to 50 percent of the risk of continuing smokers.’ Smokers have about twice the risk of dying from coronary heart disease (CHD): ‘This excess risk is reduced by about half among ex-smokers after only 1 year of smoking abstinence and declines gradually thereafter. After 15 years of abstinence the risk of CHD is similar to that of persons who have never smoked.’ Smokers also have twice the risk of dying from stroke: ‘After quitting smoking, the risk of stroke returns to the level of people who have never smoked’ within 5 to 15 years of cessation. The Surgeon General’s report also noted that smoking cessation reduces the higher risks seen in continuing smokers for chronic obstructive pulmonary disease (COPD), influenza and pneumonia, peripheral artery occlusive disease, abdominal aortic aneurism, ulcers, and so on. More recent research continues to support the findings of the 1990 Surgeon General’s report. Based on 50 years of follow-up with British male physicians, Doll and colleagues found that, on average, smokers die approximately 10 years earlier than do non-smokers. Smoking cessation, however, results in gains of about 3, 6, 9, and 10 years of life expectancy if the cessation began at age 60, 50, 40, or 30, respectively. That is, stopping by middle age reverses almost all of the excess mortality associated with smoking.2 The 2004 U.S. Surgeon General’s update indicated that cancers account for 43% of years of potential life lost (YPLL) due to smoking, circulatory diseases for a further 36%, and respiratory diseases for 20%.

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Figure 5.1 Reduced risk of death after quitting smoking, by cause of death.

Fraction of excess risk

1.20 1.00 0.80 0.60 0.40 0.20 0

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Year since quitting CHD

Lung cancer

COPD

Within these broad categories, lung cancers account for 34% of YPLL, CHD for 28%, and COPD for 13%. That is, these three conditions together account for 75% of total YPLL attributable to smoking. Figure 5.1 provides an estimate of the residual excess mortality risk with increasing duration of smoking cessation for these three signature conditions, based on the 1990 U.S. Surgeon General’s report, updated by more recent data from a study by Burns.3 The estimated trends in Figure 5.1 are based only on individuals who do not have a history of chronic disease or do not report being sick, thus eliminating the spike in early post-cessation mortality and health care costs when smoking cessation coincides with a major health event (see below). Upon smoking cessation, there is a substantial early decline in excess risk of mortality from CHD. The decline in excess risk of mortality from lung cancer follows a steadier pattern over the years. The decline in excess risk of mortality from COPD takes more time to manifest itself. While the health benefits of smoking cessation are clear, it is important to note that some excess risk remains, even over the longer term. In summarizing his paper, Burns notes that ‘it would be a tragedy if the additional prevention needs of these former smokers were ignored once they had accomplished the difficult task of cessation.’4 As observed by the U.S. Surgeon General, the risk of death from

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lung cancer, for example, always remains somewhat elevated for individuals who have smoked. This fact is in accord with a study that reported that the risk of lung cancer decreased progressively as the time since cessation grows longer, but also showed that even after 30 years of cessation the risk does not reach the low level of lifelong nonsmokers.5 At age 75, the risk of lung cancer for men who continue to smoke was estimated by Peto and co-authors to be 15.9%. The risk decreases to 9.9%, 6.0%, 3.0%, and 1.7% for those who stopped smoking around 60, 50, 40, and 30 years of age, respectively. The 1.7% lung cancer rate for former smokers who quit by age 30 is still approximately three times higher than that of lifelong non-smokers. The implication is that, as important as successful and early quitting may be,6–8 preventing the initiation of a smoking career is even more critical. One study showed that smoking during the teenage years produced permanent genetic changes in the lungs which forever increases the risk of lung cancer.9 Finally, it is important to note that the 1990 Surgeon General’s report even found a benefit of smoking cessation among those with preexisting diseases, particularly patients with CHD. This finding has been confirmed in a meta-analysis conducted by Critchley and Capewell of 20 studies that assessed the impact of smoking cessation in patients with diagnosed CHD.10 They found a 36% reduction in the risk of mortality for those who quit versus those who continued to smoke. Avoided Costs with Smoking As noted at the start of this chapter, there are a variety of issues related to smoking and cost avoidance that have proven to be controversial. The discussion that follows offers principles for economists to move forward in truly understanding the benefits of smoking cessation. First, there is the issue of avoided costs attributable to the earlier deaths of smokers. In an often-quoted study published in the New England Journal of Medicine, Barendregt and colleagues estimated that the direct medical costs of smokers at any given age in Holland are approximately 40% higher than for non-smokers.11 When total lifetime expenditures on medical costs are taken into account, however, their model suggested a different picture. If no one smoked, direct medical expenditures would ultimately be 7% higher in men and 4% higher in women, primarily due to the higher life expectancy of non-smokers and the associated medical costs incurred with the surviving elderly.

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Despite their economic analysis, the authors still conclude: ‘In formulating public health policy, whether or not smokers impose a net financial burden ought to be of very limited importance. Public health policy is concerned with health. Smoking is a major health hazard, so the objective of a policy on smoking should be simple and clear: smoking should be discouraged.’ The Berendregt study has recently been criticized for including a narrow scope of smoking-related diseases and for the lack of inclusion of indirect costs (e.g., lost productivity).12 Rasmussen and co-authors addressed these limitations in a Danish study and found that lifetime direct and indirect costs were 66% and 83% higher in male ever-smokers than in male never-smokers. The results for female smokers were similar, with lifetime direct and indirect costs 74% and 79% higher, respectively. A commonly held position in the debate about lifetime health care costs and smoking holds that the early death of smokers serves to spare them from poor health at the end of their life. On the contrary, a Danish study by Bronnum-Hansen and Juel found that not only did smoking decrease life expectancy; it also decreased the number of selfrated years of good health.13 Thus, even if it could be proven that smoking is good for the economy, it clearly is not good for smokers! A further controversy associated with smoking-related costs is the apparent finding that direct medical care costs increase, rather than decrease, after a smoker quits, at least in the immediate post-quit period.14,15 Fishman et al. suggested that there may be several reasons that account for this phenomenon. First, former smokers may seek medical care that they have delayed while smoking. Second, smoking cessation often coincides with or immediately follows a health event that motivates the effort to quit in the first place.16 Fishman and colleagues calculated the actual direct health care costs associated with a post-quit period of 7 years. As in previous studies, they found a 1-year spike in costs. On average, never-smokers cost U.S.$1,618 (in 2000 dollars), continuing smokers cost U.S.$2,238, and those who had just quit cost U.S.$3,239. This anomalous, short-term spike in costs, they suggest, ‘point[s] to intensive health service use consistent with above average medical care needs.’ By implication, smoking cessation likely coincided with or was preceded by an expensive health event that may have actually inspired the quit attempt. In subsequent years, direct medical costs remained higher than those for never-smokers, a pattern that ‘is consistent with the greater health care

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expense we might expect from persons who may have neglected health and preventative services for extended periods of time.’ Reduced Obesity Assessing the health benefits associated with weight loss is a controversial undertaking. A number of studies have indicated that fluctuations in weight may actually increase mortality compared with maintaining a steady weight.17–19 Furthermore, an inappropriate focus on weight loss may increase the risk of eating disorders.20 Finally, a number of studies suggest that a degree of overweight (as currently defined) may actually be protective in individuals with chronic conditions such as heart failure.21 A key dividing point revealed in the literature is whether the weight loss is intentional or unintentional. Astrup22 notes that this is ‘an important methodological problem, because some of the subjects may have suffered from an underlying disease process both causing weight loss and leading to an increased mortality rate.’ Results from early studies that assessed intentional weight loss in the general population found equivocal associations between weight loss and mortality.23 These mixed results were based largely on observational studies that were not specifically designed to test the hypothesis that intentional weight loss reduces mortality.24–26 Two recent prospective studies have assessed the relationship between intentional versus unintentional weight loss and increased mortality in the general population,27 as well as in individuals with diabetes.28 In the general population, intentional weight loss is associated with a 24% lower mortality rate (compared with those who reported not trying to lose weight or who did not experience weight loss). However, unintentional weight loss was associated with a 31% higher mortality rate. When intentionality was not taken into account, overall weight loss was associated with increased mortality, driven by the higher mortality associated with unintentional weight loss. This criterion likely explains the association between weight loss and higher mortality rates in previous research. Perhaps surprisingly, individuals who tried but were unsuccessful in losing weight also experienced a somewhat lower mortality rate. The authors note that the ‘most plausible explanation for our finding that attempted weight loss was independently associated with reduced mortality is that weight loss attempts are a marker for healthy

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behaviors.’ Further encouragement from this study was that the best result (a 30% reduction in mortality) was observed in those individuals with a modest intentional weight loss of 1 to 9 kg. Healthy Eating and Physical Activity In addition to any impact on the obesity rate, reducing energy intake through healthy eating and increasing energy expenditure through physical activity have independent benefits. For example, in a 1993 analysis, it was estimated that a mere 1% reduction in intake of fat and a 0.1% reduction in intake of cholesterol would prevent over 56,000 cases of coronary heart disease and cancer in the United States, saving 117,000 life-years over 20 years.29 Besides the reduced risk of mortality due to chronic diseases, there are other benefits associated with increased physical activity. Higher rates of depression, for example, are associated with a sedentary lifestyle, although the causal relationship is not yet established. Chen and Millar found that sedentary Canadians had a 60% increased risk of a depressive episode, compared with Canadians who engaged in moderate physical activity.30 Furthermore, Spirduso and Cronin found that long-term physical activity is related to postponed disability and independent living in elderly individuals.31 Multiple Risk Factors There are several arguments for treating the key risk factors in an integrated manner when setting public policy. First, it is demonstrable that each of the four risk factors under discussion have a significant independent effect on mortality and morbidity; thus, to make the most population health gains, all of the factors need to be addressed. In this book, we have chosen to focus mostly on tobacco use and obesity; but, as detailed in the case study, the B.C. plan also dealt with physical inactivity and unhealthy eating in their own right. In addition to independent health effects, the risk factors relate to one another in different ways. Researchers identify several different types of factorial interaction, including so-called mediator and moderator functions.32,33 One of the clearest relationships between factors is known as ‘overlap.’ Although there are health impacts of, say, physical inactivity that are independent of other factors, there is also a large percentage of impacts that flow from the contribution of inactivity to

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obesity. For instance, it has been shown that sedentary Canadians have a 44% higher rate of obesity than physically active Canadians. The effect on related disease rates would likely be a combination of the two factors.34 This ‘overlap’ effect explains why the population attributable fractions (PAFs) of risk factors for a particular disease often add to more than one.35,36 The interaction of risk factors can extend in more than two dimensions. For example, just as activity and weight (or adiposity) are linked, nutrition can be seen as a third element closely related to both of those factors.37,38 A U.S. study concluded in 2002 that dietary and physical activity recommendations for healthy living are ‘inextricably intertwined.’39 A causal nexus has been demonstrated in particular for vegetable and fruit consumption, physical inactivity, and obesity.40,41 The topics of obesity, physical inactivity, and unhealthy eating are integrated in Part 3 of this book. Smoking also must be brought into the discussion. Most importantly, smoking heightens the negative health impacts of being obese.42 Smoking also demonstrates that risk factors sometimes move in opposite directions. For instance, the well-known weight gain that can accompany smoking cessation must be considered in any integrated risk factor policy.43,44 Another anomaly is that an increase in physical activity sometimes leads to an increase in food intake.45 The complete story of activity and obesity is a complex one; sometimes the effect of increased exercise is not so much on body weight or total adiposity, but rather on more favourable fat distribution.46 The interconnectedness between risk factors suggested above translates into an agenda for addressing multiple factors concurrently. At least three conceptual drivers are behind such an agenda. They are: • Uncertainty. The relationships between diet, physical inactivity, and weight are still being fully worked out; in the meantime, none of the factors should be neglected, since which one should receive priority remains moot. The technical assumptions necessary in making estimates of combined impact remain complex; there are limited data, and time-related issues play a role (e.g., sequential rather than simultaneous changes tend to be the norm in real life).47 The basic assumption is that there definitely are benefits from treating multiple risk factors in the absence of complete understanding of their interaction, i.e., even as the ‘science and math’ are catching up to the complexities.48–50

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• Continuous learning. By different prevention/promotion communities working together, knowledge will be enhanced about complementary and interactive relationships between factors, ultimately improving interventions. Although evidence-based policy is always best, stopping all initiatives in the face of incomplete science can be detrimental to progress in both health and understanding. • Synergy. Perhaps of greatest interest to policymakers is the suggestion that multiple reductions in risk factors can be equal to ‘more than the sum of the parts.’ One example relates to physical activity. For reasons that are not entirely clear, adding exercise to an intervention of controlled energy intake may increase health benefits exponentially. One recent study suggested that, at biological levels, diet and physical activity ‘working in concert can remodel physiological structures and processes towards a healthful end.’51 Likewise, the multiplication can work in a negative direction. The presence of physical inactivity heightens the need for weight reduction in obese persons and/or a move towards more activity and fitness in order to attenuate significant health risks.52 Similarly, researchers have identified the multiplicative effect of smoking when combined with the other risk factors of coronary heart disease; adding one other factor (such as obesity) to smoking results in approximately a four-fold increase in risk, and a third factor creates an eight-fold increase.53 The promise of addressing multiple risk factors is great. Societies must explore the possibility of identifying a multi-modal therapy that can work simultaneously on more than one risk factor. This may happen through a secondary prevention program after screening reveals the presence of biological factors such as hypertension or after the related chronic disease begins to manifest itself. Even more beneficial would be adopting techniques from complementary disciplines to pursue primary prevention. For example, it has been noted that the behavioural science components of diet and physical activity share similar features, so that a cooperative approach may lead to advances in both measurement and intervention effectiveness.54 Another level of relationship between the risk factors may be ‘meta-causality.’ An integrated approach to risk factors allows investigation of upstream strategies that focus on poverty and social inequity, food insecurity, education, marketing, and opportunities for exercise. These forces usually have an impact on more than one factor.55 Finally, the process of targeting multiple risk factors increases the

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opportunity for collaboration between different stakeholders in the world of prevention and health promotion, and the possibility of focusing limited resources to achieve the greatest benefit. The fact that a short list of major risk factors relate to the same serious chronic diseases increases the potential for such initiatives. An example of this is the recent joining of forces between the Cancer Society, the Diabetes Association, and the Heart Association in the United States to shine a spotlight on prevention and early detection and/or intervention.56 The preceding rationales explain why many agencies treat risk factors in an integrated way. The WHO ‘Global Strategy,’ finalized in May 2004, looks at diet, physical activity, and health jointly. The same is true of the American Cancer Society’s guidelines for cancer prevention, which links nutrition, physical activity, and obesity.57 The Harvard Report on Cancer Prevention identified the 4 risk factors described in this book (plus alcohol abuse) as the major targets. It claimed that a multifactorial strategy could reduce the cancer burden in the United States by more than 50% in the coming decades.58 Among Canadian jurisdictions, Ontario is definitely following a multifactorial strategy in approaching chronic disease risk factors; the province has created state-of-the-art linkage diagrams connecting risk factors with each other and with diseases.59 The other provinces are also looking at factors such as physical inactivity, nutrition, and obesity in an integrated way.60 Indeed, the general Canadian response to the WHO ‘Global Strategy’ sums up the view of many jurisdictions around the world: ‘Multi-factorial prevention strategies, targeting multiple risk factors for single diseases or disease clusters, have met with greater success.’61 This understanding underlies, for example, the creation of the Integrated Pan-Canadian Healthy Living Strategy, as well as the existence of the very inspiration for this book, the B.C. Healthy Living Alliance. In sum, although there is considerable uncertainty in estimating the joint burden (and therefore the potential prevention benefits) of multiple risk factors, there is definite promise in simultaneous interventions. The fact that certain risk factors tend to cluster together at the same point in an individual’s life course makes such synergy even more likely.62 For instance, even modest reductions in obesity and tobacco use in vulnerable populations, along with improvements in blood pressure and cholesterol levels, would cut cardiovascular disease in half, as long as the changes were population-wide and coordinated.63 Thus, as we turn to Part 2 of this book and a particular focus on

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67

Figure 5.2 British Columbia Residents: Smoking Status in 2003. 100 90 80 % of Age Group

70 60 50 40 30 20 10 0

12-19 years 20-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years

75 years +

Age Group Never smoked Not stated Former smoker Occasional smoker Daily smoker

tobacco use, we recognize, along with the B.C. project leaders, that an integrated plan covering more than one risk factor will generally be the most potent approach.

Key Points • Smokers die approximately ten years earlier than do nonsmokers, on average, but stopping the habit by middle age reverses most of the excess mortality associated with smoking. • The risk of lung cancer, heart diseases, and respiratory diseases among former smokers, however, remains somewhat elevated when compared to lifelong non-smokers, even after 30 years of cessation. This fact stresses the primacy of preventing the uptake of tobacco use in the first place.

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• Some researchers have argued that smoking is ‘good’ for the economy as smokers die earlier, thus reducing their overall economic burden on the health care system and society. Furthermore, the early death of smokers serves to spare them from the poor health at the end of their life. More recent research indicates that lifetime direct and indirect costs are higher in smokers than non-smokers and that smoking decreases the number of years of good health when compared with non-smokers. • Assessing the health benefits of reducing obesity involves distinguishing unintentional and intentional weight loss; only the latter has been associated with lower mortality. The best results are seen with modest losses of 1 to 9 kg. • Healthy eating and physical activity can have a strong positive effect on morbidity and mortality, especially if they are pursued together. • Targeting multiple risk factors simultaneously promises to extend benefits in a synergistic way. Tackling smoking, obesity, physical inactivity, and unhealthy diets aggressively could reduce cancer rates by 50% or more.

DEVELOPING A RISK FACTOR PLAN (3): THE ECONOMIC BENEFITS OF ACHIEVING 2010 TARGETS IN BRITISH COLUMBIA Smoking and Personal Expenses One of the clear economic benefits from smoking cessation is the reduction in costs to individuals of purchasing cigarettes; the smoking status for B.C. residents in 2003 is indicated in figure 5.2. In 2003 a total of 493,000 British Columbians (14.0% of the population) were daily smokers, while a further 166,000 (4.7%) were occasional smokers. In calculating the estimated savings due to reduced personal expenditures on cigarettes, we made the following assumptions: • An annual increase in provincial taxes of $2.00 per carton, with no increase in federal taxes

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69

• An estimated average consumption of 15 cigarettes per daily smoker • Exclusion of any potential savings for occasional smokers, thus producing a conservative estimate of savings • The BCHLA targets for smoking are actually achieved. The results of this analysis are indicated on table 5.1. If BCHLA smoking cessation targets for 2010 are achieved, a conservative estimate of personal savings to former smokers would be $40 million in 2005, increasing to $290 million in 2010. Over the 6-year period from 2005 to 2010, total personal savings would be close to $1 billion ($949 million). The average annual savings per former smoker would be $2,235. Risk Factors and the Provincial Economy ESTIMATING DIRECT HEALTH CARE COSTS AVOIDED

Smoking, physical inactivity, and obesity are all associated with an increase in morbidity, resulting in an increased use of health care services and costs. What would the potential costs avoided be in the health care system if the BCHLA targets were achieved? To derive an estimate, we made the following assumptions: • Only half of the targeted reductions would be achieved in Year 1, due to the time required to implement a comprehensive provincial prevention program. • Health care utilization would be the same for physically inactive individuals who became physically active as for those who are currently physically active. • Health care utilization would be the same for obese individuals who became non-obese as for those who are currently non-obese. • Health care costs for smokers are roughly divided between cancers (40%), circulatory diseases (40%), and respiratory diseases (20%). • Reductions in smoking-related direct costs are based on the lower excess risk associated with the number of years since smoking cessation for lung cancer (as representative of the cancers), coronary heart disease (as representative of the circulatory diseases), and chronic obstructive pulmonary disease (as representative of the respiratory diseases). Based on the above assumptions, the estimated annual costs

Table 5.1 British Columbia Decreased Personal Expenditures as a Result of Smoking Cessation, 2005/06 to 2010/11

Year 1999/2000 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11

Cost / carton

$72.92 $74.92 $76.92 $78.92 $80.92 $82.92 $84.92

Reduced no. of cartons

527,798 1,067,559 1,621,236 2,197,675 2,794,039 3,409,786

Estimated savings

Cigs/ day

$ 39,542,626 $ 82,116,638 $127,948,024 $177,835,861 $231,681,714 $289,559,027

16.0 14.8 14.6 16.3 15.8 15.0 15.0 15.0 15.0 15.0 15.0 15.0

Est. cartons/ year

13,661,639 13,133,841 12,594,080 12,040,403 11,463,964 10,867,600 10,251,853

No. of daily smokers

492,926 499,055 479,775 460,058 439,832 418,775 396,990 374,497

No. of smokers

701,636

CCHS Actual

674,292 682,676 656,302 629,330 601,663 572,858 543,057 512,288

CCHS Actual BCHLA Target BCHLA Target BCHLA Target BCHLA Target BCHLA Target BCHLA Target BCHLA Target

Sources: Cigarettes per day is from CTUMS (based on daily smokers aged 15+); number of smokers in 2000 and 2003 is from CCHS and includes daily and occasional smokers age 12+; the number of daily smokers for 2004/05 and future years is based on the 73.1% daily to total smoker ratio in 2003.

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Table 5.2 BCHLA Risk Factor Targets Estimated Health Care Cost Avoidance ($ millions) Calendar year

Smoking Inactivity Obesity Total

2005

2006

2007

2008

2009

2010

4.3 3.6 4.3

14.6 11.0 13.2

27.8 18.6 22.5

43.8 26.4 32.0

62.0 34.5 41.7

83.0 42.7 51.7

12.3

38.8

68.9

102.2

138.2

177.4

Note: Columns may not add to totals shown because of rounding.

avoided in the B.C. health care system would be just over $12 million in Year 1, increasing to $177 million in Year 5 (see Table 5.2). ESTIMATING INDIRECT COSTS AVOIDED

Besides an increase in morbidity, smoking, physical inactivity, and obesity are also associated with an increase in premature mortality; both health effects result in a significant impact on indirect costs (e.g., the value of economic output lost because of illness, injury-related work disability, or premature death). What potential economic costs could be avoided if the BCHLA targets were achieved? To derive an estimate, we made the following assumptions: • Only half of the targeted reductions would be achieved in year one, due to the time required to implement a comprehensive provincial prevention program. • Mortality rates would be the same for physically inactive individuals who became physically active as for those who are currently physically active. • Mortality rates would be the same for obese individuals who became normal weight as for those who are currently normal weight. • Costs for smokers are roughly divided between cancers (40%), circulatory diseases (40%), and respiratory diseases (20%). • Reductions in smoking-related indirect costs (primarily due to premature mortality) are based on the excess risk associated with the number of years since smoking cessation for lung cancer (as representative of the cancers), coronary heart disease (as representative of the circulatory diseases), and chronic obstructive pulmonary disease (as representative of the respiratory diseases).

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Table 5.3 BCHLA Risk Factor Targets Estimated Indirect Cost Avoidance ($ millions) Calendar year 2005

2006

2007

2008

2009

2010

Smoking Inactivity Obesity

29.2 8.3 7.4

91.3 25.1 22.7

160.1 42.4 38.6

234.8 60.2 54.9

314.6 78.5 71.6

400.3 97.2 88.7

Total

44.9

139.0

241.1

349.9

464.7

586.2

Note: Columns may nopt add to totals shown because of rounding.

• Reductions in smoking-related indirect productivity costs (employers’ increased life insurance premiums, work absenteeism, provision of designated smoking areas and unscheduled smoking breaks) for former smokers are assumed to be the same as for never-smokers. Based on the above assumptions, the estimated annual indirect economic costs avoided would be just under $45 million in Year 1, increasing to $586 million in Year 5 (see table 5.3). Summary of Potential Costs Avoided When direct health care costs and indirect costs associated with productivity and premature mortality are combined, the estimated annual costs avoided would be just over $57 million in Year 1, increasing to $764 million in Year 5. During the six years leading up to the 2010 Winter Olympics, $2.4 billion in direct and indirect costs could be avoided if the BCHLA targets are achieved (see table 5.4). This cumulative $2.4 billion in costs avoided is in addition to the almost $1.0 billion that would remain in former smokers’ pockets due to decreased personal expenditures on cigarettes. The information presented above on projected annual costs avoided is summarized by risk factor in figure 5.3.

Table 5.4 BCHLA Risk Factor Targets Estimated Cost Avoidance ($ millions) Calendar Year 2007 2008

2009

2010

14.6 25.1 66.2

27.8 47.9 112.2

43.8 75.3 159.4

62.0 106.8 207.8

83.0 142.9 257.4

235.5 405.5 824.8

33.6

105.8

187.9

278.5

376.6

483.3

1,465.8

3.6 8.3

11.0 25.1

18.6 42.4

26.4 60.2

34.5 78.5

42.7 97.2

136.8 311.7

11.9

36.1

61.1

86.7

113.0

139.9

448.5

4.3 7.4

13.2 22.7

22.5 38.6

32.0 54.9

41.7 71.6

51.7 88.7

165.3 283.8

Total

11.7

35.9

61.0

86.8

113.3

140.4

449.1

Direct Indirect Productivity

12.3 23.1 21.7

38.8 72.8 66.2

68.9 128.9 112.2

102.2 190.5 159.4

138.2 256.9 207.8

177.4 328.9 257.4

537.7 1,001.0 824.8

Total

57.2

177.8

310.0

452.1

602.9

763.6

2,363.5

2005

2006

Direct Indirect Productivity

4.3 7.5 21.7

Total

Total

Smoking

Inactivity Direct Indirect Total Obesity Direct Indirect

Total

Note: Columns may not add to totals shown because of rounding.

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Figure 5.3 Estimated Cost Avoidance Associated with Achieving BCHLA Targets, by Risk Factor. 900 800

Millions of dollars

700 600 500 400 300 200 100 0

2005

2006

2007

2008

2009

Year Obesity

Inactivity

Smoking

2010

PART TWO From Setting to Achieving Targets

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setting a target is relatively easy. But to truly make the intended direction and benchmark meaningful, there needs to be a full commitment to an action plan that could feasibly move towards and even reach the target in the allotted time frame. In short, planners need to be mindful that setting targets is one thing, achieving them is another. Gathering evidence on which to base sound health care decisions is so well-established as a principle that it is simply assumed to be a priority in planning processes. This is very much the case with risk factor programs: policymakers understandably want to discover or develop the ‘best practices’ to employ in their action plans, that is, the interventions that are most effective and, even better, most cost-effective. It is now commonplace to recommend integrated approaches to health promotion across a wide range of risk factors, chronic diseases, and interventions. In fact, as we will see, the evidence from controlled trials of such communitywide, multicomponent programs has been disappointing. Nonetheless, the circumstantial evidence of California’s success with a statewide tobacco control campaign, Florida’s powerful experience with reducing youth smoking, and other such cases continue to motivate the development of comprehensive strategies at regional and local levels. Such a commitment, however, does not obviate the need to answer critical questions about selecting, prioritizing, and staging the component interventions. What is required in every jurisdiction is to seek and select interventions that will maximize the impact on desired outcomes as efficiently as possible. A large proportion of the remaining chapters in this book are dedicated to this cause. Part 2 focuses on tobacco control. At the end of a comprehensive inventory of interventions, a simple grid is provided that summarizes the best, or most promising, practices to reduce smoking prevalence. This will serve as a checklist for those seeking to build a potent action plan around tobacco use in their jurisdiction. The evaluation grid employed here attempts to capture two criteria simultaneously: effectiveness and strength of evidence. There are 3 metacategories in the overall summary, where a convenient inventory of all tobacco control interventions will be provided (see chapter 8): (1) interventions of proven effectiveness with strong evidence; (2) interventions of promising effectiveness with moderate or mixed evidence; and (3) interventions of no or low effectiveness and/or with insufficient evidence. Our effectiveness test for tobacco use relates mostly to actual decreases in smoking (or exposure to secondhand smoke) rather than ‘softer’ targets, such as expanded knowledge about the harmful effects

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of smoking or more widespread intentions to quit. The aim is to actually create an impact on chronic disease. A few words are required about the sources of evidence. The reviews in this book place a high premium on results from multiple randomized controlled trials (RCTs). In this we are not alone. RCTs represent the ‘gold standard’ in science, namely, the experiments that most reliably point to causality. Proving a causal link between a risk factor and disease or, in this case, between an intervention and modification of the risk factor, makes the resulting action plan more robust. Systematic review groups, such as the Cochrane Collaboration and the newer U.S. Task Force on Community Preventive Services (TFCPS), set high standards for their work; not surprisingly, these agencies depend heavily on RCTs. Their evaluations and summary reports are cited regularly in this book. In examining population health over whole communities, however, it is not always feasible to run a controlled experiment. For example, taking into account the impact of confounding variables becomes a very complex task, especially over a long follow-up period. The latter point is important: information about long-term outcomes are precisely what are needed when dealing with risk factors and diseases – such as smoking and cancers – that can have latency periods measured in decades. There is another reason why RCTs have limited application to risk factor research: it is rarely ethical to do experiments that expose people to known risks. Therefore, population health research has to depend on the approaches common to epidemiology, such as observational studies of risk behaviours and their outcomes in large cohorts. Although this type of research does not prove causality, it can suggest connections between risk factors and characteristics that may influence those factors. The potential interventions that emerge can be followed up in real world pilot projects. Interventions that receive a measure of confirmation can then be used in a more widespread fashion. Outcome data are continually gathered at every stage, prompting ‘course corrections’ in the action plan as necessary. Although offering a more trialand-error approach, this may be better than waiting for tightly controlled effectiveness data that, in the end, may never emerge. A final, apparently ironic point should be noted. Rather than disparaging the ‘weaker’ evidence of observational studies and pilot projects, it may very well be that such approaches have real advantages. Although there is no disputing the rigour and power of RCTs, there

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have also been problems with transferring results that involve the vagaries of risky human behaviour. Moving from the ‘laboratory’ of carefully selected study groups to real world applications has often proven challenging. Focusing research on free range homo sapiens in real world settings from the start certainly offers at least an equivalent potential for success. With this background, we now turn to the inventory of tobacco control measures that have been employed over the decades. As will be seen from the review of effectiveness and, later, cost-effectiveness, tobacco control offers a remarkable set of positive lessons that could be fruitfully employed in other arenas, including that of obesity prevention and treatment.

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6 Tobacco Control Evidence (1): Preventing Uptake

If it were not for the advent of organizations dedicated to reviewing scientific literature, pulling together the data on tobacco use would be a daunting task. Fortunately, extensive summaries have recently been completed that expertly review the current evidence on tobacco control strategies, sometimes incorporating dozens or even hundreds of studies. Our approach here is to compare and collate all of this work and offer a state-of-the-art review of reviews. In contrast with obesity control and other emerging areas of public health care, the evidence available for tobacco interventions is extensive and compelling. We start this chapter by introducing a logic model around which we have organized the data on tobacco control. Logic models have become more and more common as public policy planning tools. The model outlined in Figure 6.1 enables us to conceptualize, construct, and promote a comprehensive and powerful tobacco control policy. We then turn to the primary aim of this chapter. Our review of effective tobacco control interventions begins with the strategies that have been employed to reduce the uptake of smoking, especially among adolescents. (Note that a summary of all tobacco control interventions is presented at the end of chapter 8.) Logic Model / Organization of Interventions A logic model provides an analytical tool for examining the purpose and appropriateness of programs and for identifying key measures of success. A logic model essentially reflects a series of ‘if/then’ statements. If a program engages in activity X, then the result is output Y. If the program produces output Y, then this will cause immediate outcome Z, and so on. A logic model

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Figure 6.1 Logic Model for Tobacco Control Interventions. Inputs

Activities

Outputs

Targeted to disparate populations

Federal programs

Provincial programs

Community and national partners

Countermarketing

Community mobilization

Policy and regulatory action

School-based prevention and education curricula

Creation of smoking bans, regulations, and policies

Exposure to pro-health messages

Outcomes

Short-term

Adherence to and enforcement of bans, regulations, and policies

Knowledge and attitude change

Reduced initiation among youth

Increased cessation among youth and adults

Increased environments with no smoking

Intermediate Decreased smoking

Long-term

Reduced tobacco-related morbidity and mortality

Reduced exposure to ETS

Decreased tobacco-related disparity

... identifies the linkages between the activities of a policy, program, or initiative and the achievement of its outcomes. It succinctly clarifies the set of activities that make up a policy, program, or initiative and the sequence of outcomes that are expected to flow from these activities. As such, a logic model serves as a ‘roadmap,’ showing the chain of results connecting activities to the final outcomes and, thus, identifying the steps that would demonstrate progress toward their achievement.1

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In May 2003, to offer one provincial case, the Auditor General of British Columbia endorsed the use of logic models to develop performance measurement and accountability frameworks between health authorities and ministries. The report on performance agreements between the B.C. Ministry of Health Services and the health authorities recommends that ‘the ministry and the health authorities consider using logic models as part of the process of selecting measures of outcomes for the British Columbia health care system.’2 Various logic models relating to tobacco control have been designed, ranging from the simple to the very complex. The logic model proposed by the Centers for Disease Control and Prevention in the United States, with some minor modifications, is shown in Figure 6.1.3 The following intermediate outcomes seen in the model serve as the major topics for this and the next two chapters of this book:4 • Interventions to reduce initiation rates, especially among youth • Interventions to increase cessation rates • Interventions to reduce environmental tobacco smoke (ETS) exposure, especially in children. The interventions in each chapter will be further organized into selected categories drawn from the following list (which themselves are mostly defined by the setting where the intervention is implemented): • • • • • • •

Community-based interventions Workplace-based interventions School-based interventions Home-based interventions Clinical interventions and management Regulatory and economic interventions Comprehensive strategies.

No taxonomy of risk factor interventions is perfect, which is why so many different ones have been proposed. In our taxonomy, mass media interventions are classified under community-based interventions. Although sometimes appearing under the community category, regulatory and economic mechanisms are usually separated out as interventions requiring the direct action of senior governments. More

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targeted government policy initiatives (e.g., legislated smoking bans in schools or workplaces), however, are included here under the settings where they most apply. For our purposes, comprehensive strategies will represent a combination of two or more of the other categories. Sometimes the term comprehensive is used loosely to mean ‘multicomponent,’ but this is a misnomer, since every one of the above categories includes projects that sometimes employ multiple interventions. Social denormalization is a final category that we discuss in the menu of interventions. It refers to the process or the condition where society labels smoking as ‘abnormal.’ Campaigns for social denormalization, using marketing messages aimed at cessation and/or prevention of uptake, represent the traditional approach. Another, more recent, strategy is sometimes called ‘industry denormalization’; it involves tobacco manufacturers being portrayed as causing harm to individuals and to society. Health Canada offers the following definition, which certainly does not pull any punches: ‘Industry denormalization focuses on the tobacco industry and manufacturing of tobacco products and seeks to put a guilt feeling onto the industry.’5 Sometimes the two types of denormalization work together; research has shown that countermarketing that focuses on the deceptive or manipulative practices of tobacco companies is very effective in general antismoking campaigns.6 The Dangers of Teen Experimentation The focus of this chapter is on reducing the initiation of tobacco use among adolescents, as this is the age and stage when the large majority of people who smoke take up smoking as a long-term habit. Data confirm the crucial fact that, if smoking does not occur in adolescence, it is unlikely to ever occur. Only about 10% of new smokers begin after age 18 years.7As well, adolescents who begin at a younger age are more likely to become regular and heavier smokers, and they are less likely to quit.8,9 Individuals who begin smoking during childhood or early adolescence are also at a higher risk of developing airway diseases and lung cancers than are individuals who start later, likely due to the irreparable damage to the lungs and other tissues at a point when these organs are still developing.10,11 Symptoms of tobacco dependence also develop rapidly after the onset of intermittent smoking. Many youth report symptoms of nicotine dependence after their first few cigarettes.12 A study published in November 2004 noted that children who smoke even one cigarette by Grade 5 are twice as likely to

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be current smokers at age 17.13 DeFranza et al. reported that the median consumption of cigarettes when signs of dependence first develop was just two cigarettes per week.14 Wellman and colleagues noted that ‘the appearance of symptoms of nicotine dependence sparks a struggle between wanting to be a nonsmoker and feeling compelled to continue to smoke.’15 Smoking cessation programs need to target youth at this stage, rather than waiting for the more traditional criterion of a ‘half pack a day’ before initiating such programs. Community-Based Interventions Smoking, like other health-related behaviours, is influenced by the environment in which adolescents live. This recognition has led to the development of communitywide programs that target teens. Community interventions are defined as ‘co-ordinated, widespread programs in a particular geographical area (e.g., school districts) or region or in groupings of people who share common interests or needs, which support non-smoking behaviour.’16 Such initiatives offer the advantage of multidimensionality, with different components working together. They maximize the chance of reaching all members of a population with ongoing and broad support for the maintenance of non-smoking behaviour. Typical components of community programs include: • Mass media communications such as counter-advertising • Special (non-curricular) initiatives in schools, e.g., ‘no smoking’ policies • Age restrictions with respect to the purchase of tobacco products • Increased unit price for tobacco products (normally through taxation) • Tobacco-free public places. Sometimes the community initiatives are launched by non-profit groups, whereas others are government-mandated (see Regulatory and Economic Interventions, below). It is clear that there can be a substantial overlap between community programs for adolescents and those geared to adults. Indeed, a good argument can be made for coordinating tobacco control initiatives across all ages. Only about one-third of the studies in a major review offered (limited) support for the effectiveness of community interventions in preventing the uptake of smoking in young people.17 The more successful

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programs had multiple components (e.g., media-, school-, and homebased interventions combined) rather than, for instance, a media campaign alone. The mixed results mirror the rather equivocal review of school-based programs, even when they are allied with community programs (see the next section of this chapter).18 The studies that reported no effects on smoking prevalence comprised a wide variety of community programs; understanding the different contribution of individual program components, and their interaction, is a complex task. One possible explanation for the often weak results with community programs is the particular design of the counter-advertising component. This aspect of the plan may ultimately be the driving force behind any significant effectiveness.19 Abstracting the qualities of good advertising appears to be a worthy area of future research, although comparability of conditions across different projects remains a problem. School-Based Interventions Over the past three decades, high schools have been a key arena for the efforts to influence adolescent smoking behaviour, although admittedly, few of the tobacco education curricula have been rigorously evaluated. It is vital to assess the evidence that is available, as there continues to be uncertainty about the effectiveness of school-based educational programs. Furthermore, there is great variation in how the programs are implemented in different countries. Several categories of curricular interventions have been launched and reviewed, including: • Providing basic information, for example, on the health risks of tobacco use • Affective education, enhancing social competence and selfmanagement skills (based on the theory that susceptibility to smoking initiation is increased by weak social skills and poor self-concept) • Social influence training, the most widely used (and most studied) type; it focuses on resistance skills, such as teaching students to recognize high-risk situations; sometimes these programs involve applying social competence and self-management skills (as in the previous category) to specific antitobacco goals • Integrating curricular approaches with communitywide programs.

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Only 16 of 76 studies in a major review of school-based programs were rated as ‘category one,’ that is, meeting all quality criteria and, therefore, considered to be of highest validity. ‘Category two’ studies (37 in total) had one or more methodological deficiencies, whereas the remaining ‘category three’ papers were so flawed that their results largely had to be discounted.20 The conclusion of the review was that there is insufficient evidence to substantiate the effectiveness of basic information-giving (8 studies, none of them category 1), affective education / social competence interventions on their own or combined with social influence approaches (15 studies, only 2 rated category 1), or school programs integrated with multimodal community interventions (3 category 1 studies). A combined approach, the widely researched Life Skills Training (LST) program, used in many American states, did show good results. In one case, the program was delivered to middle-schoolers. This included offering cognitive-behavioural skills for: building selfesteem; communicating effectively and developing personal relationships; counter-advertising; and developing strategies to resist social influences to smoke. This trial stands out, even though it is rated as ‘category two,’ because of its long-term follow-up: after five years there was less weekly smoking (21% to 23% vs 27%) and less monthly smoking (26% to 27% vs 33%).21 Apart from the LST program, there was support for only one other type of intervention, namely, social influence approaches. The evidence was still only equivocal. The positive results, seen in 8 of the 15 highest quality studies, were mostly of a small magnitude.22 For example, the well-known Project TNT (Toward No Tobacco Use) from the United States employed, among other interventions, social influence techniques. Strong curricular content was combined with a refresher course in Grade 8, with the result that the increase in the prevalence rate of weekly smokers from Grade 7 to Grade 9 fell from 9% to 4%. Other impacts of the curriculum were even less significant.23 The largest and most rigorously tested social influence program, the Hutchinson Smoking Prevention Project, found no sustained effect on smoking prevalence at all across 40 Washington state school districts.24 The most widely used school-based program, Drug Abuse Resistance Education (DARE), is found in three-quarters of U.S. schools, as well as in British Columbia and the rest of Canada. The program is reportedly popular with police officers and parents.25,26 There have been many

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DARE reviews and evaluations, but few rigorous scientific evaluations. In reports from 1996 and 1999, the DARE program was shown to have no effect on smoking prevalence at five- and ten-year follow-up.27,28 Smoke-Free Schools One regulatory approach, which can be an adjunct to curricular programs, bears further mention. A large cross-sectional survey by Wakefield and colleagues revealed that school smoking bans can limit environmental tobacco smoke (ETS) exposure and lead to less intense uptake of smoking and a lower smoking prevalence rate among youth. The effects, however, were only significant if the ban was strongly enforced, that is, ‘when teenagers perceived that most or all students obeyed the rule.’29 Conclusion The rather pessimistic general assessment of curricular programs in schools has been echoed in other reviews. The recent National Cancer Prevention Policy of Australia underlined a World Bank evaluation of school-based strategies: ‘Even programs that have initially reduced the uptake of smoking appear to have only a temporary effect; they can somewhat delay initiation of smoking but not prevent it.’30 Similarly, a 2005 review concluded that, among eight programs involving followup to Grade 12, there was no evidence of long-term effectiveness.31 This does not mean that efforts to develop effective approaches in the potentially influential setting of schools should come to an end. On the contrary, innovative approaches still need to be introduced and evaluated. One recent clinical trial showed promise: when the curriculum was extended to embrace fieldwork, namely, student involvement in environmental tobacco smoke advocacy, the prevalence of regular smoking among senior students dropped from 25% to 20%.32 The best approach to school-based interventions will likely be multicomponent and include smoke-free policies. Apart from their direct effects (e.g., less second-hand smoke), such policies contribute to a culture of denormalization around smoking. Social norms in schools are as important as in any other context. For example, it is no surprise that school cultures that emphasize discipline and respect for authority show better results for smoking prevalence reduction.33 As well, sim-

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ply drawing attention to teens smoking in school, and the perception that adults care about and disapprove of teen smoking, influences the rate of adolescent tobacco use.34 Clinical Interventions and Management Neither the hospital nor the physician’s office has been a primary focus of smoking prevention. Some reviews of interventions aimed at preventing uptake of smoking among adolescents do not even include the clinical category.35 In fact, a 2003 systematic review of teen smoking prevention only found four relevant studies, two related to clinical care and two to dental care. Only one showed a significant difference in smoking prevalence at 12 months (5.1% compared with 7.8% in the control group); it was based on prevention messages mailed to patients every 3 months for a year.36 Clearly, the clinical context, including paediatric practice, is an area where activity and research could be expanded. Regulatory and Economic Interventions Controlling Sales to Minors Age restrictions on the purchase of tobacco products vary around the world, with the main difference being the person on whom the sanctions fall when the regulation is breached. The focus is either on the retailer not selling to minors or on the young person not buying or using tobacco products. There are mixed data on the results of such interventions, offering both negative37–41 and positive42,43 conclusions. The debate promises to remain lively for some time to come.44–6 A major 2004 review on interventions for preventing tobacco sales to minors identified 30 potential studies, of which 13 were of sufficient quality to be included in the evaluation. The reviewers found that simply giving information to retailers was less effective in reducing illegal sales than active enforcement and/or multicomponent educational strategies. The three papers most relevant to the issue of youth smoking rates showed little effect from limiting tobacco sales to minors. The main problem may be the inability to achieve ‘sustained levels of high compliance’ among retailers.47 For example, the recent Youth Tobacco Survey (YTS) in the United States revealed that a remarkable 71% of middle-

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schoolers who currently smoke were not asked to show proof of age when purchasing cigarettes, and 66.4% were not refused the purchase.48 All authorities agree that monitoring and enforcement, which tend to be expensive, are vital to any successful retail policy. The most recent research and discussion has centred around the impact on youth smoking when high compliance by retailers can be demonstrated.49 Programs such as Toronto’s Not to Kids! campaign, which have shown some improvement in retailer compliance rates, have yet to be evaluated in terms of their actual effect on youth smoking.50 It should be noted, though, that whatever the behaviour of retailers, motivated adolescents are very creative in maintaining a smoking habit: ‘Youth adjust their tobacco sources depending on the level of commercial availability.’51 One of the responses by the tobacco industry to legal challenges and public pressures has been to develop and disseminate programs such as ‘Operation ID’ and ‘Operation ID / School Zone.’ A review of such efforts by the Ontario Medical Association (OMA) raised numerous concerns about them and their outcomes. For instance, by emphasizing the adults-only status of tobacco use, tobacco industry programs reinforce some young peoples’ interest in taking up smoking. The conclusion is: ‘Since none of [these programs] occupy a legitimate position in best practice-based tobacco control strategy, the OMA recommends that all groups, associations and other interested parties which have formally endorsed them, be asked to withdraw their endorsement.’52 Concern has also been expressed about the tobacco industry’s rather duplicitous tactics in advertising to youth in international settings while at the same time positioning itself as being concerned about youth smoking prevention in developed countries.53 Taxation Not even the strongest proponents of retail restrictions see them as the final answer. Prohibitions of sales to minors should only be viewed as a complement to other, proven strategies. In particular, taxation policies are crucial; raising taxes on tobacco products is as or even more effective with youth as with adults (see chapter 7). Bridge and Turpin, in the recent report entitled The Cost of Smoking in British Columbia and the Economics of Tobacco Control,54 noted that the most detailed study of the relationship between price and youth smoking showed a price elasticity that varies inversely with age; this means

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that, of all age groups, price seemed to have the greatest impact on discouraging young smokers who were experimenting but not yet addicted. Also, the impact was six times higher in terms of discouraging occasional smoking compared with reducing daily smoking, which again bodes well for an intervention specifically targeted at early, tentative smokers.55 Reports by the U.S. Surgeon General and several other authorities confirm that price is more likely to affect the decision to start smoking than to affect the behaviour of current smokers.56 Circumstantial evidence in Canada strongly supports the effectiveness of price in controlling youth smoking. In the 1980s smoking prevalence among young people declined by half, a trend that sharply reversed itself when taxes on cigarettes were cut in the 1990s.57 In fact, declining prevalence for youth and adults over two decades changed direction between 1991 and 1994 when cigarette prices were cut in half (ostensibly to combat the smuggling of tobacco products into Canada through New York State).58 There are a range of data on the expected impact of taxation. A 10% price increase could reduce teenage smoking prevalence from 6% to 10%; even the lower estimate exceeds the effect in the general population.59 The International Union of Health Promotion and Education60 has concurred with the central role of taxation policy: ‘Imposing sufficiently high taxes on tobacco products is the most successful and important tobacco control intervention for preventing youth access to and consumption of tobacco products.’61 Advertising Control Although banning the public promotion and marketing of tobacco products, and especially ending advertising directed at teenagers, may seem to be mostly a finished war in Canada, several battlefronts, in fact, remain. There is strong circumstantial evidence for the effectiveness of tobacco industry marketing – and therefore for the importance of maintaining and expanding bans on such business practices. One example is that, in 2000, almost U.S.$9 billion was spent by the American tobacco industry on advertising and other types of promotion. The logical presumption is that the various companies must have a strong bottom-line rationale to justify such expenses.62 Unlike other areas of tobacco control, experimental studies with respect to advertising cannot pass ethical guidelines. The relevant reviews, therefore, depend on observational studies. In all nine papers

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examined by one standard reviewing group, originally non-smoking adolescents exposed to and influenced by tobacco advertising were more likely to have experimented with cigarettes or become smokers at follow-up.63 For example, Biener and Siegel found that 46% of nonsmoking adolescents who owned a tobacco promotion item, and could identify a favourite brand advertisement, were established smokers four years later.64 Again, the inference is that curtailing marketing, especially to impressionable teens, may be an effective means of tobacco control. Smoking in Movies Another area receiving increasing attention as part of a tobacco control policy is the portrayal of smoking in films. Movie stars have received payment for endorsing or using cigarettes on screen; this is a marketing strategy known as ‘product placement.’ Author Georgina Lovell quoted a letter from Sylvester Stallone to Brown and Williamson in which Stallone agreed to a sum of U.S.$500,000 for using their cigarette products in at least five feature films.65 Apparently this sort of overt activity is now prohibited in the United States, but other, more subliminal tobacco industry strategies66 may account for the increased rate of ‘smoking incidents’ in movies over the past 20 years.67 Indeed, there is particular evidence of significant increases in the top movies since 2001.68 The 2004 Youth Tobacco Survey in the United States discovered that fully 86.5% of high school students were exposed to actors smoking on television or in movies.69 Results of a number of cross-sectional studies suggest that adolescents are more likely to try smoking if their favourite movie stars smoke on screen.70–3 A key longitudinal cohort study by Dalton et al. found a strong relationship between exposure to smoking in movies and the initiation of smoking by adolescents.74 After controlling for baseline characteristics, they found that the 25% of adolescents exposed to the highest number of smoking occurrences in movies were 2.7 times more likely to start smoking than the 25% of adolescents exposed to the lowest number of smoking occurrences in films. There are indications that parental limitations on viewing restricted movies can reduce adolescent smoking uptake.75 Based on such evidence, Dr Glantz of the Center for Tobacco Control Research in San Francisco proposed to the Ontario Film Review Board in October 2004 that movies portraying smoking should be given an 18A rating. This

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means that any young person seeing the subliminal pro-smoking advertisement would at least have an adult accompanying him or her to help ‘debrief’ the message. Glantz suggested that ‘smoking scenes in movies are the number one recruiter of new, young smokers in the United States – 390,000 American teens every year.’76 In the same vein, the American Lung Association recently began to rate movies, using coloured lung icons: black for movies depicting heavy smoking and pink for when none of the characters smoke. The association also gives out the ‘Thumbs Down’ Hackademy Award each year to the film most egregiously flouting antismoking norms.77 According to one study, another potentially useful intervention is placing antismoking advertisements before movie showings.78 Comprehensive Strategies It is becoming evident that the divisions between all of the preceding intervention categories may be artificial. The trend in tobacco control is towards comprehensive, more fully integrated approaches, although this does make it difficult to scientifically isolate the effect of any individual component. One 2005 study did isolate the contribution of a U.S. media campaign based on so-called truth advertisements; the nationwide initiative, launched in 2000, was credited with creating 22% of the overall decline in youth smoking rates from 25.3% to 18% between 1999 and 2002.79 Florida has been lauded for investing a large proportion of its court settlement from the tobacco industry in a very effective youth antismoking campaign. The state combined counter-marketing, communitybased activities, education, and enforcement in a program that was able to reduce tobacco use among middle-school students from 18.5% to 15.0%, and among high school students from 27.4% to 25%, between 1998 and 1999. A key focus of the campaign was denormalizing tobacco and the tobacco industry, thus reducing the ‘glamour’ of smoking in the eyes of youth.80 The early positive results continued, so that by 2002, smoking had declined by 50% among middle-school students, and 35% among high school students, when compared with 1998 levels.81 The funding for Florida’s Youth Tobacco Control Program has been consistently eroded since the initial large start-up grant.82 There is circumstantial evidence that the funding reversals in Florida and other U.S. states have basically stopped the previous decline in youth smoking rates; although rates have not yet begun to climb, many authorities

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are concerned that it is only a matter of time.83 Putting it in context, a 2005 study calculated that if all states had spent the minimum annual amount of money on youth smoking prevention recommended by the Centers for Disease Control and Prevention during the 1990s, then U.S. youth smoking rates would have been as low as 13.5% in 2000.84 Social Denormalization Two conclusions are clear: youth should be considered a vulnerable or at-risk population,85 and preventing the uptake of smoking among the young is vital. Prevention efforts have focused on discouraging experimentation with cigarettes and/or deterring regular use. The importance of these goals cannot be overestimated, as communities continue to move towards the denormalization of smoking. If a ‘tipping point’86 for youth and adult tobacco control has not already been achieved, then it may at least be in sight. The first challenge is to maintain economic and other policy pressures that will solidify the movement towards making not smoking the expected social reality in developed countries; the next challenge is to see that movement extended to other parts of the world and to other aspects of health promotion. Influencing new generations will undoubtedly be both a promoter and consequence of any ‘normalization’ of healthy living. A major U.S. report concluded:87 Cigarette control policies that discourage smoking by teenagers may be the most effective way of achieving long-run reductions in smoking in all segments of the population. A tax hike would continue to discourage smoking for successive generations of young people and would gradually affect the smoking levels of older age groups ... [and] aggregate smoking and its associated detrimental health effects would decline substantially.

An encouraging aspect of tobacco control among adolescents is the synergies that can be derived by associated adult cessation programs (see chapter 7).88 It is well known that parental (and sibling) smoking is a risk factor for adolescent initiation.89 Research has shown that when parents quit smoking, the odds of their children taking up smoking are significantly reduced.90 Likewise, teenagers are able to understand and act on cessation advertising that is directed to adults. Evidence from the Australian National Tobacco Campaign shows that adolescents

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respond similarly to adults, leading to the following somewhat surprising conclusion: an adult cessation focus may even be more effective that one directly targeting teens.91 A related phenomenon is the positive multiplier effect of peers on teenage smoking. If fewer teens are smoking, fewer other teens want to emulate them. Grossman and Chaloupka noted this effect in reference to tax policy: ‘A rise in price curtails youth consumption directly and then again indirectly through its impact on peer consumption.’92 A smoke-free home is effective in preventing smoking uptake, more so than other place-based restrictions, such as bans in schools or public places. One cross-sectional survey concluded: ‘Banning smoking in the home, even when parents smoke, gives an unequivocal message to teenagers about the unacceptability of smoking.’93 While of theoretical interest, such an approach is unlikely to be embraced by society as a whole. All of the above agencies and forces spur on the efforts to achieve a tipping point in tobacco control, especially with respect to adolescents taking up smoking. Sustained momentum towards smoking being considered an ‘uncool’ option needs to be both the means and the end of a potent youth smoking policy.

Key Points • The young are a vulnerable and crucial group in terms of tobacco control. Research shows that if the smoking habit does not begin in adolescence, it is unlikely to ever be taken up. • Promising media campaigns and school programs have often shown mixed results when evaluated as single interventions. This is also true for controlling sales of tobacco products, unless the policies are strictly enforced. • Work continues in the area of advertising control and denormalizing and deglamourizing tobacco use, including monitoring the impact on youth of repeated exposure to smoking in movies. • The best single intervention for preventing youth smoking uptake seems to be sustained increases in tobacco product prices. • Even better results have been seen in well-funded comprehensive campaigns that combine taxation, media advocacy, and the most effective school programs and policies.

7 Tobacco Control Evidence (2): Smoking Cessation

Smoking cessation has been called the ‘gold standard’ of prevention strategies in health care because it produces additional years of life at costs well below those estimated for many other accepted medical treatments.1 One comprehensive review of preventive services positioned tobacco cessation counselling for adults at virtually the highest priority based on effectiveness and cost-effectiveness; it was rated second in the list of interventions, only superseded in importance by childhood vaccinations.2 Approaches to increase tobacco cessation rates include strategies to:3 • Increase the number of users who attempt to quit • Improve the success rate of individual cessation attempts • Achieve both of these goals. As in the previous chapter, here we provide an inventory of interventions in this area of tobacco control. Each intervention concerned with smoking cessation is described, and evidence of its effectiveness detailed. (Note that a summary of all tobacco control interventions is presented at the end of chapter 8.) The U.S. Task Force on Community Preventative Services (TFCPS) has produced an influential grid4 for tobacco control policies that are community-based approaches rather than therapies for individual patients. These approaches range from government legislation and/or taxation, to advertising controls or campaigns, to programs directly related to the health care system. The TFCPS identified several potential interventions related to smoking cessation, providing a good sum-

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mary of the range of available approaches:5 Communitywide approaches can include increasing the unit price for tobacco products (i.e., taxation); mass media education, including counter-advertising; and telephone support for cessation. Health-care system approaches can include: providing reminder mechanisms of smoking status, for example, highlighted notes in medical records; providing education mechanisms, for example, encouragements to physicians to work with patients on cessation plans, combined with offering guidelines and tools; reminders and education implemented together, sometimes combined with patient education materials; providing feedback protocols and allowing surveillance of the quantity and quality of cessation interventions; reducing patient out-of-pocket costs for effective cessation therapies; and telephone support for cessation. Finally, multicomponent approaches that combine two or more of the above strategies. Reorganized into the framework being used in this book (as introduced in chapter 6), each of these population-based interventions is briefly assessed here; the TFCPS conclusions and recommendation are noted in each case, augmented by other reviews.6 Finally, using other sources, the various clinical services offered to individuals are itemized and evaluated. Community-Based Interventions Mass Media Advocacy and Counter-advertising The best known and most visible aspect of tobacco control programs are advertisements on television or in other media. This type of intervention is directed either at changing individual smoking behaviour or influencing social norms about smoking.7 Producing high-quality messages for broadcast, as well as creating other forms of media advocacy, are a relatively expensive business. So, it is natural to question how much such approaches have achieved. One review (still in the protocol stage) summarized the limited support for media campaigns as a component of a comprehensive program.8 Much of the literature deals with messages directed towards youth, a topic that was covered in the previous chapter. Studies of counter-advertising specifically geared towards adults have offered mixed results. How can advertising be most effective? Three aspects of media campaigns emerge as predictors of greater success.

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1 National and state-wide campaigns have had more impact than local ones. For example, in the very successful California tobacco control program of the 1990s, it was calculated that the media component accounted for 17.4% of the decline in cigarette consumption.9 2 Sustained, pull no punches campaigns using multiple media formats demonstrate the best results; the TFCPS review concluded that highintensity counter-advertising is a strongly recommended intervention.10 3 The messages need to be carefully shaped for greatest impact. Jurisdictions should learn from the studies that have determined the best type of antismoking advertisements. The most effective media approaches reportedly are those that attack tobacco companies for deceitfulness and manipulation, reveal the harmful effects of ETS, and underline the addictive nature of nicotine.11 Advertising that rehearsed the well-known health effects of smoking, however, was less useful. Smokers, especially youthful smokers, seem to be able to discount disease threats that operate over a long latency period; even demonstrating concerns about addiction seems more ‘concrete and immediate, not merely a promise of increased statistical probabilities 30 or more years into the future.’12 Self-Help Materials Self-help or patient education materials are often a big part of media campaigns. They usually come in print form, but are also produced in audio, video, or Internet formats. Because information can be distributed quite widely at little cost, this form of intervention has attracted researchers’ attention. One review looked at no fewer than 51 trials.13 The data were inconsistent, but did suggest that standardized self-help material might stimulate modest increases in quit rates. The evidence is less supportive of adding self-help material to counselling or NRT (see below); in short, there was no indication that results were improved. Some authorities are more positive. For example, the TFCPS review recommended self-help materials as part of a multicomponent strategy.14 Many authorities agree that, where self-help resources are employed, information tailored for a particular smoker is more effective than are generic messages.15

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Web-Based Cessation Resources A new type of self-help platform is being provided through interactive websites. One example is the QuitNet service operated in conjunction with Boston University’s School of Public Health since 1996.16 In addition to standard tobacco control and health information, the site has several features aimed at encouraging an individual web-user to set a quit date and decide on a medication plan, get questions answered, and gain moral support through formal partners and online chat. At the point of registering, a modest amount of ‘tailored’ motivation occurs. This involves calculating (based on personal smoking intensity) the amount of personal spending avoided were the quit to be successful. As of May 2004, QuitNet boasted 335,000 registered users worldwide. Formal evaluations of web-based resources encounter numerous methodological challenges, including contamination of control groups due to unrestricted access to websites. Initial results from evaluations appear to show an increase in smoking cessation at 1 month after access to the site, but all studies were uncontrolled and exhibited a very low response rate.17–20 A key advantage of web-based resources is that they can reach large segments of the population at minimal overall cost. Given that a large proportion of smokers quit on their own,21 web-based resources may yet prove to be a helpful adjunct to their efforts. Telephone Help Lines Using the telephone is a standard tool in public health, especially in the hands of community health nurses. Nurse-managed help lines are very popular. Perhaps this is why use of the telephone has been thoroughly studied as a potential aid in smoking cessation. One review from 2003 found more than 50 experimental trials to consider, with 27 studies eventually meeting the strict inclusion criteria.22 Telephone contact involving smokers trying to quit comes in two formats: • Proactive, i.e., cold calls to all residents in a community or planned counselling follow-up to specific clients. • Reactive, i.e., responding to people calling in to cessation help lines (sometimes called ‘quit lines’).

100 Part Two: From Setting to Achieving Targets Table 7.1 Effectiveness of Smoking Cessation Interventions

Format of intervention

Estimated odds ratio (95% C.I.)

Estimated abstinence rate (95% C.I.)

No help Self-help Proactive telephone counselling Group counselling Individual counselling

1.0 1.2 (1.02, 1.30) 1.2 (1.1, 1.4) 1.3 (1.1, 1.6) 1.7 (1.4, 2.0)

10.8% 12.3% (10.9, 13.6) 13.1% (11.4, 14.8) 13.9% (11.6, 16.1) 16.8% (14.7, 19.1)

Source: Treating Tobacco Use and Dependence.

While the evidence for the reactive approach is limited, the literature supports both types of telephone intervention when compared against intervention methods that do not involve personal contact.23 The personal contact part of the equation appears to be important. The greatest effectiveness with the telephone usually comes through multiple encounters with the client. Of course, the frequency of contact is harder to control in reactive approaches, where the helper has to wait for the quitter to phone. We must remember that the real point is how many people actually quit smoking. The major U.S. report Treating Tobacco Use and Dependence found that proactive telephone contact did have a modest effect on abstinence rates, as indicated in table 7.1.24 Note that this review also supports the conclusion that we reported earlier, namely, that the use of self-help materials marginally increases abstinence rates. However, proactive telephone support used on its own did even a little better in terms of promoting abstinence. Multicomponent Approaches What about combining cessation strategies within one community program? Although putting interventions together can have an additive or even synergistic impact, this is not always the case. For example, trials where proactive telephone support was added to counselling or NRT (see below) failed to detect any additional effect on cessation rates.25 In contrast, a multicomponent approach, using patient education materials and proactive telephone support, has been strongly recommended by American reviewers.26 They also noted that mass media efforts often augmented the effectiveness of many different types of programs.

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Other assessments of multicomponent community programs have been less glowing. The pooled results from one review of such approaches were modestly positive.27 The estimated net decline in smoking prevalence ranged only as high as 3% per year in studies involving both men and women. One problem that the reviewers encountered was the weak methodology employed by some studies. Other Community-Based Interventions Many different types of community programs aimed at smoking cessation have been tried. Each of these approaches has had its supporters, and one never knows if a new variation might end up working very well. According to American reviewers who looked at actual cessation rates, insufficient evidence currently exists to support the following formats:28 • Televised ‘how to quit’ programs • Communitywide quit competitions • Providing information about reducing ETS exposure in the home. There is Canadian evidence that encourages caution around incentives such as quit competitions. This approach, which was tried and tested in the Province of Ontario, demonstrated successful cessation for only 0.17% of participants.29 There is still the possibility for new community-based incentive programs to fare better than those in the workplace setting (see below), but the research on this is incomplete.30 Investigation of other models continues. For example, in 2005 a Danish project that had recruited a large number of smokers from the general population was reported; the high-intensity intervention involved membership in a smoking cessation group, where a 16.3% abstinence rate was achieved, compared with a background rate of 7.3%.31 Workplace-Based Interventions The workplace can be compared with schools in that it is a setting where a large, fixed population consistently spends a great deal of time, making it a potentially useful venue in which to encourage smoking cessation among adults. Although the nature of work is rapidly changing in today’s society,

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the traditional advantages that the workplace offers for public health still pertain. These include:32 • The possibility of sustained peer group support • Occupational health staff available, in some cases, to provide help • Employees not having to dedicate personal time or money, which thus might increase participation rates. There is considerable variation from country to country in the extent and prevalence of workplace tobacco control programs. The involvement of companies in Europe has been relatively low in contrast with the United States, where according to a 1992 survey, a remarkable 87% of firms had instituted some form of smoking ban;33 the proportion is likely even higher now. Key reviews examine both workplace interventions aimed at the workforce as a population and those directed towards individual employees. Comprehensive programs that combine the two approaches have also been considered, but the available evidence on them is very limited.34 Environmental and Social Support So-called environmental support can include large and small posters and other forms of mass group communication. When such measures are part of comprehensive programs, it is difficult to isolate their impact from that of confounding interventions (especially social support mechanisms). Despite these obstacles, limited evidence may be gleaned from the literature supporting the effectiveness of poster campaigns.35,36 Social support involves a buddy system or peer group, often combined with other interventions. Limited research (only two studies) did not show a significant differential effect of social support when compared against a control group.37 Competitions and Incentives As any parent, manager, or politician knows, there is a world of difference between carrots and sticks in trying to modify behaviour. And whether incentives or disincentives are chosen, people tend to be unpredictable. A variety of incentives have been used in workplaces,

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such as salary bonuses, promotional items, luxury goods, and holidays, as well as a variety of systems.38 A basic typology of approaches includes: • Rewards for attendance at a program, or sometimes for actual success • Competitions between staff, with either individual or team winners. There is limited evidence (based on six studies) that participation rates in programs can be increased through competitions and incentives instigated by employers.39 Upcoming reviews will continue to examine this type of workplace intervention and, on a related front, programs to provide incentives to health care professionals for the delivery of smoking cessation interventions.40 Individual Cessation Campaigns Not surprisingly, the individual initiatives found to be effective in other settings, including advice from a health professional, individual and group counselling, and pharmacological treatment, yielded similar results when based in the workplace (see under Clinical Interventions and Management, below). According to Cancer Council Australia’s National Cancer Prevention Policy, the main problem with individual interventions in the workplace is that they require a formal commitment. It seems that relatively few smokers are prepared to invest the necessary time or effort, even though the employer is footing most of the bill.41 There is strong evidence that individual strategies in the workplace increase cessation rates among participants, but the absolute number of smokers who quit in employee health programs remains relatively low.42 Smoking Bans Obviously, one of the ways to reduce environmental tobacco smoke is to reduce the rate of smoking. The equation also works in the other direction. Efforts to limit smoking in the workplace or other public places sometimes motivate people to quit smoking or at least to reduce consumption.43–47 The most consistent evidence shows that workplace tobacco bans can decrease consumption during shifts (and thus reduce exposure to ETS). However, there are conflicting results concerning

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decreased smoking prevalence. In one review, 5 of 13 studies reported no change in prevalence, and 4 reported only small decreases.48 Although some of the evidence is inconsistent, in the end there is a strong argument to integrate the topics of smoking cessation and ETS control (see chapter 8). In addition to general smoking restriction by-laws in society, the current targets for specific smoking bans are the workplace, home, and school. Recently, automobiles carrying children have been added to the list. Among the various initiatives of this sort, workplace bans remain the most studied type of public tobacco restriction. A smoking ban, the most prevalent workplace-based tobacco control intervention, can take a number of forms, ranging from complete prohibition of smoking on the premises to restrictions of smoking to designated areas (with or without ventilation). A number of benefits of a smoke-free workplace have been identified in the literature, and these include:49–51 • Reduced absenteeism and increased productivity • Reduced health care and insurance costs • Reduced cleaning costs and lower risk of fires. Recent data provide additional motivation to continue exploring, expanding, and evaluating tobacco bans and smoke-free environments. The Canadian Community Health Survey for 2002–3 confirmed the reduction in consumption expected with smoking bans in workplaces. As a comparison, the survey also noted that more people in smoke-free homes quit during the preceding eight years compared with homes where other smokers lived (17% vs 12%).52 Another encouraging result emerged from a U.S. national survey that estimated that requiring all workplaces in the United States to be smoke-free would reduce smoking prevalence by 10%.53 One of the key issues in this area of tobacco control is the possible negative economic consequences associated with smoking bans, especially in the hospitality industry. Scollo and colleagues reviewed almost 100 studies that looked at the economic consequences associated with tobacco bans in restaurants and bars.54 They found that all studies (N = 35) concluding that there were negative economic consequences were supported by the tobacco industry and had serious methodological flaws. None of the better designed studies (N = 21), completed by independent researchers, found a negative impact on revenue or jobs. Obviously, such bans should be regional, otherwise

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the crossing of municipal lines to smoke in a bar, say, could indeed harm businesses in the banning municipality. School-Based Interventions Despite the importance of reducing adolescent tobacco use, relatively little research has been conducted on teen smoking cessation in schools or other settings.55 The available studies have examined two main approaches: self-initiated cessation and targeted programs. Health Canada conducted a literature review of self-initiated cessation. Having fewer friends who smoke and being a lighter smoker were predictors of quitting success; contrary to other reports, family influences were found to play less of a role.56 The adolescent smoking cessation programs identified in the literature usually involved 3 to 6 educational sessions in a high school setting; short-term cessation success was achieved, but few data were available regarding long-term follow-up. Perhaps understandably, more effort has traditionally been put into the prevention of smoking initiation among youth (see chapter 6). However, the combination of a persistent teen smoking cohort and a significant incidence rate for smoking uptake has changed the perspective of researchers and policymakers. By the late 1990s American authorities, in particular, began to develop more programs to help youth stop smoking.57 By 1999 Sussman and colleagues were able to find 17 studies in the literature that focused on youth smoking cessation, although few of them were randomized, controlled trials; on average, 21% of teen smokers quit, although this number dropped to 13% at 6 months’ follow-up – which is close to naturally occurring quit rates.58 Only 2 years later, the same lead author identified 66 adolescent cessation studies, half of them RCTs. This complement of studies incorporated a wide variety of interventions, including ones that normally would be classified as policy initiatives. The average quit rate observed over 8 months was 12%, compared with 7% in control groups.59 The cessation results observed in this growing field of research are certainly strong enough to warrant the development of further schoolbased programs. Clinical Interventions and Management Treating Tobacco Use and Dependence is a clinical practice guideline sponsored by the U.S. Public Health Service, published in 2000 (updating its

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1996 publication). This guideline identified the following recommended counselling modalities:60 brief physician advice, various kinds of counselling, and arranging supportive care. Each of these categories is elaborated below, followed by a summary of the extensive literature on drug therapy. Important secondary topics are also covered along the way. Brief Advice and Counselling Brief tobacco dependence treatment is now the basic strategy recommended for all smokers seen in primary care. This kind of intervention is sometimes referred to as physician advice, although the provider of such advice does not have to be a physician. The input to patients can comprise as little as 3 minutes of contact, a level that should be achievable in every clinical setting. Given such a limited time commitment, it is remarkable how effective the intervention can be. A 2004 review of 34 trials suggested that simple advice has at least a small positive effect on cessation rates. Compared with offering no input at all, brief advice produced an absolute increase in cessation rates of about 2.5%.61 Not surprisingly, more in-depth counselling is even more effective. Intensified person-to-person contact – individual, group, or proactive telephone counselling – can include offering tools such as problemsolving skills, various supportive techniques, and follow-up to prevent relapse. A review of 15 trials that specifically focused on cessation specialists rather than regular clinicians found that counselling was 62% (odds ratio,62 1.62) more likely to achieve successful smoking cessation compared with brief, minimal interventions.63 Based on a wealth of research in the area of clinical smoking cessation, Treating Tobacco Use and Dependence examined various types of person-to-person contact. The review clearly connected increased intensity of cessation counselling with higher abstinence rates, as indicated in table 7.2. This same report offered a meta-analysis of 45 studies looking at the duration of counselling over time, noting a strong relationship between the number of treatment sessions and abstinence rates, as indicated in table 7.3. Finally, counselling administered by both physician and non-physician clinicians (e.g., nurses, health educators, and psychologists) was found to effectively increase abstinence rates, as indicated in table 7.4. Group Therapy Groups offer members the opportunity to learn skills and techniques to change behaviour and stop smoking in the context of peer-to-peer

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Table 7.2 Effectiveness of Smoking Cessation by Level of Contact

Level of contact

Estimated odds ratio (95% C.I.)

Estimated abstinence rate (95% C.I.)

No contact Minimal counselling (< 3 minutes) Low intensity counselling (3–10 minutes) Higher intensity counselling (> 10 mins.)

1.0 1.3 (1.01, 1.60) 1.6 (1.2, 2.0) 2.3 (2.0, 2.7)

10.9% 13.4% (10.9, 16.1) 16.0% (12.8, 19.2) 22.1% (19.4, 24.7)

Source: Treating Tobacco Use and Dependence.

Table 7.3 Effectiveness of Smoking Cessation by Number of Sessions

Number of sessions

Estimated odds ratio (95% C.I.)

Estimated abstinence rate (95% C.I.)

0–1 session 2–3 sessions 4–8 sessions > 8 sessions

1.0 1.4 (1.1, 1.7) 1.9 (1.6, 2.2) 2.3 (2.1, 3.0)

12.40% 16.3% (13.7, 19.0) 20.9% (18.1, 23.6) 22.1% (21.0, 28.4)

Source: Treating Tobacco Use and Dependence.

psychosocial support. There are more than 100 different group therapy programs described in the literature.64 The groups can be led by professional facilitators, clinical psychologists, health educators, nurses, or physicians. The rationale for including group therapy in the arsenal of cessation strategies is that it lies between intensive counselling and self-help approaches: it is generally less expensive than the former and more effective than the latter. Of the wide range of counselling components used in group therapy, evidence suggests that focusing on cognitive and behavioural skills training and avoiding relapse are especially useful; a 2004 review rated multicomponent behavioural interventions as the type of group therapy with the best evidence of effectiveness.65 A 2002 review of 52 trials offered the following conclusions concerning group therapy:66 • Group programs double the cessation rate compared with self-help materials and no intervention. • There is limited evidence that adding group therapy to other inter-

108 Part Two: From Setting to Achieving Targets Table 7.4 Effectiveness of Smoking Cessation by Type of Clinician

Type of clinician

Estimated odds ratio (95% C.I.)

Estimated abstinence rate (95% C.I.)

No clinician Self-help Non-physician clinician Physician clinician

1.0 1.1 (0.9, 1.3) 1.7 (1.3, 2.1) 2.2 (1.5, 3.2)

10.2% 10.9% (9.1, 12.7) 15.8% (12.8, 18.8) 19.9% (13.7, 26.2)

Source: Treating Tobacco Use and Dependence.

ventions (e.g., physician advice, nicotine replacement therapy) increases their effectiveness. • There is no evidence that group therapy is more effective than individual counselling at similar levels of intensity. Supportive Care Suggesting and/or arranging support outside of treatment is commonly promoted as part of primary care treatment. These supportive approaches include creating a smoke-free home, using help lines and peer groups, working to enhance partner support, and assigning ‘buddies.’ The positive effect of a smoke-free home on youth smoking initiation and adult cessation has been highlighted already, and the limited evidence about help lines was noted earlier in this chapter. Some of the other means are outlined here. Peer support in groups or on a one-on-one basis are standard for many programs. A 2000 review of ‘buddy systems’ suggested that they provide some benefit in clinical settings, although the research methodology in many cases was poor. By comparison, there is a lack of evidence concerning the efficacy of using buddies in community programs.67 Better results might be expected for enhancing partner support, the distinction being that partners probably have more influence with the smoker. However, a comprehensive review of programs based on using partners revealed no increase in cessation rates among the smokers being supported; this may be attributed to the fact that the practical level of partner support did not increase in most cases.68 One recent Alberta study, not included in the latter review, did show improve-

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ments in cessation rates, but these effects persisted in men and not women at one-year follow-up.69 More study is needed of the effectiveness of using partners to improve cessation rates. So far the most promise has been shown in the context of live-in, married, or equivalent-to-married partners.70 Health Events One of the key issues associated with smoking cessation is the timing of the intervention. Former smokers frequently acknowledge that health concerns were a primary motivator in their cessation attempts. A systematic review of interventions for smoking cessation in hospitalized patients concluded that ‘high intensity behavioural interventions that include at least one-month follow-up contact are effective in promoting smoking cessation in hospitalised patients.’71 More recent studies71–4 continue to support the notion that hospitalization offers a window of opportunity for tobacco control. Smoking cessation advice provided to those being screened for cancer,75 to cancer survivors,76 or to individuals with impaired lung function77 significantly increased quit rates. Although some findings are ambiguous,78 the preponderance of evidence has led to calls for health care providers to utilize every ‘teachable moment’ to promote smoking cessation.79 Postsurgical Complications Cigarette smoking has also been associated with increased rates of postsurgical wound infections and pulmonary and cardiovascular complications. Although this conclusion used to be based on observational studies alone,80 in 2002, Moller and co-authors published the results of a randomized controlled trial investigating the effect of preoperative smoking cessation on the frequency of post-operative complications after hip and knee replacement surgery.81 Patients assigned to the experimental arm met weekly with a nurse who designed individualized smoking cessation programs, including the use of nicotine replacement therapy. In this group, a remarkable 36 of 52 patients were able to quit smoking, and the remainder reduced their consumption by at least 50%. In contrast, only 4 of the control group patients stopped smoking. As a result, patients in the experimental group had a significantly reduced postsurgical complication rate (18% vs. 52%). Similar results have recently been observed by a Vancouver-based

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group of researchers.82 However, their study noted that, while cessation rates were higher for the experimental group at 6 months, the differences no longer existed at 12 months after surgery. Given the overall evidence, some health care providers have questioned whether smokers should be given a lower priority on surgical waiting lists if they do not agree to ‘fast’ from smoking for at least six weeks prior to surgery.83,84 Summary of Non-pharmacological Interventions Comparing and assessing the evidence of effectiveness for one-on-one counselling, group therapy, and self-help materials are complex tasks. Recognizing that the data for firm delineations in each case are not at present available, an approximate ranking of the interventions (in order of declining effectiveness) is suggested below: • • • • • • •

Intense face-to-face counselling or group therapy Brief physician advice Proactive telephone support (i.e., planned follow-up) Personalized self-help material Reactive telephone support (help lines or quit lines) Websites and other computer applications allowing some tailoring Standardized self-help material.

Although standardized self-help material sits lowest on the list, one motivation to still provide such aids is that most successful quitters achieve success on their own.85 More intensive clinical counselling interventions can produce higher quit rates among the intervention sample, but such programs in Canada, for example, currently reach only 5% of the smoking population.86 Public health approaches, while less effective, can reach a much wider group: ‘Methods to support otherwise unaided quit attempts therefore have the potential to help a far greater proportion of the smoking population.’87 As such, standardized self-help materials represent ‘an important bridge between the clinical and public health approaches to smoking cessation.’88 Nicotine Replacement Therapy Nicotine replacement therapy works by exchanging the high concentrations of nicotine from cigarette smoking for lower doses delivered

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more slowly. This intervention helps reduce the cravings and withdrawal symptoms that often accompany quitting. NRT also avoids delivering the tar, chemicals, and other harmful elements of tobacco smoke. Introduced in gum form in 1984, NRT is at present the dominant strategy to help individuals quit smoking.89 Non-nicotine pharmaceuticals are also employed as aids to cessation, but not to the same degree as NRT (see below). The U.S. Treating Tobacco Use and Dependence guideline, already cited several times in this chapter, reported on pharmacotherapy and smoking cessation and noted that several NRTs reliably increase long-term smoking abstinence rates. Each of the currently available delivery systems can be considered appropriate as a first-line treatment; these include:90 gum, inhalers, sprays, and transdermal patches. Whereas all of these approaches are recommended for standard clinical practice, supplying consumers the product independent of a prescription has been more controversial. Most data have shown that over-the-counter NRT is efficacious, producing modest quit rates similar to those seen with physician-guided prescriptions.91 While the usefulness of NRT on its own has been questioned in a recent widely discussed article,92 a substantial review of more than 100 studies disagreed, concluding: All of the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler and sublingual tablets / lozenges) are effective as part of a strategy to promote smoking cessation. They increase the odds of quitting approximately 1.5 to 2 fold regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the smoker. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT.93

Other Pharmacological Therapies Nicotine can have an antidepressant effect on some smokers,94,95 which may be one reason why they find it difficult to quit, and why using antidepressants such as bupropion and nortriptyline can be helpful during cessation attempts. Such drugs not only act as a substitute for the nicotine effect, but also as a pre-emptive strike against the depression that sometimes accompanies smoking cessation. The current practice guidelines in the United States recommend the following approaches for cli-

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nicians working with smokers:96 first-line treatment with bupropion; and second-line treatment with nortriptyline or clonidine. A recent review of antidepressants for smoking cessation examined the use of the atypical antidepressants bupropion (20 trials) and nortriptyline (5 trials)97 and concluded that both agents increased the odds of cessation. In one of the trials bupropion plus a nicotine patch was more effective than either therapy used on its own, but the result was not replicated in a second study. Various classic antidepressants (e.g., selective serotonin reuptake inhibitors) did not show any effect on cessation rates, nor did anxiolytics (which are also designed to impact serotonin and other brain chemicals).98 Other drugs have been tested as aids to smoking cessation. Some have proven ineffective, including the nicotine antagonist lobeline.99 This result compares with the modest benefits of the nicotine antagonist mecamylamine, which is used in combination with NRT.100 The rationale for using nicotine antagonists is that they block the rewarding effect of nicotine and thus may reduce the urge to smoke. Opioid (narcotic) antagonists are also of interest as potential attenuators of the rewards of cigarette smoking. A limited investigation of the opioid antagonist naltrexone, however, did not demonstrate a definite positive effect.101 A final drug, considered a second-line treatment, is clonidine, which was originally prescribed to lower blood pressure. Clonidine affects the central nervous system and may reduce withdrawal symptoms. In a small number of trials, clonidine did prove effective in increasing smoking cessation, producing an absolute increase in the quit rate of about 9%.102 Provider Reminder and Education The assumption is well established that physicians, and especially those in a primary care setting, can be powerful allies for patients in any comprehensive cessation strategy.103 Unfortunately, the situation on the ground can best be characterized as an unrealized potential. While 70% of smokers visit their doctor at least once every year,104 ‘only half of current smokers report having ever been asked about their smoking status or advised to quit by their physician.’105 It seems likely, then, that systems that prompt physicians to be more proactive with smokers would be useful. This can include passive

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reminders built into patient charts, as well as various forms of continuing education. In fact, the U.S. Task Force on Community Preventive Services (TFCPS) strongly recommended (on the basis of 31 studies) a multicomponent program that includes both provider reminders and education.106 Such an approach increased delivery of advice to quit and augmented actual patient cessation rates.107 The adoption and distribution of self-help cessation materials improved the results even further. Provider reminder systems used in isolation from other interventions were more weakly recommended by the TFCPS. Insufficient evidence exists for the effectiveness of simple reminders to providers that they ‘should counsel to quit’ or for systems of provider feedback that detail what kind of advice they offer to patients. Consistent and comprehensive documentation of tobacco users and any clinical intervention offered may be prudent for other reasons, but there is no sign that it has a direct effect on cessation rates.108 Regulatory and Economic Interventions Increased Unit Price for Tobacco Products Since nicotine is addictive, the purchase of tobacco products has been considered to be more price inelastic compared with other, non-addictive products. In other words, consumers are resistant to stopping their purchase even if the price does increase. Despite this argument, Townsend and colleagues calculated that, for every 10% increase in cigarette price, there would be a 5% to 6% decline in consumption; the decline would result from a combination of absolute quitting and reduced consumption per continuing smoker.109 The estimates for other high-income jurisdictions have been similar, although the World Bank pegged the expected average decline in demand at a more conservative 4%.110 Nonetheless, given that a tax increase incurs minimal administrative costs, and usually offers a net increase of revenue to governments even with reduced unit sales, it is not surprising that the ‘cost-effectiveness of tax increases compares favourably with many health interventions.’111 A comprehensive American review supported this position, based on 8 studies, and concluded that raising the unit price of tobacco products through taxation is an intervention to be strongly recommended.112

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Reimbursement and Incentives Based on the experience with negative financial levers such as taxation, it may seem self-evident that incentives based on money will also be influential in tobacco control. Positive financial levers include reducing or eliminating out-of-pocket costs to smokers for cessation services and products and ensuring that health care providers are compensated for the time they spend on prevention counselling and prescriptions. A 2000 report from the U.S. Surgeon General agreed with the basic tenor of these approaches, concluding that reimbursement policies, financial incentives, and institutional support are all critical for effective clinical interventions in tobacco addiction.113 Surprisingly, the evidence base for the impact of such measures is, at best, modest. For example, reducing patient out-of-pocket costs for smoking cessation products has only received weak recommendations. Likewise, ensuring that insurance plans cover counselling and pharmacological treatments, and reimbursing clinicians for time spent in counselling patients, find only moderate support in the literature or in consensus statements by authorities.114 However, given the face validity of these approaches, it would appear that additional research on their effectiveness is warranted. Comprehensive Strategies The dividing line between a community-based intervention (see the earlier section) and a comprehensive program can be a fine one. The former is defined as a coordinated, multidimensional program involving different segments of the community in a specific geopolitical area.115 Comprehensive strategies are similar, but they are located at the top end of the geopolitical spectrum, that is, they involve regions as large as provinces and states; also, they are usually planned to last over a longer time frame. The evaluation of large-scale interventions is difficult. It is hard to control the confounding variables across a whole city or region. Two types of research have been attempted: controlled trials comparing communities and before-and-after studies across a whole population. Several famous community trials using multidimensional strategies were conducted in the United States and elsewhere in the early 1980s. The summary by the U.S. Surgeon General concerning these various trials remarked on ‘the lack of a consistently positive effect,’ noting

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that the impact on smoking prevalence was ‘modest.’116 The two most rigorous trials showed, at best, limited evidence that prevalence was positively affected. The first one, known as the COMMIT study, showed no difference between intervention and control communities in the United States, whereas the Australian CART study demonstrated some success among men.117,118 The U.S. Surgeon General’s assessment of recent statewide comprehensive strategies was more positive. Based on major reviews comparing data gathered before and after state campaigns, the conclusion was that smoking prevalence rates declined, certainly among adults and perhaps among youth. This was deemed to be especially a result of sustained counter-advertising and other ‘social marketing’ interventions.119 Social Denormalization The potential usefulness of mass media advocacy, or counter-advertising, in influencing public attitudes towards tobacco has been noted at various points in this and the previous chapter. Sometimes the focus is on the dangers of smoking and the health and economic benefits of quitting. Many jurisdictions have also had the goal of permanently changing the public perception towards the legitimacy of tobacco industry practices. As described in terms of adolescent audiences (in chapter 6), this approach is known as denormalization; it aims to counteract the tobacco industry’s message that smoking is normal and desirable.120 In a sense, all tobacco control efforts can be denormalizing, but the higher profile and more widespread policies, programs, and campaigns are the most important in this regard. Taxation and bans on smoking in public places would certainly be on the list of such measures. Denormalization has been successfully pursued amid the general public in Canada, Australia, the United Kingdom, and several U.S. states. The continued application of such an approach is part of Canada’s National Strategy for Tobacco Control. Within that framework, intended as a resource in the development of provincial plans, denormalization is defined as: activities undertaken specifically to reposition tobacco products and the tobacco industry consistent with the addictive and hazardous nature of tobacco products, the health, social and economic burden resulting from

116 Part Two: From Setting to Achieving Targets the use of tobacco, and practices undertaken by the industry to promote its products and create social goodwill towards the industry.121

The full benefits of new social norms surrounding tobacco and tobacco manufacturers remain to be experienced and explored, but the trends in public opinion are certainly encouraging. For example, interviews conducted in 2001 in three Ontario counties showed that 94% of respondents felt that smoking had serious consequences for health.122 A survey in the same province in 2000 showed that a majority of people thought tobacco companies were dishonest and their products dangerous; respondents supported fining the industry in response to any earnings from underage smoking and suing to recover general health care costs related to smoking.123

Key Points • Effective smoking cessation strategies are among the most important interventions in all of health care. • The modest effect of media, self-help materials, and telephone support is multiplied by the wide reach of these strategies. Sustained campaigns over large regions, especially when combined with regulatory mechanisms such as taxation, have had a dramatic impact on smoking prevalence. • Encouraging cessation in workplaces and schools has limited support in the literature, but these influential settings remain vital arenas for program development and research. • Smoking bans, usually aimed at controlling environmental tobacco smoke (ETS), also have an effect on consumption and (probably) cessation rates. The best evidence shows that such measures do not hurt the bottom line of hospitality and other businesses serving clients in public spaces. Perhaps of greatest significance, smoking bans contribute to the social denormalization of tobacco and the tobacco industry. • The most effective cessation interventions occur in clinical settings. These include face-to-face counselling and pharmacotherapy such as nicotine replacement therapy (NRT); even brief cessation advice, e.g., in the context of adverse health events, can be very useful. Clinical intervention with the addition of pharmacotherapy increases the chance of quitting from less than 10% to more than 20%.

8 Tobacco Control Evidence (3): Second-Hand Smoke, Specific Populations, and a Summary

This chapter begins with a look at the relatively new and important field of secondhand smoke, also known as environmental tobacco smoke (ETS). We especially examine exposures experienced by children, after which we consider some other specific populations in reference to tobacco use. The chapter ends with a summary of all of the tobacco control interventions that have been reviewed in Part 2 of this book. Reducing Environmental Tobacco Smoke Due to the well-documented risks,1,2 reducing exposure to ETS in public places and family settings is an important public health goal. Many players are involved with the efforts to reduce such exposure, including researchers, clinicians, midwives, community and hospital nurses, health departments, and tobacco control agencies and organizations. Children are considered to be particularly vulnerable and, thus, have received special attention with regard to ETS. Parental smoking, for instance, is a common but preventable source of childhood morbidity and mortality.3,4 Of particular concern in some jurisdictions is the uneven distribution of ETS exposure; typically, it is higher with children of low-income and less-educated parents.5 As with other arenas of tobacco control, ETS exposure in childhood can be reduced through community programs, individual interventions, and policy changes. There are complexities involved with measuring research outcomes. The choice of methods are: self-reported rates of smoking around children (which can be unreliable), reading smoke or chemical levels in the environment (e.g., a room that the

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child frequents), or detecting biochemical by-products of ETS in the body (e.g., urinary cotinine). The latter method is subject to less reporting bias, but the validity of the chemical selected and the accuracy of testing remain open areas for research.6–8 Community-Based Interventions Children of all ages can benefit to some extent from tobacco bans in workplaces (see chapter 7), and even more from similar programs in public places that they might frequent (see below). Research on other interventions in the community, schools, and so on, has been extremely limited. For example, there were only three studies identified as community-based in the most comprehensive review of ETS available up to now, and only one of them, which was actually a school-based program (see below), offered positive results.9 Obviously, this remains as an area ripe for further investigation. School-Based Interventions School smoking bans were covered in chapter 6; as was noted there, enforcement, or at least the perception of enforcement, seems to be the key to compliance. Theoretically, it is possible for children themselves to assume responsibility to either influence their parents’ smoking or to remove themselves to a smoke-free environment. A Chinese study published in 1993 focused on motivating schoolchildren to create changes in their home.10 The planned action was for the children to write a letter to their fathers, urging them to quit smoking. Although some success was reported in that program, it seems unlikely that shifting the initiative to children will become a major pathway in the effort to control ETS. Home-Based Interventions The majority of ETS programs have been aimed at directly influencing the behaviour of parents and other caregivers; appropriate individuals are recruited mostly through contact with the health care system (see below). Smokers have three options to reduce ETS for their children: quit smoking, reduce smoking, or change smoking location (sometimes called avoidance); a combination of the approaches also may be used. There is a limited literature on adult-focused programs to reduce

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ETS and limited encouragement with respect to the outcomes seen so far. A 2001 review by Emmons et al. rated a mere 5 studies as meeting its stringent requirements, with only one of those recording positive results (based on self-reports by carers).11 The one successful program offered behavioural counselling for parent and child, self-monitoring, and feedback about the child’s pulmonary function; the self-reported exposure reduction was 79% versus 34% in the control group.12 A more recent review accessed 18 studies, but recorded a similarly low success rate in reducing children’s ETS exposure; only 4 of the 18 showed a statistically significant reduction in ETS exposure (see the details on one of the projects below).13 When success was observed, intensive counselling was usually involved. The program aimed at changing a participant’s attitude and behaviour rather than merely transferring knowledge; for some reason, brief interventions in this case were less effective than when they are used in adult smoking cessation. Interventions in the Well Child Health Care Setting Opportunistic interventions can be targeted at parents or other carers in the ‘well child health care setting,’ for example, maternity hospitals, immunization clinics, and routine health checks. Only one positive study fit this category according to a key reviewer; that was Project KISS (Keeping Infants Safe from Smoke) from Boston. The intervention in Project KISS consisted of a 30- to 45-minute motivational interviewing session at the participant’s home, led by a trained health educator, and four telephone follow-ups. In describing this project, Emmons and colleagues reported a significant decline in nicotine levels in the homes of the intervention group at both three- and sixmonths’ follow-up; for example, at six months, the concentration of nicotine in the kitchen air was 2.6 µg per m3 compared with 6.9 in the control group.14 This apparently was the first study that has reported a reduction in objective measures of ETS exposure in households with healthy children. At the same time, it is interesting to note that there was no effect on parental smoking rates. Interventions in the Ill Child Health Care Setting Sometimes opportunistic interventions can be targeted at the parents of children with health problems, such as respiratory illness. Two

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projects demonstrated modest improvements in ETS exposure, one with a sample drawn from a supplemental nutrition program15 and the other with asthmatic children.16 Again, intensive counselling was the focus of the interventions, and the outcome measure, based on selfreports, was reduced smoking in the presence of children. In the first case, fewer cigarettes were smoked by mothers and others in the presence of children, but the nicotine absorption rate appeared to be unchanged; in the second case, about two fewer cigarettes were smoked per day in the presence of children, compared with 1 fewer in the control group. Regulatory and Economic Interventions Focusing on our provincial case study, smoking bans in public places have been a lively issue in British Columbia since 1992, when the Capital Region outlawed smoking in all workplaces outside of restaurants and long-term care facilities. Since then the policy has expanded to other municipalities and also to the originally excluded workplaces. While the main purpose of smoking bans is the protection of nonsmokers from ETS, a potential side effect, as noted earlier, is reduced consumption of tobacco products by smokers and possibly increased cessation rates.17 It is possible that the most significant regulatory and other interventions for ETS are yet to be developed. It seems evident that more research is needed in the area of ETS; indeed, the field has not been overly crowded lately, with the most recent successful project, led by Emmons and colleagues, being more than 5 years old. Fuller progress on ETS exposure in children may require the kind of diffuse ‘social norm’ shifts that now exist in other spheres, for example reproducing the stigma surrounding pregnant smokers and applying it to pediatric ETS. This does not mean that proactive regulation is not important; in fact, new policies are often a big part of social denormalization. One possibility that remains to be tested is the proposal made by the Ontario Medical Association to ban smoking in cars where children are passengers.18 Comprehensive Strategies All of the results included in a major review of comprehensive approaches to ETS were from uncontrolled, before-and-after studies.19

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The conclusion of the review was that carefully planned multicomponent strategies can reduce smoking within public places. Most of the studies on comprehensive approaches dated from the 1980s or earlier. This seems to be a research area of little current interest, perhaps because bans have already been successfully implemented in so many settings. The prevailing situation has reached the point where, even in the absence of rigorous testing of effectiveness or compliance rates, smoking bans in many countries are simply considered to be a given. Indeed, the normalization of smoking bans has even extended to informal policing by people who are bothered by an adjacent smoker (see the next section). Ultimate Denormalization Several studies show that assertive requests to refrain from smoking (in, e.g., office or lobby settings) can be a very effective addition to the presence of no-smoking signs and policies.20 Passers-by ‘taking matters into their own hands’ is unlikely to be acceptable as a formal public health intervention, although it may continue to grow as an informal social control mechanism.21 As health concerns and nonsmoker rights continue to be promoted, the sort of generalized stigmatization that results may be considered the mature end point of denormalization strategies. Specific Populations Most cessation interventions in tobacco control tend to use generic approaches that are applicable to all smokers, even though tobacco users are quite heterogeneous in their characteristics. The motivation behind focusing on the specific needs of certain populations is the assumption, and hope, that treatment success may be increased.22 Smokers can be stratified in many ways, for example, heavy vs light, stages-of-change, patient vs non-patient, age, socioeconomic status (SES), and geographical location.23 The categories below deal with populations where there are unusual prevalence rates and/or unusual health risks. Teen smoking has already been covered in chapter 6, but three other populations that stand out are pregnant women, Aboriginal peoples, and people with psychiatric illness. The fine-tuning of such categories in some sense has no end-point. For example, the subset of smokers who have a psychiatric illness and who also abuse alcohol or other

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substances represent specific challenges and opportunities.24 Socioeconomic status is another characteristic that could be explored; some aspects of intervening with smokers of low SES will be handled here (as well as in chapter 10, regarding lessons learned from tobacco control). Pregnant Women The negative fetal health impacts of smoking and ETS exposure during pregnancy are well attested. In addition to cases of low birth weight, cigarette smoking may account for a proportion of pre-term deliveries, miscarriages, stillbirths, placental problems, and other pregnancy complications. 25,26 Smoking during the prenatal period is the most important modifiable risk factor for poor pregnancy outcomes in developed countries.27 Three significant facts are known about smoking rates among pregnant women in countries such as Canada and the United States: • The proportion of women who quit smoking during pregnancy has increased steadily over the past decade. The progression in cessation rates among pregnant smokers, although derived from different jurisdictions, helps to tell the story: in 1986 the quit rate was 39% (U.S.); in 1993–9, 43% (U.S.); and in 2001, 51% (Ontario).28–30 • As is clear from the above data, despite considerable public focus and prevention efforts, half or more of pregnant women who are smokers still continue to smoke throughout their pregnancy; this represents 19% to 22% of all pregnancies in Canada.31 As one provincial example, in 1999 in British Columbia,32 an estimated 4,600 babies were born to mothers who smoke. • Postpartum relapse rates are very high. Although the relapse curve is not as steep as that for non-pregnant smokers in the first weeks after cessation, about 60% of women who quit during pregnancy return to smoking within 6 months of giving birth, and 80% to 90% by 12 months.33,34 Several studies have demonstrated that stopping smoking during pregnancy has health benefits for both mother and child.35 Pregnancy represents a period where women with a high motivation to quit smoking – for the sake of the baby’s health – have relatively intensive contact with health care providers. Thus, it represents a special window of opportunity within which to encourage smoking cessation.36

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intervention research and categories Given the stakes, it is vital to investigate effective interventions for smoking cessation in pregnant women, as well as for prevention of postpartum smoking relapse.37 One reason that the relapse issue is so important is the harmful impacts on newborns and infants created by environmental tobacco smoke; for example, ETS exposure in infants increases rates of asthma, lower-respiratory disease, and SIDS.38 Thus, working towards a reduction of neonatal health effects should be a component of general ETS campaigns. Continuing analysis is needed to identify the socioeconomic factors and health correlates related to smoking initiation among women of child-bearing age; cessation resistance among pregnant women and the disappointing relapse rates also require study.39 For example, recent Canadian work showed that three factors were especially associated with ongoing smoking during pregnancy: having other smokers in the household, having other children in the household, and not having postsecondary education.40 Studies in New Zealand, Great Britain, and other jurisdictions agree that ‘socioeconomically deprived women were more likely to continue to smoke beyond the first trimester of pregnancy and that this needs to be taken into account in the provision of smoking cessation support.’41 Several reviews of interventions targeting pregnant women who smoke have been conducted. The literature search does not reveal much active research since the 1990s. Most of the investigation has focused on behavioural interventions, which fall into three categories:42 • High-intensity, involving several lengthy face-to-face contacts and using multiple strategies with pregnant women who smoke • Low-intensity, involving brief initial contact as in minimal interventions, but with follow-up reinforcement • Minimal, involving delivery of a single, brief smoking cessation message to mothers in person or by mail, usually using self-help manuals, messages from health care providers, pamphlets, or videotapes. The results of each of these treatment types will be described. We will then briefly outline other types of interventions with pregnant smokers. high-intensity counselling A major 2003 review included 34 studies on smoking cessation in pregnant women.43 The projects with positive results could be charac-

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terized as intensive; they often tailored interventions for each individual smoker.44 One 1997 Australian study showing good results included the following intervention components: brief physician advice, educational video, midwife counselling, self-help manual, possibility of a prize upon success, follow-up counselling, involvement of an adult partner where possible, and (for those resistant to cessation) encouragement to attend an external antismoking course.45 Many of the reviewed projects demonstrated success. The eight highest quality trials showed an average absolute reduction of 8% in smoking rates in late pregnancy. For example, in the 1997 Australian study, the rate of smoking in the third trimester dropped from 95% to 87%.46 low-intensity and minimal counselling Interestingly, reviews show that lower-intensity approaches also can work, often matching the results of high-intensity interventions.47,48 Even a single, 15-minute counselling session with appropriate selfhelp materials (and possibly brief follow-up) has been found to double the cessation rate in pregnant women when compared against ‘spontaneous’ quitting.49 One 1996 study that used such methods increased the cessation rate from 10% to 20%.50 The brief interview format favoured today follows the ‘Five A’s’ – ask, advise, assess, assist, and arrange. The format was introduced by the U.S. Public Health Service as a general guideline to clinicians concerning smoking cessation,51 so it does not represent a unique protocol for pregnant smokers. The adaptation of the Five A’s for pregnant smokers is currently being evaluated in 13 sites across Canada and the United States.52 ineffective counselling interventions It is important to note that the positive result for brief counselling does not mean that anything will work. An evaluation of the very limited intervention currently mandated in the United Kingdom (i.e., written information distributed at the first prenatal visit) concluded that it was not effective.53 Peer counselling and partner support approaches have offered mixed results. These forms of intervention depend on positive, motivated involvement either from a non-professional not known to the patient (i.e., a peer) or from an intimate friend or colleague (e.g., a partner). One study of peer counselling (part of a cessation program for

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prenatal smokers led by women from the community) showed reduced consumption but no improvement in cessation rates.54 In another trial, the partners of pregnant women who smoke received counselling and materials to increase their ability to be supportive; partners who were themselves smokers also received cessation aids and related counselling. Interestingly, the pregnant women showed no improvement in smoking cessation, even though the partner quit rates were three times higher with the intervention.55 pharmacological interventions In spite of some fetal risks associated with nicotine replacement therapy, the benefits of this intervention for pregnant smokers are being increasingly taken into account.56 Further clinical studies of efficacy and safety are needed, especially given the easy, over-the-counter availability of NRT agents.57 On a related topic, an advisory was issued by Health Canada in August 2004 about the potential adverse events in newborns arising from oral agents such as bupropion.58 As noted earlier, bupropion is effective in aiding cessation attempts, possibly because it counteracts withdrawal symptoms such as depression. policy interventions There is some evidence that generic population-based policies will catch pregnant women to a significant (and sufficient) degree. For instance, a U.S. study suggested that ‘the decline in smoking over time among pregnant women was primarily due to the overall decline in smoking initiation rates among women of childbearing age, not to an increased rate of smoking cessation related to pregnancy.’59 Another significant fact is that the largest group of women who stop smoking in pregnancy involves those who have already stopped smoking on their own before the first prenatal visit.60 Thus, it seems that population-level approaches to cessation may be as useful to pregnant smokers as are targeted clinical interventions. Pregnant women who smoke may benefit even more than others from general programs. For example, it appears that higher taxation on cigarettes provides an above-average disincentive to both smoking during pregnancy and to postpartum relapse. The effects are significantly greater than those seen in the wider population, with 10% higher taxes increasing the quit rate among pregnant woman by a full 10%; there is a similar degree of impact on relapse rates.61

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Aboriginal Peoples Aboriginal peoples in many parts of the world are at risk for high rates of smoking, as well as for the related health consequences. For example, the rate of tobacco use among B.C. First Nations, as B.C.’s Aboriginal population is called, is close to double that of other British Columbians.62,63 In British Columbia, 54% of Aboriginal teenagers and 65% of those aged 20 to 24 misuse tobacco.64,65 Likewise, the proportion of non-smoking aboriginals exposed to ETS is twice that observed for other non-smoking residents in that province.66,67 On a positive note, compared with other Canadian Aboriginals, British Columbia’s First Nation peoples have the lowest smoking rates. In Canada, the rates are highest in the Northwest Territories, at 71% of the Aboriginal population.68 Existing tobacco cessation programs have not been as successful with First Nations peoples compared with other populations in Canada.69 There are several possible reasons, including traditional use of tobacco, easy access, low cost of tobacco on reserves (no tobacco taxes), and a general acceptance of tobacco use among Aboriginal communities.70,71 Therefore, new intervention programs developed specifically for First Nations are of cardinal importance. Reviewing one provincial case, we find that most B.C. programs designed to prevent initiation and encourage cessation among Aboriginal peoples are community-based. They feature education, the participation of elders and other leaders in program development, and the supportive involvement of peers and family.72 Emphasis is put on distinguishing non-traditional abuse of commercial tobacco from culturally appropriate use.73 The main problem with the various existing efforts is that formal and thorough program evaluations are scarce. The Honour Your Health Challenge, a component of B.C.’s ‘Aboriginal Strategy,’ involves training Aboriginal people to support culturally appropriate activities related to reducing tobacco use. Results from a survey, representing 74% of the program participants, were positive. Unfortunately, while the participants demonstrated an increase in knowledge, awareness, and access to resources, there were no data collected to show the impact on cessation rates or smoking prevalence.74 Some research has been conducted on pharmacotherapy agents to reduce tobacco use among Aboriginals, but the appropriateness and effectiveness of this type of intervention are not clear.75 Increasing tobacco prices has been shown to decrease use, especially among

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youth, but this subject also has not been rigorously researched within the context of Aboriginal communities.76 international comparisons The first impression gained through an expanded literature search is that much more study is needed in the arena of Aboriginal tobacco control. Such research needs to be as location-focused as possible, since intercultural transferability of programs and results is not axiomatic. One U.S. study showed positive results after providing native American youth with the problem-solving, personal coping, and interpersonal communication skills needed to resist pressures that lead to substance abuse.77 Over the course of the 3.5-year study, the incidence of smokeless tobacco use among youth with the acquired skills was 43% lower than in the control group. Unfortunately, cigarette smoking was unaffected by the intervention. As well, combining skills development with other community interventions showed no added benefit. Evaluations were found in the literature for five tobacco programs used with indigenous Australians. Three of these studies demonstrated some effectiveness, although the evidence is weak for actual cessation. For example, evaluation of a mainstream advertising campaign only showed that knowledge about tobacco had increased.78 In another study, training health professionals to deliver a brief intervention resulted in some behavioural changes; however, there was no evidence at 6-months’ follow-up that any patient had quit smoking.79 The most promising project assessed the effectiveness of free nicotine patches for indigenous people; it showed that 15% of participants quit smoking (according to self-report).80 In contrast, neither a trial of a CDROM resource for use with indigenous schoolchildren nor a pilot study of smoke-free workplaces showed any impact on smoking rates.81 As with the situation in British Columbia, the work with Aboriginals internationally in terms of smoking cessation seems to be at a very early stage. People with Psychiatric Disorders Diseases caused by smoking are the second highest killer of people who have a psychiatric illness.82 The lifetime prevalence of smoking among people suffering from various forms of psychiatric illness is approximately 60%, compared with about 40% in the general popula-

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tion.83 Studies have suggested that almost one-third of current U.S. smokers have some form of psychiatric illness, including schizophrenia, bipolar disorder, and depression.84,85 The risk for depression grows as the number of ‘nicotine dependence symptoms’ increases.86 Other research has concluded that smoking initiation precedes and predicts depression and bipolar disorder.87–9 Conversely, the presence of active psychiatric disorders predicts an increased risk for onset of daily smoking, for progression to nicotine dependence, and consequently, for the development of chronic disease.90–93 Canada’s National Population Health Survey confirmed the connection between depression and smoking. Adolescents with depressive symptoms are more likely than other adolescents to start smoking. However, people who smoked daily in Canada showed an increased risk of having a major depressive episode compared with non-smokers – with the odds being almost double for men.94 Although progress has been made in understanding the biological connection, including the genetic links, between smoking and mental illness, the phenomenon is not fully elucidated.95 What is clear is that smoking cessation in this group often leads to a worsening of symptoms in all of the various disorders.96 One suggestion is that tobacco may be a form of self-medication. It was noted in chapter 7 that smoking has an antidepressant effect. This may be one mechanism that causes smokers who have schizophrenic and/or depression disorders to rate the reward value of smoking higher compared with the general smoking population.97–9 The association between smoking and psychiatric illness has at least five implications for cessation treatment: • In helping patients give up smoking, health care providers need to be aware of any underlying psychiatric health problems that require attention. • Adding psychiatric components to some cessation treatments should be considered. • Those treating nicotine dependence must be prepared to monitor and respond to any onset of depression during the intervention; this includes considering the potential benefit of antidepressants. • There may be an advantage to integrating tobacco dependence treatment with other programs in psychiatric health settings. • As population tobacco use decreases, smokers with psychiatric illnesses will be increasingly represented in the remaining smoking cohort.

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approaches to cessation Despite the likely enhanced obstacles to cessation, smokers with a history of psychiatric illness have demonstrated substantial quit rates.100–2 One Canadian study found that people with psychiatric disorders are very motivated to join a cessation group.103 The usual suggestion is that programs should be tailored for such populations, as the symptoms of psychiatric illness – and the resulting affective, cognitive, and social difficulties – may mean that existing cessation approaches are not as appropriate.104 The interventions that have been tried include: • Individual counselling, often in conjunction with NRT (or other drug treatment). Using both counselling and drugs is sometimes called combination therapy. • Cognitive-behavioural therapy (CBT), which combines two popular kinds of psychotherapy. Behavioural therapy helps patients to weaken the connections between troublesome situations and habitual reactions.105 Cognitive therapy reveals how certain thinking patterns produce symptoms.106 • Motivational interviewing (MI), an intensive, directive counselling style that helps clients explore and resolve ambivalence towards personal change. MI practitioners propose that the qualifier ‘motivational’ only be used when there is a primary focus on increasing readiness for change.107 • Group counselling, using a variety of formats modified to accommodate the limitations of participants with psychiatric illnesses. Again, such therapy is often accompanied by pharmacological interventions. • Policy interventions, such as total or partial smoking bans, can be applied to mental health settings. Some jurisdictions are synthesizing evidence into coherent policies. For example, general practice guidelines have been developed in Australia for smoking cessation for people with schizophrenia.108 The guidelines, based partly on a stages-of-change model, include NRT, group counselling and frequent monitoring. Unfortunately, despite these attempts to establish a standard operating procedure, there is little current literature about targeted treatments with people who have psychiatric illness, and even less evidence of effectiveness. intervention results A 2002 review of cessation strategies in cohorts of people with psychi-

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atric illnesses found studies evenly balanced between discussions of schizophrenia and depression.109 The studies of persons with schizophrenia mostly were based on small clinical samples. The focus of the investigations was drug treatment and group work, rather than individual counselling, which is consistent with the thrust of the Australian guidelines (noted above). Nicotine patches and antipsychotic drugs such as clozapine seemed to reduce smoking, but it took the addition of group therapy to create significant quit rates. One study demonstrated cessation rates of 42% post-treatment, 16% at three months, and 12% at six months.110 The studies of people with depression used larger samples. It is important to note that the individuals recruited for such trials, while having a history of major depression, usually were not currently suffering through a depressive episode. The most effective interventions involved a combination of CBT and standard smoking cessation strategies, including pharmacotherapy. Quit rates ranged from 31% to 72% at the end of treatment, and from 12% to 46% at 12 months. How these rates compared with a control group was not reported. More recent studies with NRT have confirmed its effectiveness in patients with a history of depression, with improvement in cessation rates similar to those with the non-depressive population.111,112 It is difficult to compare the wide range of counselling theories and available modalities. Among the relevant literature, one 2004 study showed higher rates of cessation among depressed patients using CBT in group sessions compared with basic health education.113 In contrast, a randomized controlled trial of motivational interviewing versus brief advice applied to adolescents with psychiatric disorders showed no difference in smoking cessation outcomes between the 2 approaches.114 Finally, in terms of policy options, a recent comprehensive review of bans on smoking in psychiatric health settings showed that such interventions, on their own, had little or no effect on smoking cessation.115 Summary of Tobacco Control Interventions Here we summarize chapters 6 though 8, offering an inventory of tobacco control interventions, categorized according to levels of evidence. This will provide a handy tool for policymakers to pick out what works well and, just as important, what is not currently recommended. As with all discussions of interventions in this book,

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approaches that are not recommended are not necessarily ineffective – they may simply not yet be supported by compelling evidence. Interventions to Reduce Initiation Rates 1 Interventions of proven effectiveness with strong evidence – increased taxation on tobacco products. This probably is the single most effective intervention – control of activities promoting tobacco consumption, e.g., advertising, power wall displays, sponsorship of sporting events, smoking in movies 2 Interventions of promising effectiveness with moderate or mixed evidence – school curricular programs focusing on social influence training – smoke-free school policies – multicomponent community programs, e.g., school efforts combined with media campaigns – controlling tobacco sales to minors (where the effectiveness is very dependent on enforcement – encouragements to not attend movies that glamourize smoking – encouragements to create smoke-free homes. 3 Interventions of no or low effectiveness and/or with insufficient evidence – school curricula based on methods other than social influence training. Interventions to Increase Cessation Rates 1 Interventions of proven effectiveness with strong evidence – increased taxation on tobacco products. This is probably the single most effective intervention in the general population and among specific groups such as pregnant women – consumer utilization of nicotine replacement therapy, i.e., overthe-counter – sustained encouragements to physicians to treat smoking – intensive counselling, including group therapy; youth cessation as one effective target – regular clinical use of all forms of NRT, plus the antidepressant bupropion; Aboriginal smoking as one possibly effective target for NRT – both high- and low-intensity counselling of pregnant women who smoke

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– for people with psychiatric disorders, drug treatment, combined with group work (in the case of schizophrenic patients) or individual cognitive-behavioural therapy (in the case of depression) – cessation advice in the context of an adverse health event, particularly when combined with NRT. 2 Interventions of promising effectiveness with moderate or mixed evidence – counter-advertising and other forms of media advocacy, if welldesigned – mandating that insurance and/or public reimbursement plans cover patient costs (for counselling and any drugs) – ensuring that clinicians are compensated for counselling time – second-line drug treatment using nortriptyline or clonidine – proactive telephone support (especially involving multiple contacts) and partner support (especially when a parallel program for the partner is in place) – self-help materials (especially when personalized and combined with other interventions) – workplace smoking cessation campaigns (the key factor being the employee participation rate) – workplace smoking bans and poster campaigns – NRT with pregnant women who smoke – cessation help or quit lines, particularly with multiple follow-ups by the provider. 3 Interventions of no or low effectiveness and/or with insufficient evidence – basic encouragement of physicians to treat smoking – use of serotonin selective reuptake inhibitors, anxiolytics, or lobeline – televised ‘how to quit’ programs – quit competitions and workplace incentives – partner support for pregnant women who smoke – basic information distributed about pregnancy and smoking – motivational interviewing with adolescent psychiatric patients – Web-based cessation programs. Interventions to Reduce ETS Exposure, Especially in Children 1 Interventions of proven effectiveness with strong evidence – none.

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2 Interventions of promising effectiveness with moderate or mixed evidence – intensive counselling to reduce ETS exposure, especially targeting parents in health care settings – legislated smoking bans in public places. 3 Interventions of no or low effectiveness and/or with insufficient evidence – assertive requests to refrain from smoking in public places – community-based interventions to reduce ETS exposure (other than bans) – brief advice to caregivers to reduce ETS exposure – legislated smoking bans in psychiatric health settings.

Key Points • It can be argued that the research and policy innovations surrounding smoking bans in public spaces are approaching maturity. • The cutting edge work with environmental tobacco smoke (ETS) still needs to happen in domestic settings; there, the greatest success so far has involved intensive counselling with parents and other caregivers. New frontiers include discouraging or regulating smoking in cars and homes where children are present. • Both clinical counselling and generic tobacco control policies such as increased taxation are very effective in reducing smoking prevalence among pregnant women. • Attempts to deal with the high rate of smoking among Aboriginal communities in culturally sensitive ways have been well received, but effectiveness data are lacking. • Smoking-related diseases create high mortality among people who have a psychiatric illness; fortunately, combinations of specialized counselling and normal cessation strategies have proven to be effective with this population.

9 Tobacco Control Evidence (4): Cost-Effectiveness

Information on the cost-effectiveness of tobacco control interventions is more limited than information on the effectiveness of those same interventions.1 Indeed, summaries from the early 1990s typically pointed to a ‘paucity of studies’ concerning tobacco control economics.2 That situation is beginning to change. A recent comprehensive assessment of the literature between 1990 and 2001 revealed 41 costeffectiveness studies related to tobacco control, or fully 10% of the total number of economic papers in the area of health promotion.3 It still should be noted that, although these figures suggest an increased level of research, the volume of studies is still well below that found in some other spheres of health care. Three general limitations of the cost-effectiveness literature have been identified. These are: • Much of the economic evidence has been concentrated in such classical approaches to health promotion as lifestyle interventions. As a team led by Canadian researcher Bonnie Rush recently concluded: ‘The shift that is evident in health promotion thinking towards an ecological and integrated approach that encompasses both upstream and downstream determinants of health has yet to have an impact on the associated economic literature.’4 • As public health promotion interventions have become increasingly complex in response to multi-faceted health problems, the economic evaluation designs have not necessarily kept pace. Some commentators have even suggested that attempts to evaluate the cost-effectiveness of population health interventions are futile.5 • Even the evaluation of simpler mainstream interventions needs

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more work, e.g., relatively little is known about the cost-effectiveness of counter-marketing in reducing smoking rates.6 These general and specific research gaps need to be acknowledged, while taking full advantage of the literature that is available. The development of high-quality economic analysis for public health interventions will never be finished. In light of the preceding points, however, policy planners need to learn how best to employ incomplete, uncertain, or even contested cost-effectiveness evidence.7 Cost-Effectiveness in Context How attractive, from a cost-effectiveness perspective, does an intervention need to be to warrant its adoption? QALY is a term commonly used in cost-effectiveness discussion: it stands for quality adjusted life year or a year of life adjusted for its quality. A year in perfect health is considered equal to 1.0 QALY. The value of a year of ill health would be discounted to some extent, for example, a year bedridden might be assigned a value equal to 0.5 QALY. Laupacis and colleagues attempted to answer the question just posed here by suggesting a classification grid comprising five levels:8 • Grade A – The intervention being examined is both more effective and cheaper than the existing one. • Grade B – The intervention is more effective and costs less than U.S. $20,000 per QALY. • Grade C – The intervention is more effective and costs between U.S. $20,000 and U.S. $100,000 per QALY. • Grade D – The intervention is more effective and costs more than U.S. $100,000 per QALY. • Grade E – The intervention is less or equally effective but costs more than the existing one. The authors noted that there are many factors beyond the cost-effectiveness of an intervention, such as political and ethical considerations, that need to be taken into account before adopting an intervention. While the approach of Laupacis et al. has been criticized,9 it does allow for a general grouping of interventions. An important condition for any evaluation is that the research on cost-effectiveness be of high quality, generating results that are reliable. The Harvard School of Pub-

136 Part Two: From Setting to Achieving Targets Table 9.1 The Cost-Effectiveness of Selected Interventions

Intervention Bypass surgery vs. medical management Hypertension treatment vs. no treatment End-stage renal disease treatments vs. no treatment Mammography screening vs. no population based screening in 45 to 69-year-old women Driver side air bags vs. no air bags

Cost / QALY (2002 U.S.$) 35–48,000 15–210,000 15–267,000 15–219,000 15–230,000

Source: Based on data available at www.hsph.harvard.edu/cearegistry/.

lic Health maintains a comprehensive cost-effectiveness database in order to standardize the methods and practices of cost-effectiveness analysis.10 This database includes a review of available cost-effectiveness studies from 1976 to 2001, with outcomes presented as a cost per QALY in 2002 U.S. dollars. To provide a context for the following sections on the cost-effectiveness in tobacco control, we have supplied data for several interventions that are routinely used in health care (see table 9.1). This sort of information will help us to rank the costeffectiveness of interventions used in tobacco control. Increased Taxation Increasing the taxes on cigarette and other tobacco products represents a beneficial ‘perfect storm’ in terms of public health interventions. First, the measure produces increased cessation and reduced consumption, with all of the health benefits that follow; even better, the formula is strongest for at-risk populations such as pregnant women and youth. Second, in contrast with other programs, which use resources to obtain a health benefit, tobacco taxation does not add cost; in fact, it most often produces revenue that can be largely recycled into public health initiatives.11 Third, it represents an aspect of the overall denormalization of smoking and the tobacco industry; taxes are strongly associated with an unfavourable image. As a strategy, the importance of tobacco taxation is so great that some of the supporting evidence already presented will be fleshed out in greater detail here.

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The connection between price increases and reduced tobacco consumption is one of the most established effects in public health research. In 2001 the Canadian Cancer Society presented evidence of the relationship between tobacco taxation and consumption to the House of Commons Standing Committee on Finance; the submission included 300 studies. The real world experience has been clear in Canada and other jurisdictions since the early 1980s. As a result of taxation and manufacturers’ price increases, cigarette prices grew in real terms (after adjusting for inflation) for the first time in 30 years – and sales began to fall.12 The resistance to sustaining and increasing taxation has traditionally come from a few expected sources, including the tobacco industry and tobacco-growing areas such as Southern Ontario. Indeed, it might surprise some to discover that Ontario is the largest producer of tobacco in North America after North Carolina and Kentucky. In response to increased taxation, the tobacco industry fought back. The companies especially exploited the problem of cigarette smuggling, claiming that it was caused by increased taxation. A tragically ironic situation that was discovered during this period was the complicity of the tobacco industry itself in smuggling operations.13 Responding to various pressures, in February 1994 the Canadian government drastically cut tobacco taxes, and this resulted in an immediate and dramatic increase in cigarette consumption, especially among younger people. A helpful summary of the research in the area of price increase and tobacco consumption is provided by Pacula and Chaloupka.14 Their review estimated that a 10% increase in the price of a package of cigarettes would lead to a 3% to 5% reduction in the demand for cigarettes. Sensitivity to price increases varies among subgroups of the population. Adolescents, men, and those with lower SES have been found to be more price responsive. Adolescents have been a special focus of concern, as a long-term solution to the problem of tobacco use will definitely include action to inhibit teens from taking up or continuing with smoking. This subgroup of the population may be up to three times more price sensitive than adults, with a 10% price increase expected to reduce the teens’ demand for cigarettes by 6% to 10%.15,16 There has, however, been mixed evidence on the impact of price increases on smoking initiation in female adolescents, possibly reflecting the issues around body weight and the slimming effect of smoking.17 The sensitivity to price is reduced by the time a person reaches adulthood, which is often a time

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of increased earning power; a 10% price increase results in only a 3.5% decrease in demand among people in their early 20s.18 How much of this reduced demand is due to lower initiation rates, increased cessation, or simply a reduction in the number of cigarettes smoked per day? While it is difficult to tease out these contributing factors, estimates have suggested that about half of the decrease in demand is from fewer smokers and half from reduced consumption by current smokers.19–21 Price increases stand out as by far the most cost-effective intervention for smoking cessation, yielding significant results at minimal or no cost.22 One concern has been raised, however, and that is the possibly regressive nature of tobacco taxation. Since the poor tend to smoke more than wealthier individuals do, cigarette taxes place a disproportionately higher burden on poor households. It is this very sensitivity to price, though, that is a key driver behind the effectiveness of this intervention in the first place. Clinical Interventions and Management The economic literature on clinical interventions for smoking cessation is as extensive as that for any other area, apart from taxation measures. Validated smoking cessation interventions have been shown to be highly cost-effective in reducing tobacco use and consequent disease. The evidence is strong enough to apply the gold standard label to cessation when it is compared with the full range of preventive health care measures.23 There is heterogeneity in the way outcomes of cost-effectiveness are reported, which makes comparability a problem. The common methods of presentation are cost per quitter, cost per life-year saved, and cost per quality-adjusted life year (QALY) or disability-adjusted life year (DALY) saved. Sometimes the incremental cost-effectiveness of an intervention is established, which many authorities identify as the preferred approach. Counselling In 1997 recommended smoking cessation interventions from the 1996 U.S. Agency for Health Care Policy and Research guidelines were analysed to determine their relative cost-effectiveness.24 A range of five counselling methods was modelled in detail, demonstrating that the

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Table 9.2 The Cost-Effectiveness of Counselling Interventions

Counselling type

Cost per lifeyear saved (1995 U.S.$)

Cost per QALY (1995 U.S.$)

Cost per QALY (2001 U.S.$)

Minimal counselling Intensive individual Group counselling

5,423 2,461 1,496

4,015 1,822 1,108

4,666 2,117 1,288

Source: Cromwell et al. JAMA (1997).

cost per QALY averaged U.S.$1,915,25 which is a very low figure compared with standard health care practices. The general conclusion was that the most effective methods were generally the more intensive ones. The most cost-effective approach was group counselling, as seen in table 9.2; on the downside, very few smokers opted for this type of program. An earlier American study suggested a contrary conclusion; the least intensive measure, brief physician advice, only cost from U.S.$705 to U.S.$988 per year of life saved for men, and U.S.$1,204 to U.S.$2,058 for women. The upper limit with sensitivity analysis was still less than U.S.$6,000, and for a follow-up visit, less than $10,000.26 Whatever the details, the general conclusion is the same: physician counselling against smoking is at least as cost-effective as several other preventive interventions in health care. Comparable British clinical cessation guidelines from 1998 were accompanied by an analysis that substantially concurred with the U.S. assessment of cost-effectiveness, but with figures more in keeping with the study just described.27 The conclusion was that the cost per year of life saved ranged from only £248 (U.S.$43028) to £303 (U.S.$535).29 This result was matched by a 1993 Welsh study, which suggested that brief advice only cost £167 (U.S.$289) per QALY.30 In 2001 a U.K. model estimated that brief advice from a physician costs as little as U.S.$144 per quitter.31 Two recent reviews of cessation interventions, one for the World Health Organization and one for the World Bank, included cost-effectiveness summaries. The WHO report covered the same material as noted above, but it also provided some economic data specific to nicotine replacement therapy (see below). The World Bank report included a wider range of studies; unfortunately, comparison is difficult as a

140 Part Two: From Setting to Achieving Targets

variety of outcome measures were examined.32 The type of outcome measure is important; calculating costs according to years of life saved rather than allowing for changes in quality of life can underestimate the cost-effectiveness of smoking cessation by almost half.33 The 3 studies included in the World Bank review that evaluated costs per quitter showed a range from U.S.$150 to U.S.$411 (when limited to projects where the intervention was offered to all smokers).34–36 This compares with data from another recent study of cessation counselling offered by family physicians, where costs per quitter ranged from U.S.$281 to U.S.$496, depending on whether training expenses were included.37 These figures are significantly lower than the 1997 U.S. review quoted at the beginning of this section, where the cost per quitter ranged from U.S.$2,186 to U.S.$7,922.38 Although smoking cessation services offered to specific groups are reported to be more cost-effective in certain cases,39 this does not seem to apply to heavy smokers or those with established disease. The data summarized by the World Bank review suggested that the cost per year of life saved for such patients can range from U.S.$480 to U.S.$7,444.40 The upper limit reported in one study of myocardial infarction survivors was U.S.$19,000 per year of life saved, although a sensitivity analysis dropped the costs to less than U.S.$10,000 per year of life saved.41 The bottom line should not be lost in this profusion of evidence: in all of its permutations, clinical cessation counselling is highly costeffective. Pharmacotherapy Pharmacological approaches to smoking cessation include transdermal patches (commonly referred to as nicotine patches), nicotine chewing gum, nicotine nasal sprays, lozenges, aerosol inhalers, and some classes of antidepressants, including buproprion. The cost-effectiveness literature in this area has been adequate, although not exhaustive. A 1999 Canadian review42 of nicotine replacement therapy cited four U.S. economic analyses.43–46 A 2002 British review added five more studies.47 The work on antidepressants is newer, and more limited. Most economic assessments of bupropion (Zyban or Wellbutrin), for example, are from 2001 and later. nicotine replacement therapy Analyses of NRT generally have assumed that the drug is being used in conjunction with physician care; this would involve at least brief

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Table 9.3 Cost-Effectiveness of Nicotine Replacement Therapy in the Context of Physician Care, 2001(U.S.$)

Counselling type

Patch: Cost per life-year saved

Patch: Cost per QALY

Gum: Cost per life-year saved

Gum: Cost per QALY

Minimal counselling Intensive individual Group counselling

3,775 2,288 1,837

2,795 1,691 1,361

7,130 3,505 2,860

5,278 2,595 2,117

Source: Cromwell et al. JAMA (1997); Fiscella and Franks JAMA (1996).

advice. Table 9.3 is based on the work by Cromwell et al.48 and incorporates the results of Fiscella and Franks.49 Their data were subsequently updated to 2001 U.S. dollars.50 A comparison with Oster et al. is useful. In their study, the cost per life-year saved with nicotine gum was $4,113 to $6,465 for men and $6,880 to $9,473 for women, depending on age.51 Wasley and colleagues also found that costs per life-year saved with the transdermal patch were lower than with gum.52,53 A small study in a U.S. military setting suggested that the cost per quitter with transdermal patch therapy was $779 to $984.54 While the methods and results of these studies vary, they all indicate that the cost per life-year saved or cost per QALY is well under $10,000 in each case; therefore, the evidence consistently supported the conclusion that NRT is highly cost-effective according to usual health care standards. Another significant result emerged when comparing NRT treatments with counselling used by itself; the addition of NRT to counselling, at least with delivery by transdermal patch, leads to lower costs per QALY in most cases. The British evidence deviates somewhat from the pattern described up to now. Contrary to the U.S. data, the most intensive, and effective, interventions were found to be less cost-effective. The data from a review by Parrott and colleagues are shown in table 9.4.55 This result was matched in a 2001 modelling study from the United Kingdom, where adding pharmacological therapy to physician advice cost seven times more per quitter.56 It is not clear which conditions or assumptions would have produced such different results in the United Kingdom and the United States. Whatever the final interpretation, the salient

142 Part Two: From Setting to Achieving Targets Table 9.4 Cost-Effectiveness of Tobacco Cessation Interventions, United Kingdom, 2001

Type of intervention

Cost per life-year saved (£)

Brief advice Brief advice + self-help Brief advice + self-help + NRT Brief advice + self-help + NRT in a specialist clinic

248 303 815 1,022

Source: Parrott et al. BMJ (2004)

point is that even the most expensive intervention, that is, cessation supported by specialists using NRT and self-help materials, compared favourably to a review of 310 other medical interventions. The U.K. study showed the median cost across the health care spectrum to be about £17,000 (U.S.$25,500) per life-year gained, or more than 16 times the most expensive approach in clinical smoking cessation.57 The specialist cessation services represented by the intensive therapy data above constitute an important topic. They currently form the cornerstone of the National Health Service’s tobacco control strategy for each health authority in Britain. In considering intensive services, a comparison can be made with a Welsh hospital setting, where a specialist counsellor was found to produce an additional quitter at a cost of £851 (U.S.$1,477); alternately, the costs were £340 (U.S.$590) to £426 (U.S.$739) per life-year saved.58 Other U.K. research included two 1994 studies by Akehurst and Piercy that reported the incremental cost per extra life-year saved for the transdermal patch (£4,526 or U.S.$7,853) and nasal spray (£1,527 or U.S.$2,649).59,60 Although nicotine spray seems more cost-effective, there have been concerns about people becoming dependent on the treatment.61 In another U.K. comparison, Stapleton and colleagues analysed what the incremental cost per life-year saved would be if physicians could prescribe transdermal patches at no cost to the patient for up to 12 weeks:62 it ranged from £398 (U.S.$691) to £785 (U.S.$1,362), depending on the age of the patient. In sum, on the basis of all of the available information, the WHO has

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calculated the average cost of NRT plus counselling to be $2,164 per disability-adjusted life year (DALY).63 Finally, comparison data are available through managed care organizations. Two large organizations in California demonstrated the cost per quitter to be between U.S.$965 and U.S.$1,495.64 A 2004 study estimated the direct costs for managed care smoking cessation treatment to be U.S.$3,417 per life-year saved.65 One 1998 study reported that the average annual combined cost for the health plan per user who quit smoking was U.S.$928 for those with standard insurance coverage who elected NRT and/or behavioural therapy. The average cost increased to U.S.$1,127 for those with partial coverage and U.S.$1,192 for those with full coverage for smoking cessation services.66 The increased costs to the plan arose because, even though more people sign up for the program when all their costs are covered, their quit rate is significantly lower. One explanation for this phenomenon is that full-coverage people are less motivated than those who have to make co-payments. To increase effectiveness, when some managed care plans in the United States reimburse NRT costs, they require members to enrol in a complete smoking cessation class as a condition of coverage.67 Even the higher-end costs, however, still reflect the overall costeffectiveness of cessation treatment. coverage of nrt Contrary to the results in managed care settings, studies from more than a decade ago demonstrated that providing free NRT not only enhanced usage but also increased abstinence rates.68–69 Even over-thecounter use of NRT may be enhanced by subsidization,70 although professional health care is the usual setting where the principle of drug coverage has been tested. In evaluating NRT coverage, timing may be everything. A significant study of a Maryland health department’s free NRT program showed that in 2004, although enrolment and short-term quit rates increased, long-term quit rates did not improve. It was suggested that the relapse rate may be reversed if the use of the patches were to be extended beyond the 6 weeks of free supply.71 One approach to paying for a comprehensive public NRT program would be a tax increase. A 1999 study reported that a 10% increase in the tax on cigarettes could cover NRT for 3% to 30% of smokers in developed countries. The specific estimate for Canada was that an

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NRT subsidy would be generated for 9.4% of smokers.72 An alternative to free NRT would be providing a partial subsidy. The World Bank estimated the cost-effectiveness of 25% public coverage of NRT to be around U.S.$300 per DALY.73 conclusion concerning nrt Matching the British consensus, the conclusion of the WHO was that adding NRT to counselling reduces cost-effectiveness.74 Nevertheless, effectiveness is considerably increased, to the point where smoking cessation interventions using NRT compare favourably with other common preventive interventions. So the bottom line is that NRT is certainly justifiable, and even essential, for improving cessation rates. 75 This explains in part why jurisdictions are experimenting with, or considering, free NRT (sometimes with the requirement of a financial means test). A trial program in the state of Oregon that was to last until June, 2005 had to be suspended because demand exceeded supply.76 A widely reported free NRT program launched at the end of 2003 in New York City enabled one-third of its 34,000 enrolees to be abstinent at six months.77 Such short-term campaigns may increase in popularity, especially if pharmaceutical companies continue to donate products; however, it is unlikely that they will address the long-term, institutional problems. For instance, policymakers need to face the fact that many insurance programs for those people with a low income still do not cover smoking cessation therapy.78 The most substantial trial program offering free NRT has been in place for several years in parts of the United Kingdom. The cost-effectiveness in this real world setting has been estimated to be between £600 (U.S.$1,041) and £870 (U.S.$1,509) per life-year saved.79,80 Despite the success of this program, a 2001 editorial pointed out the fragility of the funding stream: The cessation services were not embedded permanently in the public health infrastructure, and this meant that all the gains could be quickly lost.81 bupropion Before 2001 there were no studies evaluating the relative cost-effectiveness of bupropion (trade name Zyban or Wellbutrin) when used for smoking cessation. Since then, sophisticated modelling has been applied in two major research projects, both using the outcome measure of incremental costs per life-year saved. Song and colleagues produced the cost-effectiveness estimates shown in table 9.5 (in 2001 U.S.$).82 The

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Table 9.5 Cost-Effectiveness of Interventions for Cessation, Incremental Costs per Life-Year Saved (U.S.$) Advice or Counselling Alone Intervention: Advice + NRT Advice + bupropion Advice + both drugs Counsel + NRT Counsel + bupropion Counsel + both drugs

3,455 2,150 2,836 1,441 920 1,282

Advice/ Counselling + NRT

Advice/ Counselling + Bupropion

2,391

4,322

1,156

2,123

Source: Song et al. Medical Decision Making (2002).

references were advice or counselling alone, or, for instance, advice or counselling plus one drug. Their conclusion was that the addition of bupropion to cessation advice added an incremental cost of $2,150, less than the $3,455 cost if NRT was added to cessation advice. The other study, published in Switzerland in 2003, evaluated a range of NRT approaches alongside bupropion. Table 9.6 presents the results for men and women (in euros83), with the range in each case reflecting different age groups.84 The incremental cost-effectiveness of bupropion is generally better than that of NRT (or even bupropion added to NRT), although such a conclusion must be treated with caution given the limited efficacy data and absence of economic analysis around adverse drug effects.85 The conclusion of another randomized controlled trial confirmed the basic cost-effectiveness of bupropion. The daily use of 150 mg of bupropion resulted in a cost per QALY of less than U.S.$1,100.86 Hospital and Community Pharmacy Settings Two hospital-based smoking cessation programs have been evaluated in terms of cost-effectiveness. At the Mayo Clinic, a non-physician counsellor developed an individual nicotine dependence treatment plan that included NRT, follow-up contacts, group therapy, and even an inpatient program. The cost-effectiveness was U.S.$6,828 per lifeyear saved.87

146 Part Two: From Setting to Achieving Targets Table 9.6 Incremental Cost per Life-Year Saved of Cessation Interventions (Euros)

Men Women

Patch

Gum

Spray

Inhaler

Bupropion

3,113 to 5,021 3,779 to 6,423

4,266 to 6,879 5,178 to 8,799

3,669 to 5,918 4,454 to 7,570

3,700 to 5,968 4,492 to 7,634

1,768 to 2,851 2,146 to 3,646

Source: Cornuz et al. Eur Clin Pharmacol (2003)

At another centre, the intervention was more modest, featuring a video, self-help material, and follow-up calls. The incremental cost per quitter was U.S.$3,697, and the incremental cost per life-year saved was U.S.$3,680. The researchers maintained that much better economies could be achieved were the program to be replicated with a larger number of participants.88 In another study, a pharmacist-supported approach to cessation was compared with self-directed methods, yielding the results shown in table 9.7 for incremental costs per quitter.89 Based on the results, pharmacist-directed cessation is a cost-effective alternative. Summary All of the cost-effectiveness evidence has consistently and strongly supported the use of NRT and bupropion in smoking cessation. Drugs are not, however, solutions by themselves; rather, they ‘must be considered as part of comprehensive prevention and cessation programs.’90 We turn now to the other aspects of such programs. Gathering evidence on wider tobacco control measures poses an immediate problem. In the past, only limited approaches to reducing the prevalence of smoking have been evaluated in terms of cost-effectiveness.91 That was the consensus 15 years ago, and it seems that the situation has not changed much since: ‘There is a dearth of cost-effectiveness analysis for most of the principal tobacco control interventions, namely, non-price measures other than NRT such as consumer education, smoking restrictions, and advertising bans.’92 Non-Price Policy Approaches The direct evidence of effectiveness for advertising bans and youth access restrictions is weak, which likely also explains why there is so

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Table 9.7 Comparing Cost-Effectiveness of Pharmacist-Directed versus Self-directed Cessation Cessation aid

Incremental cost (U.S.$) of successful quit

None (‘cold turkey’) Nicotine patch Nicotine gum Bupropion

236 936 1,232 1,150

Source: Tran et al. Pharmacotherapy (2002)

little cost-effectiveness analysis of these approaches in the literature. The limited data are summarized in this section. The WHO estimated the cost per DALY in establishing comprehensive advertising bans to be U.S.$189.93 A 2001 study calculated that, to compete with the cost-effectiveness of clinical cessation, enforcement of youth tobacco access laws would have to produce a 5% reduction in adolescent smoking prevalence and cost no more than U.S.$250 per vendor.94 Few data were found on the cost-effectiveness of bans on smoking in public places and workplaces. In one estimate, a WHO estimate put the cost per DALY in enforcing clean indoor air laws at U.S.$358.95 One recently published review concluded: ‘Cost implications to employers with different workplace ETS policies are unclear because little information exists in the literature regarding costs and cost-effectiveness of workplace smoking policies. In a related area, better assessments are needed of the effects of smoking bans on workplace productivity.’96 Mass Media and Other Communitywide Initiatives Mass media advocacy has often taken the form of counter-advertising, including warning labels on tobacco products. Very few economic analyses of basic information strategies have been undertaken. A four-year mass media campaign directed towards students demonstrated a cost per life-year saved of U.S.$696; showing the benefit of economies of scale, it was estimated that the cost would be reduced to U.S.$138, if the campaign were expanded across the United States.97 This result compares with the WHO analysis of information dissemination on tobacco control, which showed an estimated cost per DALY of U.S.$337. Antitobacco advertising is usually an aspect of a more comprehensive campaign; indeed, sometimes the media messages mainly involve

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recruiting for other intervention programs.98 As already noted, it is difficult to isolate how much a particular component contributes towards effectiveness; the cost-effectiveness of each component is equally difficult to determine. One campaign of interest included advertising, a telephone quit line, and a self-help booklet; the estimated cost per lifeyear saved was U.S.$407 and U.S.$733.99 A similar project in 2004 that included telephone counselling reported the cost per quitter to be about U.S.$1,300.100 In a Dutch initiative, publicity was combined with a quit line, a television clinic, and group programs; based on effectiveness projections derived from surveys before and after the campaign, the cost per quitter was found to be only U.S.$12 (which suggests that costs may have been highly underestimated).101 Use of a Swedish quit line in connection with programs that cover NRT expenses demonstrated a cost per quitter of U.S.$1,052 to U.S.$1,360; the cost per lifeyear saved was U.S.$283.102 Interventions targeted to specific populations can be cost-effective. An encouraging result from a U.K. study within a high-risk London population of Turks – among whom an alarming 74% of men were smokers – reported that a campaign including publicity, theatre, and self-help information (all in Turkish) had a cost-effectiveness of £105 (U.S.$182) per life-year saved.103 In sum, this range of cost-effectiveness for mass media and other communitywide campaigns rivals the low end of the results for the clinical cessation interventions. We must be cautious about such conclusions. An earlier summary suggested that some U.K. communitywide programs have ranged much higher in cost, up to U.S.$5,800 per life-year saved.104 This merely underscores the wide variability in program design and expense, not to mention the possible differences in analytical methodology. Self-Help Programs Self-help materials have already been mentioned above as a low-intensity intervention that, while showing less effectiveness than clinical approaches, also involves much lower costs per participant.105 The economic benefit of self-help programs is usually extended by the fact that they provide greater reach into the population of smokers.106 Of course, such reach depends on self-help materials getting into the hands of smokers. This either happens strictly in the clinical setting, with the cost-effectiveness analysis thus being rolled together with

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counselling, NRT, etc., or in communitywide programs. Elixhauser evaluated a combination of mass media and self-help programs 15 years ago and found that they cost from U.S.$27 to U.S.$921 per quitter at one-year follow-up.107 Other research has shown results consistent with those at the low end in Elixhauser’s study. One self-help project estimated the cost per quitter as U.S.$22 to U.S.$144.108 Another program in the Netherlands demonstrated that, at U.S.$37 to U.S.$66 per quitter, self-help materials were at least 3 times more cost-effective than was a group cessation program.109 A 2004 study reported that relapse-prevention booklets were more effective, and thus more cost-effective, than multiple contacts with a health care provider.110 Taking the evidence together, self-help programs seem to be very cost-effective. Workplace Setting A major review of smoking cessation in the workplace noted that little cost-effectiveness analysis has been done within that setting.111 Instead, employers have relied on the extensive cost-benefit literature to motivate their corporate policies.112 A recent Nova Scotia report suggested that Can.$1.00 of investment in cessation programs could yield nearly Can.$9 in long-term benefits.113 The use of bupropion has been one of the few specific interventions assessed in workplaces. A study by Halpern and others demonstrated that every $1.00 spent on bupropion treatment returned $5.00 to $6.50 in direct and indirect savings,114 and a 2004 randomized trial confirmed a positive rate of return from such therapy.115 School Setting The literature on cost-effectiveness of tobacco control in school settings is, if anything, even more limited than for workplaces. One ‘social influence’ program called Project Toward No Tobacco Use (TNT), while yielding only marginal effectiveness, was apparently still costsaving.116 A Canadian cost-benefit analysis of school programs drew a similar conclusion: assuming that a modest 4% reduction in smoking prevalence among students was maintained indefinitely, the cost-benefit ratio would be 15.4, which translates into lifetime savings of Can.$17,400 per person.117

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The main concern about school-based prevention strategies is that the outcomes seem to dissipate within one to four years; in other words, youth smoking initiation is only delayed, not prevented. Nevertheless, a simulation model assuming an original 30% effectiveness fully dissipating in four years still yielded a cost-effectiveness of about U.S.$20,000 per QALY.118 Pregnant Women Who Smoke Programs targeted at pregnant women who smoke tend to be analysed from a cost-benefit approach as well, usually focusing on the health care savings derived from reducing the incidence of low birth-weight babies.119 A 1999 study demonstrated that even a 1% drop annually in the prevalence of pregnant smokers in the United States would save half a billion dollars over seven years.120 In an older study, a lowintensity program of brief counselling was calculated to produce U.S.$6.00 of savings for every U.S.$1.00 invested.121 Likewise, homebased self-help programs for pregnant women who smoke were evaluated 20 years ago and found to produce savings two to three times that of the program costs.122,123 The cost-benefit ratio can be improved by adding components such as follow-up letters and social support.124 Early cost-effectiveness studies in this area determined that pregnancy-specific self-help materials were superior to generic cessation information.125 The cost-effectiveness literature concerning pregnant women who smoke, observed to be lacking in 1988,126 still seems remarkably scarce. Although not a full cost-effectiveness analysis, some studies have estimated the breakeven point for a cessation program with pregnant women; with moderate assumptions, the figures ranged from U.S.$32 to U.S.$80 per participant.127,128 A unique study, relevant to this area and to the issue of prevention detailing in the clinical setting, showed that an educational outreach visit to health professionals was cost-effective when compared with direct-mail strategies for promoting cessation among pregnant women smokers.129 Reviewing another economic point, recent work has confirmed that pregnant women who smoke are more sensitive to tobacco product pricing than the general population is, demonstrating price elasticities of –0.5 to –0.7:130 every 10% increase in price would result in a 5 to 7% decrease in cigarette consumption. One study indicated an even higher

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responsiveness, suggesting that a 10% increase in cigarette price would increase the probability of a pregnant woman quitting by 10%; a similar effect was noted regarding the prevention of relapse.131 In sum, the various economic data further underscore the importance of cessation programs for pregnant women who smoke.

Key Points • The pace of economic research in the area of tobacco control has accelerated, although data for some interventions remain scarce. • One the most well-established effects in public health involves the link between price increases and reduced tobacco consumption; a 10% increase translates into a 3% to 5% reduction in demand, which is a significant result that has few or no associated adminstrative costs. • All forms of clinical intervention for smoking cessation are highly cost-effective; they contribute to the overall reputation of smoking cessation as the gold standard of prevention measures. • There is wide variability in the studies of other programs, making economic comparisons difficult. Media campaigns and self-help approaches may rival the low end of the costeffectiveness range found in relation to clinical cessation. • Cost-benefit analyses of tobacco control in specific settings and populations have been very favourable.

10 Lessons from the Tobacco Wars

Forty Critical Years, Five Key Strategies From the inventory of interventions described in previous chapters, five essential strategies float to the surface. They demonstrate the most significant public health impact over the past 40 years of tobacco control research and implementation. These strategies are: • Increased price for tobacco products, usually through taxation. In terms of preventing uptake or increasing cessation, this approach works for all segments of the population. It is particularly potent for important subgroups such as teens and pregnant women. • Increased control of activities that promote tobacco consumption, as a further step towards ‘denormalizing’ both smoking and the image of the tobacco industry. This is all part of the environmental changes needed to produce a sustained shift in population health behaviour. • Increased involvement of various primary care providers in highly effective clinical cessation strategies for all smokers, and especially for at-risk target groups, e.g., people with psychiatric disorders, patients recovering from illness, or those preparing for surgery. Even as other ‘change agency’ methods are employed in primary care, it is vital to start by covering the real costs to providers and to patients of key cessation interventions, e.g., professional time and nicotine replacement therapy, respectively. • Increased high-impact media communication. This will work best when counter-advertising is combined with a comprehensive strategy that includes the best school and workplace programs together with initiatives tailored for specific populations. Further exploration

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of communication technology, from telephone to the Internet, to support quit attempts should be part of the agenda. • Increased efforts should be made to enforce smoke-free public places and encourage smoke-free homes and automobiles, especially where children are present. In 2003 the World Health Organization, in a report about Europe, highlighted these same five interventions. The authors maintained that, after 40 years of global tobacco control experience and evaluation, this very list of options represented the key priorities for any public health program related to smoking.1 The evidence review offered in our book supports the choice of these priorities and the first key learning from the history of tobacco control – that significant impacts can be derived from just a few high-leverage interventions. Several researchers have recently examined the multidecade antitobacco campaign with a view to abstracting other lessons that may be applicable to obesity and similar public health challenges. Such lessons not only provide a conceptual summary of the interventions found in the preceding chapters, they also anticipate the evaluation of obesity strategies in the next part of this book. In the framework that follows, the insights derived by Mercer and colleagues, published in 2003, have been particularly helpful.2 General Insights on Comprehensive Strategies The first point is that the worlds of public health and primary care must be brought together. Physician intervention, including brief advice, counselling, and pharmacotherapy, is one of the most effective and cost-effective of all disease prevention strategies. Not only are the health benefit returns quicker, but the overall public health impact is larger in the short-term compared with any other component of a comprehensive program. One implication of this assessment is the simple acknowledgment that clinical help for smoking cessation is a vastly underutilized resource. Neither physician efforts, nor any other type of intervention, were seen to single-handedly thwart the broad cultural acceptability of tobacco use and the once ubiquitous social cues that encouraged smoking. Systemic changes and social denormalization of both the tobacco industry and the smoking habit were required to achieve the cessation rate drops that have been observed in developed countries. Success

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required a broad-based effort. It is evident that no single component of a comprehensive program can account for the significant societal changes with respect to tobacco; each intervention, from media advocacy to school programs to social supports, is enhanced synergistically by the presence of other components of a program. The one possible exception to the preceding principle is price increases (usually spurred by taxation), which have been shown to have a strong and sustained effect independent of other interventions; for example, control through pricing has been shown to be more significant than any media campaign. Whether interventions involve taxation or other more experimental forms of environmental engineering, senior levels of government must shape their efforts to maximize support for local policies and programs; there must be multilevel, integrated strategies in all communities and populations to ensure the greatest impact on risk factor reduction. An interview published by the U.S. Center for the Advancement of Health helped to underline this point:3 Recognizing the inherent complexity of behaviour and change is what sets multilevel interventions apart from individual approaches. In some ways, this makes multilevel interventions more realistic, more real world. Synergistic Cost-Effectiveness The difficulty of isolating cost-effectiveness in multicomponent programs was already noted in the discussion of community-wide initiatives in chapter 9. A recent WHO report took a different approach, calculating the aggregate cost-effectiveness when interventions are combined. Table 10.1 offers a comparison of cost-effectiveness for various approaches used in tobacco control, and the synergies that can be created when interventions are combined; although the figures were derived in the context of the most developed countries of Europe, the results are likely very transferable to the North American context.4 The extremely low cost per disability-adjusted life year (DALY) of U.S.$274 for a comprehensive, integrated, and sustained program of tobacco control, one aimed squarely at reducing smoking prevalence and concomitant chronic disease, provides a further powerful incentive to move forward with significant public investment in tobacco control in every jurisdiction. This figure may be compared with the average intervention in health care, which costs approximately U.S.$25,000 per quality adjusted life year saved.5 Thus, a comprehensive tobacco control program offering maximum reach into a popu-

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Table 10.1 The Cost-Effectiveness of Various Approaches Used in Tobacco Control Intervention(s)

Cost / DALY (U.S.$)

A. Tax increase to 89% of retail price B. Clean indoor air enforcement C. Comprehensive advertising ban D. Information dissemination E. NRT / counselling A plus D A plus B plus D A plus C plus D A plus C A plus B plus C A plus B plus C plus D A plus B plus C plus D plus E*

13 358 189 337 2,164 45 79 58 28 63 90 274

Source: WHO European Strategy for Smoking Cessation Policy (2004). *A, B, C, D, and E are not additive costs. When done simultaneously, the cost per DALY has been shown to be less that the sum of the individual components.

lation costs approximately 1% of the amount for average medical interventions. Influence of Social Determinants The experience with tobacco control has taught policymakers to consider the impact of interventions on lower income populations. For instance, taxation may lead to unintended consequences: rather than quitting in the face of higher prices, low-income smokers may simply switch to cheaper brands or further strain their household budgets, for example, taking away from food purchasing power.6 It is commonly recognized that tobacco control, including media advocacy and other forms of health education, should be tailored as much as possible to address the needs of particular audiences.7 People of lower socioeconomic status (SES) represent a unique challenge because they often do not have the resources to respond to counter-advertising in the same way as, for example, those with higher education and incomes.8 The real and ironic possibility is that those with higher incomes may preferentially take up certain forms of health messages, which actually ends up exacerbating the already existing health inequities. Having reviewed some general insights from the tobacco wars, we now look at the lessons attached to particular types of tobacco control.

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Community-Based Interventions The effect of community programs may be relatively unproven, but even if small, given the large number of smokers and the serious health impacts of smoking, the public health benefits may still be high. As noted by Mercer and colleagues, ‘the moderate efficacy of community programs is more than offset by their substantial reach.’9 A critical aspect of community-based planning is the building of capacity, that is, increasing the number of organizations and local jurisdictions engaged in smoking cessation education and tobacco control, plus ensuring adequate finances and infrastructure to support effective strategies over a long time frame. Another key consideration is specific populations at high risk. Above all, focusing on the younger generation and interrupting the development of behavioural risk factors is essential to permanently turning the tide on smoking. Advertising, media advocacy, and other forms of counter-marketing are components that cannot be ignored if a community campaign is to succeed; not only are individual behaviours directly influenced, but a supportive environment is produced that enables other interventions to be more effective. Community interventions, as noted, need to comprise multiple components that produce synergistic effects. They also need to be sustained over the long haul – accompanied by suitable surveillance, solid evaluation, and frequent fine-tuning. School-Based Interventions Since habits such as smoking often get established early in life, school programs have been useful tools in reducing risk factor incidence. Identifying social influences that promote smoking among youth, and teaching suitable counter-measures, have been particularly useful. The effectiveness of school programs is increased when there is a sustained multistage approach, starting in primary school, intensifying in middle school, and offering booster sessions in high school. Parent involvement in school and other community programs is often a key element in their success. Clinical Interventions and Management Even the brief advice interventions advocated for within physician practices may not be well-used unless other staff in the clinical setting

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are recruited and trained to be partners in the process, for example, in helping with intake interviews, physician reminders, administering referrals, and follow-up. Disincentives such as poor or no reimbursement of physicians for their counselling time and of patients for any out-of-pocket expenses, such as those related to nicotine replacement therapy (NRT), are a barrier to expanding smoking cessation programs in the clinical setting, diluting some of the evident benefits of these approaches. Regulatory and Economic Interventions Where there are many regulations, for example, restricting minors’ access to tobacco or clean indoor air policies, it is the intensity of enforcement that has often made the difference between modest and significant effectiveness. The power of macro-environmental economic interventions (such as taxation) in tobacco control has already been noted. Marketing restrictions have also been very effective. Conclusion There are many critical lessons from tobacco control strategies over the past 4 decades that may be highly applicable to other arenas of risk factor reduction and health promotion. The U.S. Institute of Medicine has identified the following key elements as important to the success of any prevention program:10 • Interventions must address the fundamental behavioural and social causes of disease, illness, and disability. • Multiple approaches must be used concurrently – education, social and community support, law and regulations, economic incentives, and disincentives. • Multiple levels of influence must be accessed: individuals, families, schools, workplaces, communities, and even whole countries. • Interventions must recognize the special needs of target groups such as teens, seniors, and other at-risk sub-populations. • Interventions must be applied over the long term; change takes time and any success needs to be duplicated and supported in subsequent generations. • Interventions need to involve a variety of sectors that are not traditionally associated with health care, such as business, engineering, law, and the media.

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To this list could be added the following two encouragements: • Rather than feeling like dozens of initiatives are required, there can be significant impact derived from beginning with a few ‘best of the best’ interventions. • Selected, high-leverage interventions may yield synergistic costeffectiveness when incorporated in a comprehensive program, that is, the combined efficiencies are greater than the sum of the parts. We will return to this issue in the Conclusion of this book. A New Horizon Among other applications, the preceding lessons provide a road map to move forward and tackle the new frontier of obesity control. There have been passing references, however, to the current and absolute differences between obesity and smoking. These distinctions will be highlighted further as we turn to the risk factor of obesity in Part 3. Obesity is increasingly recognized as a major health risk factor in the developed world. The desire, indeed, the necessity, is to achieve the same progress on obesity in this century as was achieved in the area of smoking in the twentieth century. Key Points • After decades of experience, the priority interventions in tobacco control can be captured under five headings: price increases, controlling advertising of tobacco products, counter-advertising, clinical cessation strategies, and smoking bans. • Combining these approaches in a comprehensive program is dramatically effective and cost-effective, with a cost per year of life saved that translates into about 1% of the cost of a similar gain resulting from other interventions across the spectrum of health care. • Just as a broad-based strategy linking together public health, primary care, and government policy has been responsible for changing attitudes and creating reductions in smoking prevalence and related diseases, it is probable that a full partnership will be required to tackle obesity, unhealthy eating, and physical inactivity.

PART THREE One Risk to Rule Them All

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this part of the book integrates three risk factors: overweight/ obesity, unhealthy eating, and physical inactivity. The critical link between them is causal. There is evidence that a large proportion of overweight and obese people can trace their excess weight directly to a persistent imbalance between energy intake (i.e., food calories) and energy expenditure (i.e., physical activity). This basic formula gets translated into important hypotheses related to health care and a balanced lifestyle: • Reducing intake of food energy and/or increasing physical activity can produce weight loss. • Healthy eating (especially an appropriate level of caloric intake) and/or an active lifestyle can prevent weight gain (or regain). The specific aspects of diet and activity in reference to weight control are the focus of the following chapters. How justified is it to coalesce three factors under a lead or ‘ruling’ factor such as overweight or obesity? It could be argued that the other two risk factors warrant a separate treatment. Unhealthy diet and physical inactivity are independent risk factors for disease conditions other than obesity. In other words, there is a health benefit for an overweight person to be physically active and to consume a healthy balance of food, even if this does not eliminate all of the associated disease risk. Whatever their independent status, the interrelationship of physical activity and diet, especially in reference to levels of body fat, probably outweighs their isolated impact on health. The three risk factors, although independent predictors of disease and mortality, are inextricably bound together in terms of biology, personal behaviour, and social environment. This is why risk factor campaigns often integrate obesity, activity, and diet (e.g., the combined focus on nutrition and overweight in Healthy People 2010 in the United States), as do national public health efforts (e.g., the Vitality program of Health Canada). With the growing understanding of the so-called ecological forces at work within society and the built environment, the three factors seem to belong together even more clearly. Identical contextual considerations often come into play with obesity, physical inactivity, and unhealthy eating. For example, a comprehensive healthy school policy can influence all three factors at the same time, and probably should do so if success is to be fully realized.

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Practically, as noted in chapter 1, there is an advantage in having a smaller number of high-leverage health targets. Thus, there is possibly a ‘communication edge’ in public health campaigns when the initiatives are limited to tobacco use and just one other risk factor. But, if they are so bound together, why single out obesity over the other two factors? The rationale may be finally one of ‘optics,’ or how each risk factor plays out in the popular imagination. To put it differently, even though it is a biological rather than a behavioural risk factor (see chapter 1), obesity provides a compelling parallel to tobacco in the minds of the general public. We consider the following features of comparison to be salient: • Like smoking, obesity is hard to hide (even if people mainly use tobacco in private, it is usually pretty obvious that they are smokers). • Obesity and tobacco use have a sort of black-and-white metric attached to them. It is easy to ascertain if an individual fits the profile for research purposes. • Obesity and smoking can only be cast in negative terms with respect to health. There is no ambiguity. In contrast, eating can be either healthy or unhealthy, and the definition of unhealthy can be debated. In other words, obesity and tobacco are both unequivocally bad for health.1 This simple theme contrasts with complex and sometimes conflicted topics such as specific dietary components and physical activity dosage. Finally, given that it is an intermediate risk factor, making obesity the lead factor will tend to draw along its precursors, that is, unhealthy eating and physical inactivity. In other words, a public health focus on obesity will more readily integrate all three factors into a comprehensive program, compared with making either diet or activity the lead priority. In fact, obesity has been shown to be a strong correlate of many disease risk factors in different populations.2,3 The promise of integrating strategic risk prevention around obesity will be reflected in the intervention plan presented in the following chapters. Part 3 of this book begins by further exploring the context for addressing obesity, especially in comparison with tobacco control. This is followed by a review of the potential interventions in much the same manner that we used with tobacco control in Part 2. A summary of all obesity control interventions, categorized by effectiveness and strength

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of evidence, is presented at the end of chapter 14. The hope and promise is that ‘with sufficient knowledge of the effectiveness and required resources of these programs, it will be possible to make rational decisions regarding the best way to maintain and improve the health of the public.’4 Chapter 15 looks at a variety of key issues in the obesity arena; interestingly, one of these topics will bring us full circle, back to the topic of smoking. Chapter 16 explores the idea of multistakeholder collaboration for health. Finally, our conclusion will abstract some overall perspectives on risk factor reduction.

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11 Obesity and Tobacco Control: New Territory and Established Pathways

Growing Girth, Growing Crisis The need for intensified research into both the basic science and the possibilities of controlling of overweight and obesity has become very palpable in the past few years. While there have been remarkable reductions in tobacco consumption in developed countries, health care authorities are alarmed that obesity represents a rising epidemic. In some quarters, obesity has even been seen as a rival to smoking as a top public health concern in terms of chronic disease development and lowered quality of life.1 The resulting call for serious action is understandable. Although the following results could be duplicated for many developed countries, the situation in Canada provides as stark an example as may be found anywhere of this growing crisis. 30.0) The overall Canadian prevalence of adult obesity (BMI increased steadily between 1985 and 1998, more than doubling during the period (5.6% to 14.8%). Of Canada’s provinces and territories, only Quebec and British Columbia, each at 12%, had obesity rates below 15%.2 More recent data has only confirmed the trend lines. The special cycle (2.2) of the Canadian Community Health Survey (CCHS) from 2004, which focused on nutrition, was especially useful as it depended on measured height and weight; this method of data collection is generally superior to self-report, in terms of accuracy. Over the course of 2004 about 35,000 repondents were directly measured. Comparing the results from the last measurement-based survey in Canada (1978–9) is telling: the obesity rate has more than doubled for some ages groups, for example, young adults aged 25 to 34.3 Perhaps even more disturbing are the trends for childhood obesity.

>

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Between 1981 and 1996 the obesity rate in Canadian children aged 7 to 13 years increased more than fourfold – from 2.0% to 10.3% for boys and from 1.7% to 8.9% for girls.4 The CCHS 2.2 measured data confirmed this alarming situation: since 1978–9, the obesity rate for children aged 12 to 17 went from 3% to 9%.5 Based on the latest Canadian Community Health Survey (2003), almost half of the Canadian population is overweight or obese (BMI > 25). Of particular concern from the perspective of social determinants of health is the fact that increased poverty is associated with increased obesity rates. Putting it differently, low socioeconomic status (SES) may be a risk factor for overweight, with the strongest available evidence relating to women.6,7 This underlines the challenge of designing effective interventions that will also recognize health inequities. Tobacco and Fat: Comparing Risky Behaviours Smoking and the behavioural determinants of obesity are not exactly the same thing, in theory or in practice. A major difference involves the complexity and calibration of associated behaviours. In some sense, tobacco use is a single behaviour: one either is a smoker or one is not. The development of obesity, however, involves multiple behaviours that may be modified. Further, the key contributing behaviours have opposite modalities (more activity versus less food), with any positive movement in both cases liable to flip into an unhealthy state at a certain threshold (one can exercise too much or eat too little). In contrast, there is no such thing as stopping smoking to an unhealthy degree. Multiple behavioural inputs means that a question lingers around the topic of obesity: What is the most important component to emphasize – inactivity or poor diet? As well, how do the levers for change differ in each case? Eating and activity represent complex behaviours with many variations, unlike the relatively simple categories of smoking or not smoking. Different types and intensities of tobacco use, and the controversial issue of cutting tobacco consumption (a species of harm reduction), cannot really compare with the hundreds of different food items there are to eat. How does a personal change effort (or public health campaign) select a specific emphasis amid the wide range of physical activities and dietary components available? A socioecological difference between physical activity and diet also needs to be noted. Arguably, there are few political or commercial

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agents actively telling people to exercise less (on the contrary, both business and community leaders are happy to see individuals buy in to exercise products and programs, up to and including new video games that double as exercise routines). By comparison, there are vested business interests that may resist appropriate changes to how food is produced and marketed. In short, the context for change in the case of obesity is a much more complex phenomenon. Finally, it is important to note a significant difference between tobacco use and obesity at the moral level. Simply put, there is no real equivalent in obesity control to the powerful lever of emphasizing the rights (and health) of non-smokers.8 Despite conceptual and practical differences between smoking uptake and/or persistence and becoming obese, there are important overlaps as well. The following key points offer a good start for understanding the parallels: 1 Compulsive eating behaviour can be similar to the addiction experienced by smokers. The phenomenon can be described as ‘using food[s] for gratification beyond their nutritional requirement.’9 Motivational factors enter into decisions to adopt a sedentary lifestyle. Thus, just like with smoking, the art and science of modifying individual behaviours very much comes into play when addressing obesity. Even better than changing unhealthy behaviours, though, are efforts to stop them from starting in the first place. In this way, preventing smoking and preventing obesity in the young have taken on similar urgency. 2 Social influences, including advertising, affect smoking and overeating (and other types of unhealthy eating) in comparable ways. Likewise, environmental constraints and circumstances lead some people to limit physical activity in the same manner that social determinants can promote smoking; an example of this is a transportation policy that promotes automobile use over walking and biking. To put it in positive terms, both smoking and obesity campaigns are able to benefit from any society making ‘the healthy choice the easy choice.’ 3 Reminiscent of the experience in the ‘tobacco wars,’ we can expect certain industrial concerns and other stakeholders to be particularly resistant to policy changes and social marketing aimed at encouraging healthy food choices.

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In the balance of this chapter, we review the lessons from tobacco control that may be applicable when tackling the epidemic of obesity. The sections follow the parallels between smoking and obesity identified above: individual change, environmental strategies, and ‘responding to the response’ of industry. Individual Behavioural Change The current primary care reform movement in Canada provides a good opportunity to invest in new approaches to individual change. This could include adequately educating and compensating health care providers for dietary and exercise counselling, as well as fully covering the out-of-pocket costs of any therapies required by patients. The parallel in tobacco control is ensuring that counselling and nicotine replacement therapy (NRT) or other drugs are made liberally available to smokers seeking to quit. Complementing clinical practice has been a wide range of community programs in neighbourhoods, workplaces, and schools that are aimed at smoking prevention, smoking cessation, or reducing the harm of environmental tobacco smoke (ETS). A similar variety of programs relating to obesity in ‘key change settings’ must be piloted, evaluated, and if successful, launched widely in a sustained way. Schools have been seen as a great place to focus efforts related to pediatric obesity.10 Advertising has a role to play. It is true that experience with most marketing campaigns shows that, on their own, they increase awareness but do not necessarily result in behaviour change. Nevertheless, as seen in the antitobacco movement, they are an important component of comprehensive programs that cue and support individual choices. The simple fact is that behavioural change, even that which stresses personal motivation and self-disicpline, rarely occurs in a social vacuum. Shifting public opinion in healthy directions is vital. ‘Denormalizing’ messages have stigmatized smoking and tobacco company practices in general, as well as in the particular arenas of teen smoking uptake, smoking while pregnant, and environmental tobacco smoke. This represents an important public health success.11,12 When a population is mostly convinced about and on board a particular public health vehicle, the momentum for change can more easily build and be sustained. But, from an environmental or societywide perspective, mar-

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keting is not the only weapon in the arsenal. For tobacco use and obesity, other levers need to be pulled to create the desired risk factor improvements. Obesogenic Environment While research projects are being launched,13,14 the circumstantial or face value evidence is already strong for implicating socioeconomic forces in the increase in obesity around the world.15,16 These forces, when combined, are increasingly referred to in the literature as constituting an ‘obesogenic17 environment.’ An early proponent of the term obesogenic offered the following definition: ‘the sum of influences that the surroundings, opportunities or conditions of life have on promoting obesity in individuals or populations.’18 As already described in this book, such analysis was pioneered with tobacco control. While successful antismoking campaigns have been comprehensive in scope, and involving multiple categories of interventions, it also must be recognized that the vanguard in the tobacco wars was environmental or ecological in nature. With any progress in tobacco control, it is clear that the back was broken through large-scale socioeconomic interventions combined with targeted regulatory and educational efforts. As we have seen, macro-systemic changes to taxation and advertising regulations around tobacco represent policy levers that are without parallel in effectiveness. Such approaches are only rivalled by the sociocultural shifts in attitude brought about by counter-marketing. Indeed, based on successes in the tobacco control battle, there is a compelling rationale to start with environmental interventions and programs that affect the widest audience. The intent is to create the kind of supportive socioeconomic context that will reinforce other interventions, enabling them to be more effective. The rationale for implementing a strong environmental program parallel to that applied in tobacco control includes the following assumptions: • Individuals trying to make complex, sustained behavioural changes, or to adopt and maintain healthy behaviours in the first place, need all the help they can get. • Behaviours around obesity and overweight are sufficiently similar to smoking behaviours to warrant the same sort of environmental supports.

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As with tobacco control, interventions in the environmental sphere may become the most powerful response to obesity. While the research evidence in this area is currently limited,19 many different approaches for preventing overweight and obesity at environmental levels are being actively evaluated. These include: providing price support for healthy food, new food labelling schemes, regulating food advertising on television that is aimed at children, providing training on prevention to physicians, introducing nutrition standards for school meals and vending machines, regulating restaurant portions and nutritional messages on printed menus, and providing exercise facilities in workplaces.20,21 The list of creative proposals seems to be continually growing. How to sort through the options? Even before trying less proven or more complex environmental engineering, an advisable place to begin would involve the mechanisms that have worked most successfully with tobacco. Systemic Strategies Economic Levers The campaigns against tobacco have shown that people are price sensitive, especially younger people, even when the consumable product is addictive. One option, then, is to use special taxation on unhealthy, energy-dense foods and/or subsidies for healthy foods. Linking the two measures may be the most palatable approach from a sociopolitical perspective; in other words, use the new revenue of a junk food tax to subsidize fresh produce for people of lower economic means. Surveys in the United States, for example, reveal that the public will accept taxation on harmful products such as tobacco as long as the revenues are earmarked for related prevention efforts.22 Although economic interventions related to obesity have not been fully tested, the results of price interventions in micro-environments such as school cafeterias and vending machines are both suggestive and promising. A comparable example related to physical activity is the waiving of recreation centre entrance fees, an incentive that was recently offered to Grade 5 students in a small town in British Columbia. A comprehensive and effective economic policy will take into consideration the challenge of food security. How can individuals and families make healthy eating choices if they do not have access to such

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food in their neighbourhoods – or to the resources that allow them make appropriate purchases? Regulatory Levers One of the best options in terms of environmental control might be to ban the marketing of unhealthy foods targeted to captive audiences consisting of children, for example, television advertisements during family viewing hours. Other approaches include enhanced nutrition labelling and the use of nutrition signposting. More complex regulations would include restrictions on demonstrably unhealthy food ingredients such as trans fats – this type of fat has been banned in Denmark. All such measures echo the manufacturing and marketing strictures imposed on tobacco companies in recent decades. Industry Responses Alarmed by mounting media advocacy, proposed legislation, and early litigation attempts, processed food and restaurant lobbyists are beginning to launch a counterattack. The healthy eating proponents have begun to get the attention of business. Media advocacy, given the right context, can be very influential. An example is the popular 2003 documentary Super Size Me, which reportedly helped to change the business practices of one of the largest fast food corporations in the world.23 There are three main thrusts in the campaign led by commercial interests to support the status quo (or at least avoid penalties or imposed changes):24 • Claim that the obesity epidemic and its health impacts are exaggerated. • Point out that any overweight problem is not so much to do with overeating, and especially not overeating certain unhealthy foods containing too much sugar or fat, but rather more the result of physical inactivity. • Note that voluntary changes have already been adopted in various sectors. While these balancing positions are not wholly without merit,25 the most alarming thing to some health advocates is that the public rela-

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tions efforts of the food industry seem to be following a path very much parallel to that of tobacco manufacturers. As such, it is important for public health coalitions and program staff tackling obesity to be aware of the strategies used by tobacco companies to avoid compliance, alert for similar subversive efforts by the food industry, and be prepared to address commercial interest power structures, as appropriate.26,27 To create some early momentum, health advocates perhaps should consider combining all the tools at their disposal – litigation, regulation, public relations, and shame – to change public perception about junk food manufacturers and marketers. On another level, it is critical to ‘avoid as much as possible allowing the [food] industry to influence coalitions, professional organizations, and research agendas so that the field can develop an independent assessment of what it deems the best way to reduce and prevent obesity.’28 In sum, the expanding battle lines with Big Food appear to be drawn in ways that are very reminiscent of the past and current wars with Big Tobacco. Indeed, adding to the circumstantial evidence of a common cause, it is to be noted that some food and tobacco enterprises are owned by the same parent corporation. The perceived corporate intransigence has inspired several recent reviews of the successes in tobacco control, aimed at providing a paradigm for policymakers who are now turning their attention to obesity and other concerns.29 However, the pattern of interventions and stages of development in antitobacco campaigns need to be adapted carefully. As we have indicated, tobacco and obesity are not identical public health issues. Unlike tobacco use, obesity involves two multifaceted determinants that are essential to life: food and physical activity. Obesity control advocates might well be envious of tobacco control colleagues broadcasting their simple message, ‘Don’t smoke.’ Interventions with respect to obesity may need to be more subtle, as they deal with an arguably more complex situation. For example, there could be a partial departure from the overall tobacco control strategy with respect to private companies. Specifically, there may be interest in looking to more cooperative partnerships with the food industry. Since eating is not optional for human beings, food corporations will undoubtedly still be active in the marketplace long after tobacco companies have been substantially marginalized. Whatever the qualifications, the main agenda will remain, namely,

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for the promoters of non-obesogenic environments to be prepared for the strategies of businesses that have a vested interest in maintaining their bottom lines even at the expense of growing waistlines. General Lessons from the ‘School’ of Tobacco Control In addition to the specific pathways through the new territory of obesity, there is guidance from the experience of tobacco control of a more general nature. This can be collected under 3 main headings. Multiple, Simultaneous Attacks The triple threat of reducing uptake, increasing cessation, and controlling environmental tobacco smoke (ETS) has been important, with one battlefront often reinforcing another. The parallel in the realm of obesity control is to ensure that dietary interventions are matched by exercise prescriptions. There is some evidence that a double-barrelled healthy living approach will see the best weight management results. And even better than simply concurrent messages about diet and exercise would be integrated approaches that tackle them simultaneously at the environmental, program, and clinical levels. Comprehensive, Long-Term Approach As we have seen, behavioural risk factors can largely be addressed in two different arenas, within the overall environment of society or through interventions that focus on individuals. The former seeks to make changes that influence entire populations, whereas the latter addresses the needs of individual people who are seeking to change in some way. A comprehensive campaign needs to appropriately address both arenas. In tobacco control, additional focus probably needs to be placed on interventions for the individual. If this is not done, the result can be to create feelings of guilt and frustration among smokers who are motivated to quit but have no access to high-intensity aids to support cessation. The same mistake should not be made with obesity control. The effort needs to be comprehensive and multichannel from the start, including communitywide programs involving social support

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and follow-up, workplace programs, and specialized training in schools that fully integrates the partnering role of parents. At the same time, both macro-environmental and micro-environmental measures need to be introduced and integrated. Examples of localized approaches include cafeteria pricing and promotion, signs directing people to stairways in buildings, providing exercise facilities in the workplace, and so on. Some have suggested that the campaigns and measures need to be much broader, even international in scope. The day may arrive when a treaty such as the WHO Framework on Tobacco Control will seem to be both necessary and feasible in the area of obesity.30,31 A final aspect of any comprehensive approach to obesity control is targeting populations of specific concern. For example, some authorities have argued for special attention towards the physical activity and obesity rates among older people. Perhaps an even higher priority is the prevention of excess weight gain in the first place among young people (see chapter 15); this expression of ‘exposure’ prevention is a precise parallel to reducing smoking uptake among adolescents. Many Players, One Goal As noted by the National Cancer Institute of Canada, ‘increasingly, governments, health professionals and voluntary organizations are applying the lessons learned from the tobacco control experience to tackle the challenge of improving diets, promoting physical activity and reducing obesity on a population level.’32 Lowering overweight and obesity rates will require a full effort from every player in health care, from community agencies to advocacy organizations, not to mention political leaders, educators, parents, and other role models. Indeed, an unequivocal emphasis from all quarters is an essential part of any social-normative momentum. The campaign against smoking has taught us that this type of partnership will likely take decades to construct and will only be successful with the full support of all those involved. Researchers will play a large role in the obesity campaign. The effectiveness and economic evidence is only starting to come in. The next chapters will examine the current state of research around obesity control. While the tobacco story has provided helpful signposts, making real progress is going to require a growing body of evidence concerning which obesity interventions truly are most effective.

Obesity and Tobacco Control

Key Points • In contrast with the successes around tobacco use, developed countries seem to be losing the battle with obesity. • The situation with children is especially alarming, with juvenile obesity rates quadrupling in some jurisdictions in just 15 years. • Learning a lesson from tobacco control, it is clear that tackling the ‘obesogenic environment’ in a campaign of sustained communitywide prevention is especially important. • Proposals for systemic change probably will encounter resistance from industry and other vested interests. These roadblocks to progress must themselves be strategically resisted. • Primary prevention focusing on reducing energy intake and/ or increasing energy expenditure in an affected individual is also a vital component of a comprehensive, long-term plan.

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12 Obesity Control Evidence (1): Reducing Energy Intake

As we move into the topic of controlling overweight, unhealthy eating, and physical inactivity, readers will notice that the evidence presented is less substantial than that related to tobacco consumption and exposure to secondhand smoke. This is largely due to the longer track record enjoyed by tobacco control and the intellectual effort directed to tobacco issues. Contrary to the relatively recent advances in obesity science, the relationship between smoking and adverse health effects was clearly identified many decades ago. Three studies published in 1950, one each by Levin et al.1 and Wynder and Graham2 of the United States, and one by Doll and Hill3 of the United Kingdom, ended ‘the age of innocence about the blithe charms of the cigarette.’4 Thousands of research studies followed, probing various aspects of the tobacco exposure and health relationship, as well as examining efforts to reduce initiation rates and increase cessation rates. By comparison, understanding the relationship between obesity and adverse health outcomes is a much more recent project. Likewise, understanding the related and independent effects of physical activity and nutrition on health are still emerging fields of study. Nevertheless, evidence does exist for interventions in these new arenas of public health. The relevant data are described and evaluated here over the next three chapters. Data Sources and Organization Here, the same pattern is followed as with tobacco control, that is, consulting the results of respected review programs such as the Cochrane Collaboration and the Health Technology Assessment (in the U.K.),

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augmented by other published reviews as appropriate and available. Compared with the dozens of regularly updated reviews in the area of tobacco control, there is only a handful in connection with obesity, and only one-third of those projects have made it beyond the protocol stage at this point. As a sign that this area is very much a work in progress, the Cochrane reviews being developed on the issue of weight reduction include ones on:5 • • • • • • • •

pharmacotherapy surgery dieting or meal replacements psychological and/or behavioural interventions exercise vitamin and mineral supplements intragastric balloons alternative therapies (e.g., chitosan and ephedra).6

The long-term effectiveness of many of these interventions has not even been studied, let alone proven. That reviews of even the most mainstream interventions such as exercise and counselling are incomplete is itself very telling. One obstacle in the area of obesity control revolves around the type, quantity, and quality of available studies. However, as noted in the introduction to Part 2, measurement of effectiveness in the area of population health cannot (indeed, should not) depend only on the randomized clinical trials (RCTs), which are the staple of many review programs. Other types of study designs that are standard in epidemiological research also can play a vital role in building an evidence base. A useful principle would be be to rely on the best available results, not wait for the best possible data, tweaking the programs as new data emerge. Based on the best available evidence, then, the key obesity interventions are outlined below, together with approaches that seem to be promising candidates for further evaluation. This and the following two chapters look at the following types of initiatives to reduce the risk of excess body fat in a population: • interventions to reduce energy intake • interventions to increase energy expenditure • interventions that in some way combine the previous two types.

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As with tobacco control, a further categorization of interventions will occur under each of these main headings, ranging from community-based to comprehensive strategies. Finally, at the end of chapter 14, a full summary of obesity control interventions is provided. The Canadian Diet We turn first to the reduction of energy intake. These interventions mostly relate to various types of diet change and, especially, to modified fat or sugar consumption. From a population health point of view, it is always good to know the baseline. Statistics Canada tracks the average diet of the country’s population each year. One caution about such data is that they measure consumption indirectly through the idea of food ‘disappearance,’ or the quantity of food available and purchased. Waste is not fully accounted for, so consumption is likely inflated. Nonetheless, as long as the statistical method is consistent, gross trends are still revealed; indeed, the most recent results tell an important story. Red meat and poultry consumption was basically unchanged in 2003 compared with the previous year. Overall milk consumption declined, although more cream was consumed. Rice consumption increased modestly, continuing a trend; the ingestion of other cereal products, especially those made using wheat flour, has greatly increased over ten years, although they were slightly depressed in 2003 (perhaps reflecting the popularity of ‘low carb’ diets). Canadians ate more fruit in 2003. Vegetable consumption has also been rising, although potatoes count for nearly half the amount eaten. Surprisingly, fish consumption dipped slightly in 2003, reversing the trend seen in the preceding ten years. Most significantly, the overall ingestion of energy-dense oils and fats continued to rise, as did the total consumption of food. The positive aspect of this pattern is that the recommended requirement of many lipids, vitamins, and minerals is being regularly met, but the price being paid at the same time is high caloric consumption: as estimated indirectly by caloric availability, average consumed calories has been rising by 1% to 3% year over year in the past decade.7 Although the average young adult needs about 2,500 kcal per day (more for men, less for women),8 according to Health Canada the average caloric intake for the whole population has been significantly higher than that level – and climbing – since 1995.9

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The recently published data on 2004 food availability (again, acting as a proxy for consumption) contain both good and bad news. Canadians on average ate 37.6 kg of fresh fruit, up from 37.1 kg in 2003, but the consumption of fresh vegetables fell to the lowest level since 1992. While declines in the consumption of french fries and potato chips accounted for part of the drop, Canadians also ate less of such staples as onions, lettuce, and carrots. Most directly related to the topic of this chapter, the overall use of oils and fats continued to increase (2% to 3% over 2003). The Statistics Canada report noted that ‘much of these products are in the form of salad oils and shortening, used in salad dressings, deep-fried products and baked goods.’10 One factor frequently implicated in weight gain is the rising consumption of energy-dense, sugary beverages such as full sugar soft drinks and fruit juices, especially among youth.11–14 A mark of the complexity of obesity causation and dietary issues is that contrary evidence exists concerning soft drinks (and other high-calorie snack food), letting them off the hook as the main culprits in growing waistlines.15–18 One simple conclusion is that the source of higher calorie intake by overweight or obese people can vary over a range of food types: the basic issue is overeating, regardless of the precise food product implicated. Another facet of modern high-calorie diets is the frequency of eating away from home, especially at fast-food restaurants.19 The assumption is that this practice, which is driven by contemporary lifestyles that involve less time for meal preparation at home, leads to eating larger portions of foods that are high in fat and/or sugar. The research results supporting this explanation are convincing.20–5 A comparison with the 1999 B.C. Nutrition Survey (BCNS) of food group consumption is instructive. This was the first such comprehensive survey conducted in British Columbia in more than 30 years. The recently published report on the data showed a lower percentage of the B.C. population consuming ‘five a day’ servings of vegetables and fruit when compared with the 2000–1 Canadian Community Health Survey (CCHS) data for the province (35.4% vs 40.1%).26 The results, however, cannot be directly compared, as the data were derived from different years using different methodologies. The BCNS concurred with another, more positive picture derived from the CCHS concerning average daily servings; thus, while the majority of adult British Columbians did not meet the minimum recommendations for vegetable and fruit intake, in many cases they only needed to add one or two servings per

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day to meet that goal. The encouraging conclusion that may be drawn is that progress towards vegetable and fruit consumption targets is well within the realm of possibility. Dietary Change Diet and nutrition have been a focus of extensive study for many decades. Working out the scientific details of the biology of food, its biochemical constituents, and their relationship to metabolic functions has been a major research interest. The actual application of the insights to individual and public consumption practices, however, has proceeded at a lower level of intensity, with the notable exception of the ubiquitous interest in ‘losing weight’ or ‘dieting.’ Failure in dieting attempts is a serious factor in the obesity epidemic. Resistance to the widespread adoption of dietary changes may be due to the relatively poor track record around reducing the consumption of certain food groups in order to produce a sustained weight loss. The evidence for several proposed dietary interventions is very inconsistent.27 For example, the best known U.S. population-based campaign, that is, promoting the 5 a Day vegetable and fruit servings program, has produced what can only be described as equivocal results (see below). Nonetheless, initiatives around eating continue unabated. The dietary interventions seen most commonly in clinical care and/or public health programs have included: • Reducing dietary fat or sugar and carbohydrate intake to decrease caloric intake or achieve other health benefits • Increasing vegetable and fruit consumption • Increasing dietary fibre intake. These intervention categories coincide with Canadian dietary guidelines, as well as recent nutritional risk factor targets in developed countries, for example, Healthy People 2010 in the United States. They are also consistent with recent research on diet and overweight.28–30 The clinical application of limiting overall calories or specific energy-dense foods is a focus of this chapter, as are other programs specific to certain settings and wider environmental policies directed towards healthy eating and reducing unhealthy weight across whole populations. In terms of individual behaviours, the effectiveness of low-calorie,

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and specifically low-fat, diets is reviewed here in the context of weight maintenance as well as other beneficial health effects. The other dietary strategies noted above, which involve increasing the consumption of reportedly health-enhancing foods, have mostly been applied at population levels, for example, the promotion of 5 a Day, or five daily servings of vegetables and fruit.31 Campaigns around dietary fibre have also been very popular. These food group goals at the population level receive a more cursory treatment in this chapter insofar as they only have an indirect impact on obesity control. Community-Based Interventions Communitywide dietary interventions are sometimes referred to as nutrition education. When behaviour change is intended, the usual name applied is nutrition promotion (that is, a species of health promotion). The most popular framework for health promotion strategies of all types is ‘social marketing’ or the adaptation of commercial marketing principles to the planning, execution, and evaluation of programs to influence the health-related behaviour of target audiences.32 Media Campaigns Multimedia campaigns related to dietary change are a major component of nutrition promotion. They exhibit substantial heterogeneity: many different media are available, the campaign can vary in intensity and duration, messages can range from basic health and nutrition information to more sophisticated prompts for dietary behaviour change, and the intervention may be part of a multicomponent strategy looking at more than one risk factor. The multiple interventions used in the latter case, naturally, make it difficult to isolate the specific effect of the mass media component. Many authorities have expressed doubt about whether mass media campaigns, in the absence of other programming, can create sustained behavioural change.33 A similar caution was recently raised concerning the popular educational strategy of nutritional labels on processed foods. An extensive body of literature underlines the fact that, while using the labels is associated with lower intakes of total fat, saturated fat, and cholesterol, the very ‘consumer use’ of information that is key to the equation is itself influenced by determinants that may require additional interventions. For example, people with high fat intakes in

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their diet do not search for nutritional information as much as healthy eaters do. This creates an interesting Catch-22 for public health planners: how to get influential information in front of people who truly need it the most and encourage them to act on the information in positive ways.34 Despite these obstacles, the amount of money poured into tobacco, food, and other advertising provides circumstantial support for continuing to develop effective counter-marketing tools. If marketing did not work, corporations would not continue to invest billions of dollars in advertising. Few studies have tested the suggestion that mass media campaigns for diet change may not by themselves be effective. On this front, two different projects in West Virginia demonstrated that paid advertising alone was able to change milk-drinking habits and increase the use of fat-reduced products, although the effect was not sustained after the campaign ended. In one study, the city where the advertising occurred showed 13% of the population temporarily switching to 1% milk, compared with 7% of the population in the control city. The study also noted that more intensive social marketing in a third city produced a 20% switch rate.35 The most impressive dietary results have been seen in programs that offer a consistent message over a long period, for example, the famous 25-year health behaviour project in North Karelia, Finland. Among other changes, fat consumption and cardiovascular disease have been dramatically reduced in that region.36 Again, the mass media component was only one aspect of a multicomponent campaign. For its time in history, however, the media advocacy was very sophisticated. For example, there was a weekly television program in which the blood pressure of 10 North Karelians was measured. This show, which was very popular all over Finland and ran for 15 years, anticipated the power of today’s ‘reality TV.’ The director of the North Karelia Project recalls being stopped by strangers and asked if such and such a guest from the previous show had managed to stop smoking.37 a focus on vegetables and fruit The 5 a Day campaign, the prototype of which began in California in 1988, has now spread throughout the United States. Versions of the U.S. campaign also exist in many other countries.38 The related Canadian program is called 5 to 10 a Day for Better Health.39 Based on the principles and practices of social marketing, the various vegetable and

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fruit campaigns most typically depend on a mass media effort. Other components of a more full-spectrum social marketing approach have included enhanced public relations, point-of-sale promotions, nutrition labelling, cookbooks, and sponsorships, as well as initiatives in schools, workplaces, and churches (see below). Dietary interventions such as 5 a Day that are directed at ‘free living’ populations can be tested through before-and-after surveys, although it is difficult to control for confounding variables.40 Studies have definitely shown that the vegetable and fruit message ‘got out.’ For example, awareness in the United States of the need for 5 daily servings of vegetables and fruit rose from 7% in 1991 to 19% in 1997.41 The real test, though, is the resulting consumption patterns. Randomized research trials of the program in the United States have consistently shown an increased consumption of servings ranging from 0.2 to 1.7 per day. But an analysis that adjusted for demographic shifts concluded that there had been no significant changes.42 This is confirmed by the major U.S. risk factor surveillance system, which showed little change in nationwide vegetable and fruit consumption between 1994 and 2000.43 Some other research work, conducted more from an economic perspective, also cast doubt on the impact of advertising on vegetable sales.44 Other components that are sometimes part of a communitywide program for vegetable and fruit consumption have been investigated, including: • A newsletter, covering basic strategies to improve vegetable and fruit consumption, resulted in significantly higher intake; there was no difference in the level of improvement when the newsletter was ‘computer-tailored’ to match the characteristics of the recipient.45 • Point-of-purchase interventions in supermarkets appear to have limited effect,46 although some positive changes in consumption have been experienced with kiosks that provide computer-tailored advice.47 conclusion With an understanding of the potential benefits across a population resulting from even a small average dietary impact, new strategies within mass media and other communitywide programs are worth pursuing. The current reality cannot be ignored, namely, that increased awareness of nutrition principles and standards is the most common

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result of such campaigns. Behavioural change remains elusive, especially once the intervention ceases. Not surprisingly, the greatest changes are seen in subpopulations selected for some degree of social cohesion and peer support, for example, in schools (see below) and churches.48,49 The same can be said for people who are otherwise specially motivated, for example, those at high risk of disease. Within highly networked, educated, and motivated groups, fat intake has been reduced by 10% to 16% of energy, three to four times the rate seen in unselected cohorts.50 A recent meta-analysis of health communication campaigns in the United States concluded that they have small measurable effects in the short term.51 This general conclusion is borne out by the results of nutrition promotion campaigns (although the data are very limited). For example, a British review of health promotion noted that the best dietary result expected for a general, unselected population was 1% to 4% reduction in the degree of fat contribution to overall energy.52 This level of change could still be useful, and across a whole population may well represent a significant public health benefit. One explanation offered about the success rate in Finland (described earlier), especially when compared with similar U.S. projects, is that there was a relatively high rate of community initiation and involvement.53 Another interpretation suggests that the program achieved the ultimate goal of the ‘diffusion of innovations theory,’ that is, reaching a critical mass of adopters where the message and behavioural impact had a self-sustaining momentum.54 It should be noted that even sustained changes created through an intervention often are equaled over the long term by background changes in the control group of a study (this is the concept of ‘secular drift’).55 Evaluating the Finnish project is further complicated by other confounding factors commonly encountered in epidemiological studies. Nonetheless, North Karelia, Finland, stands out as a salutary model from which all jurisdictions might learn. Appropriate Meals Available at Restaurants With the increasing frequency of individuals and families eating out in developed countries, focusing on the menu choices in restaurants makes good intuitive sense. Canada is no exception. Some estimates put the Canadian rate of dining away from home at about five times every week or about a quarter of the meals.56 This is consistent with

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food expenditures reported by Statistics Canada. Of Can.$123.76 per capita spent on food each week in 2001, a remarkable Can.$37.52 was for meals purchased in restaurants.57 The spending levels on meals outside the home were even higher for Western Canada. The key issue is that restaurant food as a whole tends to contain more fat and saturated fat, and less fibre.58 Expanded portion size has also been a growing concern.59 Policy responses have been slow in coming. The menu assessment tools,60 proposed legislation for nutritional labelling on menus, and other interventions are still being developed. Likewise, relevant outcome studies are at an early stage.61 For example, one recent project investigated whether a promotional campaign could influence the sale of heart-healthy menu items; the slight increase in such sales was not found to be statistically significant.62 On other fronts, there is limited and somewhat dated evidence showing that labelling the healthy choices on menus can increase sales of such items.63 One restaurant strategy is ‘Eat Smart!’ This is Ontario’s program to encourage, among other things, good nutritional choices on menus; awards of excellence are given to establishments that meet the published standards. A similar program in Australia is being applied to child care centre menus.64 Access to Fast Food Restaurants The broader environmental context with respect to restaurants has been investigated. One U.S. study demonstrated that the number of fast food establishments in African-American neighbourhoods was 50% higher than in Caucasian areas. Similar results were found when comparing restaurant distribution against neighbourhood income levels: the lower the median income, the higher the concentration of fast food outlets.65 There is a clear link with the discussion in chapter 11 concerning high obesity rates in low income families; the energydense, prepared food in such restaurants appeals to those with less disposable income. In general, fast food consumption has been strongly linked to obesity.66 The planning tools to construct an intervention for socioecological determinants are not clear, nor have health outcomes related to such disparities been fully assessed. So, the priority and urgency of response to the geographical placement of restaurants has yet to be determined. What seems evident, though, is that the same socioeco-

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nomic forces that reinforce health inequities also play a role in determining the range of food available in neighbourhood eateries. Portion Sizes The issue of large portion sizes has been on the public health agenda for some time. Leisure options and disposable income in developed countries, and in certain segments of the population in developing countries, allow for such overeating habits. Such consumption patterns have, in turn, been linked to rising obesity. Any individual behavioural tendencies to overeat are probably reinforced by environmental conditions. These include relatively low overall food prices and the availability and/or marketing of large, even ‘super-sized,’ restaurant meals.67 Although the issue is becoming increasingly apparent, the appropriate responses are less so. Even the unlikely scenario of legislating against large fast food meals does not offer a complete solution; it is hard to imagine how the determined consumer could be prevented from ordering generously à la carte or simply consuming multiple combo meals! A more effective individual approach for weight control related to portion size may be to increase dietary fibre content, and in particular, to enhance vegetable and fruit consumption.68 Aside from other health benefits, intuition would suggest that filling up on high-fibre foods of low energy density but with a high satiation effect might preclude overeating other types of foods that are less healthy.69 However, research that compares ‘deprivation’ strategies for dietary change against more positive ‘substitution’ strategies is at an early stage.70 Low-Cost Vegetables and Fruit in Low-Income Communities In Canada, a report from 2003 suggested that access to vegetables and fruit (and milk products) may be constrained in low income families.71 Personal economics and awareness are not the only barriers.72 Various studies have shown that the range of healthy food available in stores is more limited in low income areas; as well, proximity and access to the stores is poor.73 One study reported that ease of access to a supermarket increased daily household fruit consumption by 84 g per adult.74 Most of this research has been conducted in the United States. One intervention proposed was to regulate stores that are licensed to receive WIC

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(Women’s Infant and Children) Supplemental Food Program coupons, requiring them to provide a well-displayed supply of fresh vegetables and fruit. Other supermarket-based interventions have been suggested that could be potentially useful in a variety of neighbourhoods, including:75 • • • •

price reductions or coupons for healthy foods point-of-purchase information on healthy choices more convenient and attractive displays promotional campaigns.

As one example, a store in one of Winnipeg’s76 poorest neighbourhoods provided subsidized fruit baskets that children can afford to buy as an alternative to purchasing candy.77 Few of these strategies have been rigorously evaluated. Studies have reported positive results for measures such as consumer knowledge, but provided little data on consumption patterns themselves. The positive affect of pricing in settings such as schools suggests that this may be a productive avenue of intervention. In general, price control may prove to be especially significant, considering the ironic fact that diets high in fat and sugar currently represent the low-effort option for consumers. It can cost more, and be more time-consuming vis-à-vis preparation, to eat a healthy diet.78 Commercial Diet Programs Although technically not part of community health efforts, the very popularity of various off-the-shelf diet products and group-based supports has generated some valuable research. One 2004 review of well-known programs showed that weight loss certainly was possible over the short term through using some of the available options.79 But there was wide variation in the weight loss achieved from person to person, and the difference between the various approaches was small on average. The main cautions about these interventions, as with self-help dieting, is the frequent experience of relapse and the lack of data on related adverse health effects.80 A 2005 review confirmed that the evidence of effectiveness for commercial programs is suboptimal.81 The one exception is Weight Watchers; it represents a commercial approach that has demonstrated a significant effect for up to two years.82

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Workplace-Based Interventions Diet interventions within workplaces are at an early stage of development, especially compared with the number of smoking cessation programs in the same setting. We review the limited available evidence. Dietary Fat The most effective projects for fat reduction in the workplace focused exclusively on dietary intake (and sometimes serum cholesterol levels) rather than on multiple risk factors. They also usually included individual screening and counselling. The 1997 U.K. health promotion review83 (mentioned earlier) found only four high-quality studies based in the workplace, a complement that has not changed appreciably. One project, conducted at 16 sites, showed a modest reduction in fat intake of 1% of total energy. Vegetables and Fruit The elements of the most effective vegetable and fruit interventions in workplaces include: • • • • •

dedicated trained leadership involvement of workers in the program design social support, especially by family members environmental changes, e.g., what is served in the cafeteria integration with a wider community campaign.

An Australian review found only two applicable studies, from which the preceding list of features was derived. The reported increase in vegetable and fruit consumption over the study period amounted to 0.1 to 0.5 servings per day.84 Based on the quantity and quality of the literature, it would be fair to say that much more research could be initiated in the workplace setting with respect to energy and nutrient intake. School-Based Interventions School programs to create dietary change have demonstrated highly

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variable components from study to study. Typically they include one or more of the following: • • • • •

curricular material schoolwide events such as assemblies and contests snack breaks posters and related communication methods changes in cafeteria menus.

Recruiting parents and teachers to be involved is also common. It is important to distinguish the traditional public health strategy based on educational approaches from the more recent appreciation of environmental influences on dietary choice.85–88 These influences include food availability, price, promotion, role modelling, and more diffuse social norms. Environmental approaches can be thought of as those that do not require the individual to actively select themselves into the program, that is, where the influence works through ‘passive’ channels.89 Educational / Multicomponent Schools are a very common location for health education programs, especially at the elementary level. Most of the controlled studies found in one 1997 review of health promotion programs were set in some form of school (including universities); the majority of the studies actually looked at children aged 8 to 12.90 The research for older student populations is more limited; the small number of reliable postsecondary studies included in a review from 2004 was at least 10 years old, and one dated from 25 years ago.91 Given the target age groups, it is to be noted that the evidence in this section overlaps with the discussion of childhood obesity in chapter 15. A variety of curricular influences on diet have been tried, usually in the context of broader programs that include other types of interventions. The most effective health education interventions in schools incorporated these features:92 • A focus on diet alone, or on diet and exercise • Longer and more frequent classroom contact, i.e., a higher intervention ‘dose’; the rule of thumb is that 15 hours tends to improve knowledge acquisition, while 50 or more hours creates an impact on behaviour

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• Parental and family involvement, sometimes enhanced by a takehome activity or snack • Food service changes: point-of-sale promotion, increased variety, and better presentation • The involvement of industry • A supportive school environment. It is evident that classic educational approaches work best within a multi-component strategy. As usual, the more complex the program, the more difficult it is to isolate the components that most contribute to any observed success. At the younger age level, two programs received wide attention in the 1990s: CATCH and Know Your Body. The latter program consisted of five basic components: skills-based health education curriculum, teacher and/or coordinator training, biomedical screening, extracurricular activities, and program evaluation. Results have been modest. For instance, CATCH decreased fat intake by 2.5% of total energy – which is within the range seen for typical communitywide programs.93 As for vegetable and fruit interventions, most of the relevant studies found by an Australian review published in 2000 were from the United States and involved children from low income families, age 9 to 11.94 Of the 16 studies examined, 14 had achieved a positive effect either for vegetable and fruit consumption or for fruit alone. The change ranged from +0.20 to +0.77 servings per day.95 A 2003 review, updated using information from the few additional studies published since the Australian report, generally agrees with the positive assessment of school-based interventions for vegetable and fruit consumption. Fruit consumption was especially enhanced in the examined projects, with increases ranging from 0.2 to 0.6 servings per day.96 A few studies in this area looked at discrete interventions that were used in combination with health education. Some of these interventions show promise, but all need further research. These approaches include:97 • peer modelling and incentive schemes98 • newsletters to train teachers and carers • price reduction for targeted food in the school cafeteria (see the next section): one project that cut prices in half managed to increase fruit sales four-fold.99

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Cafeteria Practices The main emphasis of environmental interventions in schools has been cafeteria practices, for example, the pricing strategy noted above. Some results have been promising. In one 2004 study, however, Perry and colleagues reported on a cafeteria intervention that showed only very modest gains (mainly related to fruit consumption). Their conclusion, based on this and other work, was that the multicomponent programs (described in the previous section) are more potent than stand-alone cafeteria strategies.100 This is the same conclusion reached by the U.S. Agency for Health Care Research and Quality in 2001.101 Vending Machines and Other Food Choices Even if contributing to only a small part of the obesity prevention story so far, the environmental approach to ‘healthy schools’ is becoming a stronger feature of planning and research.102 Vending machines, for instance, are a well-publicized target. One recent Minnesota study showed that only a third of its schools’ food vending machine items qualified as low-fat.103 A 2003 report by the B.C. Provincial Health Officer noted that 90% of middle and high schools sell full-sugar soft drinks, with about 10% having exclusive contracts with manufacturers.104 There is increasing concern about full-sugar soft drink consumption, especially in association with childhood obesity; we should recall, though, that the evidence is not uniform.105–7 New York City recently banned all sweetened drinks and snacks from school vending machines. A ban has also been instituted for elementary schools in Ontario, and a similar approach is being considered in British Columbia.108 Such initiatives are still relatively new, and the evidence base for the resulting health effects is not yet well developed. Other researchers are pursuing incentives rather than bans. Price decreases may be a more powerful incentive to choose healthy food than prohibited items or health warnings.109–11 One study by French and colleagues showed that reducing the price of low-fat snacks in vending machines by 10%, 25%, or 50% increased sales of those items by 9%, 39%, and 93%, respectively; interestingly, profits per machine were not affected.112 Recent research in the context of a teacher lounge examined the effects of increasing the availability of low-fat items in vending machines and adding some promotional material. These

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changes increased the sales of such items, although the results were deemed to be suggestive rather than statistically significant.113 Home-Based Interventions Family-oriented weight loss treatments have been compared with individual approaches. This usually involves recruiting family members to participate together in a weight loss program, or otherwise engaging people to play a supportive role for the primary person in the study. It seems obvious that psychological support and moral encouragement from friends and family should make a difference. Sometimes the research bears out this intuitive assessment. In a recent review of the literature, pooled results from four studies showed an overall additional weight loss of almost 3 kg when social support was part of the intervention.114 But the results of all such research have been mixed. In 1992, for example, a group of Mexican-American women were randomly assigned to a control group (with only basic information distributed), individual group (information plus in-class training), or family group (i.e., spouses and children attended the classes as well). Although both intervention groups lost significantly more weight than the control group did, there was no difference between them.115 A study published in 1999 was more promising. Individuals were recruited with three friends or family members for a four-month behavioural treatment. They maintained their weight loss (at sixmonth follow-up) at almost three times the rate of subjects recruited individually.116 Despite the equivocal evidence, many jurisdictions are persuaded that a focus on the family is vital for obesity control, especially when working with children.117–18 This conviction strongly informed the framework for one major national report, Healthy Weight 2008 – Australia’s Future: The National Action Agenda for Children and Young People and their Families.119 Clinical Interventions and Management Paralleling the efforts with tobacco control, physicians’ offices and other primary care settings are being closely examined as significant points of attack in the war on obesity.

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Brief Advice Given the experience with smoking cessation efforts, the impact of even minimal interventions by physicians and other providers should not be underestimated. One study found that merely giving people a one-sentence assessment of their fat intake as a percentage of total energy was enough to create significant decreases in fat consumption!120 As with smoking cessation, physician advice to change exercise and dietary habits is reported to be a strong predictor of intention and actual attempts to change.121 The brief physician advice that is most feasible (and affordable) in the primary care setting can be enhanced in effectiveness when combined with self-help materials and interactive communications such as telephone follow-up. Nutritional Counselling In contrast with counselling focused on weight control per se (see below), nutritional counselling is distinguished by a general emphasis on diet as related to a variety of health benefits (although weight loss is often one of the goals). The literature examining the effect of dietary counselling in primary care and other settings is complex. For example, there are many possible counselling components, including dietary assessment, self-help materials, interactive reinforcement (computer-tailored mailings, telephone counselling), small groups, family involvement or other social support, and goal-setting. The characteristics of the most successful interventions comprise: • Higher intensity counselling (more time, more frequent, more personalized) • Well-trained counsellors • Special research clinic setting (rather than primary care) • Using a greater number of counselling components. A comprehensive review of counselling for healthy eating was undertaken for the U.S. Preventive Services Task Force in 2003.122 A total of 21 studies met the eligibility criteria, such as using a randomized and controlled design; 17 of the studies looked at dietary fat, 10 at vegetables and fruit, and 7 at dietary fibre.

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Counselling for reduction of total saturated fat was effective in all cases and showed medium-to-large decreases in 12 studies. In 9 studies that specifically measured change in percentage of calories derived from saturated fat; net reductions ranged from 0.9% to 5.3%. To put this effect in context, achieving the upper limit of this range would represent a reversal of the population-level increase in calories from fats and oils over the past 10 years in Canada. Of 10 studies focusing on vegetable and fruit consumption, 8 showed only small-to-medium increases (< 0.8 servings per day), although in some cases this would be enough to move an individual into the range of recommended daily ‘dosage’ of this food group. The 2 studies with larger effects increased consumption by fully 1.4 and 3.2 servings. Counselling for increased dietary fibre produced small positive effects (0.3 to 1.6 g per day) in 5 studies. Another 2 projects showed net average changes of about 3 g per day at one-year follow-up; the best observed result was an increase of 6 g in dietary fibre intake for women. One of the main limitations in this area of research, in fact a common problem for most risk factor interventions, is the scarcity of long-term outcome data. Given that, even the modest impacts of counselling on dietary change seen in this review need to be treated with caution. Weight Loss Counselling Apart from general patient education related to diet, there are many different types of psychological intervention used specifically for weight control. Behavioural therapy and cognitive behavioural therapy (CBT) seem to be the methods of choice.123 They can be employed by physicians or by other members of the health care team to whom an overweight person may be referred. Behavioural treatments aim to provide the individual with coping skills to handle various cues to overeat and to manage any lapses in pursuing a health-enhancing diet or physical activity; therapeutic techniques include goal-setting and self-monitoring.124 Cognitive strategies seek to identify and modify aversive thinking patterns and mood states.125 When combined, the two forms of therapy appear to improve weight loss and prevent weight regain.126 As noted earlier, systematic literature reviews in the area of specific counselling for weight loss are still in progress. The protocol for one

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such review project notes that counselling appears in major clinical guidelines for obesity control mostly because ‘diet and exercise combined with psychological interventions comprise an intuitively powerful weight loss program.’127 In other words, it seems like a good idea. Unfortunately, the evidence base for this claim is limited. There are still major gaps in knowledge concerning diet, physical activity, and a combination of the two within structured or lifestyle interventions; specifically, data are limited concerning the role and benefit of counselling (whether involving behavioural, cognitive, person-centred, or even full-fledged psychoanalytical techniques). Group Counselling The best delivery mode for weight loss counselling has not yet been well investigated. A comparison of individual and group-based treatment has been the focus of a small number of trials. Some preliminary research suggests that group interventions may be at least as effective as individual ones, presumably due to the benefits of peer advice and social support.128 The results summarized in one study actually showed a very modest benefit in weight loss with group programs as measured over shorter follow-up (0.74 kg at 18 months), but an opposite effect later (i.e., smaller weight loss in group settings after five years).129 Dietary Treatment Sometimes behavioural changes aimed at weight loss are encapsulated in a ‘dietary prescription,’ which is often supported by various types of counselling. The general results of applying the classic clinical mode of writing a prescription have not been encouraging. Although reducing calories by any means produces a weight loss (providing energy expenditure levels are maintained), the usual pattern observed involves a gradual regaining of weight.130 The main reality is that much more research is needed in this area, including which type of diet stands the best chance of success. Studies usually fall into one of two categories: comparing two types of diets or comparing a diet to no intervention. The main outcome of interest is weight loss, but biological measures such as blood pressure, blood lipids, and blood glucose are sometimes included. A brief survey of the literature follows.

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The only review completed by the Cochrane group so far examined low-fat approaches in comparison with classic low-calorie diets. A small number of studies were included that provided results at 6-, 12-, and/or 18-month follow-ups. There was no significant difference in weight loss between the two types of diet at any point, nor for other outcome measures such as serum lipids, blood pressure, and fasting plasma glucose. The conclusion was that fat-restricted diets are no more effective than calorie-restricted ones in achieving long-term weight loss.131 The Health Technology Assessment (HTA) group noted that the lowfat category contained the greatest number of studies and that it is the diet most commonly recommended in the United Kingdom.132 Two of the low-fat diet studies reported prevention of type 2 diabetes onset, as well as reduced use of hypertension drugs. For reasons that are not clear, the HTA program only looked at one of the several available studies comparing low-fat and low-calorie diets, noting that there was a modest benefit for the low-fat approach.133 But the trials comparing these diets with no intervention controls actually leaned in the opposite direction, giving the edge to the low-calorie approach.134 Given the small amount of research, the HTA did not ultimately find sufficient evidence of benefit for low-calorie or very low-calorie diets versus control groups. Three studies comparing these two approaches generally revealed no significant difference in effectiveness; it is worth noting, however, that the greatest weight loss in any available study was seen in the case of one very low-calorie diet with a small sample of obese patients.135 The HTA did find a significant short-term improvement in weight loss with a protein-sparing modified fast versus a lowcalorie diet (3.57 kg at 12 months), but the effect disappears over longer follow-up; at 18 months, the weight loss was only 0.69 kg, and there were no statistically significant changes in blood lipids. In sum, a final conclusion about optimum weight loss plans remains unclear. The volume of research continues to increase in unabated fashion. The recent popularity of modified low-carbohydrate diets undoubtedly will prompt a systematic review of the growing literature on this intervention; some of the data appear to be supportive of the health benefits of a low-carbohydrate intake.136 Approved Drug Treatment Two main drugs have been approved in Canada, the United States, and other jurisdictions for long-term treatment of unhealthy weight:

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orlistat and sibutramine. Orlistat reduces fat absorption from the intestine (lowering caloric intake) by inhibiting gastrointestinal enzymes known as lipases. Sibutramine is an appetite suppressant, thought to work by influencing norepinephrine and serotonergic pathways in the brain. It reduces food intake by producing a feeling of satiety. These two drugs are normally only recommended for obese patients or overweight individuals with significant co-morbidities. They are both modestly effective, as is described below. It is important to note that both of these drugs have significant side effects. Orlistat may reduce the absorption of fat-soluble vitamins (A, D, and E) and other nutrients; as well, there can be gastrointestinal problems associated with fat malabsorption, unless dietary fat is restricted while taking the drug (thereby introducing a significant confounding effect in any research). Sibutramine may increase blood pressure and induce tachycardia (i.e., increased heart rate), as well as cause stroke and disturbances of vision through eye pain or hemorrhage. There were 28 reported adverse reactions associated with the use of sibutramine in Canada between 28 December 2000 and 28 February 2002. As a result of this experience, the drug is undergoing a safety review in Canada, as well as in other countries. orlistat Orlistat is an effective aid in weight loss, and it is also helps to reduce other biological risk factors. Multiple studies have confirmed this effect, as described in a 2004 review in the American Journal of Clinical Nutrition.137 The Cochrane group concurs with the overall positive assessment of the drug.138 All 11 studies included in their review showed greater weight reductions for orlistat plus diet versus placebo plus diet.139 The weight loss in lower risk patients was slightly better. In the five studies reporting on waist circumference (WC), orlistat consistently produced greater reductions compared with placebo, ranging from 0.7 to 3.4 cm. As noted, the impact on biological risk factors has also been very positive. Pooled results showed that orlistat-treated patients achieved greater reductions in total cholesterol levels, by a margin of 0.33 mmol/L.140 Positive results for low-density lipoproteins were of a similar order, but more modest for triglycerides; however, the highdensity lipoproteins, so-called good cholesterol, were marginally reduced. Finally, nine of the trials showed a decrease in blood pressure

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with orlistat, and five led to lower fasting blood glucose levels that were statistically significant. As with other areas of health care and prevention, long-term results are always of great interest. In four of the studies, a second year was spent evaluating weight maintenance. Orlistat-treated patients regained 7% to 22% less weight than did patients on placebo therapy. Gastrointestinal adverse events were the most commonly reported. Fecal incontinence was seen in eight of the studies; in the three studies reporting incontinence as a separate end-point, the incidence was 6% higher in orlistat-treated patients compared with controls. sibutramine Of the two approved weight loss drugs, sibutramine could be clearly deemed the superior one were it not for a somewhat poorer safety profile (see below). The Cochrane group reviewed three sibutramine weight loss studies; they showed an average reduction somewhat higher than with orlistat.141 Sibutramine-treated patients also demonstrated larger reductions in waist circumference, waist-to-hip ratio, and body mass index. A 2005 RCT confirmed that a mean weight loss of 5.0 kg is possible with sibutramine; the weight loss was dramatically higher when drug therapy was combined with lifestyle-modification counselling.142 Most biomarkers were not significantly different between the intervention and control groups, except for triglycerides (0.18–0.23 mmol/L lower with the drug) and ‘good’ high-density lipoproteins (marginally elevated). Sibutramine was also tested in two weight maintenance studies, where it performed better than placebo. In one case, 27% more patients maintained at least 80% of their original weight loss after two years.143 Adverse effects observed in the same studies included statistically significant increases in blood pressure and pulse rates. The 2005 RCT confirmed an increase of 3 mm Hg in diastolic blood pressure in the group given sibutramine therapy alone (or the drug plus brief counselling), but the differences in blood pressure among treatment groups disappeared after 1 year. The only adverse events potentially related to sibutramine that caused people to discontinue treatment were heart palpitations and facial rash.144 other drugs There are many other weight loss drugs being investigated, especially those falling in the sibutramine category, that is, suppressing appetite

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through interfering with the neurotransmission of norepinephrine, dopamine, and serotonin in the brain. Some of these agents are approved for short-term use in appetite suppression, but they demonstrate frequent adverse side effects. No high-quality studies exist for any of these products that meet normal review criteria (including following patients for at least one year). Two drugs used in the treatment of diabetes – a condition that is often associated with obesity – have been connected with weight loss as well. One drug, metformin, helps regulate glucose levels, while acarbose inhibits the digestion of starch and sucrose. These drugs are sometimes used as diet aids, but neither drug has been officially approved as a therapy for weight loss per se. Three studies with metformin conducted in the 1990s were reviewed by the Health Technology Assessment group; all three showed modest weight loss at 12 months. A longer term project, the U.K. Prospective Diabetes Study, demonstrated small weight losses with metformin at 5, 10, and 15 years.145 In 2002, some evidence for weight reduction was demonstrated for both metformin and acarbose used in patients at risk for developing diabetes.146,147 The conclusion of an HTA review was that both agents are relatively ineffective for weight loss therapy. Significantly, neither of these drugs made it into the Cochrane review of pharmacotherapy for weight loss. Finally, rimonabant, a drug developed to treat obesity and aid smoking cessation, will be receiving increased attention in the coming years. It is currently at the point of phase 3 trials.148,149 conclusion In the many and various reviews of drugs for weight loss, eventually all roads lead to Rome: ‘Rome’ in this case being guarded approval. The weight loss results provided above for orlistat and sibutramine are consistent with previous health technology assessments that examined all studies up to June 2000,150,151 as well as with a general assessment published in May 2004.152 In sum, a meta-analysis of 108 studies in 2002 confirmed that modest weight losses is all that one can expect with any drug currently on the market.153 Is the small degree of weight loss seen with the use of pharmacotherapy still a benefit? Several studies have shown that even modest weight loss (5% to 10% of original weight) leads to an improvement in cardiovascular risk factors such as high cholesterol and high blood pressure. The results of the relevant Cochrane group review, for exam-

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ple, are consistent with such findings. What is missing from the literature are studies strongly linking weight loss to reduced cardiovascular events and related mortality, rather than to biological intermediates such as lowered blood pressure.154 The best evidence for an association between weight loss and reduced disease burden has emerged in the context of diabetes, where lower incidence and associated mortality have been achieved with drugs such as metformin and acarbose over longer term follow-up (2.5 to 3.3 years).155 The specific studies showed a modest weight loss, which may have contributed to the preventive effect.156,157 The suggestion of these and other studies is that even a small amount of weight loss (< 5 kg in some cases) can be associated with a significant reduction in the incidence of diabetes (and related mortality). Admittedly, though, no clear, direct connection has yet been made (based on randomized, controlled trials) between weight loss and a reduced burden of diabetes or any other specific disease (see the full discussion on this topic in chapter 5). Surgical Treatment Bariatric surgery158 is considered an intervention of last resort for morbid obesity, after various other forms of medical management have been attempted. Morbid or severe obesity is usually defined as a body mass index (BMI) of 40.0 or more, or 35.0 or more with serious co-morbidities.159 Approximately 3% of Canadian and U.S. adults are morbidly obese, with the rate in the United Kingdom being somewhat lower.160,161 The proximate aim with each type of bariatric surgery is to restrict intake and/or malabsorption of food; the ultimate aim is modification of eating behaviour, that is, smaller quantities of food consumed, and generally eaten more slowly.162 Although the term stomach stapling is firmly fixed in the public mind, the methods of bariatric surgery are actually quite diverse. The main procedures include biliopancreatic diversion,163 gastric bypass,164 gastroplasty,165 gastric banding,166 and many variations of the same.167 Jejunoileal bypass168 is an older procedure no longer recommended in the United States or Europe due to its poor safety profile. All such surgeries are considered serious and invasive, and all are associated with significant risks of perioperative morbidity and mor-

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tality. Whatever the side effects of bariatric surgery, in most cases any risks are thought to be outweighed by the benefits.169 surgical outcomes Bariatric surgery is generally highly rated. A U.K. review published in 1997 concluded that all types of surgical interventions, and especially gastric bypass and vertical banded gastroplasty,170 were effective (although the included studies were rated poor in quality).171 More recent data concerning the usefulness of bariatric surgery continue to be reasonably positive; significantly, some results are available over longer term follow-up. For example, a Canadian study published in 2004 followed two cohorts of morbidly obese patients for a maximum of 5 years. The treatment group (n = 1,035) underwent bariatric surgery, whereas the age- and gender-matched control group (n = 5,746) were not surgically managed. The initial excess weight loss with surgery was 67% (no weight loss data were reported for the control group).172 Even more impressive, the effectiveness of bariatric surgery for weight loss and other health benefits was confirmed over ten-year follow-up in a 2004 controlled study in Sweden.173 comparing procedures The 18 studies included in the most recent Cochrane review of bariatric surgery mostly compared different procedures.174 The surgical approaches were evaluated as follows (ordered according to decreasing weight loss effect): gastric bypass > gastric banding > vertical banded gastroplasty > horizontal banded gastroplasty. These results were confirmed by a U.K. National Institute for Clinical Excellence review, as well as by the extensive Health Technology Assessment review of 2002.175 In all cases the superiority of gastric bypass for weight loss was noted; this conclusion must be balanced by the fact that gastric bypass is a technically demanding operation. Despite the deluge of U.K.-based reports, the safety and effectiveness of different surgical procedures remains uncertain. For instance, a 2004 meta-analysis of an even wider range of studies yielded somewhat different results for the comparative effectiveness of procedures, as measured by the percentage of excess weight loss (see table 12.1).176 The only result consistent with the other reviews is that gastric bypass is superior to gastric banding. The focus of this meta-analysis

202 Part Three: One Risk to Rule Them All Table 12.1 Effectiveness of Surgical Weight Loss Procedures Type of surgery

% excess weight loss +

Biliopancreatic diversion Gastroplasty Gastric bypass Gastric banding

70.1 68.2 61.6 47.5

Source: Buchwald et al. JAMA (2004)

primarily involved the impact of bariatric surgery on co-morbidities of obesity. The results showed that diabetes was resolved in an astonishing 76.8% of patients, and hypertension was resolved or improved in 78.5%. laparoscopy Surgeries such as vertical banded gastroplasty can be done laparoscopically (i.e., through small incisions allowing camera-guided procedures). This method has fewer complications than open surgery, and shorter recovery periods.177 It should be noted, however, that using laparoscopic or open methods of surgery for the same type of bariatric procedure has demonstrated no difference in weight loss.178 intragastric balloon The use of an intragastric balloon has been an available option for the treatment of severe obesity since at least 1985.179 Such a device is usually used for relatively short periods (three to six months) in conjunction with diet, exercise, and behavioural therapy. While significant weight loss is often observed, more carefully designed studies180–183 have typically determined that the ‘independent benefit of balloon treatment beyond diet, exercise, and behavioural therapy could not be demonstrated.’184 Regulatory and Economic Interventions As with tobacco control, policy-based interventions have already been somewhat anticipated under the heading of community-based interventions. Here they become the main focus of discussion as we seek to extend the evidence base and intervention options beyond the rather

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limited models introduced earlier, for example, with respect to the prevalence of fast food restaurants in different socioeconomic zones. Nutrition Labelling or ‘Signposting’ The existing regulations for nutrition labels on packaged foods in Canada are already very clear and comprehensive (see 2003 Guide to Food Labelling and Advertising.)185 In fact, Canada reportedly has the most stringent nutrition label requirements in the world.186 Labels using a standard format for ingredients and quantities per recognized unit of weight have been mandated by the Dietitians of Canada. All food companies need to comply by 2007. Health Canada estimates that the revised labels could save over $5 billion in direct and indirect costs over 20 years. Despite setting the global standard, there are health advocates who want to see the labelling system extended beyond its current applications. A major Canadian legislative initiative, Bill C-398, was withdrawn for further study in March 2004. In addition to expanded nutrition labelling on meat and processed foods, it would have required fast food chains to post caloric content next to items on menu boards and full-service restaurant chains to disclose the saturated fat, trans fat, and sodium levels of its meals. One of the responses of the Canadian restaurant industry was to point out that voluntary nutritional changes were already taking place. These include low fat and low carbohydrate menu options, the elimination of trans fats in some situations, and promotions focusing on a healthy lifestyle.187 With so-called nutritional signposting, food manufacturers whose products meet defined criteria are allowed to display a logo on the product. In New Zealand a signposting campaign in cooperation with the food industry was aimed at decreased salt levels in food; the project led to substantial reductions of salt in breads, breakfast cereals, and margarine.188 The main caution with signposting is the confusion that can result if every food company or store creates its own system. Legislation to create consistent criteria and symbols would be prudent. Food Regulation Some food components are considered especially dangerous. For example, trans fat has recently been shown to increase the risk of heart

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disease. It is a by-product of fat hydrogenation, a process used to preserve food products or change their properties, for example, keeping oils in a liquid state and ensuring margarine stays ‘spreadable.’ In common use for over 75 years, trans fats are found in about 40,000 food products.189 On 23 November 2004, the House of Commons in Ottawa voted to set up a task force to recommend ways to reduce trans fat ‘to the lowest possible levels.’190 Although exploring such approaches is on the agenda of other countries, so far only Denmark has instituted bans on partially hydrogenated oil in its food supply. The fast food industry in that country has already adapted to the new regulations, which were launched in 2003.191 The U.S. Food and Drug Administration has issued a ‘final rule’ effective 1 January 2006 requiring the labels on conventional foods and dietary supplements to declare the trans fatty acid composition.192 In the past, the food industry in North America has suggested that trans fat levels appearing on the labels of all processed food products, plus ongoing programs to encourage voluntary product reformulation, should be sufficient interventions to protect consumer health. Another cautionary position recently put forward is that a premature ban on trans fats could lead to companies using more of the harmful saturated fats in their products while they are working towards identifying substitute oils.193 Taxation One suggested regulatory response to the obesity epidemic has been to tax high-fat foods in a targeted manner, similar to tobacco product taxation. As for a suitable target, it is true that certain animal or saturated fats may be more harmful than those derived from plants and fish. But all types of fat contain approximately double the amount of calories per gram compared with carbohydrates or protein, making them a highly dense form of energy. So, apart from the direct health impact of consuming some fats (e.g., elevated serum cholesterol levels), excessive intake of any form of energy-dense fat may contribute to overweight. In 2003 the British Medical Association recommended a 17.5% valueadded tax on all fatty foods; an earlier estimate suggested that such a policy could save up to 1,000 premature deaths a year in the United Kingdom.194 Similar taxes have been proposed for foods that are high in sugar.195

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Directing consumers towards healthy foods using price controls may not automatically reduce the obesity problem. A 2003 study noted people who chose low-fat foods tended to eat larger portion sizes; in the end, almost the same amount of energy was consumed per person.196 Studies have suggested other complex relationships between portion size and energy density, possibly even a moderating effect depending on the order in which food types are consumed.197 Perhaps the most feasible regulatory proposal in a Canadian context would be a tax imposed on full-sugar soft drinks and other snack foods, similar to that seen in several U.S. states (even though twothirds of them repealed such measures in the 1990s).198 This very narrow targeting reflects the fact that evaluating other types of foods, even high-fat products, is a complex undertaking. But focusing on so-called junk food is not simply a matter of convenience: such campaigns are consistent with the understanding that one of the most likely culprits in obesity development (and other aspects of poor health) is energydense, nutrient-poor snacking. As the 1999 B.C. Nutrition Survey confirmed, fully 30% of the province’s energy intake comes from outside the 4 recommended food groups, for example, from foods such as donuts, alcohol and candy.199 But before any new legislation is framed, it is important to recall that the evidence linking any specific sort of food to obesity rates per se remains open to debate. Other Economic Levers Although further research is needed, some studies have shown that combining advice to eat more vegetables and fruit with direction to eat less fat is an effective intervention for weight management.200 From a regulatory point of view, it could be effective to extend what is known from school cafeterias to the macro-level, that is, by using a tax on fatty or sugared foods to subsidize vegetables and fruit purchases (and consumption) among low-income populations. This ‘eat more’ strategy has the additional advantage of reflecting a positive behavioural message (similar to ‘exercise more’), which may be more psychologically ‘palatable’ and powerful than prohibitions such as ‘eat less fat and sugar.’ A further, indirect economic approach, involves providing individual families with the means to purchase better food. As dietitians noted in their report, The Cost of Eating in B.C.: ‘Those living on income assistance are three times more likely to report food insecurity.’201

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Given the strong link between lower socioeconomic status and both obesity and poor diets, policies that address inadequate incomes could contribute to healthier living in general, and weight management in particular.202 We have provided an exhaustive list of interventions related to moderating energy intake, but this is only the beginning of the story. We turn in the next chapter to the other side of the obesity equation, namely, increasing energy expenditure.

Key Points • The evidence related to obesity control is at an early stage of development, especially compared with the decades of results from efforts to reduce tobacco consumption. • Public media efforts that have shown the best results in terms of healthy eating have been sustained over a very long time period, but even the more modest results of shorter campaigns may be beneficial when accumulated across a whole population. • Unlike with tobacco use, comprehensive approaches that add taxation and other regulatory approaches to media campaigns are not yet well developed; currently, the greatest momentum is attached to expanding nutrition labelling on food products. • With the amount of ‘eating out’ in developed nations, more and more attention is being paid to menu prompts, portion sizes, and even the prevalence of fast food restaurants in lowincome neighbourhoods; related intervention options have not yet been well studied. • Some school-based health curriculums have approximated the results for decreased fat intake seen in typical community campaigns. Pricing interventions that incline students towards healthy options in cafeterias and vending machines show more promise, and involving whole families in healthy eating and associated weight maintenance may be even more successful. • In the clinical setting there are effective counselling and pharmacotherapeutic approaches to influence eating and weight gain, although a clear population dietary prescription remains elusive. If required in situations of morbid obesity, there are available effective surgical options.

13 Obesity Control Evidence (2): Increasing Energy Expenditure

The rationale for pursuing physical activity in weight control includes the evidence that maintenance of weight loss is enhanced when individuals adhere to exercise programs.1 There is also a theoretic base for utilizing exercise or other physical activity in weight reduction. Energy is expended in the body in a number of ways, including:2 • The thermic effect of physical activity: this can range from 0% of total expenditure to more than 50% in elite athletes • The thermic effect of eating food: 10% to 15% of expenditure relates to digestion and absorption • The resting metabolic rate, or the amount of energy needed to maintain the structure and function of the body; this can account for 60% to 70% of all energy expenditure. Exercise can increase the energy used in each of these pathways, as well as affecting the ‘other side of the equation’ by reducing energy intake. The latter effect may be primarily psychological, for example, the result of improved body image, self-esteem, and overall mood promoting better adherence to healthy eating. Accounting for Physical Activity Research on the relationship between physical inactivity and health is complex – because of the variety of interventions, activity measures, and target outcomes that must be considered. The concept of exercise itself needs to be fine-tuned. Experts identify no fewer than three types

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of activities useful in maintaining a healthy body, namely, endurance, flexibility, and strength exercises. As a further complication, the benefits of more strenuous exercise must be weighed against potential adverse effects, including injury, osteoarthritis; and myocardial infarction. Recently, the risks of playing pick-up hockey for older men in Canada were highlighted.3 At the same time, such cautions can introduce another incentive for following a moderate daily regimen of physical activity: data have shown that the risks associated with occasional vigorous exercise decrease when a person is engaged in regular activity.4 Even combining types of exercise into the more general category of physical activity is not so simple; activity must be distinguished, for example, from various definitions of physical fitness. Some authorities suggest that fitness measurements are more important health indicators than energy expenditure or even obesity itself.5 The cut-off points for healthy activity levels are an area of ongoing discussion. Standard guidelines for physical activity have commonly suggested 30 minutes or more of at least moderate-intensity physical activity on all, or most, days of the week. The recommended length of time has recently been increased to 60 minutes, especially for children.6,7 The following are considered examples of moderate-intensity physical activities:8 normal walking, golfing on foot, slow biking, raking leaves, cleaning windows, and light restaurant work. Jogging, brisk walking, shoveling snow, and racquet sports are examples of vigorous activities. Step-counting has become a popular way to monitor activity. But the daily number of steps recommended for maintaining health in the average younger adult ranges from 7,000 to 13,000, showing that even such a simple measure is marked by uncertainty.9 As with so many aspects of physical activity research, the ‘science’ of step-counting continues to evolve.10 The energy output for many types of activities has been estimated and made available in catalogues. This makes it possible to track energy expenditure on the basis of recalled activities as recorded in activity surveys. The most commonly reported indicator in this arena is basic physical inactivity or sedentariness, as measured by a low amount of time spent during the day in work-related functions or leisure-time exercise. Data Sources and Organization Several reviews will be consulted to evaluate the effectiveness of interventions aimed at increasing the level of physical activity (or reducing

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the level of inactivity). As noted in chapter 12, the basic review work is just beginning for activity in relation to obesity. Of the 36 reviews in the Cochrane database with either ‘exercise’ or ‘physical activity’ in the title, most are related to activity as an intervention in itself for other disease conditions; interestingly, only a few reviews looked at physical activity as a preventive measure. Most of the very few reviews of actual interventions that promote physical activity are still in the protocol stage. The Canadian Task Force on Preventive Health Care (under its previous title, the Canadian Task Force on the Periodic Health Examination) offered a brief review of promotion in the primary care setting in 1994.11 A more extensive review of interventions to increase physical activity was completed in 2001 by the U.S. Task Force on Community Preventive Services (TFCPS), the group that also contributed a valuable synthesis of data on smoking interventions that was used in Part 2 of this book. The TFCPS effort served as an update of the literature review in the landmark U.S. Surgeon General’s report of 1996 entitled, Physical Activity and Health. The U.K. Health Development Agency, which has been cautious about some of the non-experimental studies included by the TFCPS, offered its own useful ‘review of reviews’ in 2004; their work managed to both test and augment the conclusions reached by the U.S. task force. The TFCPS divides the interventions to increase physical activity into four major categories, with the latter two existing at an early stage of development:12 • • • •

informational approaches behavioural and social approaches environmental and policy approaches urban planning approaches.

The TFCPS outline will be adapted to fit the standard organizational grid that has been developed for previous topics discussed in this book. As has been the pattern up to now, each intervention is briefly described and the related evidence outlined. It will quickly become apparent that many of the interventions currently demonstrate a scarcity of high-quality research data and/or a lack of consistent positive effect on physical activity. Whatever information is available is reviewed here and then collected in a final summary of obesity control interventions at the end of chapter 14.

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Community-Based Interventions The centrepiece of most community-based interventions are largescale, intense media campaigns, with messages directed to large audiences through radio and television, newspapers, billboards, and mailings. Communitywide efforts typically go beyond advertising and incorporate a multicomponent approach; this can include support groups, counselling, risk factor screening and education, community events, and environmental efforts such as creating new walking trails or building exercise facilities. A complication of such multidimensional interventions is the impossibility of isolating individual components for evaluation. In general, the information transferred in communitywide campaigns is meant to change knowledge about the benefits of physical activity, enhance awareness of opportunities to increase physical activity, and explain methods for overcoming any barriers and negative attitudes that may be getting in the way of being active.13 More recent reviews of the literature have suggested that communitywide campaigns can be effective in increasing physical activity, with absolute gains of up to 4%.14 This positive assessment seems to contradict the three well-known field trials conducted in the United States in the 1980s. Those extensive studies were all geared towards reducing cardiovascular disease and each of them included a range of interventions. Generally, the effectiveness of such approaches was described in the 1996 U.S. Surgeon General’s report as ‘disappointing.’ The evidence for improvements in physical activity was, at best, mixed; when observed, gains were qualified as modest.15 In one trial, there was actually an average weight gain in treatment cities over six years, although at a lower rate than in the control cities.16 To be sure, slowing down negative secular trends can be seen as a form of victory, albeit not one designed to fire the imagination of policymakers or the general public. The Surgeon General’s report depended on a more limited range of studies that were compared with recent reviews. As well, the generally pessimistic conclusion in 1996 may have reflected the high hopes that had surrounded these expensive large-scale projects. The bottom line is that the Surgeon General’s overall assessment is not far off the mark. The average of 4% growth in physical activity reported in more recent reviews, although significant, would still have to be qualified as modest.

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Mass Media Campaigns Promotional and informational campaigns use various media to reach a large, undifferentiated audience. These interventions are distinguished from communitywide projects per se by the absence of the other intervention components noted above. Some but not all measures in three available studies showed a modest trend towards increasing levels of physical activity. The reviewing body rated the small number of studies as low in quality and, consequently, recommended caution around dependence on media campaigns.17 The U.S. Surgeon General’s report of 1996 concluded that mass media campaigns had little impact on physical activity rates in populations.18 However, given the intense commitment to, and effectiveness of, advertising in other spheres (e.g., marketing unhealthy lifestyles), it does not seem prudent to abandon this intervention quite yet. Each media campaign is unique, and the most effective ones may not yet have been invented and tested. A promising example of community health promotion is the 10,000 Steps initiative launched in various jurisdictions. Such campaigns have sometimes been paired with the mass distribution of pedometers (i.e., step counters).19 Although the research is still at an early stage,20 many people can reach 10,000 steps a day by merely adding a 30-minute walk to their other routines; this initiative alone can lead to significant health benefits (including weight loss).21 Dr Ron Plotnikoff of the University of Alberta is testing four different strategies to encourage people with type 2 diabetes to get regular physical activity, including the use of pedometers, combined with booklets to record the number of steps taken each day.22 A much larger ‘natural experiment’ was launched across Canada in early 2004, involving the distribution of thousands of pedometers, mass advertising, and a web-based evaluation system.23 Point-of-Decision Prompts Signs can be placed by elevators and escalators that encourage people to use nearby stairs, with messages stressing either weight loss or other health benefits. In five single-intervention studies (i.e., only looking at the effect of the signs), posted messages were found to increase the number of people using stairs. Baseline rates of stair use were gener-

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ally low, ranging from 4.8% to 39.6%; adding point-of-decision prompts on average created a 54% increase.24 Individually Adapted Health Behaviour Change There are interventions that focus on teaching behavioural management skills, usually in the context of social environments that support people wanting to make changes. Group or individual behavioural counselling is often part of the intervention, typically with friends or family enlisted as the main social support. These kinds of interventions can be set in home, school, or work contexts. Behavioural change programs often teach individuals skills to incorporate physical activity into everyday life. These programs, which usually are tailored to individual interests and readiness for change, include goal-setting, building social support, problem-solving, and relapse resistance. All of the interventions evaluated by one review were delivered in group settings or by mail, telephone, or other directed media. In 18 studies, behavioural change manoeuvres were effective in increasing physical activity, as measured by various indicators. The median estimates based on pooled results indicated a 35% increase in the time spent being physically active and a 64% increase in associated energy expenditure. A limitation in this review was the lack of information about length of follow-up.25 As a comparison, the Health Development Agency in the United Kingdom noted two reviews, covering a total of 13 trials, where individuals were drawn from the community for treatment. Interventions included: weekly group counselling, mailed self-help materials (some based on a stage-of-change approach), exercise testing and prescription, telephone advice and support, supervised exercise in a facility, and behavioural modification. The evidence supported the following conclusions:26 • Interventions targeting individuals are effective in producing shortterm changes in physical activity and could even be effective over longer terms (although, according to the U.S. Surgeon General’s review, the evidence for sustained changes is not strong). • Sustained changes are most likely in the case of behavioural modification skills adapted to individual needs and/or regular contact with an exercise specialist.

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• Longer term changes are possible with a focus on moderate-intensity physical activity such as walking; recourse to vigorous sport or special exercise facilities is not essential for health benefits.27 Community (Non-Family) Social Support There are interventions that focus on building and maintaining social networks that in turn support behavioural change, for example, buddy systems, walking groups, and workplace networks. A review identified nine studies focusing on social support, the majority of which showed increases in the duration and/or frequency of physical activity. The median net time spent in physical activity increased by a range of 20% to 44%, suggesting that this is a good type of intervention to incorporate in any obesity control plan.28 Workplace-Based Interventions Workplaces afford unique opportunities to enhance physical activity levels for the same reasons that tobacco control is often emphasized in such settings. One of the main attractions is simply the amount of time people spend at work, creating an accessible population that may be open to health promotion initiatives. Examples of such interventions, which are mostly directed towards individuals, include:29 • health screening and counselling for physical activity • goal-setting, reinforcement, and relapse prevention • testing, prescription, and instruction at workplace fitness facilities. Some reviewers do not isolate the workplace as a platform for physical activity enhancement. This oversight is surprising, in that workplace physical activity programs are reported to reduce shortterm sick leave and health care costs and increase productivity.30 It is true, however, that the evidence in support of such claims appears to be meagre. According to a recent Canadian report on obesity, the same gap exists for weight control in general: ‘Very little literature explicitly addresses the promotion of healthy weights through worksite policies.’31 A literature search revealed that workplace programs were evaluated in the U.S. Surgeon General’s report, as well as in one other major review article.32 The conclusion was that typical workplace interven-

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tions have yet to demonstrate a significant increase in physical activity or fitness. One reason for this might be low program participation rates by employees. Some research has examined ecological or multidimensional approaches in the workplace.33 This theoretical framework, which is not limited to occupational settings or physical activity, looks at improving a health category across the entire ‘system’ within which a population operates. The relevant systemic levels identified are:34 • intrapersonal or individual factors (e.g., employee fitness level) • interpersonal or social factors (e.g., peer and boss influences) • institutional, organizational, and/or cultural factors (e.g., the corporate leadership commitment to promoting physical activity) • community factors (e.g., integration with wider physical activity campaigns) • public policy (e.g., governmental incentives aimed at encouraging physical activity). The physical environment also plays a role; its effect usually is incorporated into each of the other levels. In light of this theoretical framework, a range of institutional-level interventions have been suggested for physical activity in the workplace, including:35 • • • • • • • •

providing activity breaks encouraging ‘walking meetings’ on-site exercise facilities or reimbursement for off-site access incentives for employees who practise ‘active commuting’ by bicycle, etc. installation of lockers, showers, and convenient bike storage attractive stairwells, optimally located communication and collaboration with employees with a focus on valuing health friendly competition and rewards for team success.

According to the Alberta Centre for Active Living, the ecological or multilevel approach to workplace physical activity intervention holds the greatest promise for increasing participation rates and activity levels. At this point, little experimental or other evidence has been offered to support this claim.36

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School-Based Interventions Curricular programs that focus on providing information about physical activity exist in schools. These health education classes, which typically also address issues such as smoking and nutrition, are often aimed at establishing behavioural skills for good decision-making. A review of ten studies showed highly variable effects, with a balance between intervention groups that showed increased physical activity and those that showed negative changes in self-reported behaviour.37 One systematic review from 2002 found two physical activity trials that specifically measured BMI changes. No significant improvements were noted for the students in the intervention groups.38 School-Based Physical Education Programs also exist that seek to improve physical education (PE) curricula, either by increasing overall class time (i.e., longer or more frequent class periods) or creating more activity time during each class, while not sacrificing other educational goals. A total of 13 school-based studies were identified in one review. Of the 5 measuring activity levels during PE class, all recorded increases in: (1) the number of minutes spent in moderate or vigorous physical activity; (2) the percentage of class time spent in moderate or vigorous physical activity; and/or (3) the average intensity level of physical activity during class. The increase in the time spent in moderate to vigorous physical activity in class settings was about 50% more than in the control amount. A total of 11 studies also reported a significant increase in aerobic capacity; the median increase in aerobic fitness expected among school-aged children with the curriculum change was 8%.39 These sorts of results have been part of the motivation for extensive physical education initiatives in North America, for example, the widespread PE4Life projects and, in British Columbia, the Action Schools! program introduced in 2004.40 College-Age Physical and/or Health Education There are campus programs that are geared to educate postsecondary students about physical activity and encourage participation rates. Both a behavioural change component and supervised physical activ-

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ity are usually included. Only two relevant studies were found in one review, with consistent increases in physical activity in the short term, but a retrenchment to baseline levels at two-year follow-up.41 Home-Based Interventions The most successful behavioural change programs in homes involve supervised physical activity, where the supervision is delivered by telephone and enhanced by printed material.42 The telephone support may be the crucial feature. An Australian study published in 2004 showed no benefit at two- and eight-month follow-ups using stage-ofchange physical activity materials that were simply mailed to participants.43 The U.S. Surgeon General’s report of 1996 confirms that the most effective interventions employ frequent telephone contact as well as self-monitoring and incentives.44 Reducing Television Viewing and Video-Game Playing Some interventions have focused on educating children about the importance of physical activity, in combination with a behavioural challenge to eliminate or reduce time in front of the television or video-game screen. A review of three studies, although observing sizable decreases in time spent in television viewing and video-gaming, did not consistently demonstrate a significant increase in physical activity.45 It is not clear what the youth were doing with their extra time! In an oft-quoted 1999 study, Robinson provided curricular material geared to reduce time watching television and video material; he found a significant change in body fat measures after seven months.46 Although the result is being reported in the physical activity chapter of this book, reflecting the assumption that a reversal of sedentariness mediated the weight changes, it very well could represent a combined effect that included dietary improvements. As a November 2004 review concluded: ‘The usual depiction of food and obesity in television has many documented negative consequences on food habits and patterns.’47 Less television viewing may mean better eating both proximally (less sitting and snacking) and ultimately (less exposure to the marketing of unhealthy products).

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Involvement of Family Members Programs can enlist the involvement of family members, sometimes with specific enhancements to encourage support of the person receiving the main physical activity intervention. The supportive relationship can be between parents and children or between spouses. Interventions typically include joint or separate educational sessions on health, goal-setting, problem-solving, and family behavioural management. Actual physical activity may be included, plus other events related to a parallel school program. Unfortunately, the combination of techniques makes it difficult to isolate the family support component. A review of studies looking at domestic social support demonstrated mixed evidence, with some showing more physical activity and some less. When home-plus-school interventions were specifically compared with school-only approaches, there was no difference in effectiveness.48 Clinical Interventions and Management The health care setting is potentially significant for creating more active lifestyles, given that a high proportion of Canadians visit a physician at least annually.49 Patient surveys confirm that primary care clinicians are expected sources of preventive health information.50 The Canadian Health Promotion Survey showed that 60% of people making improvements in physical activity levels did so simply because of basic information about the dangers of being sedentary.51 Other surveys suggest that less than 50% of physicians counsel patients about physical activity.52 And, even when counselling is provided, it tends to be cursory.53,54 A recent review in the United Kingdom55 assessed the following interventions: • brief physician advice or counselling in primary care • referral to exercise specialists for education and counselling • input and support in outpatient clinics or health education classes. In the past, the limited evidence for the latter two categories has offered, at best, modest support for employing them in health care. In particular, various schemes related to exercise referral have not been

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very successful. This assessment, however, has recently been modified by the good results of so-called green prescriptions in New Zealand and elsewhere. We will begin by looking at physician advice, which has received the most attention in the literature, before commenting on the new referral schemes. Brief Advice / Counselling Brief advice can be effective, although it only leads to modest, shortterm gains in physical activity.56,57 The best results for brief advice (sometimes offered in conjunction with written material) focus on a single-factor intervention, that is, increasing moderate-intensity physical activity. The Canadian Task Force on the Periodic Health Examination (now retitled) suggested that there was insufficient evidence to show that intensive counselling interventions by general practitioners can influence sedentary individuals to become more active.58 This is consistent with the assessment by the U.S. Preventive Services Task Force.59,60 Several other recent reviews have reported on the scarcity and variability of evidence linking increased physical activity to counselling in primary care.61–3 One Canadian reviewer is a lonely voice in support of the opposite conclusion, namely, that intensive and repeated counselling by primary health care providers can increase physical activity.64 Future studies may alter this ambiguous scenario, but in the meantime, guided by a spirit of ‘intuitive prudence’ concerning the known health benefits of physical activity, many health agencies continue to recommend routine physical activity counselling in the primary care setting.65 Nevertheless, the conclusion of an Australian review is more cautious: Interventions in primary care will not be sufficient to increase physical activity levels in the population and need to be incorporated within multi-faceted, communitywide strategies to address this risk factor.66 Thus a final mediating position is that clinical strategies need to be integrated with public health and environmental approaches in order to have significant and sustained impact, a point that we have been making throughout this book. As noted above, only a few studies have examined efforts outside of the physician’s office. The evidence is equivocal about interventions in an outpatient clinic, but recent evidence has shown that referral to

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exercise specialists can produce long-term physical activity improvements. In one case, the positive results depended on a personalized exercise plan and incentives (i.e., reduced costs at a nearby recreation centre).67 Trained nurse practitioners have also offered effective physical activity promotion.68 One other venue that has produced good results for older patients is health education classes run by welltrained counsellors.69 There has been growing interest in the ‘green prescriptions’ pioneered in New Zealand.70 This approach involves a written recommendation for a certain health-promoting level of physical activity, backed up by telephone support offered by exercise and sports specialists. A 2003 trial in one region of New Zealand showed that green prescriptions increased mean total energy expenditure by 9.4 kcal/kg each week; the proportion of the intervention group undertaking at least 2.5 hours/week of leisure exercise increased by about 10% more than was seen in the control group.71 Continuing Medical Education One study noted that counselling methods adopted by physicians with respect to physical activity are sometimes ineffective.72 Canadian surveys of physicians have reported the following barriers to regular, effective physical activity counselling:73 • • • • •

time constraints lack of financial incentives lack of standard protocols lack of success in counselling role lack of appropriate training.

This is the context for the key physical activity intervention seen in health care systems, namely, improving the motivation and skills of physicians through continuing medical education (CME) or other means. Physicians in Canada who have been trained in physical activity counselling report greater confidence and an up to four-fold increase in the frequency of such counselling in their practice.74,75 Only three studies that looked at improving the physical activity counselling skills of physicians were identified by the 1996 U.S. Surgeon General’s report. The results point to positive effects, with 7% to

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10% of sedentary patients becoming physically active.76 One study included policy-level features in the intervention, namely, reimbursement for counselling time and automatic reminders built into the physician’s practice.77 Published guidelines can help to shape clinical practice. One recent response to the variability of protocols was a suggestion put forward in Nova Scotia,78 which followed the lead of the Canadian Task Force on Preventive Health Care in adopting (and adapting) the same ‘5 A’s’ format that has been popular in treating people for smoking cessation: • • • • •

assess physical activity level, capacity, and knowledge advise about risks and benefits agree on goals and a personalized action plan assist in finding community resources and creating social support arrange follow-up and reinforcement.79

Exercise Therapy for Weight Loss Reviews of exercise as an intervention for unhealthy weight are still in process. The available effectiveness data are outlined here, but the most significant results are presented under Combined Interventions in chapter 14. This is because it is relatively rare to find exercise studied in isolation from a modified diet. A 1995 meta-analysis of 28 exercise studies suggested that the level of weight loss achieved by increased exercise alone, that is, without controlling caloric intake, is small. For instance, over 30 weeks men only lost 3 kg more than a sedentary control group over.80 Another meta-analysis rated weight training as a somewhat more effective exercise than running, walking, or cycling; it had a similar impact on body fat loss, while preserving or increasing fat-free body mass.81 Although the evidence to support using exercise in weight loss is limited, large-scale, cross-sectional, and longitudinal studies such as the Canada Fitness Survey have shown the efficacy of exercise in weight maintenance: ‘People who were habitually more active were found to be less obese.’82 Thus, exercise and general physical activity may have a role in preventing obesity or in preventing further decline in those who are already overweight. Of course, it is important to remember that exercise has many other health benefits beyond weight control.

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Regulatory and Economic Interventions To affect whole populations, interventions in this category are directed at physical and organizational structures rather than at individuals. The aim is to increase physical activity by changing social networks or norms, by creating new laws and policies, and by enhancing community resources, or at least improving access to existing facilities. An example of the latter approach is any policy related to disabilities and access. Various innovative but untested policy proposals have been put forward in reference to physical activity, such as removing taxes on exercise equipment and offering incentives to employers who promote physical activity and fitness.83 Some of the potential policies that have been garnering a lot of recent attention relate to transportation and urban planning. Transportation Policy to Encourage Non-motorized Transit Several agencies are conducting major review projects on the connection between transportation policy and physical activity levels, although most work remains at the stage of identifying any actual linkage between transportation and health.84 A U.S. Department of Transportation roundtable began to look at this topic more thoroughly in 2004. An excerpt from their summary report reveals the close connection between transportation planning and urban planning:85 Because transportation systems affect options available for physical activity, transportation planners can have a substantial impact on the health of their communities. A community designed with sidewalks and bicycle trails that connect people’s homes to their neighbors and to schools, stores, offices, parks, and other destinations encourages higher physical activity levels than one where most daily destinations can only be reached by automobile.

Good rationales exist to further pursue this avenue of physical activity enhancement. It is well known that many trips currently involving automobiles are very short. An alternative strategy, such as cycling or walking, would have many human benefits. If travelling under selfpropulsion lasted at least 30 minutes per day, it would cut the risk of

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developing heart disease by half. Some authorities claim that this is equivalent to the health effect of not smoking.86 Although relevant research is beginning to emerge, the incorporation of physical activity and other health goals into transportation planning is still a new and evolving area.87–90 The only systematic review of this topic focused specifically on enhancing walking and cycling (examining a total of 22 studies).91 The best evidence found concerning novel approaches (such as engineering measures) shows that they have not yet proven effective, and could at best match the results seen in traditional publicity campaigns and behavioural change programs. The strongest results came from behavioural change interventions targeted at motivated subgroups; these resulted in around 5% of trips shifting to a non-motorized means of travel. Projects involving commuter subsidies and adding transit stations have also shown promise. Future research will doubtless focus more on the health effects that result from such interventions. Other novel approaches have been proposed to shift people out of their cars. For example, financial levers that may discourage urban sprawl and thus automobile commuting include gasoline taxes, tolls, and subdivision fees. Applying these approaches could lead to more walking-friendly communities and more active commuting patterns, such as walking to mass transit stations. Significant changes in the area of transportation planning are going to require unprecedented inter-agency cooperation. An integrated approach is certainly the ‘exception rather than the rule’ so far. A 2002 review of U.S. transportation plans could not identify any examples of substantive attempts to build in health and activity goals.92 A major literature review confirmed the appropriate research agenda for the future:93 Transportation planning agencies considering whether to include physical activity dimensions require analytical methods and scientific data to determine the significance of relationships between transportation, activity, and health, and relevance to their jurisdictions. Planners will also benefit from documentation of experiences of peers incorporating health and activity goals into planning processes. This should include before and after technical evaluations of short- and long-term effects to demonstrate the extent to which transportation affected physical activity and, ultimately, whether community health improved.

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Several jurisdictions are not waiting for the research to be complete before taking action. The health care authorities in the United Kingdom, acknowledging that ‘the way we travel is making us a less healthy nation,’ have identified five priority strategies:94 • Introducing patient and staff travel plans to encourage active commuting and other changes (noting that health care institutions are often one of the biggest employers in a community) • Implementing a physical activity strategy such as formal prescriptions for walking or cycling • Contributing resources to local transportation initiatives (e.g., supporting cycling campaigns such as establishing systems that integrate cycling and transit, installing racks and lockers, marking and advertising bike lanes and routes, and otherwise improving safety and comfort for bicyclists) • Supporting local accessibility planning (e.g., improved walking and cycling routes) • Assessing the health impact of local transportation plans. Such an ambitious agenda may offer a challenge to health care infrastructures in other countries. For instance, regarding the first strategy, if health care staff people do not provide an example for others to follow, then who will? Urban Planning Approaches The link between zoning, land use, built form, and various aspects of health (including physical activity levels) is a fluid area of research and discussion.95,96 According to a 2000 review, one of the more important determinants of physical activity is a person’s immediate neighbourhood.97 Relevant environmental variables for enhanced activity include the presence of sidewalks, traffic calming, adequate street lighting, dog control, enjoyable scenery, regular observation of other people exercising, and low crime levels. The growing conclusion is that new perspectives are required in urban design and planning in order to reverse the unhealthy trends of suburban sprawl:98 While older cities and towns were planned and built based on the practical idea that stores and services should be within walking distance of res-

224 Part Three: One Risk to Rule Them All idences, the design of most new residential areas reflects the supposition that people will drive to most destinations. Work, home, school, and shopping are often separated by distances that not only discourage walking but may even necessitate the use of a car in order to reach any destination safely.

The U.S. Active Living by Design national program office, a leading agency on the connection between urban planning and physical activity, made a presentation to Health Canada in 2004. They laid out a framework for future improvements in urban health that included:99 • Preparations: build partnerships, vision, and a plan of action • Promotions: use mass media for awareness and public education • Programs: e.g., establish safe routes to school; hold trail-opening events • Policies: site schools to be pedestrian-friendly; zone for mixed use • Projects: build a network of bicycle paths; install- traffic-calming measures and scenic landscaping. One of the useful tools being promulgated by planners in various jurisdictions is the Health Impact Statement (HIS). Similar to an environmental assessment, the HIS would be recommended (or required) for any development proposal. The World Health Organization defines such evaluations as ‘a combination of procedures, methods and tools by which a policy, programme or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population.’100 To have full confidence in any of these ideas and approaches will require an increase in basic information. Even such a central ‘doctrine’ as the association between the degree of suburban sprawl and obesity rates101 has been recently called into question.102 In fact, the strongest proponents of the connection between urban planning and physical activity admit that the best evidence for an environmental approach to encouraging utilitarian walking and biking comes from transportation studies.103 And the results thus far ‘are insufficient to conclude community design impacts overall physical activity.’104 The only possible exception to this rule is the observation that high-density ‘vertical’ development in cities encourages walking more than in settings marked by suburban sprawl,105–7 and the growing evidence that ‘green’ and safe neighbourhoods promote walking.108,109

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One of the challenges in assessing the factors related to walkability is coming up with appropriate indices of chacteristics such as suburban sprawl. Isolating specific urban planning interventions and testing their impact on physical activity (and other health determinants) will be a major research challenge in the next decades.110,111 ‘Built Environment’ on the Map in the United States The foregoing assessment of transportation and urban planning was confirmed in a major study released in 2005 by the Committee on Physical Activity, Health, Transportation and Land Use, a group established by the U.S. Institute of Medicine and the Transportation Safety Board. Their report entitled Does the Built Environment Influence Physical Activity? was originally commissioned by the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention.112 The committee comprised expertise from diverse fields, including transportation demand, travel behaviour, land use planning, public health, physical education, public policy, safety, and behavioural science research. As the title suggests, the study combined matters of concern to both transportation and general urban planning. The built environment can be examined at different scales, from individual sites to neighbourhoods and regions. The committee focused on the latter two levels, as very little data are available concerning site-level issues such as commercial building and home designs. The model informing the study recognized that complex factors affect the decision to be physically active, moving from the most encompassing (social context) to the most specific and individual choices. Built form occupies a sort of intermediate category, and it represents a relatively new area of inquiry in terms of physical activity. The most relevant background paper commissioned by the committee reviewed 22 studies from the world of urban planning and travel behaviour and 28 studies led by public health and physical activity specialists. Detailed evaluation of research quality, like that offered through the U.S. Task Force on Community Preventive Services (TFCPS), was not possible within the scope and resources of the committee. The parallel TFCPS work on environmental interventions is under way but not yet completed. In the review paper offered to the committee, a number of correlates of physical activity related to built form were identified. These may point the way to future intervention modalities. For example, land use

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density and diversity were shown to be positively associated with nonmotorized travel, as was having a grid-based street network, public transit infrastructure, good sidewalks, and other measures of walkability and people-friendliness (e.g., the well-known neotraditional neighbourhood design elements). As well, enjoyable scenery and seeing others at exercise was positively correlated with walking and total physical activity. Travel behaviour literature suggests that urban design is significant in one specific context, that is, walking that is related to shopping. Accessibility (distance to nearest desired destinations) stands out as a significant measure in both travel behaviour and physical activity literatures. The theoretical basis for this fact is self-evident: ‘Reducing the cost of a desired behaviour – in this case the closeness and convenience of a trip destination – helps encourage the desired behaviour.’ In the end, the committee issued the inevitable call for more research, including identifying projects where the built environment is being retrofitted or newly developed and then using them as ‘natural experiments’ or demonstration cases. Studies in this area need to have an interdisciplinary framework and inter-agency sponsorship. Comprehensive strategies that include both built environment policy and social marketing should be examined (see below). Finally, even in the absence of a full understanding of causal connections, there does not appear to be any downside to encouraging planners to develop activity-friendly environments. This will involve addressing issues as diverse as beauty, traffic, safety, recreational space, and sunlight/shade provision. Comprehensive Strategies Even in the absence of complete data about enormous topics such as urban planning, there are various efforts already being made by workplaces, community coalitions, and government agencies to change local environments and enhance the opportunities for physical activity. The initiatives include creating walking trails, building exercise facilities, or improving access to existing resources. Usually such projects are part of a comprehensive, multichannel program, where the effect of specific components cannot be isolated; hence, the whole package has to be evaluated as a unit. The components of comprehensive programs can include training in how to use exercise equipment, risk factor screening, referral to health

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care providers, and fitness campaigns. According to one review, creating or improving access to places for physical activity alone resulted in a median increase in frequency of exercise of 48%.113 This means that a ‘build it and they will come’ policy really works. Simply having more recreation centres and parks, open more often and open to more people (e.g., the disabled, low income groups, and anyone especially concerned about safety) would be a boon. The true test then becomes whether consequent increases in the prevalence of exercise at the population level can be measured. Another form of comprehensive intervention involves combining initiatives to reduce energy intake and increase energy expenditure. This is the main topic of the next chapter.

Key Points • Communitywide campaigns to increase physical activity have not achieved impressive results in the past, but new approaches – from signs directing people to stairways to behavioural change programs in the context of social support – are showing some promise. • Traditional employee physical activity programs have not been very successful to date, suggesting that they may need to be enhanced by the many ideas proposed to make the environment of workplaces more activity-friendly. • Children can be helped to be active (certainly) through enhanced school physical education programs and (likely) through interventions to reduce sedentary activities such as watching television. • Both traditional physician advice and more recent ‘green prescriptions’ for exercise have proven effective; the usefulness of intensive counselling in primary care to increase physical activity remains open to question. • Transportation and urban development policies are being explored as exciting arenas in which to make environmental changes that would influence activity levels in a community.

14 Obesity Control Evidence (3): Combined Approaches, Cost-Effectiveness, and a Compendium

As in many other areas of health promotion and prevention, combined programs incorporating multiple therapeutic strategies are popular approaches in weight loss. In the case of obesity control, combining diet, exercise, and counselling for optimal and sustainable weight loss makes good intuitive sense. However, there are still large gaps in understanding the individual and combined roles of diet, exercise, and counselling in different settings. The first section of this chapter examines the available evidence on effectiveness with respect to combined programs. Whereas the previous two chapters made energy intake and energy expenditure the main entry point, the emphasis here is on interventions where obesity reduction is the primary outcome, with no a priori limitation on the strategy employed. This chapter also pulls together the rather limited cost-effectiveness evidence for obesity control interventions. Finally, as we did in Part 2, we finish with a compendium summarizing the ‘better’ obesity control approaches that are available today, as revealed by the literature reviews found in the preceding chapters. Combined Approaches to Obesity Control Programs where obesity treatment and management are the direct focus have been used in work, school, and clinical settings.1 Data are available on relevant communitywide programs, but only where obesity was not the primary outcome of the included lifestyle interventions; typically, such programs focused, instead, on reducing one or more chronic diseases.

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Community-Based Interventions Given the importance of environmental and population-based risk factor control, programs operating at a community level continue to be of great interest.2 However, the conclusion offered by the World Health Organization in a 2000 report indicated that there had not yet been any ‘well-evaluated and properly organized public health programmes aimed at the population-level management or prevention of obesity.’3 A major Australian review in 2003 indicated that the situation had not changed.4 This suggests a need for more program development, and much more outcomes research, where obesity control is the direct focus. self-help programs One of the ‘holy grails’ being sought in community settings is an intervention that is not resource-intensive; one option is material mailed to homes that could prove to be cost-effective.5 Self-administered correspondence courses are commonly directed towards weight loss rather than maintenance (i.e., prevention of weight gain). Although earlier studies were not encouraging, more recent investigations have found some support for self-help approaches. One Canadian project involved a correspondence course that included weekly homework assignments to be returned by mail, interim weigh-ins, and/or monetary incentives; the most intensive combination of these approaches achieved a weight loss of 4.5 kg after one year.6 Newer media, such as computers and video programs, have shown some promise, but require additional long-term studies.7 Self-help groups in both the non-profit and for-profit sectors have demonstrated effectiveness in promoting weight loss, although attrition rates are very high. A particularly promising program uses intense social pressure, where anyone dropped from the program for not following the rules, or otherwise opting to drop out, is banned from rejoining for the rest of his or her life! This ‘heavy hand’ is combined with traditional behavioural therapy. The results have been encouraging. The groups, led by non-professional volunteers, have produced mean weight losses of about 13 kg, with 83% of members losing more than 10% of their initial weight.8 We noted earlier that behavioural self-help interventions for weight gain prevention are rare. Indeed, the same may be said for clinical and other settings: in 2000, only four projects based outside of public

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schools were found by a review of behavioural approaches, and they were mostly ineffective in promoting weight control.9 An exception was one trial involving behavioural change methods (goal-setting, selfmonitoring, etc.), mostly communicated by newsletter; it resulted in 82% of participants maintaining or losing weight, compared with 56% in the control group.10 In sum, self-help interventions have shown enough benefit to continue to be tested; it is likely that they will maintain their status as a useful adjunct to more intensive forms of obesity control. The involvement of professionals to reinforce self-help materials seems reasonable, although the evidence for the cost-effectiveness of intense personal contact remains mixed.11,12 At one end of the spectrum, it seems that brief follow-up offered over the telephone (even by untrained assistants) can be very useful. broad campaigns As already noted, communitywide projects have mainly focused on reducing risk factors (sometimes including overweight) to control a particular type of disease, such as cardiovascular disease or diabetes. The momentum for launching such projects in the United States may have been slowed by the modest results of multi-city, multifactorial health promotion trials in the 1980s.13 We already reported that these projects did not detect a great difference in smoking rates in the intervention communities compared with controls (see chapter 7). The same lack of impact pertained to obesity measurements. For example, the Minnesota Heart Health Program (MHHP) showed no overall effect on mean BMI at the population level.14 Sometimes improvement in BMI was seen among the participants of individual program components, including: adult education classes for weight control, exercise, and cholesterol reduction; a worksite weight control program; and a home correspondence course for weight loss and a weight gain prevention program. However, despite isolated examples of weight loss, over the seven years of intervention there was a strong upward trend in weight in all communities, independent of age, demographics, smoking habits, or other potentially confounding variables.15 The critical bottom line was that there was no difference between intervention and control communities with respect to BMI or other risk factors, although some factors did show a secular improvement across the whole population over the course of the study.16

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An assessment of the MHHP concluded: ‘Even such an intense program may not be able to generate enough additional exposure to risk reduction messages and activities in a large enough fraction of the population to accelerate the remarkably favourable secular trends in ... coronary heart disease risk factors.’17 Newer experiments with communitywide projects have been undertaken in Europe.18 The underlying optimism and energy may reflect the more positive experience with the flagship communitywide intervention in North Karelia, Finland. Although that project did not deal with weight or BMI, recent European efforts have tracked obesity, reflecting a growing interest in that risk factor. For example, a heart health program in Germany compared the intervention effects in two towns against nationwide secular trends. That program was based on the theory of ‘community related behavioural medicine,’ which aims to create an overall climate that is conducive to better health. It has a limited number of guiding rules and no predefined curricula: ‘The community members are motivated to set their own targets and develop activities in accordance with local needs and interests.’19 The rate of obesity in the intervention towns was stable, which was seen as a victory when set against the rising national prevalence rates. Success in North Karelia continues to have wide influence on the development of risk factor programs, with pilot projects launched on virtually every continent.20 A sister project in Tianjin, China’s third largest city, has unfortunately shown disappointing results; although obesity prevalence rates decreased for 45- to 65-year-olds, this improvement was masked by worsening rates in younger cohorts.21 Another example is a project in Isfahan, Iran, which is still in its early stages.22 Workplace-Based Interventions As noted above, the main setting for managing weight in adults has been the workplace or the clinic. Naturally, treatment tends to happen more in the clinical setting (see below), whereas prevention efforts have focused on workplaces. Most recent reviews in the latter case could only identify a small number of relevant studies. The programs showed some success in modifying physical activity behaviours, but they had little impact on the prevention of weight gain.23 An earlier review (of studies before 1996) did note some worksite interventions

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for weight loss; short-term weight losses up to 1 kg per week were achieved, but there were no data on long-term effects or any indication that site-wide reductions in obesity prevalence occurred.24 School-Based Interventions Turning to children, a total of five trials were included in a 2002 systematic review of school-based interventions using different therapeutic means.25 The multifaceted interventions usually included both diet and physical activity education, sometimes combined with actual exercise sessions. Significant reductions in body fat were observed in some of these projects. Singapore’s school program is particularly well known; the results form part of that country’s general success in health promotion and chronic disease prevention.26 For some reason, an architect of its decade-long school initiative recently evaluated the results as comparable to one of the least successful trials in the 2002 review noted above. This is inaccurate, for there actually have been very positive effects in Singapore over the long term. The 2% decline in obesity rates among 11- to 12- and 15- to 16-year-olds is both statistically and clinically significant.27 Another school-based program that takes a combined therapeutic approach is the Kiel Obesity Prevention Program (KOPS) in Germany. The early results of this 8-year follow-up study have been promising; after one year, the intervention schools showed a fat mass increase in overweight children of only 0.4%, compared with 3.6% in the control schools.28 The most recent study of a school-based health program was conducted in Nova Scotia.29 It involved 5,200 Grade 5 pupils in three different kinds of schools: ones with no health-promoting program, ones with policies or practices in place to offer healthy menu alternatives, and ones with a comprehensive program that combined physical activity and nutrition initiatives. The sort of interventions used in the latter case included:30 • Wellness fairs – interactive, informative days where students (and parents) take part in physical activities, nutrition activities (making healthy snacks, offering taste tests of more nutritious foods), and information sessions on linking physical activity and healthy eating with disease prevention and protection

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• Incorporating an interdisciplinary unit with learning outcomes directed at healthy eating and physical activity at the middle-school level • Development of a Playground Games handbook, with weekly introduction of new games by students at recess and lunch hour • Opening of school gyms to students after school, and offering a variety of non-competitive activities • ‘Kids teaching kids’ coaching clinics • Parent/student surveys to assist with future healthy food and physical activity program initiatives • Research on resources for classroom teachers to use in implementing daily activity programs • Changing the name of the annual sports day to ‘Active Living Day,’ with additional components added to the traditional slate of activities • Enhancements to provide desirable, low cost, nutritious foods and reduce the number of food items with a low nutritional value offered in school programs • Creating a strategy to sustain a nutritious, low-cost lunch program for all students • Increasing consumption of vegetables and fruit by increasing their availability in school and through improved marketing strategies. Two important results emerged from this project. First, in terms of diet, activity, and obesity measures, there were no significant differences between schools with no program and those with a basic nutrition program. Second, significant improvements were achieved with the comprehensive program, underlining the importance of tackling both physical activity and nutrition in school settings in a combined way. The details are provided in table 14.1. The conclusion from this and other projects, namely, that a comprehensive program – addressing environmental factors and individual dietary and activity change – works best in school settings, was confirmed in a major Australian review of the relevant literature in 2003.31 Clinical Interventions and Management ‘Binary’ studies, where a single treatment is added to diet, have produced consistent and sustained positive results for weight loss. This was confirmed by the Health Technology Assessment (HTA) review in

234 Part Three: One Risk to Rule Them All Table 14.1 Results of Nova Scotia School-Based Health Programs

Measure

No program

Nutrition program

Comprehensive, combined program

Overweight prevalence Obesity prevalence Vegetable/fruit servings Overall diet quality index Physical activity < 4 times/wk Sedentary activities > 7 hrs/day

32.8% 9.9% 5.7/day 62.3 21.9% 20.6%

34.2% 10.4% 5.8/day 62.1 24.6% 20.9%

17.9% 4.1% 6.7/day 64.5 19.9% 15.6%

Source: Vengelers et al. Am J Public Health (2005).

the United Kingdom.32 The two most effective combinations were adding exercise to diet or behavioural therapy to diet. For example, pooled results from five studies showed a reduction of about 2 kg at 12 months with exercise added to diet. Pooled results from four studies where behavioural therapy was added to diet showed positive results for up to 5-year follow-up compared with diet alone, as seen in table 14.2.33 The available results for weight loss trials involving more than two components are more equivocal.34 For example, a 1994 randomized, controlled trial that added exercise and behavioural therapy to diet did not show statistically significant additional weight changes.35 A similar result was seen in another project where exercise and cognitivebehavioural therapy (CBT) were added to diet.36 The pooled results from several trials of exercise added to diet and behavioural therapy showed an additional weight loss of only 3 kg at 12 months and just over 2 kg at 24 months.37 By comparison, the results of 11 studies of diet, behavioural therapy, and exercise versus no intervention control showed an overall weight loss at 12 months of 4 kg, which was similar to that of diet programs combined with drug therapy.38 Weight regain with combined therapies is as much a concern as with other types of interventions. All combinations of diet, exercise, and behavioural therapy showed more weight loss at 12 months than at 24 months.39 Taking all of the data together, one Canadian reviewer concluded that the most effective counselling-based weight loss interventions are those sustained over the long term and which focus on diet and exercise in a multidisciplinary way.40 This was consistent with a a conclusion from a 1997 meta-analysis of studies that showed diet plus exercise to be superior to diet or exercise alone when evaluated at 1-year follow-up (producing a mean weight loss of 8.6 kg).41

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Table 14.2 Effectiveness of Diet and Behaviour Therapy Follow-up (in months)

Weight loss (kg)

12 18 36 60

7.67 4.18 2.91 1.90

Source: Avenell et al. J Human Nutr Diet (2004).

Limited literature exists concerning how best to improve the management of obesity in clinical settings. The relevant Cochrane review identified six studies that compared interventions aimed at improving professional care against simply maintaining usual care.42 Three types of intervention showed promise as positive influences on the behaviour of providers: computerized summaries and reminders concerning obese patients; educational outreach (so-called prevention detailing); and better cooperation with hospital-run obesity services. The reminder system was particularly effective, with females losing 1.95 kg and males 5.86 kg more weight over two years.43 Regulatory and Economic Interventions Development of policy to inform macro-system changes, for example healthier built form in urban settings and sufficient family income to permit healthy choices, will require political will at various levels of government. Coalition-building and increasing public support can begin by working together on smaller initiatives. Some of these environmental pilot projects need to start as soon as possible with children, adolescents, and their families (see the related section in chapter 15). As a recent Australian report concluded: ‘Obesity develops over time and once it has developed, it is difficult to treat. The prevention of weight gain, beginning with childhood, offers the most effective means of achieving healthy weight in the population.’44 While policies aimed at environmental changes remain unproven, the urgency of the obesity problem ought to prompt some kind of action nevertheless. This was the position adopted by the director of the North Karelia project, Pekka Puska. Thirty years ago he was accused of ‘shotgun prevention’ or launching mass action without evidence.45 Of course, developing an evidence base for interventions is

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important; this truism has prompted some authorities to call not so much for the adoption of specific policies, but instead for immediate and intensive research.46 Such studies are up against a common obstacle, namely, the fact that analysis of determinants making up obesogenic environments is complex.47–9 While the research challenges are being overcome, the success in North Karelia suggests that acting on ‘best available evidence,’ and even on educated guesses, is warranted as a public health approach. Most of the potential systemic or environmental interventions related to obesity were covered earlier under healthy eating and (especially) under physical activity. The environmental approaches that target obesity in its own right rather than through a specific contributing factor (diet or activity) have not yet been well conceptualized. An integrated approach to zoning that would affect travel patterns, exercise, and food purchasing behaviours all at once would certainly qualify, but such a plan has not yet been articulated or applied. In the near term, one of the strongest options for influencing obesity rates may involve economic levers applied at the community level. Some studies have shown that individual socioeconomic status (SES) is not likely the main cause of the obesity epidemic.50 However, living in communities with a general socioeconomic disadvantage has been associated with higher BMI after controlling for age, race, individual SES, smoking, physical activity, stress, and social support.51 This points to the potential efficacy of an obesity intervention that manages to elevate the socioeconomic resources of whole communities. Cost-Effectiveness of Obesity Control Interventions While economic analysis of obesity control measures is still in its infancy, some data are available in support of the further development of such interventions. We will look at rhe breadth of sources and marshall the available cost-effectiveness evidence before assembling a summary of the obesity control area (just as we did for smoking in chapter 8). Data Sources and Measurement An inventory of health promotion cost-effectiveness studies was consulted in chapter 9 in the context of tobacco control. This same review also reported on the number of studies related to diet and physical

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activity. The number is not high. Only 8 studies were identified for both risk factors up to 2001.52 Another census provided by Avenell and colleagues in 2004 shows some improvement: of the 16 economic studies retrieved, 7 examined cost-effectiveness of obesity control and another 6 provided a cost-utility analysis.53 The gap in economic research reflects the fact that outcome evaluations in the obesity control arena are at an early stage, especially compared with the 40-year track record enjoyed by tobacco control and smoking cessation programs. Naturally, without a clear sense of effectiveness, pursuing a cost-effectiveness analysis becomes problematic. Fortunately, the situation is changing to some degree, at least for physical activity. There has been an increase in economic analysis of physical activity interventions in recent years, even in the novel area of environmental interventions. The situation for ‘energy intake’ control is worse, with few published studies on cost-effectiveness outside of the topic of bariatric surgery for morbid obesity. This fact simply underlines the need to move forward with interventions in the absence of complete data, with a full commitment to generate evaluations along the way while implementing ‘innovative ideas that are ripe for testing.’54 We will follow the framework established in the chapters that looked at intervention effectiveness. This means looking at the costeffectiveness of the two main strategies for intentionally managing obesity, that is, reducing energy intake and increasing energy expenditure. The way cost-effectiveness is reported for each side of this equation is very different at a conceptual level. Although outcome measures do vary, the most common approach with energy intake is to examine the cost per unit of weight loss or per unit of BMI reduction. Increased energy expenditure takes a different tack; instead of maintaining the spotlight on weight loss per se, the typical measurement shifts to cost per additional unit of physical activity. The equivalent measurement with respect to energy intake would involve identifying the daily rate of calories being absorbed; the impracticality of this approach is what probably moved the outcome of interest to the downstream effect of any changes in diet and/or absorption, that is, the impact reflected in weight or BMI. Another adjustment that would enhance consistency across interventions would be to track actual weight or BMI changes against different ways of promoting physical activity. It is not obvious why this

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approach has not been employed more often. Using different measurement paradigms increases the difficulty of making comparisons between energy intake interventions and energy expenditure interventions in terms of both effectiveness and cost-effectiveness. Reducing Energy Intake For the purpose of this economic review, it will be convenient to deviate from our usual grid and categorize interventions dealing with energy intake in terms of educational, medical, and surgical approaches. nutritional education The Expanded Food and Nutrition Education Program (EFNEP) is a U.S. initiative that currently operates in all 50 states. Through an experiential learning process, limited-resource audiences learn how to select and buy food that improves the nutritional quality of the meals that they serve their families. In 2003 a cost-benefit analysis of the modest Oregon version of the program demonstrated a ratio of 1 to 3.6 (i.e., over U.S.$3.50 saved for every U.S.$1.00 spent).55 Studies of the program in other settings have produced ratios up to three times higher. In the Virginia arm of the program, in 1996, the initial benefitto-cost ratio was $10.64/$1.00, with subsequent sensitivity analyses producing ratios ranging from $2.66/1.00 to $17.04/1.00.56 In addition to a communitywide approach, nutritional education also takes place in specific settings. One study of group instruction in the workplace focusing on a low-fat diet demonstrated a cost of $14.70 per kg of weight lost.57 counselling and dietary prescriptions A systematic review was conducted of cost-effectiveness research that focused on outpatient nutrition services. In the three studies specifically measuring weight reduction, the the cost per pound lost ranged from U.S.$2.40 to U.S.$10.00.58 In one RCT of dietary counselling sessions provided by a dietitian (with or without involvement by a physician), the weight loss was between 5 and 7 kg, at a cost of Aus.$7.30 to Aus.$9.76 per kg. The higher cost occurred when the physician was involved in issuing the invitation to join the program and in reviewing progress at two of the counselling sessions. The physician-involvement group also

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showed a higher program completion rate and, on average, 1 kg more weight loss per person over 12 months.59 No other cost-effectiveness studies were retrieved related to preventive nutritional services in primary care; the research gap probably relates to the fact that such services are still relatively rare. pharmacological approaches There are currently two main drugs used as aids in weight loss. An economic model for orlistat was summarized by Foxcroft and Milne.60 Orlistat tends to produce, in combination with a low-calorie diet, a reasonable weight loss. Despite the full effect lasting only over the short term once the drug is discontinued, orlistat represented an estimated cost utility of £46,000 (U.S.$79,723) per quality-adjusted life year (QALY). This result differs from modelling performed in 2004 on the other approved weight loss drug, sibutramine, which showed a cost utility of £4,780 (U.S.$8,284) per QALY.61 Another study arrived at a somewhat higher figure, namely, £10,500 (U.S.$18,198) per QALY, which clearly is still very competitive when compared with orlistat.62 This suggests that the slightly higher concerns about safety with the use of sibutramine are more than matched by its superiority in effecting weight loss. bariatric surgery Understanding the cost-effectiveness of surgery for morbid obesity is especially important today, given that the procedure has generated a certain amount of controversy. Interstingly, some U.S. insurance companies have discontinued coverage for bariatric procedures. The main concerns have revolved around perioperative death rates (as high as 2%) and poor postoperative management of dietary complications; the training of surgeons and the availability of dietetic resources may not be keeping up with the demand for this surgery.63,64 These cautions suggest that bariatric surgery may need to be weighed further before it can be universally embraced; at the very least, resources in the health care system need to catch up to patient demand so that the highest quality management can be established. Despite such issues, it is clear that bariatric surgery remains very attractive from a cost-effectiveness viewpoint. As described in chapter 12, surgery for severe obesity comes in different forms; the basic conclusion about cost-effectiveness seems to hold across the spectrum of

240 Part Three: One Risk to Rule Them All Table 14.3 Cost-Effectiveness of Surgery for Obesity Surgery type

Cost / QALY (£)

Vertical banded gastroplasty Adjustable gastric banding Gastric bypass

10,432 8,689 6,408

Source: Avenell et al. Health Technol Assess (2004).

major surgical options. Craig and Tseng modelled the gastric bypass approach and calculated a cost-effectiveness of about U.S.$5,000 to U.S.$16,000 per QALY for women, and U.S.$10,000 to U.S.$36,000 for men.65 This can be compared with a trial of vertical banded gastroplasty, which was actually cost-saving (about U.S.$4,000 per QALY) when compared with no treatment.66 An Australian review from 2003 seems to confirm the dominance of vertical banded gastroplasty in comparison with other surgical approaches; in contrast, adjustable gastric banding came in at the bottom of the list.67 The modelling of surgical results over 20 years by Clegg and colleagues yielded contrary results concerning the relative position of vertical banded gatroplasty; the cost-effectiveness results, weaker for vertical banded gastroplasty in this case, are provided in terms of 2001 U.K. currency in table 14.3 (as calculated in the summary of this research by Avenell et al.).68,69 Possible support for a favourable cost-effectiveness estimate of gastric bypass surgery may be found in the modelling of diabetes prevention performed by Australian researchers. The cost per life-year saved through gastric bypass surgery was around £6,300 (U.S.$10,919). The cost-effectiveness was even more impressive when the cohort was restricted to those with impaired glucose tolerance, a precursor of type 2 diabetes.70 There is no clear explanation for the discrepancy between the various cost-effectiveness studies. The perspective of Clegg and colleagues may provide some help: ‘Caution should be taken when comparing different surgical procedures as the economic evaluation is based on several unsophisticated assumptions, and evidence of clinical effectiveness varies between procedures.’71 The general conclusion should not be missed in the midst of the details: the outcomes of all standard forms of bariatric surgery appear to be worth the cost of the intervention.72

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A 2005 systematic review confirmed that the papers reviewed above represent all of the published studies that report cost-effectiveness in terms of cost per QALY.73 A further nine studies were identified that, while not performing a formal cost analysis, did assess important components of cost and resource use in bariatric surgery. Three main areas of discussion emerged in the latter studies. First, comparing the costs of medical care with and without surgery is an important line of investigation. Unfortunately, some of the relevant research in this area suffers from methodological limitations, for example, using a small sample or not including some of the costs.74 The studies to date have produced mixed results. For example, some work in Sweden showed little difference in hospital and medication costs before and after surgery.75,76 In contrast, a recent Canadian paper concluded that the break-even point after bariatric surgery is only 3.5 years.77 Another study suggested that the cost per pound lost from medical therapy exceeded the cost of surgical therapy in the sixth posttreatment year (U.S.$1,500/lb vs U.S.$750/lb). This result held, even though surgery cost 8 times more than a very low calorie diet. The main difference between the two approaches is that 89% of surgery patients maintained their weight loss after 5 years, while only 21% of the diet group managed to do so.78 Second, studies have been less equivocal about the impact of bariatric surgery on productivity. One older survey showed that patients receiving an operation showed a significantly higher proportion of employment and total work hours.79 Another paper emerging from the Swedish Obese Subjects project noted that surgical treatment resulted in a reduction of sick leave and disbility pension payments.80 A 2002 systematic review of 40 studies confirmed that mental health and psychosocial status improved with baratric surgery, prompting an increase in employment opportunities.81 Third, there is a lot of interest in the reduced invasiveness of laparoscopic surgery. Although operations can be longer and thus more expensive, recovery time in the hospital is shorter.82 A 2001 study concluded that laparoscopic gastric bypass is a safe and cost-effective alternative to open procedures. While direct operative costs were higher with laparoscopic surgery (U.S.$4,922 vs U.S.$3,591), hospital costs (especially related to nursing) were considerably lower.83 A 2005 review of the literature confirmed this result; although laparoscopic surgery costs more, patients experience fewer expensive and lifethreatening periopoerative complications.84

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conclusion Whatever the final conclusion for the care of the morbidly obese, the interventions for those who are only moderately overweight still require further study to allow the best medical and/or educational options to be identified and implemented. The ultimate goal is to establish cost-effective interventions that can prevent further weight gain – and reverse current rates of overweight – within an unselected population. Increasing Energy Expenditure In 2000 Sevick and colleagues found only one cost-effectiveness analysis of exercise promotion.85 The U.S. Task Force on Community Preventive Services (TFCPS) confirmed the scarcity of research in 2002, where only three cost-effectiveness studies were identified that related to increasing levels of physical activity.86 This general impression of low research volume seems to hold for specific subpopulations. For older adults, a review by King et al. noted that there is a lack of studies assessing ‘specific behavioural or program-based strategies aimed at promoting physical activity participation, as well as a dearth of studies aimed at replication, generalizability of interventions to important sub-groups, implementation, and cost-effectiveness evaluation.’87 One comprehensive review of interventions to promote physical activity concluded that, as of 2004, ‘almost no data exist on efficacy, effectiveness, or cost-effectiveness.’88 community programs Two different community-based approaches to promoting physical activity and energy expenditure have been evaluated from an economic perspective. The best-known research, conducted by Sevick and colleagues, compared the cost-effectiveness of a lifestyle intervention (offering group-based behavioural skills training and seeking to integrate moderate-intensity physical activity into daily life) against structured, supervised exercise.89 Both programs were effective at increasing physical activity and fitness, but the lifestyle intervention approach was considerably less expensive per month, at both 6-month and 24-month follow-up. The provision of free, locally held exercise classes was also tested in 2004 within an older European population. The incremental average

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QALY gain in the intervention group was 0.011, with a cost-effectiveness of €17,174 (U.S.$20,384) per QALY.90 The intervention group suffered from a low level of adherence to the classes. Those who did participate regularly experienced a more significant improvement in physical and mental health. provision of workplace physical activity opportunities Bowne and co-authors reported on a five-year study in which sedentary white-collar workers were offered an industrial physical fitness program.91 The group that participated actively experienced a 46% reduction in major medical costs and a 20% reduction in disability days. Costs of the program were U.S.$121 per participant, with savings of U.S.$353. Similarly, an analysis of a workplace health promotion program by Golaszewski and colleagues noted that benefits were 3.4 times those of costs.92 counselling and physical activity prescriptions Elly et al. assessed the cost-effectiveness of the ‘green prescription’ program in New Zealand. The intervention, which has been employed in other jurisdictions,93 involved verbal advice, a written exercise prescription from a physician, and telephone follow-up by an exercise specialist. The cost of converting one additional sedentary adult to an active state was N.Z.$1,756. The authors concluded that ‘verbal and written physical activity advice given in general practice with telephone follow-up is an inexpensive way of increasing activity for sedentary people.’94 Another intervention started off in primary care, but essentially involved referral to an exercise specialist running a tailored program in both recreation centres and home settings.95 The cost of simply moving a person from sedentariness to activity was found to be £650 (U.S.$1,127), although the cost quadrupled if the outcome threshold was pegged higher, that is, at the actual level of activity recommended for health. built environment Although there is growing interest in urban design approaches to encouraging physical activity,96 the economic studies are only beginning to emerge. The methodological obstacles are significant. One team of investigators suggested that controlled experimental research is

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unlikely to be feasible for strategies such as zoning, tax incentives, and changes in transportation policy.97 Nevertheless, members of this same team have been paving the way by offering the first cost-effectiveness study of the built environment in reference to physical activity. The project began with the construction of four new walking trails in a town, followed by a census of the resulting users. The average annual cost for persons becoming more physically active through the trails was U.S.$98, although the cost for persons actually attempting to lose weight was considerably higher.98 In another study of the same project, the authors noted that the average annual cost per trailuser was U.S.$235, which may be favourably compared against an estimated medical cost of inactivity of U.S.$622 per capita.99 The preceding study, in a sense, represents researchers following their own advice: ‘Economic and policy research ... will need to be carried out in parallel with implementation of policy changes in communities. Careful evaluation and high-quality case studies in a variety of settings and communities will be critical to advancing knowledge.’100 Happily, there is no lack of contemporary urban design projects to which public health research may attach itself and create natural before-andafter experiments. There are many economic motives prompting both the launch of pilot projects and the institution of permanent changes in urban planning. One example is the concept of a ‘walkable’ community, which is actually a matter of practical investigation in British Columbia and elsewhere.101 The Centre for Liveable Communities in Sacramento, California, identified the following potential benefits of walkable communities: increased property values, increased tourism, reduced negative impact on agriculture, improved retail sales, and improved health.102 A basic plan for a natural public health experiment would be to examine indicators such as mean BMI in a neighbourhood before and after a walking-friendly design intervention is completed; a cost-benefit analysis strictly in terms of health impacts could then be pursued. It is evident that many exciting opportunities lie ahead for both effectiveness and cost-effectiveness research related to obesity control. Summary of Obesity Control Interventions Using the same evaluation categories that were introduced for tobacco use (see Part 2), the following summary helps to make transparent the best and most promising approaches in obesity control. For conve-

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nience, some information is provided here related to issues that will be detailed in the next chapter. Interventions to Reduce Energy Intake 1 Interventions of proven effectiveness with strong evidence – counselling for reduced energy intake by primary health care providers – behavioural therapy combined with healthy eating for weight loss – sustained, community-initiated programs for reduced energy intake – Weight Watchers programs – encouragements to breastfeed to promote weight maintenance in infants – comprehensive school programs, especially including parental involvement – family/parental involvement for weight maintenance in children – reduced vending machine prices for healthy foods relative to unhealthy food products – drug treatment with orlistat or sibutramine, where indicated. 2 Interventions of promising effectiveness with moderate or mixed evidence – workplace interventions that include cafeteria changes – family support programs – counselling to increase consumption of fruit, vegetables, and fibre – low-fat and low-calorie diets for short-term weight loss – single product promotions for at least short-term change in sales patterns – labelling healthy foods on restaurant menus – all forms of surgery for morbid obesity, but especially gastric bypass. 3 Interventions of no or low effectiveness and/or with insufficient evidence – mass media campaigns for increased vegetable and fruit consumption (awareness levels are raised, which may be a precursor to action) – increased access to vegetables and fruit in low-income areas – other environmental approaches to increase healthy eating (research pending).

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Interventions to Increase Energy Expenditure 1 Interventions of proven effectiveness with strong evidence – signs encouraging stairway usage – behavioural/social approaches focusing on moderate-intensity physical activity such as walking – behavioural/social approaches based at home and reinforced by frequent telephone contact – community social support (e.g., walking groups) – school-based physical education – enhanced access to places for physical activity. 2 Interventions of promising effectiveness with moderate or mixed evidence – communitywide campaigns with multiple components – school-based physical activity for prevention of childhood obesity – reducing sedentary activities for weight maintenance in children – counselling by primary care physicians – physician training, reminders, and incentives. 3 Interventions of no or low effectiveness and/or with insufficient evidence – classroom-based health education – mass media campaigns not combined with other interventions – health education to reduce television viewing and video-game playing – family-based social support – college-based physical and/or health education – exercise by itself for weight loss – workplace programs geared to individuals – workplace ‘environmental’ interventions – transportation policy (research pending) – other forms of urban planning (research pending). Combined Interventions 1 Interventions of proven effectiveness with strong evidence – exercise combined with healthy eating for weight loss. 2 Interventions of promising effectiveness with moderate or mixed evidence – programs to encourage reduced television watching – combining a lifestyle prescription of healthy eating and exercise with counselling 3 Interventions of no or low effectiveness and / or with insufficient evidence – environmental approaches to weight gain prevention (research pending).

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Key Points • Self-help programs for weight loss and (perhaps) the prevention of weight gain can be effective, especially if reinforced through means such as telephone contact. • Communitywide programs with reduced obesity rates as a primary outcome have been rare; but recent chronic disease management programs are showing modest yet encouraging results concerning body mass index (BMI) at the population level. • The most significant arenas for direct attacks on obesity have been the school and primary care; both have employed a combination of healthy eating and physical activity interventions. • Schools have pointed to the importance of environmental changes; at the level of whole communities, zoning policies and improvements in socioeconomic status (SES) may prove to have similar effectiveness in controlling obesity. • Cost-effectiveness analyses are not fully developed, but the existing economic evidence is very supportive of obesity control measures ranging from nutritional education and bariatric surgery to exercise prescriptions, and the building of walking trails.

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15 Important Issues in Obesity Control B.C. Risk Factor Plan (4)

There are several issues that arise regarding interventions in obesity control, beginning with the topic of prevention. Is there any parallel to the exposure prevention initiatives in tobacco use, which mostly involve stopping teen smoking uptake? The natural comparison is the prevention of weight gain in the first place, and especially in the context of children. This topic is outlined below, along with the special cautions needed. Unlike using tobacco, healthy eating and physical activity are important to child development, making controlling weight more complicated. Dealing with childhood obesity is made even more complex, especially in adolescents, by the phenomena of disordered eating and the full-blown mental illnesses revolving around food. Conditions such as anorexia nervosa and bulimia are matters of grave concern, especially in reference to young women who are vulnerable to the avalanche of media messages concerning beauty and body shape. This chapter also covers the significant topic of weight gain experienced with smoking cessation, a common reality that serves to link the two main health risk factors addressed in this book. When all of these issues have been considered, we will have come to the end of our ‘treatment of the treatments.’ All of the significant raw material for tobacco control and obesity control planning will be in place. It will then be very appropriate to return to the B.C. case study one more time and lay out the strategy that the British Columbia Healthy Living Alliance (BCHLA) devised; the full plan to address risk factors in British Columbia represents the ultimate fruit of the labour that went into this book. Overweight in Children and Adolescents The incidence of overweight school-aged boys and girls in Canada increased from 15% for each sex in 1981 to 35% and 29%, respectively,

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in 1996.1 A similar alarming trend has been observed in the United States and throughout the developed world.2 Studies of twins show that there is a genetic base for some childhood obesity. But not even 5% of obese children have an underlying disease such as one of the endocrinopathies (i.e., hormone problems) to explain their condition.3 The large majority of overweight children simply manifest the classic imbalance between energy expenditure and intake, that is, the same unhealthy patterns that plague adults who have added excess kilograms to their bodies. Despite societal warning bells being sounded, the underlying conditions and resulting obesity do not seem to be reversing. A study of Canadian preschool children in 2004 showed that one-quarter of them were overweight.4 Children who are obese have an increased risk of becoming obese adults; the correlations in earlier studies were low,5 but the evidence of such a connection is increasing.6 Obese children have been observed to have higher levels of hypertension and other disease risk factors. They are subject to a wide range of health impacts, especially those related to pulmonary function.7–9 Earlier studies did not show an association between childhood weight status and adult cardiovascular disease or diabetes,10 but once again, more recent research has implicated childhood obesity in a ‘legacy of risk’ for adults. Studies have now linked severe childhood obesity to adult mortality from all causes. Likewise, adolescent overweight is associated with all-cause mortality, as well as mortality due to coronary heart disease.11,12 In addition to health risks, obese children suffer from significant social and psychological difficulties. Harassment and discrimination may exacerbate a negative body image and low self-esteem. In some cases, full-fledged eating disorders result (see below). Clearly, childhood obesity is a challenge that needs to be faced. Note that the approaches to preventing weight gain and achieving weight loss that follow below should be considered in conjunction with the evidence for school-based obesity control in chapter 14. Prevention of Weight Gain A 2003 Canadian report summarized the reality and opportunity with regard to obesity control in young people:13 Currently there is little work being carried out to address the prevention of either obesity or unhealthy body weight concerns and yet there is much to be gained from a concerted action simultaneously targeting both

250 Part Three: One Risk to Rule Them All health issues. This can be achieved through the promotion of optimal growth in children and adolescents.

Children fare no better than adults in terms of the effectiveness of interventions to lose weight. The fact is that they have recourse to fewer such options. Thus, it is intuitively clear that not gaining the weight in the first place ought to be a strong public health goal. The Canadian Guide to Clinical Preventive Health Care has only one recommendation for maintaining healthy body weight, that is, regular practice of moderate physical activity.14 Although no specific evidence related to children is offered, this basic advice still should be enough to make adults and children more active. As an added incentive to get bodies moving, it is important to note that physical inactivity also multiplies the risk of disease in already obese children.15 A major review of childhood obesity prevention, which examined evidence in the decade since the Canadian Guide was published, confirmed the conclusions about the importance of physical activity.16 Only two long-term studies produced (modest) positive results, one involving dietary education and physical activity and one with physical activity alone. Another long-term study based on diet and exercise was successful only in that it reduced the increase in obesity in the intervention group.17 Although limited data make all conclusions tentative, it seems that concentrating on strategies that increase activity levels may be the most effective approach to childhood weight maintenance. Of course, the difficulties in finding interventions to move people of any age from sedentariness towards increased activity are well known. Breastfeeding Breastfeeding is a very important topic related to obesity control in children. The practice of breastfeeding has recently been proven to have a protective effect against childhood obesity.18 In fact, one study showed that the prevalence of obesity in breastfed children was 2.8% compared with 4.5% in children who had never been breastfed.19 Since the risk of adult obesity may be twice as high in obese children compared with non-obese children,20 encouraging breastfeeding may also be an effective way to prevent adult obesity. A recent review found nine adequately designed, large-scale epidemiological studies confirming the significant protective effect of breast-

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feeding against childhood obesity.21 Although still controversial, possible explanations for this inverse association include hormonal and behavioural mechanisms and differences in macronutrient intake.22 Higher plasma-insulin concentrations in bottle-fed infants could lead to the early development of adipocytes (fat cells) and increased fat deposition.23 Breastfed infants, however, may experience inhibited adipocyte differentiation due to the bioactive factors present in breast milk.24 General caloric and protein intake are also higher in bottle-fed infants than in infants who are breast-fed.25,26 Metabolic imprinting, a phenomenon involving a lifelong predisposition to certain diseases as a result of early nutritional experience, may be an additional explanation for the increased risk of obesity in formula-fed infants.27 Breastfeeding is a simple, low-cost measure for obesity control (and other health enhancements), and one that offers no adverse effects.28 Although expanded programs aimed at encouraging breastfeeding are still under development, they are already considered to be promising tools in the prevention of obesity.29 Pediatricians are important advocates for breastfeeding and thus potential allies in the fight against obesity.30 Environmental Approaches As has been noted in other areas of health promotion, environmental approaches to childhood obesity may end up being more useful than individual therapies. As Australia’s new report on childhood obesity summarized: An approach is needed which creates living environments that support healthy eating and physical activity as well as encouraging young people and their families to adopt healthier lifestyles.31 For example, one potentially valuable intervention involves restricting junk food advertisements during peak times when children watch television.32 As noted in an earlier chapter, another approach leading to the same result is to limit children’s media time (or, to put it differently, their ‘advertisement exposure time’). There is little doubt that advertising influences the eating preferences of children and, through them, the purchasing behaviour of adult caregivers. Apart from several direct studies of this phenomenon, there is the circumstantial evidence provided by the amount of money that companies currently pay to create advertising geared for children. The annual marketing bill includes U.S.$3 billion by the fast food industry alone.33 Finally, just as there are well-known cautions around weight loss in

252 Part Three: One Risk to Rule Them All

children (see below), preventing weight gain also needs to be handled carefully. As summarized by one Canadian report, any focus on weight maintenance should recognize that ... there will always be a ‘variety of body shapes and sizes’ and that there are normal surges in body fatness during certain stages of growth, e.g., during female adolescence. ... The importance of promoting regular physical activity so that energy balance is achieved through a realistic food intake cannot be over-emphasized.34

Again, physical activity may be seen as a balancing alternative to what can too easily become a distorted emphasis on dieting. Once again, the value of the recent Nova Scotia schoolchildren study becomes apparent.35 The best impact on obesity prevalence in that population was derived through a combination of individual behaviour modification around diet and activity, supported by environmental changes. Treatment for Weight Loss The more drastic methods of weight loss used with adults, including surgery and pharmacotherapy, are usually not appropriate for children. Very low-calorie diets are also generally not employed, in order to avoid impairing growth or other physical development. The only cases where the preceding treatments are used involve severely obese adolescents; even then, gastric banding surgery has been the only promising approach.36 A recent major review of standard treatments with obese children included 18 studies.37 The present state of research is not encouraging. Most of the studies were very small and limited to specialist obesity clinics. They examined various types of counselling, the role of healthy eating, interventions to increase physical activity, and different degrees of family involvement. The review concluded that ‘there was a limited amount of quality data on the components of programs to treat childhood obesity that favour one program over another.’38 Various treatments do show declines in weight over the short term, although the improvement typically wanes with longer-term followup. Details of two projects include: • A team headed by Epstein compared decreases in sedentary behaviours with increases in physical activity among obese children. Both

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treatments, in low- and high-dose formats, produced a decrease in excess weight ranging from 22% to 27% at 6 months, although these results were cut roughly in half by 24 months.39 For reasons that are not clear, focusing on reducing sedentary behaviour had a slight edge over the approaches involving increased physical activity. • Golan and colleagues found that behavioural modification that focused mainly on parents produced a significantly greater drop in excess weight compared with the group where children were the sole agents of change (15% vs 8%).40 The positive effect of involving parents directly in behavioural treatment has been confirmed in several different studies.41 As research continues in the arena of childhood obesity, one of the challenges will be the ongoing debate over how to define the very categories of concern. Current opinion still lands on BMI as the most useful measure, although the cut-off points for unhealthy BMI levels remain unclear.42 Another important area of caution is the potential connection between abnormal weight consciousness, dieting, and disordered eating among adolescents (see the next section). Recent data showed that nearly 50% of Ontario teenagers feel unhappy about their weight.43 As seen in British Columbia and other provinces, such attitudes are penetrating into younger and younger populations.44 Research should always assess the dangers that any treatments pose for exacerbating poor body image and/or increasing the prevalence of eating disorders. In this light, it is important to recall that interventions for childhood overweight do not always have to focus on dieting. Physical activity levels may be the more appropriate priority. Whatever the resolution of these and other significant issues, there is no doubt that ongoing research is vital – given the rising tide of obesity in children. The general conclusion about childhood overweight expressed by the Cochrane group is sobering: ‘The mismatch between the prevalence and significance of the condition and the knowledge base from which to inform treatment strategies is a remarkable and outstanding feature of this review.’45 Body Image and Eating Disorders One of the contemporary aspects of the topic of weight loss is the role of body image, including the reinforcement of unhealthy attitudes

254 Part Three: One Risk to Rule Them All

about body shape and size within popular culture and (sometimes) among the friends and family of a struggling individual. It is hard to calculate the contribution that weight-obsessed messages make to the prevalence of unhealthy eating, extreme dieting behaviour,46 and fullfledged eating disorders. However, the circumstantial evidence for an association between exposure to media images and distorted ideas about weight, especially among young women, is very strong. The physical demands of some activities, such as competitive gymnastics and ballet, may also contribute to the desirability of a subnormal weight among some youth. Defining the Problem Eating disorders are illnesses associated with severe distortion of body image and resulting obsession with weight.47 These conditions represent an increasing public health problem.48 Peer pressure, teasing, family dynamics, and the media have all been found to contribute to a negative body image and the possibility of subsequent eating disorders.49–51 Results of the many studies on this topic reveal that young, dieting females exhibit the highest risk of developing an eating disorder.52 Anorexia nervosa and bulimia nervosa are currently considered the predominant eating disorders.53 Anorexia nervosa is marked by a severely calorie-restricted diet, resulting in a body weight 85% or less of expected, healthy levels.54 Bulimia nervosa is characterized by recurrent periods of binge-eating followed by compensatory behaviours such as purging.55 Binge-eating disorder (without purging) has recently been identified as a separate condition, affecting perhaps 2% of obese people (although perhaps as high as 25% of those who are severely obese).56 The consequences of the various eating disorders can be very serious, with as many as 1 in 20 to 1 in 10 cases leading to death from starvation, cardiac arrest, alcoholism, or suicide.57 Some authorities suggest that eating disorders have the highest mortality rate of any mental illness. The prevalence of eating disorders is difficult to determine, since many people are either unaware of their condition or unwilling to report it. Canadian studies have put the 1-year prevalence of anorexia at 0.7% for women and 0.2% for men, and of bulimia at 1.5% for women and 0.1% for men.58,59 In a 1999 Ontario survey, the lifetime prevalence of bulimia among women aged 15 to 65 was estimated at

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1.1%.60 In the United States, it has been estimated that 1% to 4% of young women are affected by eating disorders.61 Interventions after the Fact Treatments for eating disorders include psychotherapy, medication, and/or nutritional counselling.62 Patients are extremely difficult to treat, requiring the investment of intensive mental health resources that are often not very effective.63 Drug trials, especially for anorexia, have generally been disappointing.64 One small study of a comprehensive inpatient program found that, at 10-year follow-up, only 24% of severe anorexia patients had fully recovered; the crude mortality rate in the group was 7%65 Treatment costs for eating disorders are usually high, Can.$1,000 to Can.$1,500 per day for inpatient care.66 Along with the obvious health concerns, the economics suggest that developing more effective prevention strategies should be a priority. Efforts to prevent eating disorders, especially by counteractng influential media images of ‘preferred’ body shapes, will benefit many more people than those with a full-blown, diagnosed condition. Females in western cultures tend to exhibit a ‘normative discontent’67 with their bodies, with large numbers ‘unhappy with the way they look and preoccupied with weight and shape.’68 We must be careful not to allow society to become reactionary against all categories of weight concern. While helping those with anorexia and related conditions may offer some comfort to all ‘unnecessarily discontented’ women, being unhappy with carrying truly unhealthy weight can only be considered prudent given the serious health risks. Interventions before the Fact Current prevention strategies for eating disorders include presentations and discussion groups in schools, media literacy instruction, individual counselling for those displaying disordered eating behaviour, and programs to promote a positive and normal body image.69 Ecological and policy strategies are increasing in significance. For example, the Health Canada lifestyle program called VITALITY looks beyond individual interventions in an effort to create social environments that reinforce positive self/body image and healthy lifestyle choices.70 Advocacy groups are beginning to augment the work of official agencies in this regard. Examples include the Council on Size and Weight Discrimination in the United States, the International Size Accep-

256 Part Three: One Risk to Rule Them All

tance Association, and the National Association to Advance Fat Acceptance. ‘Fat friendly’ reactions from watchdog groups may become more prevalent if obesity truly overtakes smoking as ‘public [health] enemy no. 1.’ Further underlining the need to be careful in approaching weight concerns, there is some evidence that the stigmatization experienced by overweight people can sometimes increase psychological stress and lead to more severe obesity.71 There should be no living in denial. Obesity has a profoundly negative effect on health. The public health and preventive approach to eating disorders is at an early stage; it is evident that further research ‘must be aggressively pursued.’72 In particular, ‘longer-term effects of the intervention approaches will need to be monitored in order to demonstrate a decline in incidence of eating disorders and associated risk factors.’73 At the same time, caution is required with both individual and communitywide programs for weight control, and especially for weight loss. Clinicians and project leaders must work against reinforcing personal beliefs and/or feelings or environmental messages that promote the development of eating disorders. There should be vigilance surrounding anyone setting unhealthy or unrealistic weight-loss goals or covering up a disorder under the guise of ‘normal’ dieting.74 Thus, as they are better understood, surveillance of the risk factors for eating disorders needs to be integrated into any weight control program. At the same time, there must be a balance in any social and medical concern about thinness obsession and eating disorders. As one study concluded: Given the substantial health risk associated with overweight and the fact that during the past 2 decades the prevalence of overweight has increased sharply among children and adolescents, it is not prudent to suggest that overweight girls should accept their body shape and not be encouraged to lose weight.75

Weight Gain with Smoking Cessation One phenomenon that underlines both the complex associations between risk factors and the challenge to be faced in risk factor management is the inverse relationship between smoking and weight gain. More than 75% of adult cigarette smokers experience weight gain following smoking cessation,76 with the average increase in weight being 2.4 to 5.0 kg.77 In one study, the mean weight gain, after being adjusted for numerous cohort characteristics, was 2.8 kg in men and 3.8 kg in women; 9.8% of the men and 13.4% of the women had a weight gain

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greater than 13 kg. 78 The risk for weight gain following smoking cessation increases in people under 55 and in people who have smoked more than 15 cigarettes per day.79 Cessation-related weight gain appears to decline over time,80,81 although not all studies have found this to be the case.82 Suggested causes of the gain in weight upon smoking cessation include increased appetite and food reward, increased daily calories consumed, decreased metabolic rate and energy expenditure, an imbalance in lipid intake and fat oxidation, and changes in adipose tissue metabolism.83,84 Increased energy intake is frequently reported following smoking cessation.85 Overeating can be a major contributor to the problem, accounting for 69% of the weight gain in women in one study.86 The mechanisms are less clear; for instance, the suggestion that nicotine has an acute anorectic effect has been called into question by one study.87 Although weight gain is not likely to negate the health benefits of smoking cessation, it is often a source of concern for prospective quitters.88 Many studies suggest that the probability of increased weight may limit a smoker’s will to quit and hinder his or her long-term success.89 One project found that female smokers were more likely to be weight-concerned than were men.90 Other researchers found that weight gain was not always classified as negative by quitters.91 One study suggested that the majority of previous smokers would not necessarily relapse even after a 9 kg weight gain.92 Programs that promote self-esteem, physical activity, and healthy eating among prospective quitters are recommended to increase the odds for success while controlling the weight gain associated with smoking cessation.93 As noted at the head of this chapter, coming to the end of our discussion about the key remaining issues related to obesity control creates an opportune platform on which to present the British Columbia risk factor plan; the final instalment of our provincial case study follows below.

Key Points • Childhood obesity is a serious health concern for children and for the adults they become; mushrooming prevalence rates across the developed world add to the sense of urgency. • Preventing excessive weight gain in children depends on the

258 Part Three: One Risk to Rule Them All

obvious (enhanced physical activity) and the not-so-obvious (breastfeeding); environmental interventions are also being widely studied. • The most effective treatment for dealing with the obesity that arises when effective prevention is absent may depend on lifestyle interventions involving whole families. • When dealing with children (especially adolescents) and the topic of weight, it is important to be cognizant of eating disorders. • The weight gain that many people experience upon smoking cessation must be put in proper context: the hazards of continuing to smoke easily outweigh any potential side effects of quitting.

DEVELOPING A RISK FACTOR PLAN (4): THE WINNING LEGACY FOR BRITISH COLUMBIA The effectiveness and cost-effectiveness evidence for the various interventions were consulted in order to assemble the best comprehensive risk factor plan for British Columbia. It was meant to come into operation in 2005 and continue through the Winter Olympics in 2010. The result of the research and the BCHLA planning process culminated in The Winning Legacy: A Plan for Improving the Health of British Columbians by 2010. Selections from the executive summary of that report are presented here. (The full series of reports related to the BCHLA project are available online;94 the report titles and topics are also noted in chapter 16.) Political Context The British Columbia government’s speech from the throne on 8 February 2005 presented five ‘great goals for a golden decade’ for the province of British Columbia. One of these is to ‘lead the way in North America in healthy living and physical fitness’ by implementing the ‘most comprehensive health promotion program of its kind.’ The intended impacts include: • • • •

increasing physical activity by 20% reducing obesity and overweight by 20% reducing tobacco prevalence by 10% increasing the proportion of British Columbians who eat the recommended daily levels of vegetables and fruit by 20%.

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Why Are Such Targets Important? The scourge of tobacco use is well known. More than 80% of lung cancers and almost 90% of chronic bronchitis and emphysema are caused by smoking. Despite having the lowest rates of smoking in Canada, each year about 5,600 people in British Columbia die as a result of their smoking. What is less well known is that: • 20% or more of the cases of type 2 diabetes, stroke, coronary heart disease, and colon cancer result simply from a sedentary lifestyle. • eating recommended levels of vegetables and fruit reduces an individual’s risk of cardiovascular disease by 28%. • being obese more than doubles an individual’s risk of dying early, which equates to losing, on average, seven years of life. The chronic diseases associated with smoking, an inactive lifestyle, unhealthy eating, and being obese are significant. In a population of 4.3 million, about 1.2 million people in British Columbia suffer from one or more chronic conditions. These diseases are prolonged, disabling, and rarely curable. The ‘winning’ message of the B.C. Risk Factor Intervention Plan is simply this: ‘Much of the chronic disease burden is preventable through addressing the four risk factors of tobacco use, physical inactivity, unhealthy eating and overweight/obesity.’ The Targets Are Important from a Financial Perspective The B.C. Healthy Living Alliance (BCHLA) has estimated that the four key risk factors cost the B.C. economy approximately $3.8 billion annually. An increasing proportion of government expenditures are being used to care for British Columbians who have acute and chronic health conditions, and in 2002–3 it reached 43%. If one assumes that overall costs will increase by 2%, costs in health care by 5%, and education by 3% per year, then, in the next 17 years the entire B.C. budget would be consumed by health and education. Addressing this looming financial challenge is an urgent task. One way to reduce the burden is to work hard to prevent chronic conditions from developing in the first place. While considerable progress has been made in reducing the prevalence of tobacco use, British Columbia must join the rest of the developed world in aggressively tackling the epidemic of obesity. The on-going health and economic consequences of unhealthy eating, physical inactivity, and overweight are simply too great to permit a policy of passsivity.

260 Part Three: One Risk to Rule Them All

Improvements in all four risk factors simultaneously will yield remarkably positive effects on the health of British Columbians, on health care spending, and on productivity. With this prize in mind, the BCHLA has established serious targets to be achieved by 2010. The BCHLA and other coalitions across the developed world are committed to reducing rates of chronic disease. They know that paying attention to risk factors is a significant key to the task that lies ahead. Reducing Risk Factors Avoids Costs If the public investment is made to ultimately reach the risk factor targets suggested by the BCHLA, then: • 225,000 fewer British Columbians would be smokers • an additional 948,000 British Columbians would eat 5 or more servings of vegetables and fruit per day • an additional 351,000 British Columbians would become physically active • 349,000 more British Columbians would achieve a healthy weight. A key result of these improvements is avoided costs to the provincial economy. While it is not yet possible to track the cost avoidance related to eating a healthy diet, the combined costs that can be avoided in British Columbia for the other three risk factors are certainly compelling, as has already been indicated in figure 5.3. The cumulative $2.4 billion in potential costs avoided is in addition to the almost $1 billion that would remain in former smokers’ pockets due to not buying cigarettes. What Will It Take to Make the Targets? In addition to full funding, progress on the task will require a full commitment to: • Employ proven, cost-effective interventions • Learn continuously while using promising, cutting-edge solutions • Address behavioural factors in the context of vital environmental changes. The BCHLA has worked to arrive at a plan that incorporates these commitments. This plan, if followed, will provide a significant and sus-

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tained push to ‘lead the way in North America in healthy living and physical fitness.’ The B.C. Risk Factor Intervention Plan, which we have called The Winning Legacy, consists of 27 recommended strategies. Many of them have been tested during 40 years of global implementation and evaluation, especially the ones related to tobacco use. While evidence continues to accumulate for effective obesity control, there are already many tobacco control lessons to apply. One critical insight is that in the absence of changes to the determinants of the “obesogenic” environment, encouraging individual choice and goal-setting will not get you very far. The recommendations comprising the intervention plan reflect this reality and many other perspectives gleaned from our literature review. In particular, the evidence concerning effectiveness and cost-effectiveness consistently informed the following points: REGULATORY AND ECONOMIC INTERVENTIONS

• Consider incentives and taxation to encourage greater involvement of children in physical activities. • Advocate for the federal implementation of a standardized system of nutrition information for products that includes all foods (not just packaged), including those at point of purchase. This could include a provincial program of certification of restaurant menu items and portion control. • Implement consistent, comprehensive smoke-free legislation, including 100% workplace bans in the hospitality industry. Lobby so that B.C. pharmacies stop selling cigarettes. • Increase the price of cigarettes by Can.$2.00 per carton per year. • Consider restrictions on food advertising that is aimed at children. • Consider a focused trial of taxation measures for specific unhealthy foods. • Continue to protect against creative attempts by the tobacco industry to market their product, e.g., retail ‘power walls,’ product placements, and smoking in movies and magazine ads. • Improve compliance with restrictions on tobacco sales to minors. COMMUNITY-BASED INTERVENTIONS

• Establish community action coordinators (two per electoral riding) to mobilize strategies for risk factor reduction. • Provide modest funding for up to 1,200 community groups through-

262 Part Three: One Risk to Rule Them All

•

• • • •

out the province in order to implement their ideas on how to address risk factors. Develop a strategic media plan with clear, common messages for different at-risk populations and well-conceived short and long-term advocacy goals. Consider subsidizing pedometers as a source of instant feedback to individuals who are attempting to become more physically active. Implement point-of-decision prompts to encourage healthy behaviours. Encourage and support walking groups and physical activity events. Enhance access to physical activity places (both indoor and outdoor).

SCHOOL-BASED INTERVENTIONS

• Expand the Action Schools! B.C. program and encourage a more rapid implementation of some of its recommendations. Coordinate its measures with antismoking resources to move towards significant levels of prevention among young people • Focus on environmental approaches to risk factor interventions, including promoting healthy foods, curtailing access to unhealthy foods, creating opportunities for physical activity, and establishing tobacco-free sites. WORKPLACE-BASED INTERVENTIONS

• In partnership with Workers’ Compensation Board, unions, businesses, and others, offer funding to assist employers and employees to create a healthier work environment, from stairway-walking campaigns to on-site exercise facilities and healthy food choices. CLINICAL INTERVENTIONS AND MANAGEMENT

• Implement a program of prevention detailing to provide education and feedback to enable primary health care providers to more fully address risk factors. • Cover out-of-pocket expenses for nicotine replacement therapy initiated within a recognized clinical program. • Provide compensation to primary health care providers for lifestylemodification counselling around physical activity, healthy eating, and living smoke-free. SPECIFIC POPULATIONS

• Support health promotion programs for specific populations, including low-income people, pregnant and breastfeeding women, those with mental illness, Aboriginal people, and new Canadians.

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SURVEILLANCE, EVALUATION, AND OTHER ADMINISTRATIVE COSTS

• Provide adequate resources for appropriate surveillance and timely community-level feedback. • Provide adequate resources for the evaluation of new interventions and the dissemination of findings, particularly in areas where the effectiveness information is promising, but limited. • Provide adequate resources to administer the overall plan and ensure coordinated, comprehensive delivery. • Encourage behavioural change research that focuses on the application of what we already know and continues to consider the individual in the context of a population health (or environmental) approach. The estimated costs for implementing the preceding strategies are presented in table 15.1. The Winning Legacy as originally constituted would cost Can.$1.1 billion over 6 years, or Can.$41 annually for each British Columbian. The health and economic benefits of this investment will be enjoyed for generations to come. Moreover, it will be a model for the rest of the world, a world that will be ‘on our doorstep’ in 2010. We will get to the ultimate ‘finish line’ of reduced chronic disease if we are guided by two inspiring ‘flags’: • We do not know everything, but we know enough to act. • Setting targets is one thing, achieving them is another. Ten Reasons to Go for the Win 1 Improving the quality of life of thousands of British Columbians 2 Capitalizing on expert, highly committed coalitions 3 Seizing the unique Olympic momentum that will benefit health for decades 4 Building on best practices, based on 40 years of research 5 Protecting the most vulnerable people, including our children 6 Addressing the unique challenges in specific populations 7 Fully implementing some of the most cost-effective interventions in health care 8 Developing new evidence on obesity control that will benefit the rest of the country and the rest of the world 9 Potentially avoiding $2.4 billion in costs over 6 years 10 Inspiring the world by being the healthiest setting to ever host an Olympics.

Table 15.1 Summary of the BCHLA Risk Factor Intervention Plan, Estimated Cost ($ millions)

Interventions

Fiscal Year 2005–6

2006–7

2007–8

2008–9

2009–10

2010–11

6-year total

Regulatory and economic Net taxation of cigarettes Tax Incentives, physical activity

00(7.37) (004.42

0(12.16) (004.38

0(14.20) (004.34

0(13.03) (004.30

00(8.65) (004.27

00(0.95) (004.24

00(56.37) (0025.95

Community-based Mass media campaign Community action coordinators Community-based funding Pedometers

(026.81 (006.93 (004.50 (000.81

(027.61 (013.63 (009.27 (000.87

(028.44 (014.04 (009.55 (000.92

(029.30 (014.46 (009.83 (000.97

(030.17 (014.89 (010.13 (001.03

(031.08 (015.34 (010.43 (001.08

(0173.42 (0079.28 (0053.72 (0005.69

School-based Allocation to schools

(033.86

(034.53

(035.18

(035.82

(036.53

(037.31

(0213.25

Clinical intervention & management Prevention detailing Primary care based smoking Cost of NRT Lifestyle counselling

(002.35 (006.41 (006.51 (008.42

(002.50 (009.66 (009.51 (013.49

(02.66 (013.13 (012.56 (019.04

(002.83 (015.40 (014.30 (025.12

(003.02 (016.25 (014.65 (026.50

(003.14 (017.16 (015.02 (027.95

(0016.49 (0078.00 (0072.54 (0120.52

Special populations

(020.00

(020.60

(021.22

(021.85

(022.51

(023.19

(0129.37

Miscellaneous costs

(010.00

(010.30

(010.61

(010.93

(011.26

(011.59

(0064.68

Administration, surveillance, evaluation

(012.37

(014.42

(015.75

(017.21

(018.25

(019.66

(0097.65

Total cost

(136.03

(158.61

(173.22

(189.27

(200.80

(216.24

1,074.18

Note: Some rows and columns do not add to totals shown because of rounding.

16 Collaborating for Health

Coalitions and community partnerships provide a means of pooling the abilities, expertise and resources of numerous stakeholders to positively affect community health.1

As indicated in the introduction, this book emerged out of the British Columbia Healthy Living Alliance’s risk factor project. The aim and hope is that the project’s content and the conclusions will be highly transferable to other jurisdictions. One of the underlying features of the project has been embracing the contemporary importance of building effective coalitions and alliances to address health care issues and of crafting strategic communication plans. This chapter will look at the ‘case study behind the case study,’ that is, what it took to assemble a coalition, devise a plan, and communicate the results – all geared to maximizing health in British Columbia. We hope that the process involved will be instructive for others embarking on a similar project within their population. The Shape of Coalitions A new body of literature has emerged over the past decade on the topic of health coalitions. Of course, it must be acknowledged from the start that coalitions are not all the same. There is a typology within health care partnerships that may be organized around at least four dimensions. One axis of the classification grid relates to the geographical or population breadth. Some coalitions operate within local communities (municipalities or even neighbourhoods or school catchment areas) or for the sake of specific populations; others work at

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‘higher’ levels, influencing policy with regional, provincial/state, or national impact. The favoured language for the latter type of partnership seems to be ‘alliance.’ Alliances tend to have a number of professional staff, with less emphasis on volunteer leadership. ‘Coalition’ is commonly used for more community-oriented groups or among those working with specific populations; here representation by volunteers would be more common. Most of the research has focused on the coalition type of health care partnership, where the activity tends to be less that of policy-setting and more to do with cooperating in order to implement health delivery systems for the benefit of actual clients in specific communities. Whereas the first axis relates more or less to spatial reach, the second deals with time. The specific variable is intended or expected duration. Thus, small coalitions formed to be a catalyst for change or to address a crisis behave differently than larger groups ‘formed to address community health and resources on an ongoing basis.’2 On another axis, the focus of coalitions can be narrow (e.g., preventing breast cancer) or it can embrace a wider set of health care concerns. Finally, coalitions can have more of an advocacy role (where any government representatives are usually non-voting ‘guests’) or they may be advisory in nature (where community-based organizations are invited to the table at the instigation of government sponsors). On the basis of this typology, then, the B.C. Healthy Living Alliance would be described as an advocacy body with a provincewide mandate and broad health concerns intended to be on the agenda for a sustained period of time. Power in Numbers The BCHLA and other such alliances usually form with a definite end in mind, namely, to be ‘powerful agents for social change’ by solving complex public health challenges. Partnerships and coalitions offer a number of distinct advantages, including:3 • Enabling organizations to become involved in broader issues without having to shoulder sole responsibility for change • Mobilizing talents and resources to develop widespread public support • Increasing the critical mass behind a community effort that is beyond the scope of any one organization

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• Minimizing duplication of effort by improving trust and communication among previously independent (and even competing) groups. That is not to say that operating within coalitions is without inherent challenges. The work can be time-consuming and difficult and engender a number of frustrations. These can include the failure of promised or needed resources to materialize, conflicting interests among members, and lack of community appreciation or recognition for valuable efforts. Organizations that raise funds from the public will have a continuing need to remain individually identifiable by the target population. The members of an alliance must cooperate while still guarding their brand to some extent. It Began with Cancer Developing a chronic disease prevention plan for the province of British Columbia grew out of a more modest goal, that is, to create a comprehensive cancer prevention plan. In British Columbia, which has a population of 4.3 million, there are two main organizations with cancer as their mandate: the B.C. Cancer Agency (specializing in government-funded cancer treatment, but with a component concerned with prevention) and the Canadian Cancer Society, B.C.-Yukon Division (the community-based charitable organization focusing on prevention and support programs). Both groups have a stake in cancer research. While each organization has long had a specific prevention focus, neither had the mandate or capacity to cover the entire scope of cancer prevention. Several points became clear during early discussions. First, it was jointly recognized that a majority of cancers are due to preventable risk factors or behaviours, such as the ones addressed in this book. Second, certain risks are common to a number of diseases. Finally, it was determined that strategies to improve health in such areas must move beyond what has been traditionally seen as the health sector. The two cancer partners realized that developing a fundable vision would be more likely to succeed if there was broad community support. As a result, the Canadian Cancer Society and the B.C. Cancer Agency decided to broaden their usual planning horizons to develop a chronic disease prevention strategy for the province and to seek other partners to increase the probability of success. When first posited in 2004, a chronic disease framework and con-

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certed public health effort seemed particularly timely in light of several other developments, including the inauguration of the B.C. Healthy Living Alliance, the high-profile commitment of the provincial government to be the healthiest host of any Olympics ever held, and an impending provincial election (ultimately held on 17 May 2005). Coalition under Construction Formed in February 2003, the BCHLA is a coalition of organizations working together to improve the health of British Columbians through leadership that enhances collaborative action to promote physical activity, healthy eating, and living smoke-free. Collectively, BCHLA member organizations comprise over 40,000 volunteers, 4,300 health and recreation professionals, and 184 local governments across British Columbia. The organizational membership includes the Canadian Cancer Society – B.C.-Yukon Division, the Heart and Stroke Foundation of B.C. and Yukon, the B.C. Lung Association, the Union of B.C. Municipalities, the B.C. Recreation and Parks Association, the Public Health Association of B.C., Dietitians of Canada – B.C. Region, Canadian Diabetes Association – Pacific Division, the B.C. Pediatric Society, and Public Health Agency – Yukon Region, as well as non-voting participation from the B.C. Ministry of Health Services, Provincial Health Services Authority, and the various regional health authorities in the province (Fraser Health, Interior Health, Northern Health, Vancouver Coastal Health, and Vancouver Island Health). Many more organizations are seeking to join. As with many alliances, a considerable amount of initial energy was devoted to ‘forming and norming’ issues, such as drafting (and redrafting) terms of reference and membership criteria. While a few limited projects were completed by the BCHLA, in many ways it was a group in search of an agenda. Members of the alliance were excited about the initiative and funding offered to develop an evidence-based chronic disease prevention strategy. This represented a comprehensive vision worthy of such a broad-based coalition. The Present Moment Once British Columbia was awarded the 2010 Winter Olympics, B.C.’s premier announced his commitment to work towards the province being the healthiest jurisdiction to ever host an Olympics. This created

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a wonderful opportunity for synergy between the premier’s announcement, the BCHLA’s agenda, and the potential mobilization of the public. While perhaps this could be seen as a unique moment with unique momentum, it is not without precedent. Juridisctions around the world may be inspired by fairly recent examples where others have used an appropriate spur to get them moving on the quest for enhanced levels of public health. For instance, poor results in a seven-country study helped to launch Finland’s remarkable campaign for public health improvement in the region of North Karelia (see chapter 12). Closer to home, the shoe was on the other foot when the Canadian public was confronted (in a famous 1973 television advertisement) with the statement that the average 60-year-old Swede was more fit than the average 30-year-old Canadian. Happily, the shoe on the other foot turned out to be a running shoe. The organized response was the federal government’s ParticipAction program, which generated enormous benefits for the health of Canadians, especially through increased physical activity.4 The Planning Process Researchers have proposed different paradigms in staging the work of a coalition. For example, Butterfoss and Fransisco suggest: (1) analysing the problem; (2) gathering data and needs assessing; (3) developing an action plan; (4) implementing solutions; (5) achieving communitylevel outcomes; and (6) creating social change.5 We will adapt a similar model6 to outline the steps pursued by the BCHLA. Step 1: Issue Identification In the spring of 2004 the BCHLA began developing targets to reduce major chronic disease risk factors in the province of British Columbia. An initial step in the process was to examine the risk factors of smoking, unhealthy eating, physical inactivity, and overweight/obesity. The associated report linked these risk factors to chronic diseases such as cancer, heart disease, and diabetes, examined the current status of the risk factors in British Columbia compared with other provinces, and reviewed the target-setting efforts in other jurisdictions. The report, 2010 Target Setting for Risk Factors for Chronic Disease: Background Document for Consultation, is available at www.bchealthyliving.ca, as are all of the other reports referred to in this section.

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Step 2: Prioritization The second step of the planning process was to propose 2010 targets for the four risk factors, based on a consultative process with the province’s six health regions (more details on this process can be found earlier in this book, in the second instalment of the B.C. case study). The final targets were published in January 2005, in Healthy Living: Targets for 2010. Step 3: Strategy Development (Part 1) A third step involved gathering information on the effectiveness of interventions used over the years to control these risk factors. In real life, neither time nor resources are unlimited, so it was vital to look for methods that have actually worked. The associated report, Risk Factor Interventions: An Overview of Their Effectiveness, also recognized that many of the factors inter-relate, and therefore programs with synergistic benefits are likely possible. Step 4: Strategy Development (Part 2) The next step was to select the most cost-effective interventions for a provincewide program aimed at reducing risk factors and preventing chronic disease. The report, entitled Resources for Health: A Cost-effective Risk Factor Plan for British Columbia, examined: • the health consequences and economic costs of the four key risk factors • the benefits of achieving the BCHLA indicator targets related to the factors • the most cost-effective interventions to achieve the targets by 2010 • the investment needed if the government was serious about becoming the healthiest hosts ever of an Olympic Games. The draft report, as with all the others, was thoroughly vetted by key stakeholders. In this case, a full workshop gathered detailed feedback to allow significant changes to be incorporated into the final version. Step 5: Strategy Integration A final report, The Winning Legacy: A Plan for Improving the Health of British Columbians by 2010, provided a non-technical summary of the

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whole project. This formed the backbone of the strategy to get the word out. Since then, the material has been widely circulated. Step 6: Communication and Advocacy With the completion of the summary report, the external communication plan then began in earnest, primarily by presenting the various recommendations and supporting evidence to the Premier of British Columbia and relevant ministries during the provincial election campaign. All 5 reports were presented to the premier by four representatives of the B.C. Healthy Living Alliance on 3 March 2005, during the campaign leading to the provincial election. Premier Gordon Campbell expressed his support for the overall thrust of the documents, and he promised to respond in another meeting within a month regarding the specific actions to which his government would commit itself. (As will be explained below, the premier did indeed schedule a follow-up meeting with the alliance, but not until July, after the provincial election in which he and his party were re-elected to form the government.) Step 7: Implementation and Transition The final step, common to all such initiatives, involved securing funding, devising public announcements, and establishing initial infrastructure for implementation and evaluation. The infrastructure discussion is important given the lesson ‘that community-based coalitions with paid coordinators and formal structures are capable of generating significantly higher levels of activity than those without either a paid coordinator or formal structure.’7 The evaluation philosophy and framework are also vital; while it is easy to focus on measures of process or activity outputs, evaluating outcomes is the most robust indicator of success. Underlying both infrastructure and evaluation concerns is the issue of sustainability. How can the way in which the implementation activity is launched also manage to anticipate a longterm program? This perspective, which requires both institutionalization and flexibility, is vital to making the deep and lasting changes in population health that are the mission of the alliance. A progress report on this step in the BCHLA project is provided below. Communicating with the Government Shortly after its winning bid in 2003, the B.C. government announced its intention to be the healthiest jusidiction ever to host the Olympics.

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Within this context, the government began to assemble its strategy for healthy living under a program called ActNow. At the time, however, ActNow appeared to be a name and a vision without a great deal of substance.8 So the opportunity to populate the program with meaningful content met the needs of both government and the BCHLA. Meanwhile, dialogue with senior Ministry of Health Services staff provided the environment to share specific ideas, identify common interests, and – most important of all – build trust. The Election The proximity of the election (held on 17 May 2005) served to focus the attention of both the alliance and the government. The alliance recognized that the pre-election period was critical in terms of articulating its agenda and then securing political support from the relevant parties. The (approximate) provincial election date had been known for four years. This certainty allowed the alliance to work backwards from a predetermined point in time and create a sound game plan. In a way, the deadline forced the BCHLA to agree fairly quickly on complex issues and to develop consensus on recommendations – a process which likely would have otherwise become bogged down in wordsmithing and trivial differences. Although none of the political parties adopted the plan (summarized in the The Winning Legacy report, as noted earlier) as part of its platform, discussions continued between representatives of the BCHLA and various political candidates right up until the vote. The election resulted in the return of the incumbent party. The Post-Election Phase In July 2005 representatives of the BCHLA met again with the premier, who reconfirmed his general support for the thrust of The Winning Legacy. Interestingly, he also stated that he understood the role of the BCHLA as ‘critics’ of the government and believed it to be a legitimate part of government policymaking. When asked, he also confirmed that all of the recommendations of The Winning Legacy were on the table for discussion – none were to be excluded for ideological reasons. The premier noted he would be asking all Cabinet ministers to identify how they could contribute to a healthier population through actions implemented in their ministries.

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Representatives of the BCHLA suggested to civil servants and legislators that The Winning Legacy recommendations could be used to respond to the premier’s directive to his ministers. Coincident with these meetings, several formal and informal presentations were made to senior Ministry of Health Services staff. The Announcement On 23 March 2006, the first phase of BCHLA’s work came to a climax with the announcement of major program funding from the province. The alliance received $25.2 million, part of a $30-million one-time grant to be shared with 2010 Legacies Now. The investment in health promotion was announced at a special event with Health Minister George Abbott, who offered the following comments: ‘We are building on British Columbia’s reputation as the healthiest province in Canada by providing resources to these two groups with vital community links to promote healthier lifestyles for British Columbians. The BCHLA and 2010 Legacies Now have a depth and breadth of expertise, knowledge and community partnerships that will help us achieve the goals of ActNow BC.’ Acting for the Future While it would have been tempting to immediately invest in program delivery, the BCHLA realized that the first thing to be built on the foundation of The Winning Legacy was an environmental scan of existing programs in the province. The alliance had no interest in duplicating efforts; instead the goal was to enhance or extend the best current efforts before any innovations or new program roll-outs. Constistent with this principle, a comprehensive inventory was assembled to determine present and proposed initiatives in the area of risk factor prevention by all major players in the province. Nothing quite like this task had ever been accomplished before. The approach relied heavily on personal contact with leaders throughout the province, using a structured interview process. The environmental scan informed the subsequent gap analysis. This involved comparing the interventions proposed in the BCHLA business plan with inventory of initiatives found in the province. This phase was scheduled to be completed by the end of May 2006. The gap analysis in turn would support the decision-making by the BCHLA Coordinating Committee regarding

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which gaps to address, how this should be best accomplished (e.g., via funding or advocacy), and by whom (both lead and partner agencies). Plans for each intervention were to be developed and then rolled into a coordinated package. Program implementation was planned to commence in the fall of 2006.

Key Points • The growing body of literature on community health coalitions offers useful insight concerning the formation and function of groups like the B.C. Healthy Living Alliance (BCHLA). • Coalitions offer both advantages and challenges as they seek to bring about significant change in both individual and population health. • Principles that need to be considered by any high-level coalition include the importance of good staff and structures; a good written plan based on sound theory, thorough needs assessment, and evidence-based interventions; and a commitment to robust evaluation of both processes and outcomes. • The BCHLA has capitalized on the passionate commitment, planning abilities, and communication skills of its members, as well as on a unique time in provincial history, to leverage a strong risk factor strategy into the consciousness of the B.C. government. • Although not all jurisdictions will be selected to host an Olympic Games, many features of the BCHLA process and plan are reproducible in other jurisdictions, including the utility of looking for creative “teachable moments” that may capture the imagination of the public.

Conclusion: Four Fundamentals for Reducing Risk Factors

The essential thing ‘in heaven and earth’ is ... that there should be long obedience in the same direction; there thereby results, and has always resulted in the long run, something which has made life worth living. Friedrich Nietzsche

We had several important purposes in putting together this volume. A key focus was to identify useful interventions for controlling tobacco use and the development of obesity. A closely related theme involved drawing a comparison of these two risk factor arenas (see chapter 11). In the planning process that originally inspired this book, it was important to separate the wheat from the chaff and to pick out the best or most promising public health and clinical practices. To aid other planners, we have provided summaries of all of the interventions – the good, the less proven, and the unproven – at the end of chapters 8 and 14. We have also provided brief analyses of the cost-effectiveness data that are available for the various interventions. Financial soundness has always been a concern in health care, and certainly this is the case in the current era. The ultimate aim of this book is to set a broad agenda, one that supersedes the changing context of risk factor intervention studies. Thus, one question remains uppermost: What are the key factors required for any risk factor reduction plan to be successful? Based on a review of the literature and our experience, four fundamental issues determine the success of any risk factor reduction plan: • the dance between the personal and the environmental • comprehensiveness

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• innovation • long obedience in the same direction. Each of these perspectives is described here in more detail in order to construct a dynamic framework for specific risk factor planning. The Personal and the Environmental Risk factors such as smoking, unhealthy eating, and physical inactivity are often labelled as lifestyle factors. This description focuses on how they function as aspects of individual behaviour or as characteristics that are subject to personal choice. In the past two decades, this individualistic perspective has come under fire. Sometimes the complaint has been ideological or emotional, that is, a certain discomfort with creating a ‘culture of blame’ that highlights personal shortcomings and places responsibility for health on individuals. At best, such concerns are shaped by a recognition that forces larger than the personal are at work all the time in the promotion of risky behaviour. The U.S. Surgeon General captured this viewpoint very well in the 2001 report focusing on obesity: Many people believe that overweight and obesity is [sic] a personal responsibility. To some degree they are right, but it is also a community responsibility. When there are no safe, accessible places for children to play or adults to walk, jog, or ride a bike, that is a community responsibility. When school lunchrooms and office cafeterias do not provide healthy and appealing food choices, that is a community responsibility. When new or expectant mothers are not educated about the benefits of breastfeeding, that is a community responsibility. When we do not require daily physical education in our schools, that is also a community responsibility. There is much that we can and should do together.1

These suprapersonal forces are sometimes called environmental or ecological factors, that is, conditions that shape the context in which people live and move and have their being. We should admit right away that ‘environmental’ as used here is problematic, since it is also applied to one’s physical environment on a macro-scale (i.e., geography, climate) or to exposure to harmful agents in the environment (hence, categories such as environmental carcinogens). Regardless of

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the ambiguities, the use of environmental to describe a person’s total life context appears to be here to stay.2 An accumulating body of evidence has put the environmental context for human health on a more scientific footing. This book has touched on the reality that socioeconomic status (SES) is associated with patterns of eating and consequent obesity rates. The evidence is just beginning to emerge that other environmental factors, including transportation policies, built form, urban design, perceptions of safety, and zoning, may influence physical inactivity and, to some extent, dietary practice. The recent focus on the environment has not only been about the evidence. It also involves an inference from history. We have seen just how powerful various economic and regulatory mechanisms, as well as social denormalization, have been in tobacco control. The assumption is that influencing the same type of forces could have an impact on obesity. It is unwise to polarize the personal and the environmental too much. Neither perspective is going to disappear in terms of practical implications. For example, it is unlikely that insurance companies will stop charging smokers more for their premiums. In fact, they may well try to expand the list of risky lifestyle choices that allow differentiation around eligibility and policy rates. Employers, too, are testing the legal limits of denying jobs to applicants with health risks. Integrating the environment into health planning, although still at an early stage of research, is seen to be full of potential. The concern of this book is population health: it is precisely environmental strategies that provide the most effective means of influencing the largest number of people. In fact, the environment is not really new to risk factor interventions. Media advocacy has always sought to influence social norms, or what might be called the interior landscape or mental and emotional environment of a whole group. One of the main burdens of this book is to show that both personal and environmental interventions are needed in order to achieve the desired progress in the arena of risk factors. Positive lifestyle choices must be reinforced by a supportive environment. To quote the now ubiquitous slogan: ‘We need to make healthy choices the easy choices.’ The mandate of exposure prevention, keeping people away from disease risk factors in the first place, holds out huge promise in terms of health improvement and cost avoidance. But, to paraphrase the

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Bible’s comment on the persistence of poverty as a category, we will ‘always have smokers and the overweight among us.’ Various kinds of social engineering cannot solve everything. Thus, once we use environmental levers to begin to motivate behavioural change, the mechanisms that support intensely personal efforts also need to be made available. This means, for instance, counselling and pharmacotherapy in primary care and other settings made easily accessible to individuals who want to quit smoking, get active, lose weight, and so on. The opposite scenario, motivating change at a community level but not actively helping individuals who want to change, could be described as adding societal insult to personal injury. It contributes to guilt, frustration, and discouragement, and may actually exacerbate risky behaviour. The next point is about the importance of comprehensive plans. What we have just been saying is that any comprehensive plan must start by encompassing both personal and environmental approaches to risk factors. They are allied strategies that must ‘dance together’ if we are to create a beautiful picture of health in the future. The Power of the Comprehensive Only one of the intervention categories used in this book was labelled as comprehensive strategies, defined as interventions with multiple components drawn from two or more of the other intervention categories. So, a community-based intervention combined with a school program would qualify as comprehensive. The main message of this section of the chapter is simply this: to not be comprehensive in planning is not really an option. A multidimensional approach in multiple spheres is essential to building unstoppable momentum in impacting risk factors. Just as we observed that multiple risk factors can be synergistic, that is, creating negative health impacts that are greater than the sum of their partial effects, so also a positive example of synergy can be detected in risk factor strategies. Each intervention in a comprehensive strategy reinforces and multiplies the effect of the others. The good news is that, if the budget and other resources are limited (as they always are), then the minimal list of interventions needed for comprehensive effectiveness has already been established through research and real world practice. In terms of tobacco control, these are the non-negotiable interventions that always end up floating to the surface:

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• Increased taxation on tobacco products: in terms of increasing cessation or preventing uptake, this works for all segments of the population, but especially for important subgroups such as adolescents and pregnant women. • Increased efforts to enforce smoke-free public places and encourage smoke-free homes and automobiles, especially where children are present. • Increased control of activities that promote tobacco consumption, as a further step towards ‘denormalizing’ both smoking and the image of the tobacco industry: this is one aspect of the environmental changes needed to produce a sustained shift in population health behaviour. • Increased high-impact media advocacy: this will work best when counter-advertising is combined with a comprehensive strategy that includes the best school and workplace programs, as well as initiatives tailored for special populations. Further exploring communication technology (from telephone to the Internet) to support quit attempts should be part of the agenda. Currently, the most highprofile versions of this effort are the graphic health warnings on cigarette packages and point-of-sale posters in some jurisdictions. • Increased involvement of all primary care providers in clinical cessation efforts for all smokers and especially at-risk target groups (e.g., those with mental illness, recovering from illness, or preparing for surgery). At the same time as other system inputs, such as continuing education, are employed, success is enhanced if there is support for the real costs borne by providers and patients for any cessation interventions (e.g., counselling, or nicotine replacement therapy). In 2003 the World Health Organization highlighted all five of these interventions. Summing up 40 years of global tobacco control experience and evaluation, the authors of the report confirmed that the preceding list represents the necessary commitments for any public health program related to smoking.3 The long history of tobacco control has allowed new methods to be developed for testing the interaction, especially the synergy, between different policy components.4 One recent European paradigm weighted the key program characteristics (including overall funding levels) in terms of their perceived contribution to reducing smoking rates (see table 17.1).5 Using this scale, 28 countries in Europe were assessed. Of the 10 countries that scored over 50 points (of a possible

280 Conclusion Table 17.1 Weighting of Key Tobacco Control Interventions

Intervention

Weighting (out of 100)

Price Smoking bans Tobacco control budget Advertising ban Labelling / health warning Cessation treatment

30 22 15 13 10 10

Source: Jousensh. Effective Tobacco Control Policies in 20 European Countries (2004)

100) in tobacco control efforts, 8 showed a decrease in smoking prevalence of more than 20% between 1985 and 2003. In contrast, of the 10 countries scoring less than 40 points, only 1 achieved such a strong result. This analysis demonstrates that we simply cannot afford to pick and choose interventions. To do so would dilute their overall impact. Perhaps some interventions for nutrition and/or physical activity have so far shown such equivocal results simply because they have been implemented in isolation. Extrapolating from the experience with smoking, it is possible to construct a parallel ‘bare essentials’ program for obesity that will maximize its effectiveness through: • Increased use of financial levers, such as positioning healthy food to be the ‘low price’ choice in the marketplace and removing any economic barriers to accessing basic physical activity facilities • Increased involvement of parents and schools in influencing children and modelling healthy diet and activity levels • Increased attention to the environmental signals concerning diet and activity, from the nutrition labelling of products and menu items to the accessibility of good food and attractive exercise options. Controlling the marketing of unhealthy foods to children is potentially an important component of this approach • Increased counter-advertising and media advocacy, combined with school physical education, workplace health promotion, and communitywide programs that focus on diet and exercise (the latter enhanced by social support such as walking clubs and personal feedback through technology such as pedometers). The telephone

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can also be a simple and inexpensive tool to allow follow-up and reinforcement • Increased clinical counselling programs for diet and exercise changes, with pharmacotherapy and surgery available as needed Putting all of the above together at the same time will produce more bang in health care; even better, it may also produce ‘more bang for the buck.’ That is, a final bonus attached to comprehensive risk factor programs is that they are cost-effective. Again, the area of tobacco control offers well-documented evidence. In this regard, we refer the reader to chapter 10, where we described a comprehensive tobacco control program with maximum reach into a population – costing only 1% of the amount spent for average medical procedures for the same effect on life. The overwhelming advantage of comprehensive approaches is obvious. We already know how to build a comprehensive program to tackle tobacco. The next expression of comprehensiveness may involve tackling the factors of tobacco and obesity together. We are only beginning to understand the synergies involved in addressing multiple risk factors at the same time. Entire public research agencies are studying this topic, with the eventual data undoubtedly destined to dramatically shape our future approach to risk factors and disease prevention. Risking Innovation to Increase Knowledge Working out the integrative perspective just described, as with so many areas of risk factor policy, requires research, real world trials, and constant adaptation in the face of emerging or partial evidence. The ‘war cry,’ to quote a recent editorial, should be the following: ‘We need to know much more, but we know enough to act.’6 This pragmatic attitude is especially important in obesity control, where effectiveness and cost-effectiveness data are still rather thin. The stakes are simply too high to wait decades for conclusive research results providing the best possible evidence. We must be content to put the best available evidence into operation in natural experiments, pilot projects, and observational studies. Randomized, controlled experiments are not always possible, but we sometimes can gain much insight by investigating the effect of policies and programs that are rolled out in the real world. Although taking action without complete evidence may make some people uncomfortable, it actually is based on a good rationale. It actually provides a number of advantages, as described below.

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First, there are a number of potential interventions that already have good circumstantial or observational evidence, or at least good intuition about their ‘face validity.’ Several population-based initiatives have been proposed in many jurisdictions, especially in the area of obesity control, for example: • • • •

legislation to mandate fast food portions of a reasonable size removal of the sales tax on exercise equipment offering tax incentives to employers that provide exercise facilities taxation to encourage increased density of development and active commuting • urban design to promote walking and bicycling • policies to provide food security for individuals and families. The effectiveness of these interventions is not yet known. Many authorities are convinced, in light of the relative ineffectiveness of interventions that are geared to individuals alone, that addressing the ‘obesogenic’ environment is the most beneficial way to move forward. There is a lot of creative, cutting-edge thinking happening in this area of health care, generating ideas that deserve some experimental testing. Second, real world projects begin to help us solve the ‘translation problem’ we sometimes encounter with randomized, controlled trials. The contrived world of the ‘laboratory’ does not always tell us how an intervention will work in public health or clinical practice. The kind of evaluation grid designed to measure a program in real world operation can be more inclusive of the concerns shared by actual policymakers. For example, Glasgow and colleagues have devised a schema that helps to assess a program as it is actually applied to a population.7 The intention of their approach is to evaluate health behaviour interventions that offer a large public health impact. The five criteria in their evaluation system are known by the acronym RE-AIM: • Reach: How do we reach those who need the intervention? • Effectiveness: How do we know our intervention is effective? • Adoption: How do we develop organizations to deliver the intervention? • Implementation: How do we ensure it is delivered in a high-quality way? • Maintenance: How do we get the intervention to be delivered over the long term?

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The third reason to support action despite incomplete information is that the resulting evaluation mandate will increase the drive to collect high-quality data at the community level. Many leaders working in health authorities or in community organizations believe that more detailed data should be available, allowing any plan to be made relevant to smaller administrative units or, even better, local communities and natural neighbourhoods. Fourth, a culture of continuous learning, administrative flexibility, and program adaptability is developed within preventive health care when we choose to operate without complete evidence. This is exactly the opposite of maintaining a status quo scenario, where we are driven to perpetuate structures and programs regardless of whether they are working. Finally, testing novel interventions may lead to unintended positive consequences. For example, simply seeing a government taking action can be encouraging for the public, as well as for health care providers and advocates. Initiative will beget initiative, including personal behavioural change, professional creativity, and commitment of volunteer workers. Acting aggressively in the way we have described is not as risky as it may sound. We should not exaggerate the political exposure of government and community actors. While taking a leadership role will require some commitment to implement interventions before others have shown them to be effective, ongoing evaluation of these interventions will allow for continual reassessment and appropriate changes based on new evidence. Course corrections will minimize following the wrong trail for very long. No one today needs to feel alone when adopting an innovative approach. As noted in The Path to Health and Wellness: Making British Columbians Healthier by 2010: ‘while proof of successful strategies to reduce obesity and to promote healthy eating and active lives on a population-wide level does not yet exist, many countries are embarking on ambitious programs in a struggle to make a difference.’ Every jurisdiction has an important role to play in this regard. We must evaluate trial programs rigorously, be flexible in abandoning unhelpful approaches, communicate results widely, and help the rest of the world to adapt any successful interventions that we discover. Sufficient and Sustained Resources ‘Sufficient and sustained’ is simply a less poetic way of saying what Nietzsche said in the quotation at the head of this chapter: to see

284 Conclusion

results, we need to be committed to a ‘long obedience in the same direction.’ Both halves of the formula are vital. First, sufficient resources refer to the necessary funding, political leadership, organizational infrastructure, and trained personnel to implement a comprehensive risk factor plan and hit the targets. The absolute requirement for sufficient funding was already introduced under the heading of comprehensive plans (above). Recall that the European analysis indicated the simple presence of an adequate tobacco control budget contributed 15% towards the overall effectiveness of any plan. An underpowered plan will not perform very well. For example, one of the greatest instances of public health success in the United States has been seen in tobacco control among youth; unfortunately, the greatest tragedy also occurred in the same arena, when precious population health gains were lost as funding was withdrawn in some states. The investment of political capital also needs to be maintained. An application of this principle was seen in the Canadian context. When taxation rates on cigarettes were rolled back in the 1990s in response to vigorous lobbying by the tobacco industry, smoking prevalence rates increased dramatically. Sustained courage and political will are basically another type of vital currency to invest in risk factor programs. The battle lines over healthy eating in the developed world are just beginning to be drawn; political capacity needs to be expanded right away to face this challenge. The finish line in a health care race inevitably leads back to the bottom line. The lesson about sufficient public investment in health promotion and disease prevention, learned the hard way through the ups and downs in the history of tobacco control, must be applied in the same measure to unhealthy eating, inactivity, and obesity. The simple truth is that it is practically useless to devise a multifaceted risk factor plan, announce it to great fanfare, and then not fund or otherwise support it adequately. The closely related idea of a sustained campaign is crucial. The war on tobacco has made substantial gains in developed nations, but it took a concerted effort over a 40-year period. The famous North Karelia project in Finland saw dietary changes and a significantly reduced cardiovascular mortality after a 30-year program. Canada’s province of Nova Scotia is pursuing a 20-year health strategy.8 The mechanisms of long-term change are well understood. A general attitude shift often needs to precede individual behavioural

Four Fundamentals for Reducing Risk Factors

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improvements. So-called diffusion of innovations in society takes a lot of time. The holy grail of an entrenched social norm, one that favours healthy behaviours and is against unhealthy influences, needs to be solidified by a high-quality social marketing campaign over many decades. The public agreement required to eliminate avoidable chronic disease must move beyond the short-term political cycle and towards a multigenerational perspective. In the context of our provincial case study, the excitement that British Columbians are feeling over hosting the 2010 Winter Olympic Games must be translated into long-term momentum. The province needs to still be at the ‘risk factor game’ when it finally hosts the summer Olympics 60 or so years from now! Tomorrow’s Health Heroes? The sort of long-term momentum that we have been describing, especially in the obesity-reduction race, which has barely begun, will require leadership on many fronts, including basic research and policy formation. This book was completed at a point in public health history that was both poignant and pointed. In the summer of 2005, Sir Richard Doll died. The Canadian Medical Association Journal described him as ‘one of the world’s most accomplished epidemiologists.’9 Doll was most famous for leading the charge against tobacco use. He and Austin Hill demonstrated in a famous 1950 paper that smoking was an important cause of the rapidly increasing epidemic of lung cancer in the United Kingdom.10 More than 50 years later, Doll was still publishing the results of a study in which 40,000 physicians had been enrolled; the conclusions: over half of all smokers are killed by the habit, and cessation can dramatically improve the mortality statistics.11 While both the government and the public were slow to pick up on Doll’s original work published in 1950, the impact of further research and a growing tide of public and legal activism eventually did lead to a world where not smoking is the norm. Contrast this with the middle of the twentieth century: Doll himself smoked when he began his work, along with 80% of the men in the United Kingdom. Following the conclusions of his own studies, Doll quit smoking, which no doubt contributed to his being active in his work until his death at the age of 92. One of the rallying cries at the close of this book involves this question: Who will be the Richard Dolls of this era – who are the people who will help to create a similarly dramatic change of climate around

286 Conclusion

unhealthy eating, a sedentary lifestyle, and rising obesity rates? But it will take more than individual heroes. Ultimately, what is required is a full team effort consisting of government commitment, public health leadership, and empowered action by millions of ordinary people. Engaging the whole community at all levels is essential to turn around the continuing crises related to population health risks and chronic disease. In this cause, everyone needs to be a champion, dedicated to the creation of a winning legacy.

Notes

Chapter 1. Introduction 1 Broemeling A, Watson D, Black C. Chronic Conditions and Co-morbidity among Residents of British Columbia. Vancouver: UBC Centre for Health Services and Policy Research, 2005. 2 Ibid. 3 Centers for Disease Control and Prevention (CDCP). Available at http: // www.cdc.gov/nccdphp/burden_ pres/bcd_04.htm. Accessed March 2005. The mortality assessments probably will be somewhat adjusted due to new information related to obesity (see Chapter 2), but there is no dispute about the serious health impact of obesity, especially when combined with the other effects of physical inactivity and unhealthy diet. 4 Ellison LF, Morrison HI, de Groh M, et al. Health consequences of smoking among Canadian smokers: An update. Chron Dis Can. 1999; 20(1): 36–9. More recent estimates have put the figure at between 46,000 and 47,500, if deaths from second-hand smoke are included. Makomaski Illing EM, Kaiserman MJ, Mortality attributable to tobacco use in Canada and its regions, 1998. Can J Public Health 2004; 95(1): 38–44. 5 Gilmore J. Report on Smoking in Canada, 1985 to 2001. Ottawa: Statistics Canada, 2002. 6 Bray F, Tyczynski JE, Parkin DM, et al. Going up or coming down? The changing phases of the lung cancer epidemic from 1967 to 1999 in 15 European Union countries. Eur J Cancer 2004; 40(1): 96–125. 7 U.S. Surgeon General (USSG). The Health Consequences of Smoking: A Report of the Surgeon General. Washington: Department of Health and Human Services (DHHS), 2004. Available at http://www.cdc.gov/tobacco/sgr/ sgr_2004/ index.htm. Accessed March 2005.

288 Notes to pages 8–9 8 Smoking prevalence among U.S. adults was 42% in 1965 and only 23% by 2000. Giovino GA. Epidemiology of tobacco use in the United States. Oncogene 2002; 21(48): 7326–40. 9 Adult male and female smokers lost an average of 13.2 and 14.5 years of life, respectively; 78% of smoking-related mortality in the U.S. is due to chronic bronchitis, emphysema, and heart attacks. CDCP. Cigarette smoking-attributable morbidity – United States, 2000. Morbid Mortal Weekly Rep 2003; 52(35): 842–4. 10 CDCP. Annual smoking-attributable mortality, years of potential life lost, and economic costs – United States, 1995–1999. Morbid Mortal Weekly Rep 2002; 51(14): 300–3. 11 Peto R, Darby S, Deo H, et al. Smoking, smoking cessation, and lung cancer in the U.K. since 1950: combination of national statistics with two case-control studies. Br Med J 2000; 321(7257): 323–9. 12 Health Canada. Youth Smoking Survey, 2002. Available at http://www. hc-sc.gc.ca/hecs-sesc/tobacco/ research/yss/. Accessed July 2004. 13 Health Canada. Report on the Health of Canadians. Ottawa: Public Health Agency of Canada, 1996. Available at http://www.hc-sc.gc.ca/hppb/ phdd/report/1996/chap3e.htm. Accessed July 2004. 14 DHHS. Healthy People 2000 Progress Review: Tobacco. Washington: DHHS, 1997. Available at http://odphp.osophs.dhhs.gov/pubs/HP2000/ PROGRVW/Tobacco/Tobacco.html. Accessed March 2005. 15 World Health Organization. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva: WHO, 2002. Available at http:// www.who.int/whr/2002/en/. Accessed March 2005. 16 Ibid. 17 Ibid. 18 Manson JE, Skerrett PJ, Greenland P, et al. The escalating pandemics of obesity and sedentary lifestyle: A call to action for clinicians. Arch Int Med 2004; 164(3): 249–58. 19 James PT, Rigby N, Leach R. The obesity epidemic, metabolic syndrome and future prevention strategies. Eur J Cardiovasc Prev Rehab 2004; 11(1): 3–8. 20 Colman R. Cost of Obesity in British Columbia. GPIAtlantic, 2001. 21 Prentice AM, Jebb SA. Obesity in Britain: Gluttony or sloth? Br Med J 1995; 311(7002): 437–9. 22 Rashad I, Grossman M. The economics of obesity. Public Interest 2004; 156. Available at http://www. thepublicinterest.com/. Accessed July 2004. 23 Colman. Cost of Obesity. 2001. 24 Jain A. Fighting obesity. Br Med J 2004; 328(7452): 1327–8. 25 Colman. Cost of Obesity.

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26 Rashad, Grossman. Economics of obesity, 156. 27 Christiansen E, Garby L, Sorensen TI. Quantitative analysis of the energy requirements for development of obesity. J Theor Biol. 2005; 234(1): 99–106. 28 Christiansen E, Garby L. Prediction of body weight changes caused by changes in energy balance. Eur J Clin Invest. 2002; 32(11): 826–30. 29 Colman R, Walker S. The Cost of Physical Inactivity in British Columbia. GPIAtlantic, 2004. This is consistent with evaluations made according to the 1998 Health Canada guideline, which found that 66% of Canadians engage in below-optimum levels of physical activity. 30 USSG. Health Consequences of Smoking. 31 Canadian Fitness and Lifestyle Research Institute. Physical Activity Monitors and Surveys, 1981–2000. Available at http://www.cflri.ca/cflri/pa/. Accessed July 2004. 32 Craig CL, Russell SJ, Cameron C, et al. Twenty-year trends in physical activity among Canadian adults. Can J Public Health 2004; 95(1): 59–63. 33 WHO. World Health Report 2002, xvi. 34 Fries JF, Koop CE, Sokolov J, et al. Beyond health promotion: Reducing need and demand for medical care. Health Aff 1998; 17(2): 70–84. 35 Harvard Center for Cancer Prevention. Harvard Reports on Cancer Prevention. Available at http://www.hsph.harvard.edu/cancer/publications/ reports.html#volu me1. Accessed March 2005. 36 Sweanor D, Kyle K. Legislation and applied economics in the pursuit of public health. In: de Beyer J, Brigden LW, eds. Tobacco Control Policy: Strategies, Successes, and Setbacks. Washington: World Bank, 2003. pp. 71–96 Available at http://www1.worldbank.org/tobacco/pdf/2850–Ch04.pdf. Accessed Oct. 2004. 37 This is comparable to the results in a ‘flagship’ tobacco control state, California. 38 In the U.S., 82% of indoor workers faced some restrictions on workplace smoking by 1983, and 47% worked in smoke-free environments. Farrelly MC, Evans WN, Sfekas AE. The impact of workplace smoking bans: Results from a national survey. Tobacco Control 1999; 8(3): 272–7. 39 The B.C. government Tobacco Control Strategy, published in May 2004, notes that First Nations prefer the term ‘tobacco demarketing’ in order to avoid the sense that their traditional and/or sacred uses of tobacco are not normal. 40 See the discussion on denormalization at http://www.ncth.ca/NCTH_new .nsf/0/BB9C061688D983 AA85256E160077E4C8?OpenDocument. Accessed Oct. 2004.

290 Notes to pages 12–16 41 Letter to Ujjal Dosanjh, Federal Minister Of Health, signed by over 50 Canadian public health officials and advocates, Nov 1, 2004. Available at http:// www.nsra-adnf.ca/news_info.php?news_id=238& language=en. Accessed Nov. 2004. Chapter 2. Risk Factors and the Burden of Disease 1 Davis CH, MacKinnon DP, Schultz A, et al. Cumulative risk and population attributable fraction in prevention. J Clin Child Adolesc Psychol 2003; 32(2): 228–35. 2 One way to compute PAF: [(Incidence in pop.) – (Incidence in unexposed group)]/(Incidence in pop.). 3 Greenland S, Robins JM. Conceptual problems in the definition and interpretation of attributable fractions. Am J Epidemiol. 1988; 128(6): 1185–97. The authors identify three concepts: excess fraction, etiologic fraction, and incidence-density fraction. 4 WHO. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva: WHO, 2002. Available at http://www.who.int/whr/2002/en/. Accessed March 2005. 5 Ibid. 6 See, e.g.: Vineas P, Alavanja M, Buffler P, et al. Tobacco and cancer: Recent epidemiological evidence. J Nat Cancer Inst 2004; 96(2): 99–106. 7 Ellison LF, Morrison HI, de Groh M, et al. Health consequences of smoking among Canadian smokers: An update. Chron Dis Can 1999; 20(1): 36–9. 8 Stampfer M. New insights from the British doctors study. Br Med J. 2004; 328(7455): 1507. Risks for persistent smoking are substantially larger than was previously suspected. 9 Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. Br Med J 2005; 92(3): 426–9. 10 USSG. The Health Consequences of Smoking: A Report of the Surgeon General. Washington: Department of Health and Human Services, 2004. Available at http://www.cdc.gov/tobacco/sgr/sgr_2004/index.htm. Accessed March 2005. 11 Fagerstrom K. The epidemiology of smoking: Health consequences and benefits of cessation. Drugs 2002; 62(suppl 2): 1–9. 12 Morabia A. Smoking (active and passive) and breast cancer: Epidemiologic evidence up to June 2001. Environ Mol Mutagen 2002; 39(2–3): 89–95. 13 Terry PD, Rohan TE. Cigarette smoking and the risk of breast cancer in women: A review of the literature. Cancer Epidemiol Biomarkers Prev 2002; 11(10 pt 1): 953–71.

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14 Hecht SS. Tobacco smoke carcinogens and breast cancer. Environ Mol Mutagen 2002; 39(2–3): 119–26. 15 Collaborative Group on Hormonal Factors in Breast Cancer. Alcohol, tobacco and breast cancer – collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease. Br J Cancer 2002; 87(11): 1234–45. 16 Johnson KC, Hu J, Mao Y. Passive and active smoking and breast cancer risk in Canada, 1994–97. The Canadian Cancer Registries Epidemiology Research Group. Cancer Causes Control 2000; 11(3): 211–21. 17 Chaturvedi P. Does smoking increase the risk of breast cancer? Lancet Oncol 2003; 4(11): 657–8. 18 Morabia A, Lash TL. Breast cancer, passive and active cigarette smoking and N-acetyltransferase 2 genotype. Pharmacogenetics 2002; 12(1): 85–8. 19 Li Y, Millikan RC, Bell DA, et al. Cigarette smoking, cytochrome P4501A1 polymorphisms, and breast cancer among African-American and white women. Breast Cancer Res 2004; 6(4): R460–73. 20 Al-Delaimy WK, Cho E, Chen WY, et al. A prospective study of smoking and risk of breast cancer in young adult women. Cancer Epidemiol Biomarkers Prev 2004; 13(3): 398–404. 21 Terry PD, Miller AB, Rohan TE. Cigarette smoking and breast cancer risk: A long latency period? Int J Cancer 2002; 100(6): 723–8. 22 Reynolds P, Hurley S, Goldberg DE, et al. Active smoking, household passive smoking, and breast cancer: Evidence from the California Teachers Study. J Nat Cancer Inst 2004; 96(1): 29–37. 23 The PAFs have been calculated based on information from the Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and economic costs – United States, 1995–1999. Morbid Mortal Weekly Rep 2002; 51(14): 300–3. 24 Ellison et al. Health consequences of smoking. 25 Makomaski Illing EM, Kaiserman MJ. Mortality attributable to tobacco use in Canada and its regions, 1998. Can J Public Health 2004; 95(1): 38–44. 26 Single E, Rehm J, Robson L, et al. The relative risks and etiologic fractions of different causes of death and disease attributable to alcohol, tobacco and illicit drug use in Canada. Can Med Assoc J 2000; 162(12): 1669–75. 27 Makomaski Illing, Kaiserman. Mortality attributable to tobacco use. 28 USSG. Health Consequences of Smoking. 29 Calculated in the U.S. Surgeon General’s report as the time between premature death and life expectancy at the age of death, summed over all premature deaths. YPLL provides an estimate of the burden of premature death in a given population.

292 Notes to page 19 30 Kenchaiah S, Evans JC, Levy D, et al. Obesity and the risk of heart failure. N Engl J Med 2002; 347(5): 305–13. 31 Kurth T, Gaziano JM, Rexrode KM, et al. Prospective study of body mass index and risk of stroke in apparently healthy women. Circulation 2005; 111(15): 1992–8. 32 Jood K, Jern C, Wilhelmsen L, et al. Body mass index in mid-life is associated with a first stroke in men: A prospective population study over 28 years. Stroke 2004; 35(12): 2764–9. 33 Wang Y, Rimm EB, Stampfer MJ, et al. Comparison of abdominal adiposity and overall obesity in predicting risk of type 2 diabetes among men. Am J Clin Nutr 2005; 81(3): 555–63. 34 Dagenais GR, Auger P, Bogaty P, et al. Increased occurrence of diabetes in people with ischemic cardiovascular disease and general and abdominal obesity. Can J Cardiol 2003; 19(12): 1387–91. 35 Wannamethee SG, Shaper AG, Walker M. Overweight and obesity and weight change in middle-aged men: Impact on cardiovascular disease and diabetes. J Epidemiol Community Health 2005; 59(2): 134–9. 36 WHO. World Health Report 2002. 37 Goodpaster BH, Krishnaswami S, Harris TB, et al. Obesity, regional body fat distribution, and the metabolic syndrome in older men and women. Arch Int Med 2005; 165(7): 777–83. 38 Eckel RH, Grundy SM, Zimmet PZ. The metabolic syndrome. Lancet 2005; 365(9468): 1415–28. 39 Droyvold WB, Midthjell K, Nilsen TI, et al. Change in body mass index and its impact on blood pressure: A prospective population study. Int J Obes Relat Metab Disord 2005. 40 Canadian Institute for Health Information (CIHI). Obesity in Canada, 2003. Available at http://secure.cihi.ca/ cihiweb/dispPage.jsp?cw_page=GR _1066_E. Accessed March 2005. 41 Gardner G, Halweil B. Underfed and Overfed: The Global Epidemic of Malnutrition. Washington: Worldwatch Institute, 2000. 42 Bergstrom A, Pisani P, Tenet V, et al. Overweight as an avoidable cause of cancer in Europe. Int Cancer 2001; 91(3): 421–30. 43 Johnston E, Johnson S, McLeod P, et al. The relation of body mass index to depressive symptoms. Can J Public Health 2004; 95(3): 179–83. 44 Needham BL, Crosnoe R. Overweight status and depressive symptoms during adolescence. J Adolesc Health 2005; 36(1): 48–55. 45 Gustafson D, Rothenberg E, Blennow K, et al. An 18-year follow-up of overweight and risk of Alzheimer disease. Arch Int Med 2003; 163(13): 1524–8. 46 Gustafson D, Lissner L, Bengtsson C, et al. A 24-year follow-up of body mass index and cerebral atrophy. Neurology 2004; 63(10): 1876–81.

Notes to pages 19–25

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47 Whitmer RA, Gunderson EP, Barrett-Connor E, et al. Obesity in middle age and future risk of dementia: A 27-year longitudinal population study. Br Med J 2005 (Apr 29) [E-published ahead of print]. 48 Katzmarzyk P, Janssen I. The economic costs associated with physical inactivity and obesity in Canada: An update. Can J Appl Physiol 2004; 29(1): 90–115. 49 Wilkins K. Incident arthritis in relation to excess weight. Health Rep 2004; 15(1): 39–49. 50 Okoro CA, Hootman JM, Strine TW, et al. Disability, arthritis, and body weight among adults 45 years and older. Obes Res 2004; 12(5): 854–61. 51 Jia H, Lubetkin EI. The impact of obesity on health-related quality of life in the general adult U.S. population. J Public Health 2005 (Apr 8) [E-published ahead of print]. 52 Fontaine KR, Barofsky I. Obesity and health-related quality of life. Obes Rev 2001; 2(3): 173–82. 53 Colman R. Cost of Obesity in British Columbia. GPIAtlantic 2001. 54 Su D. Body mass index and old-age survival: A comparative study between the Union Army Records and the NHANES-I Epidemiological Follow-Up Sample. Am J Human Biol 2005; 17(3): 341–54. 55 WHO. World Health Report 2002. 56 Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in the United States, 2000. JAMA 2004; 291(10): 1238–45. 57 See the correction by Mokdad et al. available at http://jama.ama-assn.org/ cgi/content/extract/293/3/293. Accessed April 2005. 58 Flegal KM, Graubard BI, Williamson DF, et al. Excess deaths associated with underweight, overweight, and obesity. JAMA 2005; 293(15): 1861–7. 59 Su. Body mass index and old-age survival. 60 Peeters A, Barendregt J, Willekens F, et al. Obesity in adulthood and its consequences for life expectancy: A life-table analysis. Ann Int Med 2003; 138(1): 24–32. 61 Peeters A, Bonneux L, Nusselder W, et al. Adult obesity and the burden of disability throughout life. Obes Res 2004; 12(7): 1145–51. 62 Hu FB, Willett WC, Li T, et al. Adiposity as compared with physical activity in predicting mortality among women. N Eng J Med 2004; 351(26): 2694–703. 63 As indicated by the overlap in the 95% confidence interval between this group and those of a ‘healthy’ weight according to usual BMI criteria. 64 Flegal et al. Excess deaths. 65 Massie BM. Obesity and heart failure – risk factor or mechanism? N Eng J Med 2002; 347(5): 358–9. 66 Baik I, Ascherio A, Rimm EB, et al. Adiposity and mortality in men. Am J Epidemiol 2000; 152(3): 264–71.

294 Notes to pages 25–7 67 Ajani U, Lotufo P, Gaziano JM, et al. Body mass index and mortality among U.S. male physicians. Ann Epidemiol 2004; 14(10): 731–9. 68 Adiposity refers to the degree of body fat. 69 Katzmarzyk P, Janssen I, Ardern C. Physical inactivity, excess adiposity and premature mortality. Obes Rev 2003; 4(4): 257–90. 70 Curtis JP, Selter JG, Wang Y, et al. The obesity paradox. Arch Int Med 2005; 165: 55–61. 71 Lopez-Jimenez F, Jacobsen SJ, Reeder GS, et al. Prevalence and secular trends of excess body weight and impact on outcomes after myocardial infarction in the community. Chest 2004; 125(4): 1205–12. 72 Gregg EW, Cheng YJ, Cadwell BL, et al. Secular trends in cardiovascular disease risk factors according to body mass index in U.S. adults. JAMA 2005; 293(15): 1868–74. 73 Mayor S. Deaths associated with obesity may be declining in the United States. Br Med J 2005; 330(7497): 921. 74 Flegal et al. Excess deaths. 75 Cooper R, Cutler J, Desvigne-Nickens P, et al. Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States: Findings of the national conference on cardiovascular disease prevention. Circulation 2000; 102(25): 3137–47. 76 Gregg et al. Secular trends. 77 Su. Body mass index. 78 See the news report at http://edition.cnn.com/2005/HEALTH/diet.fitness/04/20/obesity.dea ths.ap/. Accessed April 2005. 79 Arterburn DE, McDonell MB, Hedrick SC, et al. Association of body weight with condition-specific quality of life in male veterans. Am J Med 2004; 117(10): 738–46. 80 Hubbard VS. Defining overweight and obesity: What are the issues? Am J Clin Nutr 2000; 72: 1067–8. 81 Mark DH. Deaths attributable to obesity. JAMA 2005; 293(15): 1918–19. 82 USSG. Physical Activity and Health: A Report of the Surgeon General. Washington: DHHS, 1996. 83 Derouich M, Boutayeb A. The effect of physical exercise on the dynamics of glucose and insulin. J Biomech 2002; 35(7): 911–17. 84 Leon AS. Physical Activity and Cardiovascular Health: A National Consensus. Champaign, Illinois: Human Kinetics, 1997. 85 USSG. Physical Activity and Health. 86 The conclusion of one study states that ‘fifty years of research confirms the inverse relationship between physical activity and coronary heart disease.’ Batty GD, Lee IM. Physical activity and coronary heart disease. Br Med J 2004; 328(7448): 1089–90.

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87 Batty GD. Physical activity and coronary heart disease in older adults: A systematic review of epidemiological studies. Eur J Public Health 2002; 12(3): 171–6. 88 Lee IM, Rexrode KM, Cook NR, et al. Physical activity and coronary heart disease in women. JAMA 2001; 285(11): 1447–54. 89 Lee CD, Folsom AR, Blair SN. Physical activity and stroke risk: A metaanalysis. Stroke 2003; 34(10): 2475–81. 90 Hu FB, Stampfer MJ, Colditz GA, et al. Physical activity and risk of stroke in women. JAMA 2000; 283(22): 2961–7. 91 Hu FB, Sigal RJ, Rich-Edwards JW. Walking compared with vigorous physical activity and risk of type 2 diabetes in women: A prospective study. JAMA 1999; 282(15): 1433–9. 92 Slattery ML, Edwards S, Curtin K, et al. Physical activity and colorectal cancer. Am J Epidemiol 2003; 158(3): 214–24. 93 Macera CA, Hootman JM, Sniezek JE. Major public health benefits of physical activity. Arthritis Rheum 2003; 49(1): 122–8. 94 Katzmarzyk, Janssen. Economic costs. 95 Lagiou P, Trichopoulou A, Trichopoulos D. Nutritional epidemiology of cancer: Accomplishments and prospects. Proc Nutr Soc 2002; 61(2): 217–22. 96 Doll R, Peto R. The Causes of Cancer. Oxford: Oxford University Press, 1981. 97 World Cancer Research Fund (WCRF). Food, Nutrition and the Prevention of Cancer: A Global Perspective. London: WCRF, 1997. 98 Adami HO, Day NE, Trichopoulos D, et al. Primary and secondary prevention in the reduction of cancer morbidity and mortality. Eur J Cancer 2001; 37(suppl 8): S118–27. Some estimates put the proportion higher, as high as 50%. See the section below called Combining the Factors. 99 WHO. The World Health Report 2002. Also, National Institute of Public Health (NIPH). Determinants of the Burden of Disease in the EU. Stockholm: NIPH. 1997. Tobias M. The Burden of Disease and Injury in New Zealand. Public Health Intelligence Occasional Bulletin No. 1. Wellington: New Zealand Ministry of Health, 2001. Mathers C, Vos T, Stevenson C. The Burden of Disease and Injury in Australia. AIHW Catalogue No. PHE 17. Canberra: Australian Institute of Health and Welfare (AIHW); 1999. Vos T, Begg S. The Victorian Burden of Disease Study: Mortality. Melbourne: Public Health and Development Division, Victorian Government Department of Human Services, 1999. 100 Riboli E, Norat T. Epidemiologic evidence of the protective effect of fruit and vegetables on cancer risk. Am J Clin Nutr 2003; 78(suppl 3): S559–69. 101 Hung H, Jsohipura K, Jiang R, et al. Fruit and vegetable intake and the risk of major chronic disease. J Nat Cancer Inst 2004; 96(21): 1577–84.

296 Notes to pages 29–34 102 Van Gils C, Peeters P, Bueno-de-Mesquita H, et al. Consumption of vegetables and fruits and risk of breast cancer. JAMA 2005; 293(2): 183–93. 103 Riboli, Norat. Epidemiologic evidence of the protective effect of fruit and vegetables. 104 Willett W. Diet and cancer: An evolving picture. JAMA 2005; 293(2): 233–4. 105 Schatzkin A, Kipnis V. Could exposure assessment problems give us wrong answers to nutrition and cancer questions? J Nat Cancer Inst 2004; 96(21): 1564–5. 106 WHO. World Health Report 2002. 107 Bazzano L, He J, Ogden L, et al. Fruit and vegetable intake and risk of cardiovascular disease in U.S. adults: The first National Health and Nutrition Examination Survey epidemiologic follow-up study. Am J Clin Nutr 2002; 76(1): 93–9. Chapter 3. The Economic Cost of Risk Factors 1 Max W. The financial impact of smoking on health-related costs: A review of the literature. Am J Health Promot 2001; 15(5): 321–31. 2 Centers for Disease Control and Prevention (CDCP). Annual smokingattributable mortality, years of potential life lost, and economic costs – United States, 1995–99. Morbid Mortal Weekly Rep 2002; 51(14): 300–3. 3 Max W, Rice D, Sung H, et al. The economic burden of smoking in California. Tobacco Control 2004; 13(3): 264–7. 4 Single E, Robson L, Xie X, et al. The economic costs of alcohol, tobacco and illicit drugs in Canada, 1992. Addiction 1998; 93(7): 991–1006. 5 Kaiserman M. The cost of smoking in Canada, 1991. Chron Dis Can 1997; 18(1): 13–19. 6 Bridge J, Turpin B. The Cost of Smoking in British Columbia and the Economics of Tobacco Control. Ottawa: Health Canada, Feb. 2004. 7 Colman R, Rainer R, Wilson J. The Cost of Smoking in New Brunswick and the Economics of Tobacco Control. GPIAtlantic, April 2003. 8 Birmingham CL, Muller JL, Palepu A, et al. The cost of obesity in Canada. Can Med Assoc J 1999; 160(4): 483–8. 9 Trakas K, Lawrence K, Shear N. Utilization of health care resources by obese Canadians. Can Med Assoc J 1999; 160(10): 1457–62. 10 Raebel M, Malone D, Conner D, et al. Health services use and health care costs of obese and nonobese individuals. Arch Int Med 2004; 164(19): 2135–40. 11 Daviglus ML, Liu K, Yan LL, et al. Relation of body mass index in young adulthood and middle age to Medicare expenditures in older age. JAMA 2004; 292(22): 2743–9.

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12 Katzmarzyk PT, Janssen I. The economic costs associated with physical inactivity and obesity in Canada: An update. Can J Appl Physiol 2004; 29(1): 90–115. 13 Previous work by Ronald Colman (Cost of Obesity in British Columbia, GPIAtlantic, 2001) used a BMI of > 25.0 in estimating the costs of overweight and obesity in British Columbia. For this project we have chosen to use the work by Katzmarzyk and Janssen (2004) due to their more conservative cut-off for obesity. 14 Hu FB, Willett WC, Li T, et al. Adiposity as compared with physical activity in predicting mortality among women. N Engl J Med 2004; 351(26): 2694– 703. 15 See, e.g., Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada. Can Med Assoc J 2000; 163(11): 1435–40. Also Garrett NA, Brasure M, Schmitz KH, et al. Physical inactivity: Direct cost to a health plan. Am J Prev Med 2004; 27(4): 304–9. 16 Katzmarzyk, Janssen. Economic costs. 17 Frazao E. High costs of poor eating patterns in the United States. In: America’s Eating Habits: Changes and Consequences. Washington: U.S. Department of Agriculture, 1999. 18 See http://www.bcbudget.gov.bc.ca/bfp/bgt2004_part1_table-1–5.htm. Accessed Jan. 2005. Chapter 4. Risk Factor Targets around the World 1 Alberta Government. Health and Wellness website. Available at http:// www.health.gov.ab.ca/about/reform/ framework.html. Accessed April 2005. 2 Towards Outcome Measurement for Ontario Boards of Health, 2002. Available at http://www.phred-redsp.on.ca/pubs_library/Reports/Ottawa/ PlanEvaluationModelJan02. PDF. Accessed July 2004. 3 Toronto Public Health. Toronto’s Health Status: Focus on Tobacco, 2003. Available at http://www.city. toronto.on.ca/health/hsi/pdf/ hsi_tobacco_profile_control_program. pdf. Accessed July 2004. 4 Targeting Cancer. Cancer 2020 Background Report, 2003. Available at http:// www.ontario.cancer.ca/vgn/images/ portal/cit_776/51/53/ 45984922od_advocacy_cancer_2020_bkgd_en.pdf. Accessed Aug. 2004. 5 Secretary of State for Health. Smoking Kills, 1998. Available at http:// www.archive.official-documents.co.uk/document/cm41/4177/chap09.htm. Accessed March 2005. 6 Department of Health and Human Services (DHHS). Healthy People 2000:

298 Notes to pages 42–7

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9

10 11

12

13 14 15 16 17 18 19

20 21

22 23 24

25 26

Final Review. Note that some methodological changes over the years make comparability problematic. Washington: DHHS, 2001. DHHS. Healthy People 2010: Objectives for Improving Health. Washington, 2000. Churchill P. Provincial, Territorial and International Experiences with Setting Nutrition Related Targets. Ottawa: Health Canada, Office of Nutrition Policy and Promotion (ONPP), 2003. Richards K. Nutrition Indicator and Target Development from a Provincial/Territorial, Federal and International Perspective. Ottawa: Health Canada, ONPP, 2004. Targeting Cancer, Cancer 2020. Progress on Health Outcome Targets – 1998: Obesity. Available at http:// www.moh.govt.nz/moh.nsf/Files/ phot_31_36/$file/phot_31_36.pdf. Accessed July 2004. Progress on Heath Outcome Targets – 1999: Obesity. Available at http:// www.moh.govt.nz/moh.nsf/7004be0c19a98 f8a4c25692e007bf833/ 5b3ac5e440f6ccd7cc2569b8007e5e9f/$FILE/obesit y.pdf. Accessed July 2004. Ministry of Health. Obesity in New Zealand. Available at http://www. moh.govt.nz/moh.nsf/wpg_Index/About-Obesity. Accessed July 2004. DHHS. Healthy People 2000. DHHS. Healthy People 2010. Defined as at or above the gender and age-specific 95th percentile of BMI. Churchill. Provincial, Territorial and International Experiences. Richards. Nutrition Indicator. Salmon J, Ball K, Crawford D, et al. Reducing sedentary behaviour and increasing physical activity among 10-year-old children: Overview and process evaluation of the ‘Switch-Play’ intervention. Health Promot Int 2005; 20(1): 7–17. Targeting Cancer, Cancer 2020. Specifically, 60 minutes of light physical activity daily, at least 30 minutes of moderate physical activity 4 days/week, or at least 20 minutes of vigorous physical activity at least 3 days/week. DHHS. Healthy People 2000. DHHS. Healthy People 2010. Swales C. The Cost Benefits of the Physical Activity Strategy for Northern Ireland – A Summary of Key Findings. Belfast: Health Promotion Agency for Northern Ireland. 2002. Churchill. Provincial, Territorial and International Experiences. Richards. Nutrition Indicator.

Notes to pages 47–61

299

27 Targeting Cancer, Cancer 2020. 28 DHHS. Healthy People 2000. 29 DHHS. Healthy People 2010. Chapter 5. The Benefits of Reducing Risk Factors 1 USSG. The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Washington: Department of Health and Human Services, 1990. 2 Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. Br Med J 2004; 328(7455): 1519–28. 3 Burns D. Primary prevention, smoking, and smoking cessation. Cancer 2000; 89(suppl 11): 2506–9. 4 Ibid. 5 Peto R, Darby S, Deo H, et al. Smoking, smoking cessation, and lung cancer in the U.K. since 1950: Combination of national statistics with two casecontrol studies. Br Med J 2000; 321(7257): 323–9. 6 Taylor DH Jr, Hasselblad V, Henley SJ, et al. Benefits of smoking cessation for longevity. Am J Public Health 2002; 92(6): 990–6. 7 Wakai K, Seki N, Tamakoshi A, et al. Decrease in risk of lung cancer death in males after smoking cessation by age at quitting: Findings from the JACC study. Jap J Cancer Res 2001; 92(8): 821–8. 8 Ebbert JO, Yang P, Vachon CM, et al. Lung cancer risk reduction after smoking cessation: Observations from a prospective cohort of women. J Clin Oncol 2003; 21(5): 921–6. 9 Wiencke JK, Thurston SW, Kelsey KT, et al. Early age at smoking initiation and tobacco carcinogen DNA damage in the lung. J Nat Cancer Inst 1999; 91(7): 614–19. 10 Critchley J, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database of Systematic Reviews (CDSR), 2004. 11 Barendregt JJ, Bonneux L, Van Der Maas PJ. The health care costs of smoking. N Engl J Med 1997; 337(15): 1052–7. 12 Rasmussen S, Prescott E, Sorensen T, et al. The total lifetime costs of smoking. Eur J Public Health 2004; 14(1): 95–100. 13 Bronnum-Hansen H, Juel K. Abstention from smoking extends life and compresses morbidity: A population-based study of health expectancy among smokers and never smokers in Denmark. Tobacco Control 2001; 10(3): 273–8. 14 Wagner EH, Curry SJ, Grothaus L, et al. The impact of smoking and quitting on health care use. Arch Int Med 1995; 155(16): 1789–95.

300 Notes to pages 61–3 15 Pronk N, Goodman M, O’Conner P, et al. Relationship between modifiable health risks and short-term health care charges. JAMA 1999; 282(23): 2235– 9. 16 Fishman P, Khan Z, Thompson E, et al. Health care costs among smokers, former smokers, and never smokers in an HMO. Health Serv Res 2003; 38(2): 733–49. 17 Mikkelsen KL, Heitmann B, Keiding N, et al. Independent effects of stable and changing body weight on total mortality. Epidemiology 1999; 10(6): 671–8. 18 Wannamethee SG, Shaper AG, Walker M. Weight change, weight fluctuation and mortality. Arch Int Med 2002; 162(22): 2575–80. 19 Yaari S, Goldbourt U. Voluntary and involuntary weight loss: Associations with long-term mortality in 9,228 middle-aged and elderly men. Am J Epidemiol 1998; 148(6): 546–55. 20 Burns M, Gavey N. ‘Healthy weight’ at what cost? ‘Bulimia’ and a discourse of weight control. J Health Psychol 2004; 9(4): 549–65. 21 Curtis J, Selter J, Wang Y, et al. The obesity paradox: Body mass index and outcomes in patients with heart failure. Arch Int Med 2005; 165(1): 55–61. 22 Astrup A. Weight loss and increased mortality: Epidemiologists blinded by observations? Obes Rev 2003; 4(1): 1–2. 23 See, e.g., Yaari, Goldbourt, Voluntary and involuntary weight loss. Diehr P, Bild DE, Harris TB, et al. Body mass index and mortality in nonsmoking older adults: The Cardiovascular Health Study. Am J Public Health 1998; 88(4): 623–9. French SA, Folsom AR, Jeffrey RW, et al. Prospective study of intentional weight loss and mortality in older women: The Iowa Women’s Health Study. Am J Epidemiol 1999; 149(6): 504–14. 24 Astrup Weight loss. 25 Yang D, Fontaine K, Wang C, et al. Weight loss causes increased mortality: Cons. Obes Rev 2003; 4(1): 9–16. 26 Sorensen TI. Weight loss causes increased mortality: Pros. Obes Rev 2003; 4(1): 3–8. 27 Gregg E, Gerzoff R, Thompson T, et al. Intentional weight loss and death in overweight and obese U.S. adults 35 years of age and older. Ann Int Med 2003; 138(5): 383–9. 28 Gregg E, Gerzoff R, Thompson T, et al. Trying to lose weight, losing weight, and 9-year mortality in overweight U.S. adults with diabetes. Diabetes Care 2004; 27(3): 657–62. 29 Frazao E. High costs of poor eating patterns in the United States. In America’s Eating Habits: Changes and Consequences. U.S. Department of Agriculture, 1999. 30 Chen J, Millar W. Health effects of physical activity. Health Rep 1999; 11(1): 21–30.

Notes to pages 63–4

301

31 Spirduso W, Cronin D. Exercise dose-response effects on quality of life and independent living in older adults. Med Sci Sports Exercise 2001; 33(suppl 6): S598–608. 32 Kraemer HC, Stice E, Kazdin A, et al. How do risk factors work together? Mediators, moderators, and independent, overlapping, and proxy risk factors. Am J Psychiatry 2001; 158(6): 848–56. 33 Bauman AE, Sallis JF, Dzewaltowski DA, et al. Toward a better understanding of the influences on physical activity: The role of determinants, correlates, causal variables, mediators, moderators, and confounders. Am J Prev Med 2002; 23(suppl 2): 5–14. 34 Gilmore J. Body mass index and health. Health Rep 1999; 11(1): 31–43. 35 Rowe A, Powell KE, Flanders D. Why population attributable fractions can sum to more than one. Am J Prev Med 2004; 26(3): 243–9. 36 Llorca J, Delgado-Rodriguez M. A new way to estimate the contribution of a risk factor in populations avoided nonadditivity. J Clin Epidemiol 2004; 57(5): 479–83. 37 WHO. WHO Global Strategy on Diet, Physical Activity and Health. European Regional Consultation. Copenhagen: WHO; 2003. Available at http:// www.who.int/hpr/NPH/docs/ regional_ consultation_report_euro.pdf. Accessed March 2005. 38 Katz DL. Pandemic obesity and the contagion of nutritional nonsense. Public Health Rev 2003; 31(1): 33–44. 39 Brooks GA, Butte NF, Rand WM, et al. Chronicle of the Institute of Medicine physical activity recommendation: How a physical activity recommendation came to be among dietary recommendations. Am J Clin Nutr 2004; 79(5): 921S-30S. 40 Perez CE. Fruit and vegetable consumption. Health Rep 2002; 13(3): 23–31. 41 Serdula MK, Byers T, Mokdad AH, et al. The association between fruit and vegetable intake and chronic disease risk factors. Epidemiology 1996; 7(2): 161–5. 42 Gilmore Body mass index. 43 Rodu B, Stegmayr B, Nasic S, et al. The influence of smoking an smokeless tobacco use on weight amongst men. J Int Med 2004; 255(1): 102–7. 44 Rashas I, Grossman M. The economics of obesity. The Public Interest 2004; 156. Available at http://www.thepublicinterest.com/. Accessed July 2004. 45 Pi-Sunyer FX, Woo R. Effect of exercise on food intake in human subjects. Am J Clin Nutr 1985; 42(suppl 5): 983–90. 46 USSG. Physical Activity and Health: A Report of the Surgeon General. Washington: DHHS, 1996. 47 WHO. The World Health Report 2002: Reducing Risks, Promoting Healthy Life.

302 Notes to pages 64–6

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Geneva: WHO, 2002. Available at http://www.who.int/whr/2002/en/. Accessed March 2005. Bruzzi P, Green SB, Byar DP, et al. Estimating the population attributable risk of multiple risk factors using case-control data. Am J Epidemiol. 1985; 122(5): 904–14. DiPietro L. Physical activity, body weight, and adiposity. Exercise Sport Sci Rev 1995; 23: 275–303. Centers for Disease Control and Prevention (CDCP). Physical Activity and Good Nutrition: Essential Elements to Prevent Chronic Diseases and Obesity, 2004. Available at http://www.cdc.gov/nccdphp/aag/pdf/aag_ dnpa2004.pdf. Accessed April 2005. Baranowski T. Why combine diet and physical activity in the same international research society? Int J Behav Nutr Phys Activity 2004; 1(1): 2. Blair SN, Brodney S. Effects of physical inactivity and obesity on morbidity and mortality: Current evidence and research issues. Med Sci Sports Exercise 1999; 31(suppl 11): S646–62. Burns DM. Epidemiology of smoking-induced cardiovascular disease. Prog Cardiovas Dis 2003; 46(1): 11–29. Baranowski. Why combine diet and physical activity? WHO. Development of a WHO Strategy. Eyre H, Kahn R, Robertson RM. Preventing cancer, cardiovascular diseases and diabetes: A common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association. CA A Cancer J Clin 2004; 54(4): 190–207. Byers T, Nestle M, McTiernan A, et al. American Cancer Society guidelines on nutrition and physical activity for cancer prevention. CA A Cancer J Clin 2002; 52(2): 92–119. Colditz GA, Samplin-Salgado M, Ryan CT, et al. Harvard report on cancer prevention, vol. 5. Fulfilling the potential for cancer prevention: policy approaches. Cancer Causes Control 2002; 13(3): 199–212. Public Health Research, Education & Development Program. Towards Outcome Measurement for Ontario Boards of Health, 2002. Available at http://www.phred-redsp.on.ca/pubs_library/Reports/Ottawa/ PlanEvaluationModelJan02. PDF. Accessed July 2004. Churchill P. Provincial, Territorial and International Experiences with Setting Nutrition Related Targets. Ottawa: Health Canada, Office of Nutrition Policy and Promotion, 2003. Health Canada. Government of Canada Comments on WHO draft Global Strategy on Diet, Physical Activity and Health. Available at http://www.who.int/ hpr/canada3.pdf. Accessed April 2005.

Notes to pages 66–84

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62 WHO. Diet, Nutrition and the Prevention of Chronic Diseases. Geneva: WHO, 2003. 63 WHO. World Health Report 2002. Reducing Risks, Promoting Healthy Life. Geneva: WHO, 2002. Chapter 6. Tobacco Control Evidence (1) 1 Treasury Board of Canada. Guide to the Development of Results-Based Management and Accountability Framework. Available at http://www.tbs-sct.gc.ca/ eval/pubs/RMAF-CGRR/rmafcgrr03_e.asp. Accessed Jan. 2004. 2 Auditor General of BC. A Review of Performance Agreements between the Ministry of Health Services and the Health Authorities. Victoria: AGBC, 2003, 48. 3 Centers for Disease Control and Prevention (CDCP). Advancing Tobacco Control through Evidence-Based Programs. 2004. Available at http:// www.cdc.gov/nccdphp/promising_practices/tobacco/opportunit ies.htm. Accessed Oct. 2004. 4 The ‘Healthy People 2010’ project in the U.S. distinguishes these three categories from a fourth category, namely, environmental policies involving legislation and/or regulations related to how tobacco is sold, priced, promoted, and used in public. The Cancer Council of Australia also identifies a fourth category, falling under the controversial area of harm reduction, i.e., to reduce the exposure of users to the harmful health consequences of tobacco products. The U.S. CDCP offers yet another fourth category, namely, identifying populations disproportionately affected by tobacco use and eliminating such disparities. 5 See the Health Canada discussion at http://www.hc-sc.gc.ca/hecs-sesc/ tobacco/roundtable/ denormalization.html. Accessed March 2005. 6 See the report at http://www.head-start.lane.or.us/health/wellness/ information/tobacco-control-program.html. Accessed March 2005. 7 Sowden A, Arblaster L, Stead L. Community interventions for preventing smoking in young people. Cochrane Database of Systematic Reviews (CDSR), 2003. 8 Tyas SL, Pederson LL. Psychosocial factors related to adolescent smoking: A critical review of the literature. Tobacco Control 1998; 7(4): 409–20. 9 Taioli E, Wynder EL. Effect of the age at which smoking begins on frequency of smoking in adulthood. N Eng J Med 1991; 325(13): 968–9. 10 Knoke JD, Shanks TG, Vaughn JW, et al. Lung cancer mortality is related to age in addition to duration and intensity of cigarette smoking: An analysis of CPS-I data. Cancer Epidemiol 2004; 13(6): 949–57. 11 Patel BD, Luben RN, Welch AA, et al. Childhood smoking is an indepen-

304 Notes to pages 84–8

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15 16 17 18 19

20 21

22

23

24 25

26 27

dent risk factor for obstructive airways disease in women. Thorax 2004; 59(8): 682–6. DiFranza JR, Wellman RJ. Preventing cancer by controlling youth tobacco use. Semin Oncol Nurs 2003; 19(4): 261–7. Jackson C, Dickinson D. Cigarette consumption during childhood and persistence of smoking through adolescence. Arch Pediatr Adolesc Med 2004; 158(11): 1050–6. DiFranza JR, Savageau JA, Rigotti NA, et al. Development of symptoms of tobacco dependence in youths: 30 months follow-up data from the DANDY study. Tobacco Control 2002; 11: 228–35. Wellman RJ, DiFranza JR, Savageau JA, Dussault GF. Short-term patterns of early smoking acquisition. Tobacco Control 2004; 13: 251–7. Sowden, Arblaster, Stead. Community interventions. Ibid. The two reviews included 5 of the same studies. Wakefield M, Flay B, Nichter M, Giovino G. Effects of anti-smoking advertising on youth smoking: A review. J Health Communication 2003; 8(3): 229–47. Thomas R. School-based programmes for preventing smoking. CDSR 2002. Botvin GJ, Baker E, Dusenbury L, et al. Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population. JAMA 1995; 273(14): 1106–12. By comparison, an earlier meta-analysis of studies from 1974 to 1991 showed that school-based programs likely would produce at most a 5% reduction in teen smoking, or perhaps as high as 20% to 30% under optimum conditions. Rooney BL, Murray DM. A meta-analysis of smoking prevention programs after adjustment for errors in the unit of analysis. Health Educ Q 1996; 23(1): 48–64. Dent CW, Sussman S, Stacy AW, et al. Two-year behavior outcomes of project towards no tobacco use. J Consult Clin Psychol 1995; 63(4): 676–7. Thomas School-based programmes for preventing smoking. Health Canada. A Summary of Evaluations of the Drug Abuse Resistance Education (DARE) Program, 2002. Available at http://www.hc-sc.gc.ca/ hecs-sesc/cds/publications/substanceyoungpeople/chapter4_2.htm. Accessed Nov. 2004. Curtis CK. The Efficacy of the Drug Abuse Resistance Education Program in West Vancouver Schools. West Vancouver: Police Department. 1999. Clayton RR, Cattarello AM, Johnstone BM. The effectiveness of Drug Abuse

Notes to pages 88–9

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30 31

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33 34 35

36

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40 41

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Resistance Education (project DARE): 5-year follow-up results. Prev Med 1996; 25(3): 307–18. Lynam DR, Milich R, Zimmerman R, et al. Project DARE: No effects at 10year follow-up. J Consult Clin Psychol 1999; 67(4): 590–3. Wakefield MA, Chaloupka FJ, Kaufman NJ, et al. Effect of restrictions on smoking at home, at school, and in public places on teenage smoking: Cross-sectional study. Br Med J 2000; 321(7257): 333–7. See also, Trinidad DR, Gilpin EA, Pierce JP. Compliance and support for smoke-free school policies. Health Educ Res 2005; 20(4): 466–75. Jha P, Chaloupka F. Curbing the Epidemic: Governments and the Economics of Tobacco Control. Washington: World Bank, 1999. Wiehe SE, Garrison MM, Christakis DA, et al. A systematic review of school-based smoking prevention trials with long-term follow-up. J Adolesc Health 2005; 36(3): 162–9. Winkleby MA, Feighery E, Dunn M, et al. Effects of an advocacy intervention to reduce smoking among teenagers. Arch Pediatr Adolesc Med 2004; 158(3): 269–75. Aveyard P, Markham WA, Lancashire E, et al. The influence of school culture on smoking among pupils. Social Sci Med 2004; 58(9): 1767–80. Eisenberg ME, Forster JL. Adolescent smoking behavior: Measures of social norms. Am J Prev Med 2003; 25(2): 122–8. NHS Centre for Reviews and Dissemination. Preventing the uptake of smoking in young people. Effective Health Care 1999; 5(5): 1–12. Available from http://www.york.ac.uk/inst/crd/ehc55.pdf. Accessed Dec. 2004. Christakis DA, Garrison MM, Ebel BE, et al. Pediatric smoking prevention interventions delivered by care providers: A systematic review. Am J Prev Med 2003; 25(4): 358–62. Woollery T, Asma S, Sharp D. Clean indoor-air laws and youth access restrictions. In: Jha P, Chaloupka F, eds. Tobacco Control in Developing Countries. Oxford: Oxford University Press, 2000, 273–86. Rigotti NA, DiFranza JR, Chang Y, et al. The effect of enforcing tobaccosales laws on adolescents’ access to tobacco and smoking behavior. N Eng J Med 1997; 337(15): 104–51. Altman DG, Wheelis AY, McFarlane M, et al. The relationship between tobacco access and use among adolescents: A four-community study. Soc Sci Med 1999; 48(6): 759–75. Levy D, Friend K. A simulation model of tobacco youth access policies. J Health Politics, Policy Law 2000; 25(6): 1023–48. Staff M, Bennett CM, Angle P. Is restricting tobacco sales the answer to adolescent smoking? Prev Med 2003; 37(5): 529–33.

306 Notes to pages 89–91 42 Chaloupka F, Grossman M. Price, Tobacco Control Policies, and Youth Smoking. Working Paper 5740. Cambridge, Mass.: National Bureau of Economic Research. 1996. 43 Cummings K, Hyland A, Saunders-Martin T, et al. Evaluation of an enforcement program to reduce tobacco sales to minors. Am J Public Health 1998; 88(6): 932–6. 44 Fichtenberg CM, Glantz SA. Youth access interventions do not affect youth smoking. Pediatrics 2002; 109(6): 1088–92. 45 Ling PM, Landman A, Glantz SA. It is time to abandon youth access tobacco programmes. Tobacco Control 2002; 11(1): 3–6. 46 DiFranza JR. Is it time to abandon youth access programmes? Tobacco Control 2002; 11(3): 282; author reply 283–4. 47 Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors. CDSR 2005. 48 Tobacco use, access, and exposure to tobacco in media among middle and high school students – United States, 2004. Morbid Mortal Weekly Rep 2005; 54(12): 297–301. Available at http://www.cdc. gov/mmwr/preview/ mmwrhtml/mm5412a1.htm. Accessed April 2005. 49 DiFranza. Is it time to abandon youth access programmes? 50 Toronto Public Health. Not to Kids! Available at http://www.city.toronto. on.ca/not_to_kids/ nottokids_info.htm. Accessed Nov. 2004. 51 Dent C, Biglan A. Relation between access to tobacco and adolescent smoking. Tobacco Control 2004; 13: 334–8. 52 Ontario Medical Association (OMA) position statement. More Smoke and Mirrors: Tobacco Industry-Sponsored Youth Prevention Programs in the Context of Comprehensive Tobacco Control Programs in Canada, Feb. 2002. Available at http://www.oma.org/phealth/smokeandmirrors.htm. Accessed Nov. 2004. 53 Assunta M, Chapman S. Industry-sponsored youth smoking prevention programme in Malaysia: A case study in duplicity. Tobacco Control 2004; 13(suppl II): II37–42. 54 Bridge J, Turpin B. The Cost of Smoking in British Columbia and the Economics of Tobacco Control. Ottawa: Health Canada, 2004. 55 A 10% price increase produced an 18% reduction in occasional smoking, but only a 3% reduction in daily smoking. Harris JE, Chan SW. The continuum-of-addiction: Cigarette smoking in relation to price among Americans aged 15–29. Health Econ 1999; 8(1): 81–6. 56 Bridge, Turpin. Cost of Smoking. 57 Stephens T, Pederson LL, Koval JJ, et al. The relationship of cigarette prices and no-smoking bylaws to the prevalence of smoking in Canada. Am J Public Health 1997; 87(9): 1519–21.

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58 Stephens T. Trends in the prevalence of smoking, 1991–1994. Chron Dis Can 1995; 16(1). 59 Bridge, Turpin. Cost of Smoking. 60 The IUHPE is a leading global network working to promote health worldwide and contribute to the achievement of equity in health between and within countries. One of its key recent publications is Model Legislation for Tobacco Control, a policy development and legislative drafting manual. 61 IUHPE. Model Legislation for Tobacco Control, Part 9: Tobacco Product Sales. Available at http://www.fctc.org/modelguide/lsection09.html#98. Accessed Nov. 2004. 62 Lovato C, Linn G, Stead LF, Best A. Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours. CDSR 2003. 63 Ibid. 64 Biener L, Siegel M. Tobacco marketing and adolescent smoking: More support for a causal inference. Am J Public Health 2000; 90(3): 407–11. 65 Lovell G. You Are the Target: Big Tobacco: Lies, Scams – Now the Truth. Vancouver: Chyran Communication, 2002. 66 Mekemson C, Glantz SA. How the tobacco industry built its relationship with Hollywood. Tobacco Control 2002; 11(suppl I): I81–91. 67 Glantz SA, Kacirk KW, McCulloch C. Back to the future: Smoking in movies in 2002 compared with 1950 levels. Am J Public Health 2004; 94(2): 261–3. 68 Mekemson C, Glik D, Titus K, et al. Tobacco use in popular movies during the past decade. Tobacco Control 2004; 13(4): 400–2. Although there is evidence of a modest overall decline in movie smoking in the 1990s, there was a notable increase in smoking incidents in restricted movies in the same period. 69 Tobacco use, access, and exposure to tobacco. 70 Distefan JM, Gilpin EA, Sargent JD, et al. Do movie stars encourage adolescents to start smoking? Evidence from California. Prev Med 1999; 28(1): 1–11. 71 Tickle JJ, Sargent JD, Dalton MA, et al. Favourite movie stars, their tobacco use in contemporary movies and its association with adolescent smoking. Tobacco Control 2001; 10(1): 16–22. 72 Sargent JD, Beach ML, Dalton MA, et al. Effect of seeing tobacco use in films on trying smoking among adolescents: Cross-sectional study. Br Med J 2001; 323(7326): 1394–7. 73 Distefan JM, Pierce JP, Gilpin EA. Do favourite movie stars influence adolescent smoking initiation? Am J Public Health 2004; 94(7): 1239–44. 74 Dalton MA, Sargent JD, Beach ML, et al. Effect of viewing smoking in movies on adolescent smoking initiation: A cohort study. Lancet 2003; 362(9380): 281–5.

308 Notes to pages 92–4 75 Sargent JD, Beach ML, Dalton MA, et al. Effect of parental R-rated movie restriction on adolescent smoking initiation: A prospective study. Pediatrics 2004; 114(1): 149–56. 76 CKNW News report. Available at http://www.newswire.ca/en/releases/ archive/October2004/29/ c6409.html. Accessed Nov. 2004. 77 Cobb C. Anti-smoking campaign targets films. Vancouver Sun 2004 (Dec 20), A8. 78 Edwards CA, Harris WC, Cook DR, et al. Out of the smokescreen: Does an anti-smoking advertisement affect young women’s perception of smoking in movies and their intention to smoke? Tobacco Control 2004; 13(3): 277–82. 79 Farrelly MC, Davis KC, Haviland ML, et al. Evidence of a dose-response relationship between ‘truth’ antismoking ads and youth smoking prevalence. Am J Public Health 2005; 95(3): 425–31. 80 U.S. National Center for Chronic Disease Prevention and Health Promotion. Best Practices for Comprehensive Tobacco Control Programs, 1999. Available at http://www.cdc.gov/tobacco/research_data/stat_nat_data/ bpfactsheet.htm. Accessed Nov. 2004. 81 American Lung Association of Florida. Available at http://lungaction.org/ lungflorida/alert-description.tcl?alert_id=2697316. Accessed April 2005. 82 American Cancer Society. Available at http://www.cancer.org/docroot/ COM/content/div_FL/COM_4_5x_ Florida_Tobacco_Control_Program. asp?sitearea=COM. Accessed Nov. 2004. 83 Tobacco use, access, and exposure to tobacco. The specific Florida data still showed a decrease in the prevalence of high school ever smokers (i.e., even one or two puffs), for 2004 over 2003, but no change for middle schoolers. Florida Youth Tobacco Survey. Data summarized at http://www.doh.state .fl.us/disease_ctrl/epi/FYTS/2004FYTS_Report1 _CigaretteUse.pdf. Accessed April 2005. 84 Tauras JA, Chaloupka FJ, Farrelly MC, et al. State tobacco control spending and youth smoking. Am J Public Health 2005; 95(2): 338–44. 85 There are a number of factors common to society and youth culture that can promote smoking, including stress, the accessibility and availability of tobacco products, perceptions that tobacco use is normative, the model, influence, and approval of peers, and lack of knowledge of health consequences. USSG. Preventing Tobacco Use among Young People: A Report of the Surgeon-General. Atlanta: Centers for Disease Control and Prevention, 1994. 86 The term ‘tipping point’ was popularized in a 2000 book by that title. In it, author Malcolm Gladwell defines a tipping point as the confluence of factors that create a ‘social epidemic,’ i.e., a condition where a significant idea

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is spontaneously spreading and being taken up by a population in a way similar to a viral infection. Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. New York: Little, Brown, 2002. Grossman M, Chaloupka FJ. Cigarette taxes: The straw to break the camel’s back. Public Health Rep 1997; 112(4): 290–7. Hill D. Why we should tackle adult smoking first. Tobacco Control 1999; 8(3): 333–5. Cancer Council Australia. National Cancer Prevention Policy, 2004–06. Available at http://www.cancer.org.au/documents/NatCancerPreventPol _04-06.pdf. Accessed March 2005. Farkas AJ, Distefan JM, Choi WS, et al. Does parental smoking cessation discourage adolescent smoking? Prev Med 1999; 28(3): 213–18. Cancer Council Australia. National Cancer Prevention Policy. Grossman, Chaloupka. Cigarette taxes. Wakefield et al. Effect of restrictions on smoking at home, at school, and in public places on teenage smoking.

Chapter 7. Tobacco Control Evidence (2) 1 Warner KE. Cost effectiveness of smoking cessation therapies: Interpretation of the evidence and implications for coverage. Pharmacoeconomics 1997; 11(6): 538–49. 2 Coffield AB, Maciosek MV, McGinnis JM, et al. Priorities among recommended clinical preventive services. Am J Prev Med 2001; 21(1): 1–9. Providing adolescents with anti-tobacco messages or advice to quit was also rated highly, though the evidence was less certain. 3 Hopkins DP, Briss PA, Ricard CJ, et al. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001; 20 (suppl 2): 16–66. 4 For example, it informed a key section of The Cancer Council Australia’s National Cancer Prevention Policy, 2004–06. NSW: The Cancer Council Australia, 2004. 5 Hopkins et al. Reviews of evidence. 6 Summarized in: Task Force on Community Preventive Services. Strategies for reducing exposure to environmental tobacco smoke, increasing tobaccouse cessation, and reducing initiation in communities and health-care systems. Morbid Mortal Weekly Rep 2000; 49(RR12): 1–11. 7 Wellings K, Macdowall W. Evaluating mass media approaches to health promotion: A review of methods. Health Educ 2000; 100(1): 23–32. 8 Bala M, Strzeszynski L, Hey K. Mass media interventions for smoking

310 Notes to pages 98–101

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13 14 15 16 17

18 19

20 21 22 23 24 25 26 27 28 29

cessation in adults. Cochrane Database of Systematic Reviews (CDSR), 2004. Hu TW, Sung HY, Keeler TE. Reducing cigarette consumption in California: Tobacco taxes vs an anti-smoking media campaign. Am J Public Health 1995; 85(9): 1218–22. Hopkins et al. Reviews of evidence. Goldman LK, Glantz SA. Evaluation of antismoking advertising campaigns. JAMA 1998; 279(10): 772–7. DeMeyrick J. Forget the ‘blood and gore’: An alternative message strategy to help adolescents avoid cigarette smoking. Health Educ 2001; 101(3): 99– 107. Lancaster T, Stead LF. Self-help interventions for smoking cessation. CDSR, 2002. Hopkins et al. Reviews of evidence. Lancaster, Stead. Self-help interventions. Available at http://www.quitnet.com/. Accessed Dec. 2004. Feil E, Noell J, et al. Evaluation of an internet-based smoking cessation program: Lessons learned from a pilot study. Nicotine Tobacco Res 2003; 5(2): 189–94. Lenert L, Munoz RF, et al. Design and pilot evaluation of an internet smoking cessation program. J Am Inform Assoc 2003; 10(1): 16–20. Lenert L, Munoz RF, et al. Automated email messaging as a tool for improving quit rates in an internet smoking cessation program. J Am Inform Assoc 2004; 11: 235–40. Cobb N, Graham A, Bock BC, et al. Initial evaluation of a ‘real-world’ Internet smoking cessation system. Nicotine Tob Res 2005; 7(2): 207–16. Fiore MC. The new vital sign: Assessing and documenting smoking status. JAMA 1991; 266(22): 3183–4. Stead LF, Lancaster T, Perera R. Telephone counselling for smoking cessation. CDSR, 2003. Ibid. USSG. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Washington: DHHS, 2000. Stead, Lancaster, Perera. Telephone counselling. Hopkins et al. Reviews of evidence. Secker-Walker RH, Gnich W, Platt S, et al. Community interventions for reducing smoking among adults. CDSR, 2002. Hopkins et al. Reviews of evidence. Bains N, Pickett W, Laundry B, et al. Predictors of smoking cessation in an incentive-based community intervention. Chron Dis Can 2000; 21(2): 54–61.

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30 Nelson DJ, Lasater TM, Niknian M, et al. Cost effectiveness of different recruitment strategies for self-help smoking cessation programs. Health Educ Res 1989; 4(1): 79–85. 31 Pisinger C, Vestbo J, Borch-Johnsen K, et al. Smoking cessation intervention in a large randomised population-based study: The Inter99 study. Prev Med 2005; 40(3): 285–92. 32 Moher M, Hey K, Lancaster T. Workplace interventions for smoking cessation. CDSR, 2003. 33 Linnan LA, Emmons KM, Galuska EC, et al. Smoking control at the workplace: Current status and emerging issues. Rhode Is Med 1993; 76(10): 510–14. 34 Moher, Hey, Lancaster. Workplace interventions. 35 Dawley HH Jr, Dawley LT, Correa P, et al. A comprehensive worksite smoking control, discouragement, and cessation program. Int J Addict 1991; 26(6): 685–96. 36 Serra C, Cabezas C, Bonfill X, et al. Interventions for preventing tobacco smoking in public places. CDSR, 2000. 37 Moher, Hey, Lancaster. Workplace interventions. 38 Hey K, Perera R. Competitions and incentives for smoking cessation. Cochrane Tobacco Addiction Group. CDSR, 2004. 39 Moher, Hey, Lancaster. Workplace interventions. 40 Hey, Perera. Competitions and incentives. 41 Cancer Council Australia. National Cancer Prevention Policy. 42 Moher, Hey, Lancaster. Workplace interventions. 43 Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behaviour: Systematic review. Br Med J 2002; 325(7357): 188. 44 Woodruff TJ, Rosbrook B, Pierce J, et al. Lower levels of cigarette consumption found in smoke-free workplaces in California. Arch Int Med 1993; 153(12): 1485–93. 45 Gilpin EA, Pierce JP. The California Tobacco Control Program and potential harm reduction through reduced cigarette consumption in continuing smokers. Nicotine Tobacco Res 2002; 4 (suppl 2): S157–66. 46 Chapman S, Borland R, Scollo M, et al. The impact of smoke-free workplaces on declining cigarette consumption in Australia and the United States. Am J Public Health 1999; 89(7): 1018–23. 47 Shields M. A Step Forward, A Step Back: Smoking Cessation and Relapse. Ottawa: Statistics Canada, 2004. 48 Moher, Hey, Lancaster. Workplace interventions. 49 Harden A, Peersman G, Oliver S, et al. A systematic review of the effectiveness of health promotion interventions in the workplace. Occup Med 1999; 49(8): 540–8.

312 Notes to pages 104–8 50 Eriksen MP, Gottlieb NH. A review of the health impact of smoking control at the workplace. Am J Health Promot 1998; 13(2): 83–104. 51 Price P. Passive Smoking: Health Effects and Workplace Resolutions. Hamilton: Canadian Centre for Occupational Health and Safety, 1989. 52 Statistics Canada. Canadian Community Health Survey. Available at http:// www.statcan.ca/english/research/82–618–MIE/82–618–MIE20040 01.pdf. Accessed Dec. 2004. 53 Farrelly MC, Evans WN, Sfekas AE. The impact of workplace smoking bans: Results from a national survey. Tobacco Control 1999; 8(3): 272–7. 54 Scollo M, Lal A, Hyland A, et al. Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry. Tobacco Control 2003; 12(1): 13–20. 55 O’Connell ML, Freeman M, Jennings G, et al. Smoking cessation for high school students: Impact evaluation of a novel program. Behav Modif 2004; 28(1): 133–46. 56 Health Canada. Examining Youth Smoking Cessation and Relapse Prevention, 2002. Available at http://www.hc-sc.gc.ca/hecs-sesc/tobacco/prog_arc/ youth_smoking/index.html. Accessed Dec. 2004. 57 Lamkin L, Davis B, Kamen A. Rationale for tobacco cessation interventions for youth. Prev Med. 1998; 27(5 pt 3): A3–8. 58 Sussman S, Lichtman K, Ritt A, et al. Effects of thirty-four adolescent tobacco use cessation and prevention trials on regular users of tobacco products. Substance Use and Misuse 1999; 34(11): 1469–503. 59 Unpublished results reported in Monitor on Psychology 2001; 32(5). Available at http://www.apa.org/monitor/jun01/cessation.html. Accessed Dec. 2004. 60 USSG. Treating Tobacco Use and Dependence. 61 Lancaster T, Stead LF. Physician advice for smoking cessation. CDSR, 2004; 4: CD000165.pub2. 62 C.I. = Confidence Interval, the 95% confidence interval range given means that the ‘true’ number will fall within the given range 95 out of a 100 times. Odds ratios are a way of comparing whether the probability of a certain event is the same for two groups. An odds ratio of 1 implies that the event is equally likely in both groups. An odds ratio greater than one implies that the event is more likely than compared with the reference group. 63 Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. CDSR, 2002; 3: CD001292. 64 Hajek P. Current issues in behavioral and pharmacological approaches to smoking cessation. Addict Behav 1996; 21(6): 699–707. 65 Manske S, Miller S, Moyer C, et al. Best practice in group-based smoking cessation: Results of a literature review applying effectiveness, plausibility, and practicality criteria. Am J Health Promot 2004; 18(6): 409–23.

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66 Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. CDSR, 2002; 2: CD001007. 67 May S, West R. Do social support interventions (‘buddy systems’) aid smoking cessation? A review. Tobacco Control 2000; 9(4): 415–22. 68 Park E-W, Schultz JK, Tudiver F, et al. Enhancing partner support to improve smoking cessation. CDSR, 2004; 3: CD002928.pub2. 69 Carlson LE, Goodey E, Bennett MH, et al. The addition of social support to a community-based large-group behavioral smoking cessation intervention: Improved cessation rates and gender differences. Addict Behav 2002; 27(4): 547–59. 70 Park EW, Tudiver F, Schultz JK, et al. Does enhancing partner support and interaction improve smoking cessation? A meta-analysis. Ann Fam Med 2004; 2(2): 170–4. 71 Munafo M, Rigotti N, Lancaster T, et al. Interventions for smoking cessation in hospitalized patients: A systematic review. Thorax 2001; 56(8): 656–63. 72 Quist-Paulsen P, Gallefoss F. Randomised controlled trial of smoking cessation intervention after admission for coronary heart disease. Br Med J 2003; 327(7426): 1254–7. 73 Sivarajan Froelicher ES, Miller NH, et al. High rates of sustained smoking cessation in women hospitalized with cardiovascular disease. Circulation 2004; 109: 587–93. 74 Hilleman D, Mohiuddin S, Packard K. Comparison of conservative and aggressive smoking cessation treatment strategies following coronary artery bypass graft surgery. Chest 2004; 125(2): 435–8. 75 Cox L, Clark M, Jett J, et al. Change in smoking status after spiral chest computed tomography scan screening. Cancer 2003; 98(11): 2495–501. 76 Emmons K, Butterfield R, Puleo E, et al. Smoking among participants in the childhood cancer survivors cohort: The Partnership for Health Study. J Clin Oncol 2003; 21(2): 189–96. 77 Godtfredsen N, Prescott E, Osler M, et al. Predictors of smoking reduction and cessation in a cohort of Danish moderate and heavy smokers. Prev Med 2001; 33(1): 46–52. 78 Wiggers L, Smets E, de Haes J, et al. Smoking cessation interventions in cardiovascular patients. Eur J Endovasc Surg 2003; 26(5): 467–75. 79 McBride C, Ostroff J. Teachable moments for promoting smoking cessation: The context of cancer care and survivorship. Cancer Control 2003; 10(4): 325–33. 80 Moller A, Villebro N, Pederson T. Interventions for preoperative smoking cessation. CDSR, 2001. 81 Moller A, Villebro N, Pedersen T, et al. Effect of preoperative smoking inter-

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vention on postoperative complications: A randomised clinical trial. Lancet 2002; 359(9301): 114–17. Ratner P, Johnson J, Richardson C. Efficacy of a smoking-cessation intervention for elective-surgical patients. Res Nurs Health 2004; 27(3): 148–61. Peters M, Morgam L, Gluch L. Smoking cessation and elective surgery: The cleanest cut. Med J Aust 2004; 180: 317–18. Mackay B. Taking a stand in Timmins: Quit smoking, or forgo surgery. Can Med Assoc J 2003; 168(12): 1582. Fiore MC, Novotny TE, Pierce JP, et al. Methods used to quit smoking in the United States: Do cessation programs help? JAMA 1990; 263: 2760–5. Health Canada. Guide to Tobacco Use Cessation Programs in Canada. Available at http://www.hc-sc.gc.ca/hecs-sesc/tobacco/quitting/cessation/ tobtop.html. Accessed Nov. 2004. Lancaster, Stead. Self-help interventions. Curry SJ. Self-help interventions for smoking cessation. J Consult Clin Psychol 1993; 61(5): 790–803. Hebert R. What’s new in nicotine and tobacco research? Nicotine Tobacco Res 2000; 2: 313–15. Summarized in: USSG, Quick Reference Guide for Clinicians. Available at http://www.surgeongeneral.gov/ tobacco/tobaqrg.pdf. Accessed Oct. 2004. Hughes JR, Shiffman S, Callas P, et al. A meta-analysis of the efficacy of over-the-counter nicotine replacement. Tobacco Control 2003; 12: 21–7. Pierce JP, Gilpin EA. Impact of over-the-counter sales on effectiveness of pharmaceutical aids for smoking cessation. JAMA 2002; 288: 1260–4. Silagy C, Lancaster T, Stead L, et al. Nicotine replacement therapy for smoking cessation. CDSR, 2004. Paperwalla KN, Levin TT, Weiner J, et al. Smoking and depression. Med Clin North Am 2004; 88(6): 1483–94. Laje RP, Berman JA, Glassman AH. Depression and nicotine: Preclinical and clinical evidence for common mechanisms. Curr Psychiatry Rep 2001; 3(6): 470–4. See n90. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Tobacco Addiction Group. CDSR, 2004. Hughes JR, Stead LF, Lancaster T. Anxiolytics for smoking cessation. Cochrane Tobacco Addiction Group. CDSR, 2003. Stead LF, Hughes JR. Lobeline for smoking cessation. Cochrane Tobacco Addiction Group. CDSR, 2003. Lancaster T, Stead LF. Mecamylamine (a nicotine antagonist) for smoking cessation. Cochrane Tobacco Addiction Group. CDSR, 2003.

Notes to pages 112–15

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101 David S, Lancaster T, Stead LF. Opioid antagonists for smoking cessation. Cochrane Tobacco Addiction Group. CDSR, 2002. 102 Gourlay SG, Stead LF, Benowitz NL. Clonidine for smoking cessation. Cochrane Tobacco Addiction Group. CDSR, 2004. 103 Bridge J, Turpin B. The Cost of Smoking in British Columbia and the Economics of Tobacco Control. Ottawa: Health Canada, 2004. 104 Fiore MC, McCarthy DE, Jackson TC, et al. Integrating smoking cessation treatment into primary care: An effectiveness study. Prev Med 2004; 38(4): 412–20. 105 See n86. 106 U.S. Task Force on Community Preventive Services. Available at http:// www.thecommunityguide.org/. Accessed Nov. 2004. An example of provider education is the U.S. Public Health Service clinical guidelines described elsewhere in this section. Clinicians are instructed in patient assessment and in how to handle those who are willing to quit, those who are unwilling, and former smokers who need to be prevented from relapsing. See Treating Tobacco Use and Dependence. 107 Hopkins et al. Reviews of evidence. 108 Ibid. 109 Townsend J, Roderick P, Cooper J. Cigarette smoking by socio-economic group, sex and age: Effects of price, income and health publicity. Br Med J 1994; 309: 923–7. 110 World Bank. Curbing the Epidemic: Governments and the Economics of Tobacco Control. Washington: World Bank, 1999. 111 Ranson MK, Jha P, Chaloupka FJ, et al. Global and regional estimates of the effectiveness and cost-effectiveness of price increases and other tobacco control policies. Nicotine Tobacco Res 2002; 4(3): 311–19. 112 Hopkins et al. Reviews of evidence. 113 USSG. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta: CDCP, 2000. 114 USSG. Treating Tobacco Use and Dependence. 115 Secker-Walker RH, Gnich W, Platt S, et al. Community interventions for reducing smoking among adults. Cochrane Tobacco Addiction Group. CDSR, 2004. 116 USSG. Reducing Tobacco Use. 117 COMMIT Research Group. Community intervention trial for smoking cessation (COMMIT). II. Changes in adult cigarette smoking prevalence. Am J Public Health 1995; 85: 193–200. 118 Hancock L, Sanson-Fisher R, Perkins J, et al. The effect of a community action program on adult quit smoking rates in rural Australian towns: The CART Project. Prev Med 2001; 32: 118–27.

316 Notes to pages 115–19 119 USSG. Reducing Tobacco Use. 120 Schar EH, Gutierrez KK. Smoking Cessation Media Campaigns from around the World: Recommendations from Lessons Learned. Copenhagen: WHO, 2001. 121 Available at http://www.hc-sc.gc.ca/hecs-sesc/tobacco/policy/ new_directions/executive_summary.html. Accessed Dec. 2004. 122 Results available at http://www.healthunit.org/smoke/execsum/ 2002survey.htm. Accessed April 2005. 123 Ashley MJ, Cohen JE. What the public thinks about the tobacco industry and its products. Br Med J 2003; 12: 396–400. Chapter 8. Tobacco Control Evidence (3) 1 Hackshaw AK, Law MR, Wald NJ. The accumulated evidence on lung cancer and environmental tobacco smoke. Br Med J 1997; 315: 980–8. 2 He J, Vupputuri S, Allen K, et al. Passive smoking and the risk of coronary heart disease: A meta-analysis of epidemiologic studies. N Eng J Med 1999; 340: 920–6. 3 Roseby R, Waters E, Polnay, A et al. Family and career smoking control programmes for reducing children’s exposure to environmental tobacco smoke. Cochrane Tobacco Addiction Group. Cochrane Database of Systematic Reviews (CDSR), 2004. 4 World Health Organization. International Consultation on Environmental Tobacco Smoke (ETS) and Child Health. Geneva: WHO, 1999. 5 Emmons KM, Wong M, Hammond K, et al. Intervention and policy issues related to children’s exposure to environmental tobacco smoke. Prev Med 2001; 32: 321–31. 6 Hovell MF, Zakarian JM, Wahlgren DR, et al. Reported measures of environmental tobacco smoke exposure: Trials and tribulations. Tobacco Control 2000; 9 (suppl 3): 22–8. 7 Bono R, Vincenti M, Schiliro T, et al. Cotinine and N-(2–hydroxyethyl)valine as markers of passive exposure to tobacco smoke in children. J Expo Anal Environ Epidemiol 2004; 15(1): 66–73. 8 Sexton K, Adgate JL, Church TR, et al. Children’s exposure to environmental tobacco smoke: Using diverse exposure metrics to document ethnic/ racial differences. Environ Health Perspect 2004; 112(3): 392–7. 9 Roseby et al. Family and career. 10 Zhang D, Qiu X. School-based tobacco-use prevention – People’s Republic of China, May 1989–January 1990. Morbid Mortal Weekly Rep 1993; 42(19): 370–1, 377. 11 Emmons et al. Intervention and policy issues. 12 Hovell MF, Meltzer SB, Zakarian JM, et al. Reduction of environmental

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tobacco smoke exposure among asthmatic children: A controlled trial. Chest 1994; 106(2): 440–6. Roseby et al. Family and career. Emmons KM, Hammond SK, Fava JL, et al. A randomized trial to reduce passive smoke exposure in low-income households with young children. Pediatrics 2001; 108(1): 18–24. Hovell MF, Zakarian JM, Matt GE, et al. Decreasing environmental tobacco smoke exposure among low income children: Preliminary findings. Tobacco Control 2000; 9 (suppl 3): 70–1. Wahlgren DR, Hovell MF, Meltzer SB, et al. Reduction of environmental tobacco smoke exposure in asthmatic children: A 2-year follow-up. Chest 1997; 111(1): 81–8. Stephens T, Pederson LL, Koval JJ, et al. The relationship of cigarette prices and no-smoking bylaws to the prevalence of smoking in Canada. Am J Public Health 1997; 87(9): 1519–21. Available at http://www.no-smoking.org/oct04/10-14-04-5.html. Accessed Oct. 2004. Serra C, Cabezas C, Bonfill X, et al. Interventions for preventing tobacco smoking in public places. Cochrane Tobacco Addiction Group. CDSR, 2004. Leedom C, Persuad D, Shovein J. The effect on smoking behaviour of an assertive request to refrain from smoking. Int. J Addict 1986; 21: 1113–17. Serra et al. Interventions. Hatsukami DK. Targeting treatments to special populations. Nicotine Tobacco Res 1999; 1 (suppl 2): S195–200, 207–10. For instance, one study identified these specific traits in youth susceptible to smoking: lower economic status, living in a single-parent home, lack of parental support, lower self-image, low levels of academic achievement, and lack of skills to resist influences to use tobacco. USSG. Preventing Tobacco Use among Young People: A Report of the Surgeon-General. Atlanta: Centers for Disease Control and Prevention; 1994. Also, the recently published B.C. tobacco control policy has chosen to focus on (in addition to aboriginals): young adults (20–24 years) who have the highest smoking rate, and middle-aged adults (25–44 years) who are beginning to manifest smoking-related chronic diseases. B.C. Ministry of Health Services (MHS). Targeting our Effort. Victoria: MOHS, 2004. Unrod M, Cook T, Myers MG, et al. Smoking cessation efforts among substance abusers with and without psychiatric comorbidity. Addict Behav 2004; 29(5): 1009–13. Kramer MS. Determinants of low birth weight: Methodological assessment and meta-analysis. Bull WHO 1987; 65: 663–737.

318 Notes to pages 122–3 26 British Medical Association (BMA). Smoking and Reproductive Life. Available at www.bma.org.uk. Accessed Feb. 2004. 27 Colman G, Grossman M, Joyce T. The effect of cigarette excise taxes on smoking before, during and after pregnancy. J Health Econ 2003; 22: 1053– 72. 28 Fingerhut LA, Kleinman JC, Kendrick JS. Smoking before, during, and after pregnancy. Am J Public Health 1990; 80(5): 541–4. 29 Colman GJ, Joyce T. Trends in smoking before, during, and after pregnancy in ten states. Am J Prev Med 2003; 24(1): 29–35. 30 Johnson IL, Ashley MJ, Reynolds D, et al. Prevalence of smoking associated with pregnancy in three Southern Ontario Health Units. Can J Public Health 2004; 95(3): 209–13. 31 Albrecht SA, Maloni JA, Thomas KT, et al. Smoking cessation counselling for pregnant women who smoke: Scientific basis for practice for AWHONN’s SUCCESS Project. J Obstet Gynecol Neonatal Nurs 2004; 33(3): 298–305. 32 Bridge J, Turpin B. The Cost of Smoking in British Columbia and the Economics of Tobacco Control. Ottawa: Health Canada, 2004. 33 McBride CM, Curry SJ, Lando HA, et al. Prevention of relapse in women who quit smoking during pregnancy. Am J Public Health 1999; 89(5): 706–11. 34 Dolen-Mullen P, Richardson MA, Quin VP, et al. Postpartum return to smoking: Who is at risk and when. Am J Health Promot 1997; 11(5): 323–30. 35 BMA. Smoking and Reproductive Life. 36 Orleans CT, Barker DC, Kaufman NJ, et al. Helping pregnant smokers quit: Meeting the challenge in the next decade. Tobacco Control 9(suppl III): 6–11. 37 Fang WL, Goldstein AO, Butzen AY, et al. Smoking cessation in pregnancy: A review of postpartum relapse prevention strategies. Am Board Fam Pract 2004; 17(4): 264–75. 38 BMA. Smoking. 39 The rate of smoking among women peaks between age 25 and 44, which overlaps with the childbearing years. 40 Paterson JM, Neimanis IM, Bain E. Stopping smoking during pregnancy: Are we on the right track? Can J Public Health 2003; 94(4): 297–9. 41 McLeod D, Pullon S, Cookson T. Factors that influence changes in smoking behaviour during pregnancy. NZ Med J 2003; 116(1173): U418. 42 Valanis B, Lichtenstein E, Mullooly JP, et al. Maternal smoking cessation and relapse prevention during health care visits. Am J Preven Med 2001; 20(1): 1–8. 43 Lumley J, Oliver S, Waters E. Interventions for promoting smoking cessation during pregnancy. Cochrane Tobacco Addiction Group. CDSR, 2004.

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44 Windsor RA, Boyd NR, Orleans CT. A meta-evaluation of smoking cessation intervention research among pregnant women: Improving the science and art. Health Educ Res 1998; 13(3): 419–38. 45 Walsh RA, Redman S, Brinsmead MW, et al. A smoking cessation program at a public antenatal clinic. Am J Public Health 1997; 87(7): 1201–4. 46 Ibid. 47 Dolen-Mullen P. Maternal smoking during pregnancy and evidence-based intervention to promote cessation. Prim Care 1999; 26: 577–89. 48 Valanis et al. Maternal smoking cessation. 49 Melvin CL, Dolen-Mullen P, Windsor RA, et al. Recommended cessation counselling for pregnant women who smoke: A review of the evidence. Tobacco Control 2000; 9 (suppl 3): 80–4. 50 Hartmann KE, Thorp JM, Pahel-Short L, et al. A randomized controlled trial of smoking cessation intervention in pregnancy in an academic clinic. Obst Gynecol 1996; 87(4): 621–6. 51 A helpful summary of this quideline is available at http://www. smokefreefamilies.uab.edu/smokces.doc. Accessed Oct. 2004. 52 Albrecht et al. Smoking cessation counselling. 53 Acharya G, Jauniaux E, Sathia L, et al. Evaluation of the impact of current antismoking advice in the U.K. on women with planned pregnancies. J Obstet Gynaecol 2002; 22(5): 498–500. 54 Malchodi CS, Oncken C, Dornelas EA, et al. The effects of peer counselling on smoking and reduction. Obstet Gynecol 2003; 101(3): 504–10. 55 McBride CM, Baucom DH, Peterson BL, et al. Prenatal and postpartum smoking abstinence: A partner-assisted approach. Am J Prev Med 2004; 27(3): 232–8. 56 Benowitz NL, Dempsey DA, Goldenberg RL, et al. The use of pharmacotherapies for smoking cessation during pregnancy. Tobacco Control 2000; 9(suppl III): 91–4. 57 Ebrahim SH, Merritt RK, Floyd RL. Smoking and women’s health: Opportunities to reduce the burden of smoking during pregnancy. Can Med Assoc J 2000; 163(3): 288–9. 58 See the advisory at http://www.hc-sc.gc.ca/english/protection/warnings/ 2004/2004_44.htm. Accessed April 2005. 59 Ebrahim SH, Floyd RL, Merritt RK, et al. Trends in pregnancy-related smoking rates in the United States, 1987–1996. JAMA 2000; 283(3): 361–6. 60 Lumley, Oliver, Waters. Interventions. 61 Colman, Grossman, Joyce. Effect of cigarette excise taxes. 62 Wardman AE, Khan N. Tobacco cessation pharmacotherapy use among

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80 81 82 83 84 85

First Nations persons residing within British Columbia. Nicotine Tobacco Res 2004; 6(4): 689–92. Angus Reid Group. Tobacco Use in British Columbia, 1997. Available at http:// healthplanning.gov.bc.ca/ tobacrs/index.html. Accessed Oct. 2004. B.C. MHS. Honouring Our Health: An Aboriginal Tobacco Strategy for British Columbia. Victoria: MHS, 2001. Available at http://www.tobaccofacts.org/ tob_control/strategy.html. Accessed Oct. 2004. Angus Reid Group. Tobacco Use. Ibid. B.C. Ministry of Health Services (MHS). Targeting Our Efforts, 2004. Health Canada. Guide to Tobacco Use Cessation Programs in Canada: Priority Populations, no date. Available at http://www.hc-sc.gc.ca/hecs-sesc/ tobacco/quitting/cessation/tobrpt2.html. Accessed Oct. 2004. Ibid. Alberta Alcohol and Drug Abuse Commission. Framework for Developing Tobacco Reduction Strategies for Young Adults. Ottawa: R.A. Malatest and Assoc., 2003. B.C. MHS. Honouring Our Health. Ibid. Ibid. Ibid. Wardman, Khan. Tobacco cessation pharmacotherapy. B.C. MHS. Honouring Our Health. Schinke SP, Tepavac L, Cole KC. Preventing substance use among native American youth: Three-year results. Addict Behav 2000; 25(3): 387–97. Ivers E. A review of tobacco interventions for Indigenous Australians. Aust N Z J Public Health 2003; 27(3): 294–9. Harvey D, Tsey K, Cadet-James Y, et al. An evaluation of tobacco brief intervention training in three indigenous health care settings in north Queensland. Aust N Z J Public Health 2002; 26(5): 426–31. Ivers RG, Farrington M, Burns CB, et al. A study of the use of free nicotine patches by Indigenous people. Aust N Z J Public Health 2003; 27(5): 486–90. Ivers. Review of tobacco interventions. Available at http://www.sane.org/. Accessed Oct. 2004. Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness: A population-based prevalence study. JAMA 2000; 284(20): 2606–10. Leonard S, Adler LE, Benhammou K, et al. Smoking and mental illness. Pharmacol, Biochem Behav 2001; 70: 561–70. Other categories of mental illness include posttraumatic stress disorder, attention-deficit disorder, obsessive-compulsive disorder, and anxiety.

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Addictive disorders, and especially nicotine dependence, of course, represent special areas of interest. John U, Meyer C, Rumpf HJ, et al. Depressive disorders are related to nicotine dependence in the population but do not necessarily hamper smoking cessation. J Clin Psychiatry 2004; 65(2): 169–76. Scarinci IC, Thomas J, Brantley PJ, et al. Examination of the temporal relationship between smoking and major depressive disorder among lowincome women in public primary care clinics. Am J Health Promot 2002; 16(6): 323–30. Gonzalez-Pinto A, Gutierrez M, Ezcurra J, et al. Tobacco smoking and bipolar disorder. J Clin Psychiatry 1998; 59(5): 225–8. This interesting result does not suggest that smoking cessation would prevent the onset of mood disorders, as ex-smokers show the same risk for such onset as current smokers. Breslau N, Novak SP, Kessler RC. Daily smoking and the subsequent onset of psychiatric disorders. Psychol Med 2004; 34: 323–33. Breslau N, Novak SP, Kessler RC. Psychiatric disorders and stages of smoking. Biol Psychiatry 2004; 55(1): 69–761. Ismail K, Sloggett A, DeStavola B. Do common mental disorders increase cigarette smoking? Am J Epidemiol 2000; 152(7): 651–7. Strine TW, Balluz L, Chapman DP, et al. Risk behaviors and healthcare coverage among adults by frequent mental distress status, 2001. Am J Prev Med 2004; 26(3): 213–16. Caroline P, Carney RF, Woolson LJ, et al. Occurrence of cancer among people with mental health claims in an insured population. Psychosom Med 2004; 66: 735–43. Available at http://www.statcan.ca/english/studies/82–003/archive/ 1999/hrar199 9011003s0a05.pdf. Accessed Oct. 2004. McChargue DE, Spring B, Cook JW, et al. Reinforcement expectations explain the relationship between depressive history and smoking status in college students. Addict Behav 2004; 29(5): 991–4. Dalack GW, Becks L, Hill E, et al. Nicotine withdrawal and psychiatric symptoms in cigarette smokers with schizophrenia. Neuropsychopharmacology 1999; 21(2): 195–202. Spring B, Pingitore R, McChargue DE. Reward value of cigarette smoking for comparably heavy smoking schizophrenic, depressed, and nonpatient smokers. Am J Psychiatry 2003; 160(2): 316–22. McChargue et al. Reinforcement expectations. One Australian review provided this inventory of possible benefits of smoking to schizophrenic patients: Improved cognition, relaxation, anti-

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Notes to pages 129–30 depressant effect, modification of psychotic symptoms, reduced side effects from antipsychotic drugs. Royal Australian College of General Practioners. Smoking Cessation in Schizophrenia: General Practice Guidelines, 2001. Available at http://www.racgp.org.au/document.asp?id=5319. Accessed Oct. 2004. Lasser et al. Smoking and mental illness. Hitsman B, Borrelli B, McChargue DE, et al. History of depression and smoking cessation outcome: A meta-analysis. J Consult Clin Psychol. 2003; 71(4): 657–63. John et al. Depressive disorders. Addington J, el-Guebaly N, Addington D, et al. Readiness to stop smoking in schizophrenia. Can J Psychiatry 1997; 42: 49–52. Addington J. Group treatment for smoking cessation among persons with schizophrenia. Psychiatric Serv 1998; 49(7): 925–8. Behavioural counselling is sometimes used to prevent relapse. Available at http://www.cognitivetherapy.com/basics.html. Accessed Oct. 2004. Available at http://motivationalinterview.org/clinical/whatismi.html. Accessed Oct. 2004. Smoking Cessation in Schizophrenia. El-Guebaly N, Cathcart J, Currie S, et al. Smoking cessation approaches for persons with mental illness or addictive disorders. Psychiatric Serv 2002; 53(9): 1166–70. Addington J, el-Guebaly N, Campbell W, et al. Smoking cessation treatment for patients with schizophrenia. Am J Psychiatry 1998; 155: 974–6. Thorsteinsson HS, Gillin JC, Patten CA, et al. The effects of transdermal nicotine therapy for smoking cessation on depressive symptoms in patients with major depression. Neuropsychopharmacology 2001; 24(4): 350–8. John et al. Depressive disorders. Haas AL, Munoz RF, Humfleet GL, et al. Influences of mood, depression history, and treatment modality on outcomes in smoking cessation. J Consult Clin Psychol 2004; 72(4): 563–70. Brown RA, Ramsey SE, Strong DR, et al. Effects of motivational interviewing on smoking cessation in adolescents with psychiatric disorders. Tobacco Control 2003; 12 (suppl 4): 3–10. El-Guebaly N, Cathcart J, Currie S, et al. Public health and therapeutic aspects of smoking bans in mental health and addiction settings. Psychiatric Serv 2002; 53(12): 1617–22.

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Chapter 9. Tobacco Control Evidence (4) 1 Naidoo B, Warm D, Quigley R, et al. Smoking and Public Health: A Review of Reviews of Interventions to Increase Smoking Cessation, Reduce Smoking Initiation and Prevent Further Uptake of Smoking. London: Health Development Agency, 2004. Available at http://www.hda-online.org.uk/documents/ smoking_evidence_ briefing.pdf. Accessed Dec. 2004. 2 Cohen D, Fowler G. Economic implications of smoking cessation therapies: A review of economic appraisals. Pharmacoeconomics 1993; 4(5): 331–44. 3 Rush B, Shiell A, Hawe P. A census of economic evaluations in health promotion. Health Educ Res 2004; 19(6): 707–19. 4 Ibid. 5 Ibid. 6 Warner K. Tobacco control policy: From action to evidence and back again. Am J Prev Med 2001; 20(suppl 2): 2–5. 7 Rush, Shiell, Hawe. Census of economic evaluations. 8 Laupacis A, Feeny D, Detsky A, et al. How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. Can Med Assoc J 1992; 146(4): 473–81. 9 Gafni A, Birch S. Guidelines for the adoption of new technologies: A prescription for uncontrolled growth in expenditures and how to avoid the problem. Can Med Assoc J 1992; 148(6): 913–17. 10 See http://www.hsph.harvard.edu/cearegistry/. Accessed Jan. 2005. 11 Taxation and banning advertising and promotion are sometimes called ‘stroke-of-the-pen’ interventions with virtually no attendant cost; however, conservative estimates will always assume substantial implementation and administrative costs. 12 Sweanor D, Kyle K. Legislation and Applied Economics in the Pursuit of Public Health: Canada. Available at http://www1.worldbank.org/tobacco/pdf/ 2850–Ch04.pdf. Accessed Oct. 2004. 13 See the Fact Sheet on Tobacco Smuggling at http://tobaccofreekids.org/ campaign/global/docs/ smuggling.pdf. Accessed April 2005. 14 Pacula R, Chaloupka F. The effects of macro-level interventions on addictive behavior. Subst Use Abuse 2001; 36(13): 1901–22. 15 Chaloupka F, Pacula R. The impact of price on youth tobacco use. In: Changing Adolescent Smoking Prevalence. Monograph No. 14: Washington: National Cancer Institute, 2001. 16 Ross H, Chaloupka F. The effect of cigarette prices on youth smoking. Health Econ 2003; 12: 217–30.

324 Notes to pages 137–9 17 Cawley J, Markowitz S, Taurus J. Lighting up and slimming down: The effects of body weight and cigarette prices on adolescent smoking initiation. J Health Econ 2003; 23: 293–311. 18 Tauras J. Public policy and smoking cessation among young adults in the United States. Health Pol 2004; 68: 321–32. 19 Chaloupka F. How effective are taxes in reducing tobacco consumption? Available at http://tigger.uic.edu/~fjc/ Presentations/Papers/ taxes_consump_rev.pdf. Accessed Jan. 2005. 20 Wasserman J, Manning W, Newhouse J, et al. The effects of excise taxes and regulations on cigarette smoking. J Health Econ 1991; 10(1): 43–64. 21 Tauras. Public policy. 22 Some analysis have included the cost of enforcing and collecting taxes into their analysis. See, e.g. Ranson M, Jha P, Chaloupka F, et al. Global and regional estimates of the effectiveness and cost-effectiveness of price increases and other tobacco control policies. Nicotine Tobacco Res 2002; 4: 311–19. 23 Warner K. Cost effectiveness of smoking-cessation therapies: Interpretation of the evidence and implications for coverage. Pharmacoeconomics 1997; 11(6): 538–49. 24 Cromwell J, Bartosch W, Fiore M, et al. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. Agency for Health Care Policy and Research. JAMA 1997; 278(21): 1759–66. Note that the guidelines, but not the economic analysis, were updated in 2000 (see Treating Tobacco Use and Dependence). 25 All costs in the cost-effectiveness section of this report are provided in U.S. dollars unless otherwise noted. 26 Cummings S, Rubin S, Oster G. The cost-effectiveness of counselling smokers to quit. JAMA 1989; 261(1): 75–9. 27 Parrott S, Godfrey C, Raw M, et al. Guidance for commissioners on the cost effectiveness of smoking cessation interventions. Health Educational Authority. Thorax 1998; 53(suppl 5 pt 2): S1–38. Note that the guidelines (but not the economic analysis) were also updated (just like the parallel U.S. guidelines), in 2000. See West R, McNeill A, Raw M Smoking cessation guidelines for health professionals: An update. Health Education Authority. Thorax 2000; 55(12): 987–99. 28 Currency conversion into U.S. dollars is based on the exchange rate on 23 Dec. 2005. 29 Discounting is a method of adjusting for the fact that individuals prefer to incur costs in later periods and enjoy benefits in the current period. Applying a discount rate transforms future values into current values. Parrott S,

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Godfrey C. Economics of smoking cessation. Br Med J 2004; 328(7445): 947– 9. This paper provided a 2001–2 update of the cost figures, which are quoted in our book. Cohen, Fowler. Economic implications. Orme M, Hogue S, Kennedy L, et al. Development of health and economic consequences of smoking interactive model. Tobacco Control 2001; 10: 55–61. As summarized in Song F, Raftery J, Aveyard P, et al. Cost-effectiveness of pharmacological interventions for smoking cessation: A literature review and a decision analytic analysis. Med Dec Making 2002; 22(suppl 5): S26–37. Ronckers S, Ament A. Cost-effectiveness of Treatment for Tobacco Dependence. Washington: World Bank, 2003. Available at http://www1.worldbank.org/ tobacco/pdf/Ronchers-Cost%20Effectiveness-whole.pdf. Accessed Dec. 2004. Parrott, Godfrey. Economics of smoking cessation. Altman D, Flora J, Fortmann S, et al. The cost-effectiveness of three smoking cessation programs. Am J Public Health 1987; 77(2): 162–5. Bertera R, Oehl L, Telephak J. Self-help versus group approaches to smoking cessation in the workplace: Eighteen-month follow-up and cost analysis. Am J Health Promotion 1990; 4: 187–92. Parrott et al. Guidance for commissioners. Buck D, Richmond R, Mendelsohn C. Cost-effectiveness analysis of a family physician delivered smoking cessation program. Prev Med 2000; 31(6): 641–8. Cromwell et al. Cost-effectiveness. Cohen, Fowler. Economic implications. Ronckers, Ament. Cost-effectiveness of Treatment. Krumholz H, Cohen B, Tsevat J, et al. Cost-effectiveness of a smoking cessation program after myocardial infarction. J Am Coll Cardiol 1993; 22(6): 1697–702. Reid R, Coyle D, Papadakis S, et al. Nicotine Replacement Therapies in Smoking Cessation. Ottawa: Canadian Council on Tobacco Control, 1999. Oster G, Huse D, Delea T, et al. Cost-effectiveness of nicotine gum as an adjunct to physician’s advice against cigarette smoking. JAMA 1986; 256(10): 1315–18. Fiscella K, Franks P. Cost-effectiveness of the transdermal nicotine patch as an adjunct to physicians’ smoking cessation counselling. JAMA 1996; 275(16): 1247–51. Cromwell et al. Cost-effectiveness. Wasley M, McNagny S, Phillips V, et al. The cost-effectiveness of the nicotine transdermal patch for smoking cessation. Prev Med 1997; 26(2): 264–70.

326 Notes to pages 140–3 47 48 49 50 51 52 53

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Song et al. Cost-effectiveness. Cromwell et al. Cost-effectiveness. Fiscella, Franks. Cost-effectiveness of the transdermal nicotine patch. Update of original 1995 figures provided at http://www.treatobacco.net/ health/showReference.cfm?kid =98&sid=2. Accessed Jan. 2005. Oster et al. Cost-effectiveness. Wasley et al. Cost-effectiveness. See the comment in Stapleton J. Cost-effectiveness of the nicotine transdermal patch. Prev Med 1998; 27: 304. The correction was accepted by the original authors. Miller M, Draugalis J, Ortmeier B, et al. A retrospective analysis of the costs and consequences of a tobacco-cessation program for active duty service members. Mil Med 1996; 161(7): 420–4. Parrott et al. Guidance for commissioners. Updated to 2001–2 pounds in Parrott, Godfrey, Economics of smoking cessation. Orme M, Hogue S, Kennedy L, et al. Development of health and economic consequences of smoking interactive model. Tobacco Control 2001; 10: 55–61. As summarized in Song et al., Cost-effectiveness. Tengs T, Adams M, Pilskin J, et al. Five hundred life-saving interventions and their cost-effectiveness. Risk Anal 1995; 15: 369–90. Prathiba B, Tjeder S, Phillips C, et al. A smoking cessation counsellor: Should every hospital have one? J Roy Soc Health 1998; 118(6): 356–9. Akehust R, Piercy J. Cost-effectiveness of the use of transdermal Nicorette patches relative to GP counselling and nicotine gum in the prevention of smoking related diseases. B J Med Econ 1994; 7: 115–22. Akehust R, Piercy J. Cost-effectiveness of the use of Nicorette nasal spray to assist quitting smoking among heavy smokers. B J Med Econ 1994; 7: 155–84. Cheung A, Tsevat J. Economic evaluations of smoking interventions. Prev Med 1997; 26: 271–3. Stapleton J, Lowin A, Russell M. Prescription of transdermal nicotine patches for smoking cessation in general practice: Evaluation of costeffectiveness. Lancet 1999; 354(9174): 210–15. WHO. European Strategy for Smoking Cessation Policy. Geneva: WHO, rev. 2004. Schauffler H, McMenamin S, Olson K, et al. Variations in treatment benefits influence smoking cessation: results of a randomised controlled trial. Tobacco Control 2001; 10(2): 175–80. Warner K, Mendez D, Smith D. The financial implications of smoking cessation treatment by managed care organizations. Inquiry 2004; 41(1): 57–69. Curry S, Grothaus L, McAfee T, et al. Use and cost effectiveness of

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smoking-cessation services under four insurance plans in a health maintenance organization. N Engl J Med 1998; 339(10): 673–9. Novotny T, Clare Cohen J, Yurekli, A, et al. Smoking cessation and nicotinereplacement therapies. In: Jhap, Chaloupka FJ. Tobacco Control in Developing Countries. Washington: World Bank, 1999. 287–307. Cox J, McKenna J. Nicotine gum: Does providing it free in a smoking cessation program alter success rates? J Fam Pract 1990; 31(3): 278–80. Hughes J, Wadland W, Fenwick J, et al. Effect of cost on the self-administration and efficacy of nicotine gum: A preliminary study. Prev Med 1991; 20(4): 486–96. Tauras J, Chaloupka F. The demand for nicotine replacement therapies. Nicotine Tobacco Res 2003; 5(2): 237–43. Alberg A, Stashefsky Margalit R, Burke A, et al. The influence of offering free transdermal nicotine patches on quit rates in a local health department’s smoking cessation program. Addict Behav 2004; 29(9): 1763–78. Novotny et al. Smoking cessation. Jhap, Chaloupka FJ. Curbing the Epidemic: Governments and the Economics of Tobacco Control. Washington: World Bank, 1999. Note that this book is an abridgment of Tobacco Control in Developing Countries. WHO. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva: WHO, 2002. Available at http://www.who.int/whr/2002/en/. Accessed March 2005. Smeeth L, Fowler G. Nicotine replacement therapy for a healthier nation. Br Med J 1998; 317: 1266–7. News story available at http://www.katu.com/printstory.asp?ID=73602. Accessed Jan. 2005. Miller N, Frieden T, Liu SY, et al. Effectiveness of a large-scale distribution programme of free nicotine patches: A prospective evaluation. Lancet 2005; 365: 1849–54. Novotny et al. Smoking cessation. Stapleton J. Cost effectiveness of NHS smoking cessation services. Available at http://www.ash.org. uk/html/cessation/ashcost.pdf. Accessed Dec. 2004. Statistics on Smoking Cessation Services in the Health Action Zones in England, April 1999 to March 2000. London: Government Statistical Service, 2001. Raw M, McNeill A, Watt J, et al. National smoking cessation services at risk. Br Med J 2001; 323: 1140–1. Song et al. Cost-effectiveness. The same decision analytic analysis was used by Woolacott N, Jones L, Forbes, C et al. The clinical effectiveness and costeffectiveness of bupropion and nicotine replacement therapy for smoking

328 Notes to pages 145–8

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cessation: A systematic review and economic evaluation. Health Tech Assess 2002; 6(16): 1–245, with the results also being summarized by the National Institute for Clinical Effectiveness. One Euro is valued at U.S.$1.19 on 23 Dec. 2005. Cornuz J, Pinget C, Gilbert A, et al. Cost-effectiveness analysis of the firstline therapies for nicotine dependence. Eur J Clin Pharmacol 2003; 59(3): 201–16. Woolacott et al. Clinical effectiveness and cost-effectiveness. Javitz H, Swan G, Zbikowski S, et al. Cost-effectiveness of different combinations of bupropion SR dose and behavioral treatment for smoking cessation: A societal perspective. Am J Managed Care 2004; 10(3): 217–26. Croghan I, Offord K, Evans R, et al. Cost-effectiveness of treating nicotine dependence: The Mayo Clinic experience. Mayo Clinic Proc 1997; 72(10): 917–24. Meenan R, Stevens V, Hornbrook M, et al. Cost-effectiveness of a hospitalbased smoking cessation intervention. Med Care 1998; 36(5): 670–8. Tran M, Holdford D, Kennedy D, et al. Modeling the cost-effectiveness of a smoking-cessation program in a community pharmacy practice. Pharmacotherapy 2002; 22(12): 1623–33. Novotny et al. Smoking cessation. Elixhauser A. The costs of smoking and the cost effectiveness of smokingcessation programs. J Public Health Pol 1990; 11(2): 218–37. Gilbert A, Cornuz J. Which Are the Most Effective and Cost-Effective Interventions for Tobacco Control? Geneva: WHO, 2003. WHO. European Strategy. DiFranza J, Peck R, Radecki T, et al. What is the potential cost-effectiveness of enforcing a prohibition on the sale of tobacco to minors? Prev Med 2001; 32(2): 168–74. WHO. European Strategy. Brownson R, Hopkins D, Wakefield M. Effects of smoking restrictions in the workplace. Annu Rev Public Health 2002; 23: 333–48. Secker-Walker R, Worden J, Holland R, et al. A mass media programme to prevent smoking among adolescents: costs and cost effectiveness. Tobacco Control 1997; 6(3): 207–12. See, e.g., McDonald P. A low-cost, practical method for increasing smokers’ interest in smoking cessation programs. Can J Public Health 2004; 95(1): 50–3. Ratcliffe J, Cairns J, Platt S. Cost-effectiveness of a mass media-led antismoking campaign in Scotland. Tobacco Control 1997; 6(2): 104–10. Prices converted by Ronckers S, Ament A. Cost-effectiveness of Treatment for Tobacco

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Dependence. Washington: World Bank, 2003. Available at http:// www1.worldbank.org/tobacco/pdf/Ronchers-Cost%20Effectivenesswhole.pdf. Accessed Dec. 2004. McAlister A, Rabius V, Geiger, A, et al. Telephone assistance for smoking cessation: One year cost effectiveness estimations. Tobacco Control 2004; 13: 85–6. Mudde A, De Vries H. The reach and effectiveness of a national mass media-led smoking cessation campaign in the Netherlands. Am J Public Health 1999; 89(3): 346–50. Tomson T, Helgason A, Gilljam H. Quitline in smoking cessation: A cost-effectiveness analysis. Int J Technol Assess Health Care 2004; 20(4): 469–74. Stevens W, Thorogood M, Kayikki S. Cost-effectiveness of a community anti-smoking campaign targeted at a high risk group in London. Health Promot Int 2002; 17(1): 43–50. Buck D, Godfrey C, Parrott, S et al. Cost-effectiveness of Smoking Cessation Interventions. London: Health Education Authority; 1997. Summarized in Ranson M, Jha P, Chaloupka F et al. Global and regional estimates of the effectiveness and cost-effectiveness of price increases and other tobacco control policies. Nicotine Tobacco Res 2002; 4: 311–19. Warner K. Cost effectiveness of smoking-cessation therapies: Interpretation of the evidence and implications for coverage. Pharmacoeconomics 1997; 11(6): 538–49. Curry S. Self-help interventions for smoking cessation. J Consult Clin Psychol 1993; 61(5): 790–803. Elixhauser. Costs of smoking. Results summarized in Mudde, De Vries, Reach and effectiveness of a national mass media-led smoking cessation campaign. Altman et al. Cost-effectiveness. Mudde A, de Vries H, Strecher V. Cost-effectiveness of smoking cessation modalities: Comparing apples with oranges? Prev Med 1996; 25(6): 708–16. Brandon T, Meade C, Herzog T, et al. Efficacy and cost-effectiveness of a minimal intervention to prevent smoking relapse: Dismantling the effects of amount of content versus contact. J Consult Clin Psychol 2004; 72(5): 797–808. Moher M, Hey K, Lancaster T. Workplace interventions for smoking cessation. Cochrane Tobacco Addiction Group. Cochrane Database of Systematic Reviews (CDSR), 2004. Parrott S, Godfrey C, Raw M. Costs of employee smoking in the workplace in Scotland. Tobacco Control 2000; 9(2): 187–92.

330 Notes to pages 149–50 113 Cancer Care Nova Scotia. Cost of Tobacco in Your Workplace. Available at http://cancercare.ns.ca/media/documents/TobaccoIn Workplace.pdf. Accessed Jan. 2005. This figure was derived from a 1996 simulation model described in Warner K, Smith R, Smith D, et al. Health and economic implications of a work-site smoking-cessation program: A situation analysis. J Occup Environ Med 1996; 38(10): 981–92. 114 Halpern M, Khan Z, Young T, et al. Economic model of sustained-release bupropion hydrochloride in health plan and work-site smoking-cessation programs. Am J Health System Pharm 2000; 57(15): 1421–9. 115 Javitz H, Swan G, Zbikowski S, et al. Return on investment of different combinations of bupropion SR dose and behavioral treatment for smoking cessation in a health care setting: An employer’s perspective. Value Health 2004; 7(5): 535–43. 116 Wang L, Crossett L, Lowry R, et al. Cost-effectiveness of a school-based tobacco-use prevention program. Arch Pediatr Adolesc Med 2001; 155(9): 1043–50. 117 Stephens T, Kaiserman M, McCall D, et al. School-based smoking prevention: Economic costs versus benefits. Chron Dis Can 2000; 21(2). 118 Tengs T, Osgood N, Chen L. The cost-effectiveness of intensive national school-based anti-tobacco education: Results from the tobacco policy model. Prev Med 2001; 33(6): 558–70. 119 Cohen, Fowler. Economic implications. 120 Lightwood J, Phibbs C, Glantz S. Short-term health and economic benefits of smoking cessation: Low birth weight. Pediatrics 1999; 104(6): 1312–20. 121 Marks J, Koplan J, Hogue C, et al. A cost-benefit/cost-effectiveness analysis of smoking cessation for pregnant women. Am J Prev Med 1990; 6(5): 282–9. The conclusions of this study with reference to low birth-weight costs were confirmed by the U.S. Centers for Disease Control. Data summarized at http:// www.cdc.gov/tobacco/research_data/economics/ health_econ_impact.pdf. Accessed Jan. 2005. 122 Ershoff D, Aaronson N, Danaher B, et al. Behavioral, health, and cost outcomes of an HMO-based prenatal health education program. Public Health Rep 1983; 98(6): 536–4. 123 Ershoff D, Quinn V, Mullen P, et al. Pregnancy and medical cost outcomes of a self-help prenatal smoking cessation program in a HMO. Public Health Rep 1990; 105(4): 340–7. 124 Windsor R, Lowe J, Perkins L, et al. Health education for pregnant smokers: Its behavioral impact and cost benefit. Am J Public Health 1993; 83(2): 201–6. 125 Windsor R, Warner K, Cutter G. A cost-effectiveness analysis of self-help

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smoking cessation methods for pregnant women. Public Health Rep 1988; 103(1): 83–8. Ibid. Shipp M, Croughan-Minihane M, Petitti D, et al. Estimation of the breakeven point for smoking cessation programs in pregnancy. Am J Public Health 1992; 82(3): 383–90. Hueston W, Mainous A, Farrell J. A cost-benefit analysis of smoking cessation programs during the first trimester of pregnancy for the prevention of low birthweight. J Fam Pract 1994; 39(4): 353–7. McParlane E, Mullen P, DeNino L. The cost effectiveness of an education outreach representative to OB practitioners to promote smoking cessation counselling. Patient Educ Couns 1987; 9(3): 263–74. Ringel J, Evans W. Cigarette taxes and smoking during pregnancy. Am J Public Health 2001; 91(11): 1851–6. Colman G, Grossman M, Joyce T. The effect of cigarette excise taxes on smoking before, during and after pregnancy. J Health Econ 2003; 22(6): 1053–72.

Chapter 10. Lessons from the Tobacco Wars 1 Gilbert A, Cornuz J. Which Are the Most Effective and Cost-Effective Interventions for Tobacco Control? Geneva: WHO, 2003. 2 Mercer SL, Green LW, Rosenthal AC, et al. Possible lessons from the tobacco experience for obesity control. Am J Clin Nutr 2003; 77(suppl 4): S1073–82. 3 Interview with Glasgow R. How multilevel intervention approaches work. Center for the Advancement of Health. Issue Briefings for Health Reporters 2003; 8(2). Available at http://www.cfah.org/factsoflife/ vol8no2.cfm. Accessed Dec. 2005. 4 WHO. European Strategy for Smoking Cessation Policy. Geneva: WHO, rev. 2004. 5 Tengs T, Adams M, Pilskin J, et al. Five hundred life-saving interventions and their cost-effectiveness. Risk Anal. 1995; 15: 369–90. 6 Thomson GW, Wilson NA, O’Dea D, et al. Tobacco spending and children in low income households. Tobacco Control 2002; 11: 372–5. 7 Crampton P, Salmond C, Woodward A, et al. Socioeconomic deprivation and ethnicity are both important for anti-tobacco health promotion. Health Educ Behav 2000; 27(3): 317–27. 8 See, e.g., the Alberta-based report Poverty and Health Care Reform. 2002. Available at http://www.ywcaofcalgary.com/pdf/PovertyHealthReform .pdf. Accessed Jan. 2005.

332 Notes to pages 156–66 9 Mercer et al. Possible lessons from the tobacco experience, See the discussion on ‘reach’ and other evaluation criteria in the Conclusion of this book. 10 Sinedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington: National Academy Press, 2000. Part Three 1 We are limiting this characterization to obesity, closely defined. As will be noted later, some people who are slightly to moderately overweight (according to current criteria) appear to enjoy a health benefit. 2 Goodman E, Dolan LM, Morrison JA, et al. Factor analysis of clustered cardiovascular risks in adolescence: Obesity is the predominant correlate of risk among youth. Circulation 2005; 111(15): 1970–7. 3 Lee ZS, Critchley JA, Chan JC, et al. Obesity is the key determinant of cardiovascular risk factors in the Hong Kong Chinese population: A crosssectional clinic-based study. Hong Kong Med J 2000; 6(1): 13–23. 4 Mark DH. Deaths attributable to obesity. JAMA 2005; 293(15): JAMA 1918– 19. Chapter 11. Obesity and Tobacco Control 1 See, e.g., Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in the United States, 2000. JAMA. 2004; 291(10): 1238–45. These authors suggest that 400,000 deaths annually in the United States are attributable to poor diet and physical inactivity, compared with 430,000 attributable to tobacco. It should be noted that the calculations of the number of deaths attributable to poor diet and physical inactivity in this article were inflated by a significant degree. (See the correction by Mokdad et al. Available at http://jama.ama-assn.org/cgi/content/extract/293/3/293. Accessed April 2005.) Thus, the comparison with tobacco is somewhat tempered. Indeed, the most recent report from the same journal has lowered the annual mortality attributable to obesity further, to about 112,000 – which, of course, is still a very significant figure. Flegal KM, Graubard BI, Williamson DF, et al. Excess deaths associated with underweight, overweight, and obesity. JAMA 2005; 293(15): 1861–7. See the full discussion in Chapter 2. 2 Katzmarzyk PT. The Canadian obesity epidemic, 1985–1998. Can Med Assoc J 2002; 166(8): 1039–40. 3 Statistics Canada. Summary available at http://www.statcan.ca/Daily/ English/050706/d050706a.htm. Accessed Dec. 2005. 4 Tremblay MS, Katzmarzyk PT, Willms JD. Temporal trends in overweight and obesity in Canada, 1981–1996. Int J Obes 2002; 26(4): 538–43 See also,

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Tremblay MS, Willms JD. Secular trends in the body mass index of Canadian children (correction), 1981–1996. Can Med Assoc J 2001; 164(7): 970. See n. 3. Sobal J, Stunkard AJ. Socioeconomic status and obesity: A review of the literature. Psychol Bull 1989; 105(2): 260–75. Zhang Q, Wang Y. Socioeconomic inequality of obesity in the United States: Do gender, age, and ethnicity matter? Soc Sci Med 2004; 58(6): 1171–80. Warner KE. Lessons for addressing obesity from the history of tobacco control. Available at www.bmsg.org/documents/Warnertobaccomemo.pdf. Accessed Dec. 2005. Mercer SL, Green LW, Rosenthal AC, et al. Possible lessons from the tobacco experience for obesity control. Am J Clin Nutr 2003; 77(suppl): S1073–82. Kendall PRW. An Ounce of Prevention: A Public Health Rationale for the School as a Setting for Health Promotion. A Report by the Provincial Health Officer. Victoria: B.C. Ministry of Health Planning, 2003. Available at http: / /www.health.gov.bc.ca/pho/pdf/o_prevention.pdf. Accessed Dec. 2005. Ten great public health achievements – United States, 1900–1999. Morbid Mortal Weekly Rep. 1999; 48(12): 241–3. Achievements in public health, 1900–1999: tobacco use – United States, 1900–1999. Morbid Mortal Weekly Rep. 1999; 48(43): 986–93. Liu GC, Cunningham C, Downs SM, et al. A spatial analysis of obesogenic environments for children. Proc AMIA Annu Symp 2002; 459–63. Lobstein T, Dibb S. Evidence of a possible link between obesogenic food advertising and child overweight. Obes Rev 2005; 6(3): 203–8. Chopra M, Galbraith S, Darnton-Hill I. A global response to a global problem: The epidemic of overnutrition. Bull WHO 2002; 80(12): 952–8. Caterson ID, Gill TP. Obesity: epidemiology and possible prevention. Best Pract Res Clin Endocrinol Metab 2002; 16(4): 595–610. A word apparently coined in 1996, and established in the medical literature in a key article in 1999. See Swinburn B, Egger G, Raza F. Dissecting obesogenic environments: The development and application of a framework for identifying and prioritizing environmental interventions for obesity. Prev Med 1999; 29: 563–70. Swinburn B. Dissecting and influencing obesogneic environments. Powerpoint presentation available at http://depts.washington.edu/obesity/ confdec2001/washington2001.pp t#1. Accessed Dec. 2005. Swinburn B, Egger G. Preventive strategies against weight gain and obesity. Obes Rev. 2002; 3: 289–301. Kumanyika S, Jeffrey RW, Morabia A, et al. Obesity prevention: The case for action. Int J Obes. Relat Metab Disord 2002; 26: 425–36.

334 Notes to pages 170–6 21 Swinburn, Egger, Raza. Dissecting obesogenic environments. 22 Warner. Lessons. 23 News report available at http://edition.cnn.com/2004/US/03/02/ mcdonalds.supersize.ap/. Accessed Dec. 2004. 24 A good review of food industry concerns and positions can be found within the Center for Consumer Freedom. Available at http://www. consumerfreedom.com/. Accessed Dec. 2004. 25 A rather dramatic example of the first point, namely, inaccurate mortality statistics, was provided by the Centers for Disease Control and Prevention in Atlanta. Their researchers recently had to retract the results published in March 2004, concerning annual U.S. deaths attributable to obesity. News report available at http://www.medicalnewstoday.com/medicalnews .php?newsid=16869. Accessed Dec. 2004. As well, evidence will be presented later in this book that supports the possible primacy of exercise over dieting as an effective weight control measure. 26 Trochim WMK, Stillman FA, Clark PI, et al. Development of a model of the tobacco industry’s interference with tobacco control programmes. Tobacco Control 2003; 12: 140–7. 27 Thomson G, Wilson N. Directly eroding tobacco industry power as a tobacco control strategy: Lessons for New Zealand? NZ Med J 2005; 118(1223): U1683. 28 Dorfman L, Woodruff K, Lingas EO, et al. Accelerating Policy on Nutrition: Lessons from Tobacco, Alcohol, Firearms, and Traffic Safety, Berkeley: Media Studies Group, 2004. Available at http://www.bmsg.org/documents/ Acceleration MtgReportPrelim.pdf. Accessed Dec. 2005. 29 Mercer et al. Possible lessons. See Chapter 10. 30 Diabetes New Zealand. Tobacco Control: What Can Be Learnt and Applied to Nutrition Policy. Available at http://diabetes.org.nz/ resources/files/ DiabetesTobPolicy.doc. Accessed Dec. 2005. 31 Daynard RA. Lessons from tobacco control for the obesity control movement. J Public Health Pol 2003; 23(3–4): 291–5. 32 Canadian Cancer Society. Progress in Cancer Prevention: Modifiable Risk Factors. Available on the Institute’s website at http://www.ncic.cancer.ca/ ncic/internet/standard/0,3621,84658243_85787780_399354909_ langId-en,00.html. Accessed Dec. 2005. Chapter 12. Obesity Control Evidence (1) 1 Levin ML, Goldstein H, Gerhardt PR. Cancer and tobacco smoking: a preliminary report. JAMA 1950; 143(4): 336–8.

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2 Wynder EL, Graham EA. Tobacco smoking as a possible etiologic factor in bronchiogenic carcinoma: A study of 684 proved cases. JAMA 1950; 143(4): 329–36. 3 Doll R, Hill AB. Smoking and carcinoma of the lung. Br Med J 1950; 221(2): 739–48. Questions about the adverse health effects of tobacco use go back at least to the 1600s when King James I wrote A Counter-Blaste to Tobacco, published in 1604. See, Kluger R Ashes to Ashes: America’s Hundred-Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris. New York: Vintage Books, 1997. 4 Kluger Ashes to Ashes, 133. 5 Vlassov VV. Weight reduction for reducing mortality in obesity and overweight. Cochrane Database of Systematic Reviews (CDSR), 2003. 6 Dunshea-Mooij CAE, Ni Mhurchu C, Bennett D, et al. Chitosan for overweight or obesity. CDSR, 2003. 7 Data summarized at http://www.statcan.ca/Daily/English/040526/ d040526e.htm and http://www.statcan.ca /Daily/English/041014/ d041014d.htm. Accessed Nov. 2004. 8 Rousseau E. Meeting nutritional needs during adolescence. Pro-Teen 2000; 9(1&2): 31–49. Available at www.acsa-caah.ca/pdf/ang/pt091.pdf. Accessed Dec. 2004. 9 Data summarized at http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/ review_food_supply_e.html. Accessed Nov. 2004. 10 Full Statistics Canada report available at http://www.statcan.ca/english/ freepub/21-020-XIE/21-020-XIE2004002.pdf. Summary available at http: //www.statcan.ca/Daily/English/051018/d051018e.htm. Accessed Dec. 2005. 11 Health Canada. Trends in the Health of Canadian Youth. Available at http: //www.hc-sc.gc.ca/english/media/releases /1999/99118ebk3.htm. Accessed Feb. 2005. 12 Berkey CS, Rockett HR, Field AE, et al. Sugar-added beverages and adolescent weight change. Obes Res 2004; 12(5): 778–88. 13 Bray GA, Nielsen SJ, Popkin BM. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. Am J Clin Nutr. 2004; 79(4): 537–43. 14 Phillips S, Jacobs Starkey L, Gray-Donald K. Food habits of Canadians: Food sources of nutrients for the adolescent sample. Can J Diet Pract Res 2004; 65(2): 81–4. 15 Newby PK, Peterson KE, Berkey CS, et al. Beverage consumption is not associated with changes in weight and body mass index among low-income preschool children in North Dakota. J Am Diet Assoc 2004; 104(7): 1086–94.

336 Notes to pages 179–80 16 Field AE, Austin SB, Gillman MW, et al. Snack food intake does not predict weight change among children and adolescents. Int J Obes Relat Metab Disord 2004; 28(10): 1210–16. 17 Phillips SM, Bandini LG, Naumova EN, et al. Energy-dense snack food intake in adolescence: Longitudinal relationship to weight and fatness. Obes Res 2004; 12(3): 461–72. 18 Bandini LG, Vu D, Must A, et al. Comparison of high-calorie, low-nutrientdense food consumption among obese and non-obese adolescents. Obes Res 1999; 7(5): 438–43. 19 Nielsen SJ, Siega-Riz AM, Popkin BM. Trends in energy intake in U.S. between 1977 and 1996: Similar shifts seen across age groups. Obes Res 2002; 10(5): 370–8. 20 Thompson OM, Ballew C, Resnicow K, et al. Food purchased away from home as a predictor of change in BMI z-score among girls. Int J Obes Relat Metab Disord 2004; 28(2): 282–9. 21 Pereira MA, Kartashov AI, Ebbeling CB, et al. Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. Lancet 2005; 365(9453): 36–42. 22 Bowman SA, Gortmaker SL, Ebbeling CB, et al. Effects of fast-food consumption on energy intake and diet quality among children in a national household survey. Pediatrics 2004; 113(1 pt 1): 112–18. 23 Nielsen SJ, Popkin BM. Patterns and trends in food portion sizes, 1977– 1998. JAMA 2003; 289(4): 450–3. 24 Rolls BJ. The supersizing of America: Portion size and the obesity epidemic. Nutr Today 2003; 38(2): 42–53. 25 Diliberti N, Bordi PL, Conklin MT, et al. Increased portion size leads to increased energy intake in a restaurant meal. Obes Res 2004; 12(3): 562–8. 26 Forster-Coull L, Barr SI, Levy-Milne R. British Columbia Nutrition Survey: Report on Food Group Use. Victoria: B.C. Ministry of Health Services, 2004. 27 Nyren O. On the long and winding road to an evidence-based diet. Acta Oncol 2003; 42(4): 260–2. 28 Newby PK, Muller D, Hallfrisch J et al. Dietary patterns and changes in body mass index and waist circumference in adults. Am J Clin Nutr. 2003; 77(6): 1417–25. 29 Drapeau V, Despres JP, Bouchard C, et al. Modifications in food-group consumption are related to long-term body-weight changes. Am J Clin Nutr. 2004; 80(1): 29–37. 30 Newby PK, Muller D, Hallfrisch J, et al. Food patterns measured by factor analysis and anthropometric changes in adults. Am J Clin Nutr. 2004; 80(2): 504–13.

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31 Foerster SB, Kizer KW, Disogra LK, et al. California’s ‘5 a day – for better health!’ campaign: An innovative population-based effort to effect largescale dietary change. Am J Prev Med 1995; 11(2): 124–31. 32 Alcalay R, Bell RA. Promoting Nutrition and Physical Activity through Social Marketing: Current Practices and Recommendations. Davis: University of California, Center for Advanced Studies in Nutrition and Social Marketing. 2000. 33 Reger B, Wootan MG, Booth-Butterfield S. Using mass media to promote healthy eating: A community-based demonstration project. Prev Med 1999; 29(5): 414–21. 34 Lin CT, Lee JY, Yen ST. Do dietary intakes affect search for nutrient information on food labels? Soc Sci Med 2004; 59(9): 1955–67. 35 Reger B, Wootan MG, Booth-Butterfield S. A comparison of different approaches to promote community-wide dietary change. Am J Prev Med 2000; 18(4): 271–5. 36 Pietinen P, Lahti-Koski M, Vartiainen E, et al. Nutrition and cardiovascular disease in Finland since the early 1970s: A success story. J Nutr Health Aging 2001; 5(3): 150–4. 37 An interview in the New Scientist 2005 (Feb. 12); 2486: 44. 38 For example, Dixon H, Borland R, Segan C, et al. Public reaction to Victoria’s ‘2 Fruit ‘n’ 5 Veg Every Day’ campaign and reported consumption of fruit and vegetables. Prev Med 1998; 27(4): 572–82. 39 Source: http://www.5to10aday.com/eng/index.htm. Accessed Nov. 2004. 40 Fraser GE. A search for truth in dietary epidemiology. Am J Clin Nutr 2003; 78(suppl): S521–5. 41 Stables GJ, Subar AF, Patterson BH, et al. Changes in vegetable and fruit consumption and awareness among U.S. adults: Results of the 1991 and 1997 5 A Day for Better Health Program surveys. J Am Diet Assoc 2002; 102(6): 809–17. For an international comparison see, Ashfield-Watt PA, Stewart E, Scheffer J. 5+ a day: Are we getting the message across? Asia Pac J Clin Nutr 2004; 13(suppl): S38. 42 Stables et al. Changes in vegetable and fruit consumption. 43 Serdula MK, Gillespie C, Kettel-Khan L, et al. Trends in fruit and vegetable consumption among adults in the United States: Behavioral Risk Factor Surveillance System, 1994–2000. Am J Public Health 2004; 94(6): 1014–18. 44 Rickersten K. The effects of advertising in an inverse demand system: Norwegian vegetables revisited. Eur Rev Agric Econ 1998; 25(1): 129–40. 45 Lutz SF, Ammerman AS, Atwood JR, et al. Innovative newsletter interventions improve fruit and vegetable consumption in healthy adults. J Am Diet Assoc 1999; 99(6): 705–9.

338 Notes to pages 183–5 46 Kristal AR, Goldenhar L, Muldoon J, et al. Evaluation of a supermarket intervention to increase consumption of fruits and vegetables. Am J Health Promot 1997; 11(6): 422–5. 47 Anderson ES, Winett RA, Wojcik JR, et al. A computerized social cognitive intervention for nutrition behavior: Direct and mediated effects on fat, fiber, fruits, and vegetables, self-efficacy, and outcome expectations among food shoppers. Ann Behav Med 2001; 23(2): 88–100. 48 For example, Campbell MK, Demark-Wahnefried W, Symons M, et al. Fruit and vegetable consumption and prevention of cancer: The Black Churches United for Better Health project. Am J Public Health 1999; 89(9): 1390–6. 49 Glanz K, Yaroch AL. Strategies for increasing fruit and vegetable intake in grocery stores and communities: Policy, pricing, and environmental change. Prev Med 2004; 39(suppl): S75–80. 50 Roe L, Hunt P, Bradshaw H, et al. Health Promotion Interventions to Promote Healthy Eating in the General Population: A Review. London: Health Education Authority, 1997. 51 Snyder LB, Hamilton MA, Mitchell EW, et al. A meta-analysis of the effect of mediated health communication campaigns on behavior change in the United States. J Health Communication 2004; 9(suppl 1): 71–96. 52 Roe et al. Health Promotion Interventions. 53 Schwab M, Syme SL. On paradigms, community participation, and the future of public health. Am J Public Health 1997; 87(12): 2049–50. 54 Puska P, Koskela K, McAlister A, et al. Use of lay opinion leaders to promote diffusion of health innovations in a community programme: lessons learned from the North Karelia project. Bull WHO 1986; 64(3): 437–46. 55 Roe et al. Health Promotion Interventions. 56 Toronto Public Health. Nutrition Matters: Dining Out. Available at http: //www.toronto.ca/health/pdf /nm_dining.pdf. Accessed March 2005. 57 Data available at http://www.statcan.ca/english/Pgdb/famil27b.htm. Accessed March 2005. 58 Glanz K, Hoelscher D. Increasing fruit and vegetable intake by changing environments, policy and pricing: Restaurant-based research, strategies, and recommendations. Prev Med 2004; 39: S88–93. 59 Young LR, Nestle M. The contribution of expanding portion sizes to the U.S. obesity epidemic. Am J Public Health 2002; 92(2): 246–9. 60 Cassady D, Housemann R, Dagher C. Measuring cues for healthy choices on restaurant menus: Development and testing of a measurement instrument. Am J Health Promotion 2004; 18(6): 444–9. 61 Glanz, Hoelscher. Increasing fruit and vegetable intake. 62 Fitzgerald CM, Kannan S, Sheldon S, et al. Effect of a promotional cam-

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paign on heart-healthy menu choices in community restaurants. J Am Diet Assoc 2004; 104(3): 429–32. Seymour JD, Yaroch AL, Serdula M, et al. Impact of nutrition environmental interventions on point-of-purchase behaviour in adults: A review. Prev Med 2004; 39: S108–36. Glanz, Yaroch. Stratrgies for increasing fruit and vegetable intake. Block JP, Scribner RA, DeSalvo KB. Fast food, race/ethnicity, and income: A geographic analysis. Am J Prev Med 2004; 27(3): 211–17. Pereira, et al. Fast-food habits. Levitsky DA, Youn T. The more food young adults are served, the more they overeat. J Nutr 2004; 134(10): 2546–9. Ludwig DS, Pereira MA, Kroenke CH, et al. Dietary fiber, weight gain, and cardiovascular disease risk factors in young adults. JAMA 1999; 282(16): 1539–46. Pereira MA, Ludwig DS. Dietary fiber and body-weight regulation: Observations and mechanisms. Pediatr Clin North Am 2001; 48(4): 969–80. Heald AH, Golding C, Sharma R, et al. A substitution model of dietary manipulation is an effective means of optimising lipid profile, reducing Creactive protein and increasing insulin-like growth factor-1. Br J Nutr 2004; 92(5): 809–18. Kirkpatrick S, Tarasuk V. The relationship between low income and household food expenditure patterns in Canada. Public Health Nutr 2003; 6(6): 589–97. Krebs-Smith SM, Kantor LS. Choose a variety of fruits and vegetables daily: Understanding the complexities. J Nutr 2001; 131(2 suppl 1): S487–501. Sloane DC, Diamant AL, Lewis LB, et al. Improving the nutritional resource environment for healthy living through community-based participatory research. J Gen Int Med 2003; 18(7): 568–75. Rose D, Richards R. Food stores access and household fruit and vegetable use among participants in the U.S. Food Stamp Program. Public Health Nutr 2004; 7(8): 1081–8. Glanz, Yaroch. Strategies. The capital of the province of Manitoba, Canada. CBC News. Grocery wins diabetes prevention award, 20 Dec. 2004. Available at http://www.cbc.ca/story/ science/national/2004/12/20/ diabetes-prevent041220.html?print. Accessed Dec. 2004. Drewnowski A, Darmon N, Briend A. Replacing fats and sweets with vegetables and fruits – a question of cost. Am J Public Health 2004; 94(9): 1555–9. Truby H, Millward D, Morgan L, et al. A randomized controlled trial of 4

340 Notes to pages 187–90

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different commercial weight loss programmes in the U.K. in obese adults: Body composition changes over 6 months. Asia Pac J Clin Nutr 2004; 13(suppl): S146. Astrup A, Meinert Larsen T, Harper A. Atkins and other low-carbohydrate diets: Hoax or an effective tool for weight loss? Lancet 2004; 364(9437): 897–9. Tsai AG, Wadden TA. Systematic review: An evaluation of major commercial weight loss programs in the United States. Ann Int Med 2005; 142: 56– 66. Heshka S, Anderson JW, Atkinson RL et al. Weight loss with self-help compared with a structured commercial program: A randomized trial. JAMA 2003; 289(14): 1792–8. Roe et al. Health Promotion Interventions. Australia’s National Public Health Partnership (NPHP). An Intervention Portfolio to Promote Fruit and Vegetable Consumption, 2000. Available at http: //www.nphp.gov.au/publications/signal/intfv1.pdf. Accessed Nov. 2004. Glanz K, Mullis R. Environmental interventions to promote healthy eating: A review of models, programs, and evidence. Health Educ Q 1988; 15: 395–415. Glanz K, Lankenau B, Foerster S, et al. Environmental and policy approaches to cardiovascular disease prevention through nutrition: Opportunities for state and local action. Health Educ Q 1995; 22: 512–27. Wechsler H, Devereaux RS, Davis M, et al. Using the school environment to promote physical activity and healthy eating. Prev Med 2000; 31: S121–37. French SA, Story M, Jeffery RW. Environmental influences on eating and physical activity. Annu Rev Public Health 2001; 22: 309–35. French SA, Stables G. Environmental interventions to promote vegetable and fruit consumption among youth in school settings. Prev Med 2003; 37(6 pt 1): 593–610. Roe et al. Health Promotion Interventions. Seymour et al. Impact of nutrition environmental interventions. Perry CL, Bishop DB, Taylor G, et al. Changing fruit and vegetable consumption among children: The 5-a-Day Power Plus program in St Paul, Minnesota. Am J Public Health 1998; 88(4): 603–9. Luepker RV, Perry CL, McKinlay SM, et al. Outcomes of a field trial to improve children’s dietary patterns and physical activity: The Child and Adolescent Trial for Cardiovascular Health. CATCH collaborative group. JAMA 1996; 275(10): 768–76. NPHP. An Intervention Portfolio. Perry et al. Changing fruit and vegetable consumption.

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96 French, Stables. Environmental interventions. 97 NPHP. Intervention Portfolio. 98 Lowe CF, Horne PJ, Tapper K, et al. Effects of a peer modelling and rewards-based intervention to increase fruit and vegetable consumption in children. Eur J Clin Nutr 2004; 58(3): 510–22. 99 French SA, Story M, Jeffery RW, et al. Pricing strategy to promote fruit and vegetable purchase in high school cafeterias. J Am Diet Assoc 1997; 97(9): 1008–10. 100 Perry CL, Bishop DB, Taylor GL, et al. A randomized school trial of environmental strategies to encourage fruit and vegetable consumption among children. Health Educ Behav 2004; 31(1): 65–76. 101 Ammerman A, Lindquist C, Hersey J, et al. Efficacy of interventions to modify dietary behavior related to cancer risk. Evidence Report/Technology Assessment No. 25. Washington: Agency to Healthcare Research and Quality, 2001. 102 See, e.g., Berenbaun S. Nutrition in Saskatchewan Schools: Policy, Practice and Needs, 2004. Available at http: //ww1.heartandstroke.sk.ca/Images/ English/SK-Nutrition-Report-April-2004.pdf. Accessed Nov. 2004. 103 French SA, Story M, Fulkerson JA, et al. Food environment in secondary schools: A la carte, vending machines, and food policies and practices. Am J Public Health 2003; 93(7): 1161–7. 104 Kendall PRW. An Ounce of Prevention: A Public Health Rationale for the School as a Setting for Health Promotion. Victoria: Ministry of Health Planning, 2003. 105 Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: A prospective, observational analysis. Lancet 2001; 357: 505–8. 106 French SA, Hannan PJ, Story M. School soft drink intervention study. Br Med J 2004; 329(7462): E315–16. 107 Field et al. Snack food intake. 108 News stories at http: //www.bcctv.ca/displayresults.jsp?id=/news/ stories/2004/11/news-20041107–06.htm and http: //www.ctv.ca/ servlet/ArticleNews/story/CTVNews/1096472213533_9188 1413 ?hub=Health. Accessed Nov. 2004. And http://www.torontofreepress .com/2004/weinreb102604.htm. Accessed Feb. 2005. 109 Hannan P, French SA, Story M, et al. A pricing strategy to promote sales of lower fat foods in high school cafeterias: Acceptability and sensitivity analysis. Am J Health Promot 2002; 17(1): 1–6. 110 French SA, Wechsler H. School-based research and initiatives: Fruit and vegetable environment, policy, and pricing workshop. Prev Med 2004; 39: S101–7.

342 Notes to pages 191–4 111 Horgen KB, Brownell KD. Comparison of price change and health message interventions in promoting healthy food choices. Health Psychol 2002; 21(5): 505–12. 112 French SA, Jeffery RW, Story M, et al. Pricing and promotion effects on low-fat vending snack purchases: The CHIPS Study. Am J Public Health 2001; 91(1): 112–17. This study updated and confirmed earlier work by the same authors. French et al. Pricing strategy. 113 Fiske A, Cullen KW. Effects of promotional materials on vending sales of low-fat items in teachers’ lounges. J Am Diet Assoc 2004; 104(1): 90–3. 114 Avenell A, Broom J, Brown TJ, et al. Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technol Assess 2004; 8(21). 115 Cousins JH, Rubovits DS, Dunn JK, et al. Family versus individually oriented intervention for weight loss in Mexican American women. Public Health Rep 1992; 107(5): 549–55. 116 Wing RR, Jeffery RW. Benefits of recruiting participants with friends and increasing social support for weight loss and maintenance. J Consult Clin Psychol 1999; 67(1): 132–8. 117 Dietz WH, Gortmaker SL. Preventing obesity in children and adolescents. Annu Rev Public Health 2001; 22: 337–53. 118 Glenny AM, O’Meara, Melville A, et al. The treatment and prevention of obesity: A systematic review of the literature. Int J Obes Relat Metab Disord 1997; 21(9): 715–37. 119 Source: http: //www.asso.org.au//freestyler/gui/files/healthy_weight _2008.pdf. Accessed Dec. 2004. 120 Armitage CJ, Conner M. Efficacy of a minimal intervention to reduce fat intake. Soc Sci Med 2001; 52(10): 1517–24. 121 Thomas RJ, Kottke TE, Brekke MJ, et al. Attempts at changing dietary and exercise habits to reduce risk of cardiovascular disease: Who’s doing what in the community? Prev Cardiol 2002; 5(3): 102–8. 122 Pignone MP, Ammerman A, Fernandez L, et al. Counseling to promote a healthy diet in adults: A summary of the evidence for the U.S. Preventive Services Task Force. Am J Prev Med 2003; 24(1): 75–92. 123 Liao KL. Cognitive-behavioural approaches and weight management: An overview. J Roy Soc Health 2000; 120(1): 27–30. 124 Shaw K, Kenardy J, O’Rourke P, et al. Psychological interventions for obesity. Cochrane Metabolic and Endocrine Disorders Group. CDSR; 2003. 125 Wilson GT. Cognitive behavior therapy for eating disorders: Progress and problems. Behav Res Ther 1999; 37(suppl 1): S79–95.

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126 Cooper Z, Fairburn CG. A new cognitive behavioural approach to the treatment of obesity. Behav Res Ther 2001; 39(5): 499–511. 127 Shaw et al. Psychological interventions. 128 Hayaki J, Brownell KD. Behaviour change in practice: Group approaches. Int J Obes Relat Metab Dis 1996; 20(suppl 1): S27–30. 129 Avenell et al. Systematic review. 130 Dunshea-Mooij et al. Chitosan for overweight or obesity. 131 Pirozzo S, Summerbell C, Cameron C, et al. Advice on low-fat diets for obesity. CDSR, 2004. 132 Avenell et al. Systematic review. 133 Shah M, Baxter JE, McGovern PG, et al. Nutrient and food intake in obese women on a low-fat or low-calorie diet. Am J Health Promot 1996; 10: 179–82. 134 Avenell et al. Systematic review. 135 Stenius-Aarniala B, Poussa T, Kvarnstrom J, et al. Immediate and longterm effects of weight reduction in obese people with asthma: Randomised controlled study. Br Med J 2000; 320(7238): 827–32. 136 For example, Miyashita Y, Koide N, Ohtsuka M, et al. Beneficial effect of low carbohydrate in low calorie diets on visceral fat reduction in type 2 diabetic patients with obesity. Diabetes Res Clin Prac 2004; 65(3): 235–41. 137 Hutton B, Fergusson D. Changes in body weight and serum lipid profile in obese patients treated with orlistat in addition to a hypocaloric diet: A systematic review of randomized clinical trials. Am J Clin Nutr 2004; 80(6): 1461–8. 138 Padwal R, Li SK, Lau DCW. Long-term pharmacotherapy for obesity and overweight. Cochrane Metabolic and Endocrine Disorders Group. CDSR 2004. 139 The average weight loss seen in the pooled data was about 2.9% more with the drug, or 2.7 kg, after 12 months. 140 The unit is millimoles per litre (mmol/L). To establish the context, in a healthy adult, a blood cholesterol level of less than 5.2 mmol/L is considered normal. Levels in the range of 5.2 to 6.2 mmol/L are considered borderline, and anything above 6.2 mmol/L is unhealthy. In people with heart problems, the cholesterol level should be 4.1 mmol/L or lower. A newer measurement unit used in blood lipid chemistry is milligrams per decalitre (mg/dL). 141 4.3 kg (4.6%) greater than in placebo therapy after 12 months, compared with 2.7 kg. 142 Wadden TA, Berkowitz RI, Womble LG, et al. Randomized trial of lifestyle modification and pharmacotherapy for obesity. N Engl J Med 2005; 353: 2111–20.

344 Notes to pages198–200 143 James WP, Astrup A, Finer N, et al. Effect of sibutramine on weight maintenance after weight loss: A randomised trial. STORM Study Group. Sibutramine Trial of Obesity Reduction and Maintenance. Lancet 2000; 356(9248): 2119–25. 144 Wadden et al. Randomized trial. 145 Avenell et al. Systematic review. 146 Diabetes Prevention Program Research Group (DPPRG). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346: 393–403. 147 Chiasson JL, Josse RG, Gomis R, et al. Acarbose for prevention of type 2 diabetes mellitus: The STOP-NIDDM randomised trial. Lancet. 2002; 359: 2072–7. This study was the only one included by the Health Technology Assessment (HTA) review program. 148 Despres J-P, Golay A, Sjostrom L. Effects of rimonabant on metabolic risk factors in overweight patients with dyslipidemia. N Engl J Med 2005; 353: 2121–34. 149 Halford JCG. Pharmacotherapy for obesity. Appetite 2006; 46: 6–10. 150 O’Meara S, Riemsma R, Shirran L, et al. A rapid and systematic review of the clinical effectiveness and cost-effectiveness of orlistat in the management of obesity. Health Technol Assess 2001; 5(18). 151 O’Meara S, Riemsma R, Shirran L, et al. The clinical effectiveness and cost effectiveness of sibutramine in the management of obesity: A technology assessment. Health Technol Assess 2002; 6(6). 152 Avenell et al. Systematic review. 153 Haddock CK, Poston WSC, Dill PL, et al. Pharmacotherapy for obesity: A quantitative analysis of four decades of published randomized clinical trials. Int J Obes Relat Metabol Disord 2002; 26: 262–73. 154 Padwal, Li, Lau. Long-term pharmacotherapy for obesity and overweight. 155 Note, once again, that these drugs do not cause weight loss directly, but rather enhance insulin availability. 156 DPPRG. Reduction in the incidence of type 2 diabetes. 157 Chiasson et al. Acarbose for prevention of type 2 diabetes mellitus. 158 Surgery on the stomach and/or intestines to help the patient with extreme obesity lose weight. 159 National Institute for Clinical Excellence (NICE). Guidance on the Use of Surgery to Aid Weight Reduction for People with Morbid Obesity. Technology Appraisal Guidance. London: NICE, 2002; 46. 160 Colquitt J, Clegg A, Sidhu M, et al. Surgery for morbid obesity. CDSR, 2003. 161 Trakas K, Oh PI, Singh S, et al. The health status of obese individuals in Canada. Int J Obes Relat Metabol Disord 2001; 25(5): 662–8.

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162 Restrictive surgery, which includes gastroplasty and gastric banding, reduces the size of the stomach so that the patient feels full with less food. Malabsorptive procedures, which include biliopancreatic bypass and gastric bypass, parts of the gastrointestinal tract are surgically bypassed so that absorption of food is limited. NICE. Guidance. 163 A surgical procedure that diverts pancreatobiliary secretions via the small intestine into the large intestine, the remaining small intestine being grafted to the stomach after removal of half of the stomach. 164 Surgical procedure in which the stomach is transected high on the body. The resulting stomach portion is grafted to a loop of the small intestine. 165 Surgical treatment of the stomach to reduce its size. 166 A gastric band device is introduced into the abdomen and is placed around the upper part of the stomach. The resulting pouch (or the ‘new stomach’) dramatically reduces the functional capacity of the stomach. 167 Colquitt et al. Surgery. 168 A surgical procedure consisting of the grafting together of two parts of the intestine to bypass the nutrient-absorptive segment of the small intestine. 169 NICE. Guidance. 170 Creation of a small pouch in the upper stomach with a narrow outlet reinforced by a mesh band to prevent stretching. The pouch fills quickly and empties slowly with solid food, producing a feeling of fullness. This restricts food intake. 171 NHS, Centre for Reviews and Dissemination. Systematic Review of Interventions in the Treatment and Prevention of Obesity. London: NHS, 1997. 172 Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Sur 2004; 240(3): 416–23. 173 Sjostrom L, Lindroos AK, Peltonen M, et al. Swedish Obese Subjects Study Scientific Group. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004; 351(26): 2683–93. 174 Colquitt et al. Surgery. 175 Clegg AJ, Colquitt J, Sidhu MK, et al. The clinical effectiveness and costeffectiveness of surgery for people with morbid obesity: A systematic review and economic evaluation. Health Technol Assess 2002; 6(12). 176 Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: A systematic review and meta-analysis. JAMA 2004; 292(14): 1724–37. 177 Colquitt et al. Surgery. 178 NICE. Guidance. 179 Benjamin S, Maher K, Cattau E, et al. Double-blind controlled trial of the

346 Notes to pages 202–4

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182

183

184 185 186 187 188

189

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191 192

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Garren-Edwards gastric bubble: An adjunctive treatment for exogenous obesity. Gastroenterology 1988; 95(3): 581–8. Ibid. Hogan RB, Johnston JH, Long BW, et al. A double-blind, randomized, sham-controlled trial of the gastric bubble for obesity. Gastrointest Endosc 1989; 35(5): 381–5. Mathus-Vliegen EM, Tytgat GN, Veldhuyzen-Offermans EA. Intragastric balloon in the treatment of super-morbid obesity: Double-blind, shamcontrolled, crossover evaluation of 500–milliliter balloon. Gastroenterology 1990; 99(2): 362–9. Mathus-Vliegen EM, Tytgat GN. Intragastric balloon for treatment-resistant obesity: Safety, tolerance, and efficacy of 1-year balloon treatment followed by a 1-year balloon-free follow-up. Gastrointest Endosc 2005; 61(1): 19–27. Ibid. Available at http://www.inspection.gc.ca/english/fssa/labeti/guide/ toce.shtml. Accessed Feb. 2005. News report at http://www.cbc.ca/news/background/food/ foodlabels.html. Accessed Dec. 2004. News release at http://www.crfa.ca/newsroom/2004/menu_ labelling_legislation.asp. Accessed Nov. 2004. Young L, Swinburn B. Impact of the Pick the Tick food information programme on the salt content of food in New Zealand. Health Promot Int 2002; 17: 13–19. American Public Health Association (APHA) website. Available at http: //www.apha.org/journal/nation /transfatexclus804.htm. Accessed April 2005. News report at http://www.google.ca/search?q=cache:jLJMDtoFQDIJ :news.tradingchar ts.com/ futures/6/0/61439406.html+canada+ votes+to+ban+trans+fats&hl=en. Accessed Dec. 2004. APHA website. Available at http://www.apha.org/journal/nation/ transfatexclus804.htm. Accessed April 2005. Food and Drug Administration. Food Labeling: Trans Fatty Acids in Nutrition Labeling, Nutrient Content Claims, and Health Claims. Available at http: //www.owlsoft.com/TrFatRule.pdf. Accessed April 2005. Gocery Manufacturers of America website. Available at http://www .gmabrands.com/publicpolicy/docs /comment.cfm?DocID=1429. Accessed April 2005. News report at http://news.bbc.co.uk/1/hi/health/2973914.stm. Accessed Dec. 2004.

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195 Jacobson MF, Brownell KD. Small taxes on soft drinks and snack foods to promote health. Am J Public Health 2000; 90(6): 854–7. 196 Matthiessen J, Fagt S, Biltoft-Jensen A, et al. Size makes a difference. Public Health Nutr 2003; 6(1): 65–72. 197 Kral TV, Rolls BJ. Energy density and portion size: Their independent and combined effects on energy intake. Physiol Behav 2004; 82(1): 131–8. 198 Jacobson, Brownell. Small taxes. 199 Forster-Coull, Barr, Levy-Milne. B.C. Nutrition Survey. 200 Rolls BJ, Ello-Martin JA, Tohill BC. What can intervention studies tell us about the relationship between vegetable and fruit consumption and weight management? Nutr Rev 2004; 62(1): 1–17. 201 Report available at http://www.bcasw.org/currentnewsPDF/ coeibc2004_fullreport.pdf. Accessed Feb. 2005. 202 Raine KD. Overweight and Obesity in Canada: A Population Health Perspective. Edmonton: University of Alberta, Centre for Health Promotion Studies, 2004. Chapter 13. Obesity Control Evidence (2) 1 Shaw K, Del Mar C, O’Rourke P, et al. Exercise for obesity. Cochrane Database of Systematic Reviews (CDSR), 2004. 2 Ibid. 3 News item at http://www.canada.com/fortstjohn/story.html?id= 1da0d319–c9fb-4086–a173–9010b20672b3. Accessed March 2005. 4 Beaulieu MD. Physical activity counselling. In: Canadian Task Force on the Periodic Health Examination: Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994. 5 Wessel TR, Arant CB, Olson MB, et al. Relationship of physical fitness vs body mass index with coronary artery disease and cardiovascular events in women. JAMA 2004; 292(10): 1179–87. 6 See, e.g., the U.S. Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity, 2001. Available at http: //www.surgeongeneral .gov/topics/obesity/. Accessed Nov. 2004. 7 Health Canada. Nutrition Recommendations for Canadians: Draft Recommendation on Energy. Available at http://www.hc-sc.gc.ca/hpfb-dgpsa/ onppbppn/comment_period_rec_on_energy_e.pdf. Accessed Nov. 2004. 8 A moderate amount of physical activity uses approximately 150 calories (kcal) of energy per day, or 1,000 calories per week. 9 Tudor-Locke CE, Myers AM. Methodological considerations for researchers

348 Notes to pages 208–13

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13 14 15 16

17 18 19

20 21 22

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and practitioners using pedometers to measure physical (ambulatory) activity. Res Q Exercise Sport 2001; 72(1): 1–12. Tudor-Locke C, Bassett DR. How many steps/day are enough? Preliminary pedometer indices for public health. Sports Med 2004; 34(1): 1–8. Beaulieu. Physical activity counselling. Source: http://www.thecommunityguide.org/pa/default.htm. Accessed Nov. 2004. Also in Kahn EB, Ramsey LT, Brownson RC, et al. The effectiveness of interventions to increase physical activity: A systematic review. Am J Prev Med 2002; 22(suppl 4): 73–107. Kahn et al. Effectiveness of interventions. Ibid. USSG. Physical Activity and Health: A Report of the U.S. Surgeon General. Washington: Department of Health and Human Services, 1996. Taylor CB, Fortmann SP, Flora J, et al. Effect of long-term community health education on body mass index: The Stanford Five-City Project. Am J Epidemiol 1991; 134(3): 235–49. Kahn et al. Effectiveness. USSG. Physical Activity and Health. See, e.g., the description of the Queensland, Australia, project at http:// www.centre4 activeliving.ca/Publications/WellSpring/2003/ Spring/ 10000Steps.html. Accessed Dec. 2004. Tudor-Locke, Bassett. How many steps/day? See, e.g., the results summarized on the website at http://www. diabetesincontrol.com/ studies/steps.pdf. Accessed Dec. 2004. For details see, http://www.google.ca/search?q=cache:XdB6dQ1gXBIJ :www.cihr-irsc.gc.ca/e/ 25276.html+british+columbia+pedometers&hl =en. Accessed Dec. 2004. CIHR, Institute of Nutrition, Metabolism and Diabetes (at Simon Fraser University). Available at http://www.cihr-irsc.gc.ca/e/18058.html. Accessed Dec. 2004. U.S. Task Force on Community Preventive Services (TFCPS). Available at http://www.thecommunityguide.org/pa/default.htm. Accessed Nov. 2004. Ibid. Hillsdon M, Foster C, Naidoo B, et al. The Effectiveness of Public Health Interventions for Increasing Physical Activity. London: Health Development Agency, 2004. A study has shown that those with the highest cardiorespiratory fitness levels demonstrated regular walking as the strongest common denominator. Stofan JR, DiPietro L, Davis D, et al. Physical activity patterns associated

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34 35

36 37 38 39 40 41 42 43

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with cardiorespiratory fitness and reduced mortality: The Aerobics Center Longitudinal Study. Am J Public Health 1998; 88(12): 1807–13. Kahn et al. Effectiveness. Dishman RK, Oldenburg B, O’Neal H, et al. Worksite physical activity interventions. Am J Prev Med 1998; 15(4): 344–61. USSG. Physical Activity and Health. Raine KD. Overweight and Obesity in Canada: A Population Health Perspective. Edmonton: University of Alberta, Centre for Health Promotion Studies, 2004. Dishman et al. Worksite physical activity interventions. Stokols D, Pelletier KR, Fielding JE. The ecology of work and health: Research and policy directions for the promotion of employee health. Health Educ Q 1996; 23(2): 137–58. McElroy KR, Bibeau D, Steckler A, et al. An ecological perspective on health promotion programs. Health Educ Q 1988; 15: 351–77. Buckman DR, Carman JS Aldana SG. Fruits and Vegetables and Physical Activity at the Worksite. California 5 a day Worksite Program, no date. Available at http://www.phi.org/pdf-library/dhs-worksite.pdf. Accessed Nov. 2004. Program description at http://www.centre4activeliving.ca /Research/ 2003Workplace/BeforeYouStart.htm. Accessed Nov. 2004. Kahn et al. Effectiveness. University of York. The prevention and treatment of childhood obesity. Effective Health Care 2002; 7(6). Kahn et al. Effectiveness. Website available at http://www.pe4life.org/. Accessed Nov. 2004. Kahn et al. Effectiveness. U.K. Health Development Authority website. Available at http:// www.hda-online.org.uk/hdt/1203 /evidence.html. Accessed May 2005. Marshall AL, Bauman AE, Owen N, et al. Reaching out to promote physical activity in Australia: A statewide randomized controlled trial of a stagetargeted intervention. Am J Health Promot 2004; 18(4): 283–7. USSG. Physical Activity and Health. See also, King AC, Role of exercise counselling in health promotion. Br J Sports Med 2000; 34: 80–1; and the review in Castro CM, King AC, Telephone-assisted counseling for physical activity. Exercise Sport Sci Rev 2002; 30(2): 64–8. Kahn et al. Effectiveness. Robinson TN. Television viewing and childhood obesity. Pediatr Clin North Am 2001; 48(4): 1017–25.

350 Notes to pages 216–18 47 Caroli M, Argentieri L, Cardone M, et al. Role of television in childhood obesity prevention. Int J Obes Relat Metab Disord 2004; 28(suppl 3): S104–8. 48 Kahn et al. Effectiveness. 49 Wilson D, Ciliska D. Family physicians and exercise counselling: Can they be influenced to provide more? Can Fam Physician 1992; 38: 2003–10. 50 Whitlock E, Orleans C, Pender N, et al. Evaluating primary care behavioural counselling interventions: An evidence-based approach. Am J Prev Med 2002; 22(4): 267–84. 51 Beaulieu. Physical activity counselling. 52 Wechsler H, Levine S, Idelson RK, et al. The physician’s role in health promotion revisited – a survey of primary care practitioners. N Engl J Med 1996; 334(15): 996–8. Some estimates are as low as 12% of physicians prescribing exercise appropriately in their practice. 53 Wells KB, Lewis CE, Leake B, et al. The practices of general and subspecialty internists in counseling about smoking and exercise. Am J Public Health 1986; 76(8): 1009–13. 54 Walsh H. Exercise counselling by primary care physicians in the era of managed care. Am J Prev Med 1999; 16(4): 312. 55 Hillsdon et al. Effectiveness of Public Health Interventions. 56 Ibid. This report looked at 5 reviews covering 22 studies. 57 This conclusion is fully supported in Smith BJ. Promotion of physical activity in primary health care: update of the evidence on interventions. J Sci Med Sport 2004; 7(suppl 1): 67–73. 58 Beaulieu. Physical Activity Counselling. 59 Kahn et al. Effectiveness. 60 Berg AO. U.S. Preventive Services Task Force. Behavioral counseling in primary care to promote physical activity: Recommendation and rationale. Am J Nurs 2003; 103(4): 101–7. 61 Eaton CB, Menard LM. A systematic review of physical activity promotion in primary care office settings. Br J Sports Med 1998; 32: 11–16. 62 Eakin EG, Glasgow RE, Riley KM. Review of primary care-based physical activity intervention studies: effectiveness and implications for practice and future research. J Fam Pract 2000; 49(2): 158–68. 63 Eden KB, Orleans CT, Mulrow CD, et al. Does counseling by clinicians improve physical activity? A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002; 137(3): 208–15. 64 Raine. Overweight and Obesity in Canada. 65 USSG. Physical Activity and Health. 66 Smith BJ, Merom D, Harris, P et al. Do Primary Care Interventions to Promote

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Physical Activity Work? 2002. Available at http://www.cpah.unsw.edu.au/ NICS.pdf. Accessed Nov. 2004. Hillsdon et al. Effectiveness. Rehman L, Thompson A, Campagna P. Physical Activity Counselling by Healthcare Professionals in Nova Scotia: The Need for a Consistent Message, 2003. Available at http://www.cancercare.ns.ca/media /documents/ PhysicalActivityCounsellingFinalReportJune1.pdf. Accessed Nov. 2004. Mayer JA, Jermanovich A, Wright BL, et al. Changes in health behaviors of older adults: The San Diego Medicare Preventive Health Project. Prev Med 1994; 23(2): 127–33. See the website at http://www.pushplay.org.nz/page.asp?PageID=41. Accessed May 2005. Elley CR, Kerse N, Arroll B, et al. Effectiveness of counselling patients on physical activity in general practice: Cluster randomised controlled trial. Br Med J 2003; 326(7393): 793. Orleans CT, George LK, Houpt JL, et al. Health promotion in primary care: A survey of U.S. family practitioners. Prev Med 1985; 14(5): 636–47. Tobin M. Physical Activity Counselling by Health Professionals, 2000. Available at http://www.cfpc.ca/ English/cfpc/programs/patient%20care/ physical%20activity/research /physical%20activity/default.asp?s=1. Accessed Nov. 2004. Wilson, Ciliska. Family physicians and exercise counselling. Tobin. Physical Activity Counselling. USSG. Physical Activity and Health. Logsdon DN, Lazaro CM, Meier RV. The feasibility of behavioral risk reduction in primary medical care. Am J Prev Med 1989; 5(5): 249–56. Rehman, Thompson, Campagna. Physical Activity Counselling. Estabrooks PA, Glasgow RE, Dzewaltowski DA. Physical activity promotion through primary care. JAMA 2003; 289(22): 2913–16. Garrow J, Summerbell C. Meta-analysis: Effect of exercise, with or without dieting, on the body composition of overweight subjects. Eur J Clin Nutr 1995; 49: 1–10. Ballor D, Keesey R. A meta-analysis of the factors affecting exerciseinduced changes in body mass, fat mass and fat-free mass in males and females. Int J Obes Relat Metab Disord 1991; 15: 717–26. Shaw et al. Exercise for obesity. Raine. Overweight and Obesity. See the comprehensive bibliography at http://www.cdc.gov/nccdphp/ dnpa/pdf/aces-workingpaper2.pdf. Accessed Nov. 2004.

352 Notes to pages 221–4 85 Available at http://www.planning.dot.gov/Documents/Health/ IntHealthTA.htm#over2. Accessed Nov. 2004. 86 Dora C. A different route to health: Implications of transport policies. Br Med J 1999; 318(7199): 1686–9. 87 Shriver K. Influence of environmental design on pedestrian travel behavior in four Austin neighbourhoods. Transport Res Rec 1997; 1578: 64–75. 88 Litman T. Integrating public health objectives in transportation decisionmaking. Am J Health Promot 2003; 18(1): 103–8. 89 Killingsworth RE, Schmid TL. Community design and transportation policies: New ways to promote physical activity. Physician Sports Med 2001; 15(2). 90 Ogilvie D, Egan M, Hamilton V, et al. Promoting walking and cycling as an alternative to using cars: systematic review. Br Med J 2004; 329: 763–8. 91 Ibid. 92 Noerager K, Lyons W. Evaluation of Statewide Long-Range Transportation Plans 2002. Available at http://www.fhwa.dot.gov/hep10/state/ evalplans.htm. Accessed Nov. 2004. 93 Volpe National Transportation Systems Center. Integrating Health and Physical Activity Goals into Transportation Planning, April 2004. Available at http://www.planning.dot.gov/Documents/Health/Bibliography.htm. Accessed Nov. 2004. See also Handy S. Understanding the link between urban form and nonwork travel behavior. J Plan Educ Res 1996; 15: 183–98. 94 Report available at http://www.publichealth.nice.org.uk/page.aspx?o =503416. Accessed May 2005. 95 Hoehner CM, Brennan LK, Brownson RC, et al. Opportunities for integrating public health and urban planning approaches to promote active community environments. Am J Health Prom 2003; 18(1): 14–20. 96 Wilkinson WC, Eddy N, MacFadden G, et al. Increasing Physical Activity through Community Design. Available at http://www.bikewalk.org/ Assets/ PDF/IPA_full.pdf. Accessed Nov. 2004. 97 King AC, Castro C, Wilcox S, et al. Personal and environmental factors associated with physical inactivity among different racial-ethnic groups of U.S. middle-aged and older-aged women. Health Psychol 2000; 19(4): 354–64. 98 Jackson RJ, Kochtitzky C. Creating a Healthy Environment: The Impact of the Built Environment on Public Health. Available at http://www.sprawlwatch .org/health.pdf. Accessed Nov. 2004. 99 Available at http://www.activelivingbydesign.org/fileadmin/template/ documents/ health_canada_ feb2004.ppt#1. Accessed Nov. 2004. 100 Available at http://www.who.int/hia/about/defin/en/print.html. Accessed Nov. 2004.

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101 Ewing R, Schmid T, Killingsworth R, et al. Relationship between urban sprawl and physical activity, obesity, and morbidity. Am J Health Promot 2003; 18(1): 47–57. 102 Cox W, Utt RD. Sprawl and Obesity: A Flawed Connection. Available at http:/ /www.heritage.org/ Research/SmartGrowth/wm337.cfm?renderforprint=1. Accessed Nov. 2004. 103 Coogan PF, Coogan MA. When worlds collide: Observations on the integration of epidemiology and transportation behavioral analysis in the study of walking. Am J Health Promot 2004; 19(1): 39–44. 104 Active Living by Design website. Available at http://www.activelivingbydesign.org/fileadmin/template/ documents/health_canada_ feb2004.ppt#1. Accessed Nov. 2004. 105 Ewing et al. Relationship between urban sprawl and physical activity, obesity, and morbidity. 106 Ewing R. Can the physical environment determine physical activity levels? Exercise Sport Sci Rev 2005; 33(2): 69–75. 107 Frank LD, Schmid TL, Sallis JF, et al. Linking objectively measured physical activity with objectively measured urban form. Am J Prev Med 2005; 28(2S2): 117–25. 108 Fuzhong L, Fisher J, Brownson RC, et al. Multilevel modelling of built environment characteristics related to neighbourhood walking activity in older adults. J Epidemiol Commun Health 2005; 59: 558–64. 109 Ellaway A, Macintyre S, Bonnefoy X. Graffiti, greenery, and obesity in adults: Secondary analysis of European cross-sectional survey. Br Med J 2005; 331: 611–12. 110 Frank LD, Andresen MA, Schmid TL. Obesity relationships with community design, physical activity, and time spent in cars. Am J Prev Med 2004; 27(2): 87–96. 111 Zlot AI, Schmid TL. Relationships among community characteristics and walking and bicycling for transportation or recreation. Am J Health Promot 2005; 19(4): 314–17. 112 Available at http://trb.org/publications/sr/sr282.pdf. Accessed March 2005. 113 Kahn et al. Effectiveness. Chapter 14. Obesity Control Evidence (3) 1 See the 2003 Australian review at http://www.heartfoundation.com.au/ downloads/Ov_Ob_interventions_ report.pdf. Acccessed May 2005. 2 Luepker RV. Community trials. Prev Med 1994; 23(5): 602–5.

354 Notes to pages 229–31 3 World Health Organization. Obesity: Preventing and Managing the Global Epidemic. Geneva: WHO, 2000. 4 See n1. 5 Harvey EL, Glenny AM, Kirk SF, et al. An updated systematic review of interventions to improve health professionals’ management of obesity. Obes Rev 2002; 3(1): 45–55. 6 Cameron R, MacDonald MA, Schlegel RP, et al. Toward the development of self-help health behaviour change programs: Weight loss by correspondence. Can J Public Health 1990; 81(4): 275–9. 7 Latner JD. Self-help in the long-term treatment of obesity. Obes Rev 2001; 2(2): 87–97. 8 Latner JD, Stunkard AJ, Wilson GT, et al. Effective long-term treatment of obesity: A continuing care model. Int J Obes Relat Metab Disord 2000; 24(7): 893–8. 9 Hardeman W, Griffin S, Johnston M, et al. Interventions to prevent weight gain: A systematic review of psychological models and behaviour change methods. Int J Obes Relat Metab Disord 2000; 24(2): 131–43. 10 Forster JL, Jeffery RW, Schmid TL, et al. Preventing weight gain in adults: A pound of prevention. Health Psychol 1988; 7(6): 515–25. 11 Marrs RW. A meta-analysis of bibliotherapy studies. Am J Community Psychol 1995; 23(6): 843–70. Note: Bibliotherapy is defined as the use of written materials or computer program, the listening of audiotapes, or viewing of videotapes, for the purpose of gaining understanding in or solving problems relevant to a person’s developmental or therapeutic needs. 12 Latner JD. Self-help. 13 Reseachers in the U.S. have noted a lack of enthusiasm for community trials among granting bodies. 14 Jeffery RW, Gray CW, French SA, et al. Evaluation of weight reduction in a community intervention for cardiovascular disease risk: Changes in body mass index in the Minnesota Heart Health Program. Int J Obes Relat Metab Disord 1995; 19(1): 30–9. 15 Jeffery RW. Community programs for obesity prevention: The Minnesota Heart Health Program. Obes Res 1995; 3(suppl 2): S283–8. 16 The same result was seen in the Stanford Five-City Project. Barr-Taylor C, Fortmann SP, Flora J, et al. Effect of long-term community health education on body mass index: The Stanford Five-City Project. Am J Epidemiol 1991; 134(3): 235–49. 17 Luepker RV, Murray DM, Jacobs DR, et al. Community education for cardiovascular disease prevention: risk factor changes in the Minnesota Heart Health Program. Am J Public Health 1994; 84(9): 1383–93. 18 See, e.g., Weinehall L, Hellsten G, Boman K, et al. Can a sustainable com-

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munity intervention reduce the health gap? – 10-year evaluation of a Swedish community intervention program for the prevention of cardiovascular disease. Scand J Public Health 2001; 56(suppl): 59–68. Scheuermann W, Razum O, Scheidt R, et al. Effectiveness of a decentralized, community-related approach to reduce cardiovascular disease risk factor levels in Germany. Eur Heart J 2000; 21(19): 1591–7. New Scientist interview. 2005 (Feb 12); 2486: 44. Yu Z, Song G, Guo Z. Changes in blood pressure, body mass index, and salt consumption in a Chinese population. Prev Med 1999; 29(3): 165–72. Sarraf-Zadegan N, Sadri G, Malek Afzali H, et al. Isfahan Healthy Heart Programme: A comprehensive integrated community-based programme for cardiovascular disease prevention and control: Design, methods and initial experience. Acta Cardiol 2003; 58(4): 309–20. See the 2003 Australian report, n1. Hennrikus DJ, Jeffery RW. Worksite intervention for weight control: A review of the literature. Am J Health Promot 1996; 10(6): 471–98. University of York. The prevention and treatment of childhood obesity. Effective Health Care 2002; 7(6). Toh CM, Chew SK, Tan CC. Prevention and control on non-communicable diseases in Singapore: A review of national health promotion programmes. Singapore Med J 2002; 43(7): 333–9. Toh CM, Cutter J, Chew SK. School-based intervention has reduced obesity in Singapore. Br Med J 2002; 324: 427. Muller MJ, Asbeck I, Mast M, et al. Prevention of obesity – more than an intention. Int J Obes Relat Metab Disord 2001; 25(suppl 1): 66–74. Veugelers PJ, Fitzgerald AL. Effectiveness of school programs in preventing childhood obesity: A multilevel comparison. Am J Public Health 2005; 95(3): 432–5. Available at http://www.ssdha.nshealth.ca/Annapolis%20Valley%20 Health%20Promot ing%20School% 20Project-Summary%20s_.pdf. Accessed May 2005. See n1. Avenell A, Brown TJ, McGee MA, et al. What interventions should we add to weight-reducing diets in adults with obesity? A systematic review of randomized controlled trials of adding drug therapy, exercise, behaviour therapy or combinations of these interventions. J Human Nutr Diet 2004; 17(4): 293–316. Ibid. Liao K. Cognitive-behavioural approaches and weight management: An overview. J Roy Soc Health 2000; 120(1): 27–30.

356 Notes to pages 234–7 35 Blonk MC, Jacobs MA, Biesheuvel EH, et al. Influences on weight loss in type 2 diabetic patients: Little long-term benefit from group behaviour therapy and exercise training. Diabet Med 1994; 11(5): 449–57. 36 Avenell et al. What interventions? 37 Ibid. 38 Ibid. 39 Ibid. 40 Raine KD. Overweight and Obesity in Canada: A Population Health Perspective. Edmonton: University of Alberta, Centre for Health Promotion Studies, 2004. 41 Miller WC, Koceja DM, Hamilton EJ. A meta-analysis of the past 25 years of weight loss research using diet, exercise or diet plus exercise intervention. Int J Obes Relat Metabol Disord 1997; 21(10): 941–7. 42 Harvey EL, Glenny A, Kirk SF, et al. Improving health professionals’ management and the organisation of care for overweight and obese people. Cochrane Effective Practice and Organisation of Care Group. Cochrane Database of Systematic Reviews (CDSR), 2005. 43 Rogers JL, Haring OM, Wortman PM, et al. Medical information systems: Assessing impact in the areas of hypertension, obesity and renal disease. Med Care 1982; 20(1): 63–74. 44 National Obesity Taskforce, 2003. Healthy Weight 2008. Australia’s Future: The National Action Agenda for Children and Young People and Their Families. Available at http: //www.asso.org.au//freestyler/gui/files/ healthy _weight_2008.pdf. Accessed Dec. 2004. 45 New Scientist interview. 46 Raine. Overweight and Obesity in Canada. 47 Swinburn B, Egger G, Raza F. Dissecting obesogenic environments: The development and application of a framework for identifying and prioritizing environmental interventions for obesity. Prev Med 1999; 29(6 pt 1): 563–70. 48 Carter MA, Swinburn B. Measuring the ‘obesogenic’ food environment in New Zealand primary schools. Health Promot Int 2004; 19(1): 15–20. 49 Hinde S, Dixon J. Changing the obesogenic environment: Insights from a cultural economy of car reliance. Transport Res Part D 2005; 10: 31–53. 50 Zhang Q, Wang Y. Trends in the association between obesity and socioeconomic status in U.S. adults: 1971 to 2000. Obes Res 2004; 12(10): 1622–32. 51 Robert SA, Reither EN. A multilevel analysis of race, community disadvantage, and body mass index among adults in the U.S. Soc Sci Med 2004; 59(12): 2421–34. 52 Rush B, Shiell A, Hawe P. A census of economic evaluations in health promotion. Health Educ Res 2004; 19(6): 707–19.

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53 Avenell A, Broom J, Brown T, et al. Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technol Assess 2004; 8(21). 54 Pratt M, Macera C, Sallis J, et al. Economic interventions to promote physical activity. Am J Prev Med 2004; 27(suppl 3): 136–45. 55 Schuster E, Zimmerman Z, Engle M, et al. Investing in Oregon’s Expanded Food and Nutrition Education Program (EFNEP): Documenting costs and benefits. J Nutr Educ Behav 2003; 35(4): 200–6. 56 Rajgopal R, Cox R, Lambur M, et al. Cost-benefit analysis indicates the positive economic benefits of the Expanded Food and Nutrition Education Program related to chronic disease prevention. J Nutr Educ Behav 2002; 34(1): 26–37. 57 Siggard R, Raben A, Astrup A. Weight loss during 12 weeks’ ad libitum carbohydrate-rich diet in overweight and normal-weight subjects at a Danish work site. Obes Res 1996; 4(4): 347–56. 58 Pavlovich W, Waters H, Weller W, et al. Systematic review of literature on the cost-effectiveness of nutrition services. J Am Diet Assoc 2004; 104(2): 226–32. 59 Pritchard D, Hyndman J, Taba F. Nutritional counselling in general practice: A cost-effective analysis. J Epidemiol Community Health 1999; 53: 311–16. 60 Foxcroft D, Milne R. Orlistat for the treatment of obesity: Rapid review and cost-effectiveness model. Obes Rev 2000; 1: 121–6. 61 Warren E, Brennan A, Akehurst R. Cost-effectiveness of sibutramine in the treatment of obesity. Med Decis Making 2004; 24(1): 9–19. 62 Study summarized in O’Meara S, Riemsma R, Shirran L, et al. The clinical effectiveness and cost-effectiveness of sibutramine in the management of obesity: A technology assessment. Health Technol Assess 2002; 6(6). 63 Scheier L. Bariatric surgery: Life-threatening risk or life-saving procedure? J Am Diet Assoc 2004; 104(9): 1338–40. 64 Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: A population-based analysis. J Am Coll Surg 2004; 199(4): 543–51. 65 Craig B, Tseng D. Cost-effectiveness of gastric bypass for severe obesity. Am J Med 2002; 113: 491–8. 66 Van Gemert W, Adang E, Kop M, et al. A prospective cost-effectiveness analysis of vertical banded gastroplasty for the treatment of morbid obesity. Obes Surg 1999; 9(5): 484–91. 67 Available at http://www7.health.gov.au/msac/pdfs/summary/ summaryref14.pdf. Accessed Jan. 2005. 68 Clegg A, Colquitt J, Sidhu M, et al. The clinical effectiveness and cost-effectiveness of surgery for people with morbid obesity: A systematic review and economic evaluation. Health Technol Assess 2002; 6(12).

358 Notes to pages 240–2 69 The price conversion is provided in Avenell A, Broom J, Brown T et al., Systematic review. 70 Segal L, Dalton A, Richardson J. Cost-effectiveness of the primary prevention of non-insulin dependent diabetes mellitus. Health Promot Int 1998; 13(3): 197–209. 71 Clegg et al. Clinical effectiveness and cost-effectiveness of surgery. 72 Salem L, Jensen CC, Flum DR. Are bariatric surgical outcomes worth their cost? A systematic review. J Am Coll Surg 2005; 200(2): 270–8. 73 Ibid. 74 Ibid. 75 Agren G, Narbro K, Jonsson E, et al. Cost of in-patient care over 7 years among surgically and conventionally treated obese patients. Obes Res 2002; 10(12): 1276–83. 76 Narbro K, Agren G, Jonsson E, et al. Pharmaceutical costs in obese individuals: Comparison with a randomly selected population sample and longterm changes after conventional and surgical treatment – the SOS intervention study. Arch Int Med 2002; 162(18): 2061–9. 77 Sampalis JS, Liberman M, Auger S, et al. The impact of weight reduction surgery on health-care costs in morbidly obese patients. Obes Surg 2004; 14(7): 939–47. 78 Martin LF, Tan TL, Horn JR, et al. Comparison of the costs associated with medical and surgical treatment of obesity. Surgery 1995; 118(4): 599–606. 79 Naslund I, Agren G. Social and economic effects of bariatric surgery. Obes Surg 1991; 1: 137–40. 80 Narbro K, Agren G, Jonsson E, et al. Sick leave and disability pension before and after treatment for obesity: A report from the Swedish Obese Subjects (SOS) study. Int J Obes Relat Metabol Disord 1999; 23(6): 619–24. 81 Herpertz S, Kielmann R, Wolf AM et al. Does obesity surgery improve psychosocial functioning? A systematic review. Int J Obes Relat Metab Disord 2003; 27(11): 1300–14. 82 Chua T, Mendiola R. Laparoscopic vertical banded gastroplasty: The Milwaukee experience. Obes Surg 1995; 5(1): 77–80. 83 Nguyen N, Goldman C, Rosenquist C, et al. Laparoscopic versus open gastric bypass: A randomized study of outcomes, quality of life, and costs. Ann Surg 2001; 234(3): 279–89. 84 Paxton JH, Matthews JB. The cost effectiveness of laparoscopic versus open gastric bypass surgery. Obes Surg 2005; 15(1): 24–34. 85 Sevick M, Dunn A, Morrow M, et al. Cost-effectiveness of lifestyle and

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structured exercise interventions in sedentary adults: Results of project ACTIVE. Am J Prev Med 2000; 19(1): 1–8. 86 Kahn E, Ramsey L, Brownson R, et al. The effectiveness of interventions to increase physical activity: A systematic review. Am J Prev Med 2002; 22(suppl 4): 73–107. 87 King A. Physical activity interventions targeting older adults: A critical review and recommendations. Am J Prev Med 1998; 15(4): 316–33. 88 Pratt et al. Economic interventions. 89 Sevick et al. Cost-effectiveness. 90 Munro J, Nicholl J, Brazier J, et al. Cost-effectiveness of a communitybased exercise programme in over 65-year-olds: Cluster randomized trial. J Epidemiol Community Health 2004; 58: 1004–10. 91 Bowne D, Russell M, Morgan J, et al. Reduced disability and health care costs in an industrial fitness program. J Occup Med 1984; 26(11): 809–16. 92 Golaszewski T, Snow D, Lynch W, et al. A benefit-to-cost analysis of a work-site health promotion program. J Occup Med 1992; 34(12): 1164–72. 93 Petrella R, Koval J, Cunningham D, et al. Can primary care doctors prescribe exercise to improve fitness? The Step Test Exercise Prescription (STEP) project. Am J Prev Med 2003; 24(4): 316–22. 94 Elley R, Kerse N, Arroll B, et al. Cost-effectiveness of physical activity counselling in general practice. N Z Med J 2004: 117(1207): U1216. 95 Stevens W, Hillsdon M, Thorogood M, et al. Cost-effectiveness of a primary care based physical activity intervention in 45 74-year-old men and women: A randomised controlled trial. Br J Sports Med 1998; 32: 236–41. 96 Sallis J, Bauman A, Pratt M. Environmental and policy interventions to promote physical activity. Am J Prev Med 1998; 15: 379–97. 97 Pratt et al. Economic interventions. 98 Wang G, Macera C, Scudder-Soucie B, et al. Cost-effectiveness of a bicycle/pedestrian trail development in health promotion. Prev Med 2004; 38: 237–42. 99 Wang G, Macera C, Scudder-Soucie B, et al. Cost analysis of the built environment: The case of bike and pedestrian trials in Lincoln, Neb. Am J Public Health 2004; 94(4): 549–53. 100 Pratt et al. Economic interventions. 101 Littman T. Economic Value of Walkability. Victoria: Transport Policy Institute, 2004. Available at http://www.vtpi.org/walkability.pdf. Accessed Jan. 2005. 102 Local Government Commission Centre for Liveable Communities, The Economic Benefits of Walkable Communities. Available at http://

360 Notes to pages 249–50 www.lgc.org/freepub/PDF/Land_Use/focus/ walk_to_ money.pdf. Accessed Feb. 2005. Chapter 15. Important Issues in Obesity Control 1 Tremblay MS, Willms JD. Secular trends in the body mass index of Canadian children. Can Med Assoc J 2000; 163(11): 1429–33. 2 Ogden C, Flegal K, Carroll M, et al. Prevalence and trends in overweight among U.S. children and adolescents, 1999–2000. JAMA 2002; 288(14): 1728–32. 3 Feldman W, Beagen BL. Screening for childhood obesity. In: Canadian Task Force on the Periodic Health Examination: Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994. 4 Canning PM, Courage ML, Frizzell LM. Prevalence of overweight and obesity in a provincial population of Canadian preschool children. Can Med Assoc J 2004; 171(3): 240–2. 5 Johnston FE. Health implications of childhood obesity. Ann Intern Med 1985; 103: 1068–72. 6 Whitaker RC, Wright JA, Pepe MS, et al. Predicting obesity in young adulthood from childhood and parents obesity. N Engl J Med 1997; 337: 869–73. 7 Leung AK, Robson WLM. Childhood obesity. Postgrad Med 1990; 87: 123–33. 8 Ball GD, McCargar LJ. Childhood obesity in Canada: A review of prevalence estimates and risk factors for cardiovascular diseases and type 2 diabetes. Can J Appl Physiol 2003; 28(1): 117–40. 9 Dietz WH. Health consequences of obesity in youth: Childhood predictors of adult disease. Pediatrics 1998; 101(suppl 3): 518–25. 10 Javier-Nieto F, Szklo M, Comstock GW. Childhood weight and growth rate as predictors of adult mortality. Am J Epidemiol 1992; 136: 201–13. 11 Leung, Robson. Childhood obesity. 12 Fontaine KR, Redden DT, Wang C, et al. Years of life lost due to obesity. JAMA 2003; 289: 187–93. 13 Flynn MA. Community Prevention of Obesity in Canada: The Technical Document, Calgary: Community Prevention of Obesity Steering Committee, March 2003. 14 Feldman, Beagen. Screening for childhood obesity. 15 Ball, McCargar. Childhood obesity in Canada. 16 Campbell, K, Waters E, O’Meara S, et al. Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews (CDSR), 2004. 17 Muller MJ, Asbek I, Mast M, et al. Prevention of obesity – more than an

Notes to pages 250–2

18 19 20 21 22 23 24 25

26 27 28 29

30 31

32 33

34 35

36

361

intention: Concept and first results of the Kiel Obesity Prevention Study (KOPS). Int J Obesity 2001; 25(suppl 1): S66–74. Martorell R, Stein A, Schroeder D. Early nutrition and later adiposity. Am Soc Nutr Sci 2001; 874S-80S. Von Kries R, Koletzko B, Sauerwald T, et al. Breastfeeding and obesity: Cross-sectional study. Br Med J 1999; 319: 147–50. Balaban G, Silva G. Protective effect of breastfeeding against childhood obesity. J Pediatr 2004; 80(1): 7–16. Arenz S, Ruckerl R, Koletzko B, et al. Breast-feeding and childhood obesity – a systematic review. Int J Obes Relat Metab Disord 2004; 28: 1247–56. Ibid. Lucas A, Sarson D, Blackburn A, et al. Breast vs bottle: Endocrine responses are different with formula feeding. Lancet 1980; 1: 1267–9. Arenz et al. Breast-feeding and childhood obesity. Whitehead R. For how long is exclusive breast-feeding adequate to satisfy the dietary energy needs of the average young baby? Pediatr Res 1995; 37: 239–43. Balaban, Silva. Protective effect of breastfeeding. Waterland R, Garza C. Potential mechanisms of metabolic imprinting that lead to chronic disease. Am J Clin Nutr 1999; 69: 179–97. Balaban, Silva. Protective effect. Renders C, Seidell J, Van Mechelen W, et al. Overweight and obesity in children and adolescents and preventative measures. Ned Tijdschr Geneesk 2004; 148(42): 2066–70. Lightdale J, Oken E. Breastfeeding, food choices, restrictive diets, and nutritional fads. Curr Opin Pediatr 2002; 14(3): 344–9. National Obesity Taskforce, 2003. Healthy Weight 2008. Australia’s Future: The National Action Agenda for Childen and Young People and Their Families. Accessed: http://www.asso.org.au//freestyler/gui/files/ healthy_ weight_2008.pdf. Accessed Dec. 2004. Nestle M, Jacobson MF. Halting the obesity epidemic: A public health policy approach. Public Health Rep 2000; 115: 12–24. Henry J. Kaiser Family Foundation: The role of media in childhood obesity. Issue Brief, Feb. 2004. Available at http://www.kff.org/entmedia/ loader.cfm?url=/commonspot/security/getfile.cfm& PageID=32022. Accessed Feb. 2005. Flynn. Community Prevention of Obesity. Veugelers PJ, Fitzgerald AL. Effectiveness of school programs in preventing childhood obesity: A multilevel comparison. Am J Public Health 2005; 95(3): 432–5. Widhalm K, Dietrich S, Prager G. Adjustable gastric banding surgery in

362 Notes to pages 252–4

37 38 39 40

41 42 43 44 45 46 47 48 49

50 51

52 53 54 55 56

morbidly obese adolescents: experiences with eight patients. Int J Obes Relat Metab Disord 2004; 28: S42–5. Summerbell CD, Ashton V, Campbell KJ, et al. Interventions for treating obesity in children. CDSR, 2004. Ibid. Epstein LH, Paluch RA, Gordy CC, et al. Decreasing sedentary behaviors in treating pediatric obesity. Arch Pediatr Adolesc Med 2000; 154(3): 220–6. Golan M, Weizman A, Apter A, et al. Parents as the exclusive agents of change in the treatment of childhood obesity. Am J Clin Nutr 1998; 67: 1130–5. Summerbell et al. Interventions for treating obesity in children. Bellizi MC, Dietz WH. Workshop on childhood obesity. Am J Clin Nutr 1999; 70(1): S173–5. Jones JM, Bennett S, Olmstead MP et al. Disordered eating attitudes and behaviours in teenaged girls. Can Med Assoc J 2001; 165: 547–52. McCreary Centre Study. Mirror Images: Weight Issues among B.C. Youth. 1998. Available at http://www.mcs.bc.ca/pdf/weight.pdf. Accessed Nov. 2004. Summerbell et al. Interventions. Sometimes called disordered eating. National Eating Disorders Screening Program. Available at: http:// www.mentalhealthscreening.org/eat/eat-faq.htm. Accessed Nov. 2004. Gucciardi E, Celasun N, Ahmad F, et al. Eating disorders. Women’s Health Surveillance Report. Ottawa: Health Canada, 2001. Hoskins ML, Dellebuur K. Consuming Identities: Young Women, Eating Disorders and the Media. Vancouver: B.C. Centre of Excellence for Women’s Health, 2000. Polivy J, Herman CP. Causes of eating disorders. Annu Rev Psychol 2002; 53: 187–213. Lieberman M, Gauvin L, Bukowski WM, et al. Interpersonal influence and disordered eating behaviours in adolescent girls: The role of peer modeling, social reinforcement, and body-related teasing. Eat Behav 2001; 2(3): 215–36. Pratt BM, Woolfenden SR. Interventions for preventing eating disorders in children and adolescents. CDSR, 2003. Polivy, Herman. Causes of eating disorders. Gucciardi et al. Eating disorders. See N47. Yanovski SZ. Binge eating disorder and obesity in 2003: Could treating an eating disorder have a positive effect on the obesity epidemic? Int J Eat Disord 2003; 34(suppl): S117–20.

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57 Keel PK, Dorer DJ, Eddy KT, et al. Predictors of mortality in eating disorders. Arch Gen Psychiatry 2003; 60(2): 179–83. 58 Offord DR, Boyle MH, Campbell D, et al. One-year prevalence of psychiatric disorder in Ontarians 15 to 64 years of age. Can J Psychiatry 1996; 41: 559–563 59 Bland RC, Newman SC, Orn H. Period prevalence of psychiatric disorders in Edmonton. Acta Psychiatr Scand 1988; 77(suppl 338): S33–42. 60 Gucciardi et al. Eating disorders. 61 Eating Disorders. Washington: Office on Women’s Health: U.S. Department of Health and Human Services; 2000. 62 See n47. 63 Pratt, Woolfenden. Interventions for preventing eating disorders. 64 Zhu AJ, Walsh BT. Pharmacologic treatment of eating disorders. Can J Psychiatry 2002; 47(3): 227–34. 65 Eckert ED, Halmi KA, Marchi P, et al. Ten-year follow-up of anorexia nervosa: Clinical course and outcome. Psychol Med 1995; 25(1): 143–56. 66 Hoskins, Dellebuur. Consuming Identities. 67 Rodin, J. Cultural and psychosocial determinants of weight concerns. Ann Inter Med 1993; 119: 643–5. 68 Battle EK, Brownell KD. Confronting a rising tide of eating disorders and obesity: Treatment vs prevention and policy. Addict Behav 1996; 21(6): 755–65. 69 Hoskins, Dellebuur. Consuming Identities. 70 The VITALITY Approach. Available at http://www.hc-sc.gc.ca/hpfbdgpsa/onpp-bppn/vitality_approach_e.html. Accessed Nov. 2004. 71 Myers A, Rosen JC. Obesity stigmatization and coping: Relation to mental health symptoms, body image, and self-esteem. Int J Obes Relat Metab Disord 1999; 23(3): 221–30. 72 Battle, Brownell. Confronting a rising tide of eating disorders and obesity. 73 Pratt, Woolfenden. Interventions. 74 Foster GD, Wadden TA, Vogt RA, et al. What is a reasonable weight loss? Patients’ expectations and evaluations of obesity treatment outcomes. J Consult Clin Psychol 1997; 65(1): 79–85. 75 Field AE, Cheung L, Wolf AM, et al. Exposure to the mass media and weight concerns among girls. Pediatrics 1999; 103(3): E36. 76 Lerman C, Berrettini W, Pinto A, et al. Changes in good reward following smoking cessation: A pharmacogenetic investigation. Psychopharmacology 2004; 174: 571–7. 77 Froom P, Melamed S, Benbassat J. Smoking cessation and weight gain. J Fam Pract 1998; 46(6): 460–5.

364 Notes to pages 257–66 78 Williamson DF, Madans J, Anda RF, et al. Smoking cessation and severity of weight gain in a national cohort. N Engl J Med 1991; 324(11): 739–45. 79 Ibid. 80 Chen Y, Horne SL, Dosman JA. The influence of smoking cessation on body weight may be temporary. Am J Public Health 1993; 83: 1330–2. 81 Mizoue T, Ueda R, Tokui N, et al. Body mass decrease after initial gain following smoking cessation. Int J Epidemiol 1998; 27(6): 984–8. 82 Williamson et al. Smoking cessation and severity of weight gain. 83 Lerman et al. Changes in good reward. 84 Filozof C, Fernandex Pinilla MC, Fernandez-Cruz A. Smoking cessation and weight gain. Obes Rev 2004; 5: 95–103. 85 Hatsukami D, LaBounty L, Hughes J, et al. Effects of tobacco abstinence on food intake among cigarette smokers. Health Psychol 1993; 12(6): 499–502. 86 Filozof, Fernandex Pinilla, Fernandez-Cruz. Smoking cessation and weight gain. 87 Perkins KA, Sexton JE, DiMarco, A et al. Acute effects of tobacco smoking on hunger and eating in male and female smokers. Appetite 1994; 22(2): 149–58. 88 Froom, Melamed, Benbassat. Smoking cessation and weight gain. 89 Botella-Carretero JI, Escobar-Morreale HF, Martin I, et al. Weight gain and cardiovascular risk factors during smoking cessation with bupropion or nicotine. Hormone Metab Res 2004; 36(3): 178–82. 90 Meyers AW, Klesges RC, Winders SE, et al. Are weight concerns predictive of smoking cessation? A prospective analysis. J Consult Clin Psychol 1997; 65(3): 448–52. 91 Ortiz A, Martinez M, Torres A, et al. Predictors of smoking cessation success. Puerto Rico Health Sci J 2003; 22(2): 173–7. 92 Meyers et al. Are weight concerns predictive of smoking cessation? 93 You Can Control Your Weight as You Quit Smoking, 2003. Available at http://win.niddk.nih.gov/publications/smoking.htm. Accessed Nov. 2004. 94 Go to www.bchealthyliving.ca or www.krueger.bc.ca. Chapter 16. Collaborating for Health 1 Granner ML, Sharpe PA. Evaluating community coalition characteristics and functioning: A summary of measurement tools. Health Educ Res 2004; 19(5): 514–32. 2 Ibid. 3 Butterfoss FD, Francisco VT. Evaluating community partnerships and coalitions with practitioners in mind. Health Promot Pract. 2004; 5(2): 108–14.

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4 The mouse that roared: A marketing and health communications success story. Can J Public Health 2004; 95(suppl 2): S1–44. Available at http://www .cpha.ca/shared/cjph/archives/CJPH_95_ Suppl_2_e.pdf. Accessed Dec. 2005. 5 Butterfoss, Francisco. Evaluating community partnerships and coalitions. 6 Yoo S, Weed NE, Lempa ML, et al. Collaborative community empowerment: An illustration of a six-step process. Health Promot Pract 2004; 5(3): 256–65. 7 Garland B, Crane M, Marino C, et al. Effect of community coalition structure and preparation on the subsequent implementation of cancer control activities. Am J Health Promot 2004; 18(6): 424–34. 8 See the B.C. government website at http://www.healthservices.gov.bc.ca/ prevent/actnow.html. Accessed Dec. 2005. Chapter 17. Conclusion 1 Satcher D. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity, Washington: Public Health Service, 2001. 2 Sometimes, to focus in on the context which is shaped more by human controls, the word ‘social’ is introduced. Thus, we find terms such as ‘social environment’ and ‘socioenvironmental factor’; these are sometimes distinguished from a person’s socioeconomic and sociocultural context. All of these forces are sometimes gathered up in what is known as the socioecological model. 3 Gilbert A, Cornuz J. Which are the most effective and cost-effective interventions for tobacco control? Geneva: WHO, 2003. 4 Levy D, Chaloupka F, Gitchell J. The effects of tobacco control policies on smoking rates: A tobacco control scorecard. J Public Health Manag Pract 2004; 10(4): 338–53. 5 Joossens L. Effective Tobacco Control Policies in 28 European Countries. Brussels: European Network for Smoking Prevention. Oct. 2004. 6 Harris J, Holman P, Carande-Kulis V. Financial impact of health promotion: We need to know much more, but we know enough to act. Am J Health Promot 2001; 15(5): 378–82. 7 Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: The RE-AIM framework. Am J Public Health 1999; 89(9): 1322–7. 8 See the news report at http://www.gpiatlantic.org/clippings/mc_ 20yr-health_herald1–22–03.shtml. Accessed Feb. 2005. 9 Jha P, Zatonski WA. Smoking and premature mortality: Reflections on the contributions of Sir Richard Doll. Can Med Assoc J 2005; 173(5): 476–7.

366 Notes to page 285 10 Doll R, Hill AB. Smoking and carcinoma of the lung. Br Med J 1950; 2(4682): 739–48. 11 Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. Br Med J 2004; 328(7455): 1519.

Index

5 a Day, 180, 182, 183 5 to 10 a Day for Better Health, 182 10,000 Steps, 211 Aboriginals, 12, 121, 126, 127, 131 Adipocytes, 251 Advertising, 90–3, 96, 98, 127, 131, 148, 156, 167, 182, 183, 210, 211, 223, 261; restriction, 11, 146, 147, 169, 171, 251 Alcohol, 23, 28, 29, 66, 121, 205, 254 American Cancer Society, 28, 66 American Journal of Clinical Nutrition, 197 American Lung Association, 93 Arthritis, 19, 27, 28, 35, 208 Auditor General (B.C.), 83 Australia, 115, 127, 129, 130, 185, 240 Australian National Tobacco Campaign, 94 Avenell, A., 237, 240 B.C. Cancer Agency, 267 B.C. Healthy Living Alliance (BCHLA), 5, 49–56, 66, 69, 72–4, 248, 258, 259, 260, 265, 266, 268–73

B.C. Lung Association, 49, 268 B.C. Ministry of Health Services, 49, 83, 272, 273 B.C. Nutrition Survey, 179, 205 B.C. Paediatric Society, 49, 268 B.C. Provincial Health Officer, 191 B.C. Recreation and Parks Association, 49, 268 Behavioural therapy, 107, 109, 119, 143, 202, 229, 234, 245 Blindness, 19 Body mass index (BMI), 19, 23–6, 34, 36, 39, 43, 44, 165, 166, 198, 200, 215, 230, 231, 236, 237, 244, 253 British Medical Association, 204 California, 77, 98, 143, 244 Canada, 5–9, 11, 12, 15–19, 27, 33, 36, 38, 41, 43, 45–7, 63, 64, 66, 87, 91, 110, 115, 122, 124, 128, 137, 143, 165, 168, 179, 184–6, 194, 196, 197, 200, 203, 205, 208, 211, 217, 219, 248, 249, 258, 273, 284; Alberta, 41, 43, 45, 47, 108, 211; British Columbia, 5–7, 9, 10, 12, 13, 15, 16, 18, 32– 4, 38, 46, 49–56, 63, 67, 70, 71, 87, 120, 122, 126, 127, 165, 170, 179,

Index 191, 215, 244, 248, 253, 257–62, 265, 267, 269, 270, 271, 285; Manitoba, 187; New Brunswick, 34; Newfoundland and Labrador, 43, 45, 47; Northwest Territories, 126; Nova Scotia, 33, 43, 149, 220, 232, 252, 284; Ontario, 41–3, 45, 47, 66, 101, 116, 120, 122, 137, 185, 191, 253, 254; Quebec, 165 Canada’s National Strategy for Tobacco Control, 115 Canadian Cancer Society, 11, 49, 66, 137, 267, 268 Canadian Community Health Survey (CCHS), 104, 165, 166, 179 Canadian Diabetes Association, 49, 66 Canadian Guide to Clinical Preventive Health Care, 250 Canadian Task Force on Preventive Health Care, 209, 218, 220 Cancer, 6, 10, 17, 20, 23–5, 29, 30, 58, 63, 66, 69, 71, 78, 109, 267, 269; acute myeloid leukemia, 20; bladder, 16–18, 20, 28, 29; breast, 16, 27–9, 35, 37; colon, 6, 28, 35, 37, 259; colorectum, 16, 27, 29; endometrium, 28; esophagus, 16, 17, 20, 28, 29; kidney, 16–18, 20, 28, 29; larynx, 17, 18, 20, 29; liver, 16, 28; lung, 15, 17, 18, 20, 21, 29, 58, 60, 69, 71, 84, 259; mouth, 16–20, 28, 29; ovary, 28; pancreas, 16, 20, 28; pharynx, 17–20, 28, 29; prostate, 27, 28; rectum, 28; small intestine, 28; stomach, 20, 28, 29; thyroid, 28; trachea/bronchus, 17, 18, 20; uterus, 17, 18, 20, 28 Cardiovascular system, 15, 19, 23–6, 29, 30, 58, 62, 66, 69, 71, 109, 182,

368

199, 200, 230, 249, 254, 259, 269; aortic aneurysm, 17, 18, 20, 58; atherosclerosis, 18, 20; cardiac arrhythmias, 6; cerebrovascular disease, 6, 17, 18, 20; coronary heart disease (CHD), 6, 16, 23, 27, 28, 35, 37, 58–60, 63, 65, 69, 71, 231, 249, 259; heart attack, 26, 58, 140, 208; hypercholesterolemia, 24, 29; hypertension, 6, 17, 18, 24, 28, 29, 35, 37, 65, 196, 202; ischemic heart disease, 6, 17, 18, 20, 21, 26, 30; other arterial diseases, 17, 18, 20; pulmonary heart disease, 18; rheumatic heart disease, 18; tachycardia, 197 CART study, 115 CATCH, 190 Center for Tobacco Control Research (U.S.), 92 Central nervous system, 112 Chaloupka, F.J., 95, 137 Children, 8, 9, 17, 42, 45, 83–5, 96, 107, 117–20, 123, 125, 150, 165, 166, 168, 170, 171, 187, 189, 191, 192, 215, 216, 217, 232, 235, 246, 248, 249, 250, 251, 252, 261, 279 China, 231 Chronic disease, 5–7, 10, 19, 21, 26, 30, 38, 41, 50, 59, 62, 63, 65, 66, 77, 78, 128, 154, 165, 228, 232, 265, 269, 270, 285 Clinical trial, 88, 125 Cochrane collaboration, 78, 176, 177, 196, 197, 198, 199, 201, 209, 235, 253 Cognitive therapy, 107 Cognitive-behavioural therapy (CBT), 86, 129, 130–2, 194, 234 COMMIT study, 115 Confidence interval, 19, 27

369 Index Continuing medical education (CME), 219 Cost: benefits, 238, 244; effectiveness, 7, 15, 78, 96, 113, 134–6, 138–150, 153, 154, 228, 230, 236, 237, 239, 240–4, 257, 260, 270, 275, 281; per life-year saved, 138–48, 240; per obese individual, 36, 39; per quitter, 138, 140, 141, 143, 146, 148, 149; per smoker, 33, 34, 39, 61; utility, 237 Counter-advertising, 85–7, 93, 97, 98, 115, 132, 135, 147, 152, 155, 156, 169, 181, 279, 280 Craig, B., 240 Cromwell, 141 Cross-sectional study, 92, 95, 220 Dalton, M.A., 92 Degenerative joint disease, 6 Denmark, 61, 204 Denormalization, 12, 84, 88, 93, 94, 115, 120, 121, 136, 152, 153, 168, 277, 279 Developed world, 6–9, 15, 32, 90, 94, 122, 143, 153, 154, 165, 184, 249 Developing world, 7, 8 Diabetes, 6, 19, 26, 27, 29, 30, 37, 196, 199, 200, 202, 230, 240, 249, 269; type 2, 6, 27, 28, 35, 240, 259 Diet/food: breastfeeding, 250, 251; calories, 29, 161, 178–180, 194, 196, 197, 203, 204, 220, 241, 245, 251, 252, 254, 257; carbohydrates, 27, 178, 180, 196, 204; cholesterol, 63, 66, 181, 188, 197, 199, 230; fast food, 171, 179, 185, 186, 203, 204; fruits and vegetables, 28–30, 38, 46–8, 52, 53, 55, 64, 178–83, 186–8,

190, 193, 194, 205, 245, 259; healthy eating, 48, 52, 63, 64, 161, 170, 171, 177, 187, 232, 233, 248, 276, 286; junk food, 10, 172, 205, 251; milk, 178, 182, 186; soft drinks, 179, 191, 205; trans fat, 171, 203, 204; vending machine, 170, 191, 245 Dietitians of Canada, 49, 203, 268 Disability adjusted life year (DALY), 138, 143, 144, 147, 154 Doll, R., 15, 28, 58, 176, 285 Dopamine, 199 Drug treatment: acarbose, 199, 200; antipsychotic, 130; bupropion, 111, 112, 125, 140, 144, 145, 146, 149; clonidine, 112, 132; lobeline, 112; mecamylamine, 112; metformin, 199, 200; naltrexone, 112; opioid, 112; orlistat, 197–9, 239, 245; placebo, 197, 198; rimonabant, 199; sibutramine, 197–9, 239, 245 Drug Abuse Residence Education (DARE), 87, 88 Eat Smart!, 185 Eating disorders, 253–6; anorexia nervosa, 254, 255; binge eating, 254; bulimia nervosa, 254 Elderly, 60, 174, 208 Epidemiology, 16, 78, 177, 184 Europe, 8, 22, 29, 102, 153, 154, 231 Expanded Food and Nutrition Education Program (EFNEP), 238 Females, 19, 23–5, 28, 29, 44, 52, 57, 60, 61, 101, 109, 122, 123, 125, 136, 137, 139, 141, 145, 166, 178, 192, 194, 235, 240, 254, 255, 256 Florida Youth Tobacco Control Program, 93

Index

370

Food and Drug Administration (FDA) (U.S.), 204

Hutchinson Smoking Prevention Project, 87

Gastrointestinal system, 16, 197, 198; bariatric surgery, 200, 201, 202, 237, 239, 240; gallbladder disease, 19 Germany, 231 Glasgow, 282

Illing, E.M., 16, 17 Independent risk factor, 15, 24, 27, 39, 161 Institute of Medicine (IOM), 157, 225 International Union of Promotion and Education, 91 Intervention: clinical, 83, 89, 113, 125, 138, 148, 156, 192, 217, 233, 262; community-based, 83, 85, 86, 97, 101, 114, 118, 126, 127, 156, 178, 181, 202, 210, 229, 261, 278; environmental, 102, 170, 171, 173, 191, 251, 278; home-based, 83, 118, 192, 216; one on one counselling, 106, 110, 123, 193; physician’s advice, 106, 109, 124, 139, 141, 153, 193, 217, 218, 243, 246; regulatory and economic, 83, 85, 88, 89, 113, 120, 129, 157, 169, 170, 171, 202–5, 221, 235, 260; school-based, 215, 232, 246, 262; self-help programs, 98– 100, 110, 113, 124, 132, 142, 146, 148–50, 193, 212, 229, 230; telephone support, 99, 100, 106, 110, 132, 148, 152, 193, 212, 216, 219, 243, 246; work-based, 83, 101, 104, 132, 149, 188, 213, 231, 243, 262

Health Authority (B.C.), 10, 52, 54; Fraser Health, 49, 268; Interior Health, 49, 268; Northern Health, 49, 268; Vancouver Coastal Health, 49, 268; Vancouver Island Health, 49, 268 Health Canada, 84, 105, 125, 161, 178, 203, 224, 255 Health care providers, 30, 103, 108, 109, 110, 112–14, 117, 122–4, 127, 128, 132, 149, 150, 217, 218, 226, 256; nurses, 99, 106, 107, 109, 117, 219; physicians, 97, 106–8, 112, 131, 132, 140, 142, 156, 157, 217, 219, 220, 238 Health Development Agency (U.K.), 212 Health Service Delivery Area (B.C.), 52, 54 Health Technology Assessment (HTA), 176, 196, 199, 201, 233 Healthy People 2010, 46, 47, 161, 180 Heart and Stroke Foundation, 11, 49, 268 Heart Association (U.S.), 66 Hill, A.B., 285 Honour Your Health Challenge, 126 Hu, F.B., 23, 24, 36 Hung, H., 29, 30

Janssen, I., 19, 27, 28, 34, 36 Kaiserman, M.J., 16, 17, 33 Katzmarzyk, P., 19, 27, 28, 34, 36 (Keeping Infants Safe from Smoke) KISS, 119 Kidney failure, 19 Kiel Obesity Prevention Program (KOPS), 232

371 Index King, A., 242 Know Your Body, 190 Laupacis, A., 135 Life skills training (LST), 87 Longitudinal study, 92, 220 Macular degeneration, 16 Males, 15, 19, 23, 25, 44, 52, 57, 58, 60, 61, 101, 109, 115, 128, 137, 139, 141, 145, 148, 178, 208, 220, 235, 254, 256, 257 Media: advocacy, 97, 115, 132, 147, 154–6, 182, 279, 280; campaigns, 86, 93, 147, 181, 182, 210, 211, 245 Mercer, S.L., 153, 156 Metabolism, 19, 27, 180, 207, 257 Minnesota Heart Health Program (MHHP), 230, 231 Morbidity, 9, 15, 24, 63, 69, 71, 117, 197, 200–2, 239 Mortality, 7, 9, 14, 15, 18, 19, 21, 23, 25–7, 30, 36, 58–60, 62, 63, 71, 117, 161, 200, 249, 254, 255, 259 Motivational interviewing (MI), 119, 129, 130 Musculoskeletal disorders, 19 National Cancer Institute of Canada, 174 National Cancer Prevention Policy, 88, 103 National Institute for Clinical Excellence (U.K.), 201 Netherlands, 60, 148, 149 New York, 91, 144, 191 New Zealand, 44, 47, 203, 218, 219, 243

Norepinephrine, 199 North Karelia Project, 182, 184, 231, 235, 236, 269, 284 Northern Ireland, 46 Nortriptyline, 111, 112, 132 Not to Kids!, 90 Obesity control, 158, 162, 167, 172, 174, 177, 178, 192, 195, 209, 228–30, 236, 237, 244, 248, 249, 251, 260–1 Obesogenic environment, 169, 173, 260, 282 Observational study, 62, 78, 91 Ontario Medical Association (OMA), 90 ‘Operational ID’ and ‘Operation ID/ School Zone,’ 90 Oregon, 144, 238 Osteoporosis, 16, 37 Ottawa, 204 Pacula, R., 137 Peto, R., 15, 28, 60 Pharmacotherapy, 111, 114, 125, 126, 129, 130, 140, 141, 153, 179, 199, 239, 252, 278, 281 Physical activity, 9, 24, 25, 28, 45, 46, 47–51, 53, 56, 63–6, 69–71, 161, 166, 167, 172, 174, 176, 177, 194, 195, 207–27, 231–3, 236, 237, 242–5, 248, 250, 252, 253, 257, 259, 260, 261–2, 269, 280 Population attributable fraction (PAF), 14, 16, 17, 19, 27, 64 Pregnant women, 41, 42, 58, 120–5, 131, 132, 150–2, 168, 279 Premature wrinkling, 16 Project TNT (Toward No Tobacco Use) (U.S.), 87, 149

Index

372

Provincial Health Services Authority, 49, 268 Psoriasis, 16 Psychiatric disorders, 121, 127–30, 132, 152, 248, 249, 254; bipolar disorder, 128; dementia, 19; depression, 6, 19, 63, 128, 130, 131; schizophrenia, 128, 129, 132 Public Health Agency (Yukon), 49, 268 Public Health Association of B.C., 49, 268

194, 197, 210, 226, 229, 230, 231, 249, 256, 257, 260, 261, 265, 267, 269, 270, 275–7, 281, 284; physical inactivity, 6, 7, 9, 10, 12–14, 19, 27, 30, 32, 36–9, 41, 45, 46, 56, 63–6, 69, 71, 72, 161, 162, 166, 167, 171, 176, 207, 208, 216–18, 220, 243, 246, 250, 252, 253, 259, 276, 277, 286; unhealthy eating, 7, 12, 13, 28, 30, 36, 38, 41, 47, 64, 161, 162, 167, 170, 176, 258, 259–60 Rush, B., 134

Quality adjusted life year (QALY), 135, 136, 138, 139, 141, 145, 150, 154, 239, 240, 241, 243 QuitNet, 99

Serotonin, 112, 199 Singapore, 232 Single, E., 16 Sleep apnea, 19 Smoking: addiction, 91, 98, 113, 114, 167; antismoking campaigns, 12, 84, 153, 169, 170, 172; cigarette, 15, 42, 67, 70, 72, 84, 85, 90–2, 94, 98, 109, 110, 112, 122, 127, 136, 137, 150, 151, 176, 256, 257, 261–2; cigarette control policies, 11, 94; nicotine, 84, 98, 111, 112, 119, 127– 40, 141, 145, 257; nicotine replacement therapy, 98, 100, 108–11, 125, 130, 132, 140–6, 149, 152, 157, 168, 279; restriction, 88, 102–4, 115, 118, 130, 132, 146; sales to minors, 11, 89; second-hand smoke, 11, 16– 18, 77, 83, 88, 98, 101, 103, 104, 117– 20, 122, 123, 126, 132, 133, 147, 173, 176; tobacco control, 11, 12, 77, 78, 81, 83, 91–6, 98, 99, 102, 104, 114, 115, 117, 120, 122, 127, 131, 134, 136, 146, 147, 149, 152–6, 162, 168, 169, 171, 173, 174, 176–8, 192, 202, 213, 277–9, 281, 284; tobacco industry, 11, 12, 84, 90–3, 98, 104, 115,

Reproductive and neonatal health, 16, 19; impaired development, 16; low birth weight, 16–18, 21, 58, 122, 150; miscarriage, 16, 122; respiratory distress syndrome (newborn), 17, 18, 21; stillbirth, 16, 122; sudden infant death syndrome (SIDS), 17, 18, 21, 123 Respiratory system, 15, 17–19, 58, 69, 71, 119, 123, 249; asthma, 6, 18, 19, 120, 123; chronic bronchitis, 15, 17, 18, 21, 259; chronic obstructive pulmonary disease (COPD), 6, 58, 59, 69, 71; emphysema, 15, 17, 18, 21, 259; influenza, 15, 17, 18, 21, 58; lung disease, 15, 58; pneumonia, 15, 17, 18, 21, 58 Riboli, E., 29 Risk factors, 6, 7, 10, 12–14, 19, 30, 32, 36, 38, 41–6, 48–56, 53, 57, 63–8, 73, 74, 77, 78, 83, 94, 122, 156, 161–3, 166, 169, 173, 180, 181, 183, 188,

373 Index 116, 136, 137, 152, 153, 168, 171, 172, 261, 284; tobacco tax, 11, 69, 90, 91, 96, 97, 113–15, 125, 126, 131, 136–8, 143, 152, 154, 157, 169, 279, 284 Stakeholder, 10, 51, 65, 163, 167 Statistics Canada, 178, 179, 185 Stroke, 6, 16, 19, 27, 28, 30, 35, 37, 58, 259 Study/experiment types: case study, 29, 32, 63, 120, 265; controlled experiment/trial, 78, 99, 102, 114, 119, 127, 130, 184, 189, 196, 198, 201, 220, 230; literature review, 81, 85, 86, 89, 99, 101, 104, 105, 118, 121, 123, 127, 129, 130, 152, 188, 190, 192, 194, 196, 197, 209, 215, 218, 222, 229, 231, 233, 240–2; meta-analysis, 25, 29, 60, 106, 184, 199, 201, 220, 234; prospective study, 25, 29, 30, 199; randomized controlled trial (RTC), 78, 105, 109, 130, 145, 149, 177, 183, 192, 193, 198, 200, 234, 238, 281, 282; survey, 9, 19, 22, 23, 27, 36, 44, 104, 116, 148, 165, 170, 179, 183, 195, 217, 219, 241, 254 Super Size Me (movie), 171 Sweden, 241 Task Force on Community Prevention Services (TFCPS), 78, 96–8, 113, 225, 242 Teens/Youth, 8, 15, 42–5, 60, 83, 85, 86, 88–95, 98, 105, 108, 115, 120, 126–8, 131, 132, 136, 137, 146, 147, 150, 152, 156, 167, 174, 179, 190, 208, 248–50, 253, 254, 255 Treating Tobacco Use and Dependence, 100, 105–7, 110, 111

Ulcers, 58 Union of BC Municipalities, 49 United Kingdom, 42, 47, 115, 124, 139, 141, 142, 144, 148, 176, 188, 196, 200, 204, 212, 223 United States, 8, 9, 19, 22, 23, 26, 32, 33, 38, 41–4, 46–8, 61, 63, 64, 83, 87, 89, 92–4, 100, 102, 104, 111, 114, 115, 122, 124, 128, 139, 141, 143, 147, 150, 170, 174, 180, 182, 183–6, 190, 196, 200, 210, 230, 239, 249, 255, 284 U.S. Center for the Advancement of Health, 154 U.S. Centers for Disease Control and Prevention, 16, 22, 83, 94, 225 U.S. Preventive Services Task Force, 193, 218 U.S. Public Health Service, 105, 124 U.S. Surgeon General, 8, 15, 17, 27, 57–60, 91, 114, 115, 209–13, 216, 219, 276 Waist circumference (WC), 197, 198 Wakefield, 88 Weight loss, 62, 161, 187, 192, 194–8; intentional weight loss, 62, 63; unintentional weight loss, 62 Weight Watchers, 187, 245 Wellbutrin, 140, 144 West Virginia, 182 WIC Supplemental Food Program, 187 Winning Legacy, The, 5, 257, 261, 263, 270, 272, 273 World Bank, 11, 88, 113, 139, 144 World Health Organization (WHO), 30, 48, 66, 139, 142, 144, 147, 152, 154, 229, 279

Index Years of life, 63, 96 Years of potential life lost (YPLL), 19, 23, 58, 59

Youth Tobacco Survey (YTS), 89 Zyban, 140, 144

374