MASSACHUSETTS TOBACCO CONTROL PROGRAM

A significant anti-smoking movement emerged in Massachusetts in the late 1970s. This movement led to anti-smoking advocates proposing that cities and towns pass ordinances and regulations restricting smoking in public places. In 1987, the Massachusetts legislature passed the Clean Indoor Air Act which restricted smoking in public places. In the same year, the MDPH invited anti-smoking advocates to collaborate on the development of a state plan for non-smoking and health. A planning committee made up of health professionals, voluntary organisations, and advocates identified three “areas for action”. With some modifications, these three actions have continued to the present day to be the goals of the Massachusetts Tobacco Control Program (MTCP): (1) prevent young people from starting to use tobacco products and reduce their access to tobacco products; (2) persuade and help smokers to stop smoking; and (3) protect non-smokers by reducing their exposure to environmental tobacco smoke (ETS).^2,4

In 1990, the Massachusetts office of American Cancer Society (ACS) and the MDPH collaborated on an application to the National Cancer Institute to fund the Americans Stop Smoking Intervention Study for Cancer Prevention (Project ASSIST).⁵ Funding of the Massachusetts' project ASSIST energised the ACS and the larger tobacco control advocacy community. ACS independently organised the Coalition for a Healthy Future and financed the passing of ballot Question 1, the Massachusetts tobacco excise tax that created the Health Protection Fund and provided funding for the MTCP.^6,7

MTCP activities began in October 1993 with a $14 million media campaign designed to provide information to Massachusetts residents about the negative health effects of smoking. In late 1993 and early 1994, MTCP began funding community based services throughout Massachusetts. The media campaign aimed at changing public attitudes toward smoking, coupled with a grass roots social movement that changed community norms around smoking and reached out to smokers to help them quit, are the two core strategies of MTCP. As MTCP educated the public through its media campaign and community based tobacco control programmes about the health and social problems associated with tobacco use, people in the cities and towns of Massachusetts changed their attitudes toward smoking as well as their laws and public health regulations restricting smoking in public and private places (see below). Figure 1 outlines how the MTCP interventions, including media campaigns, treatment and other smoking intervention services, and the promulgation of regulations and laws, impact upon the goal of reducing adult smoking.

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Figure 1

Massachusetts Tobacco Control Program (MTCP) model for promoting adult smoking cessation.

CHANGES IN PUBLIC OPINION, PERCEPTION AND ATTITUDES

MTCP's strategies to change public opinion, perception and attitudes are working, as supported by results from the Massachusetts Adult Tobacco Survey (MATS). The MATS is an ongoing (monthly) random digit dial telephone survey of Massachusetts residents over the age of 18 years, aggregated annually to give yearly estimates. A complex, multi-stage design is used with stratification by geographic region and clustering within strata. An initial screening interview is carried out with a household member who provides demographic and smoking status information about other adults in the household, and one member of the household is then randomly selected for extended interview. The interview schedule collects data on smoking history, efforts to quit smoking, environmental exposure to tobacco smoke, and attitudes towards tobacco control policies.

Approximately 225 adults are interviewed monthly, with an average of 2700 interviews per year. Response rates have varied from a high of 75.8% in 1995 to 72.5% in 1996, 68.5% in 1997, 70.7% in 1998, and 69.0% in 1999. (This drop in response rates follows a national trend of lower response rates to random digit dial surveys reported by many national survey centres.⁸) The data are weighted to adjust the sample to be reflective of the general population and for potential bias caused by non-response. A fuller description of the MATS and major findings and highlights can be found on the Massachusetts Tobacco Control website (http://www.state.ma.us/dph/mtcp/report/mats.htm).⁸ The 1999 report of the MATS study, An independent evaluation of the Massachusetts Tobacco Control Program, prepared by Abt Associates, is available on http://www.state.ma.us/dph/mtcp/report/abtrep.htm .⁹ In the following sections, all statistics are based on Cochran-Mantel-Haenszel test of association using SAS (version 8.02)-callable SUDAAN, release 800.

According to the 1999 MATS, an overwhelming majority of non-smokers believe that second hand smoke can harm children (96%) and can cause lung cancer (89%).⁹ Increased awareness of the harm from second hand smoke appears to have led to public support of restrictions in public and private places. More than 98% of the adults surveyed expressed support for restricting smoking in public buildings, and for some form of restriction on smoking in restaurants (over half prefer a complete ban).⁹ Almost three quarters of the Massachusetts population is now protected by smoking restrictions and bans in restaurants, compared to less than one quarter who were protected before Question 1.⁹ People are also taking individual action. The proportion of people who allow visitors to smoke in their homes has steadily declined from 57.3 (3.7)% in 1993 to 36.9 (3.7)% in 1999 (p < 0.01). The proportion of people who asked an acquaintance not to smoke also rose from 30.3 (6.0)% in 1995 to 35.5 (4.8)% in 1999 (p = 0.19).¹⁰

Change in public attitudes appear to have resulted in changed social norms around tobacco use since as smoking became less socially acceptable at work, at social events, and around children, smoking behaviours changed. Like non-smokers, smokers also recognised that tobacco smoke could harm their families. In 1995, 71.8 (14.9)% believed that it could harm children while by 1999, 91.2 (4.4)% held this belief (p < 0.05). In 1995, 58.2 (15.3)% of smokers believed tobacco smoke could cause lung cancer, with an increase to 71.8 (7.8)% in l999 (p = 0.13).¹⁰ MTCP strategies not only raise awareness of the health risk of smoking, but appear to also encourage smokers to take action. For example, the Smoke-Free Homes Campaign that urged smokers and non-smokers to “make your home a smoke-free zone to protect the health of your children” was designed to appeal to smokers' concern for their children. An individual action taken by a smoker to restrict smoking may be an early indication that a smoker is contemplating quitting. Smokers who have made decisions not to smoke in certain places smoke an average of 15.0 cigarettes a day, significantly fewer than the 17.4 smoked by people who have not made this decision.⁹

MTCP SMOKING INTERVENTION PROGRAMMES

For many smokers, recovering from nicotine addiction involves multiple quit attempts, assisted by trained health professionals and pharmacotherapy. MDPH has had a longstanding commitment to assist individuals in their recovery from addictions, including helping smokers overcome their dependency on tobacco. Since MTCP began funding programmes in 1993, it has devoted considerable resources (an average of $6.98 million annually; $8.86 million in fiscal year 2001) to developing state-of-the-art services for smokers. Services include telephone and online counselling, community based tobacco treatment programmes, and other unique smoking intervention programmes aimed at hard-to-reach smokers.

The Massachusetts Quitline provides free, confidential telephone information, supportive counselling, and referral to a community based tobacco treatment programme and the website www.trytostop.org . Adapted from the California Smokers' Helpline model,¹¹ the Massachusetts Quitline uses a stage based model of counselling, incorporating motivational interviewing.¹² The Quitline is staffed 48 hours a week with trained counsellors. Follow up counselling is scheduled at regular intervals.

The website www.trytostop.org offers a self guided interactive tool called the Quit Wizard that analyses input from a website visitor and produces a customised quit plan. The website www.trytostop.org links visitors to other resources through icons that prompt a visitor to seek help “on the phone” through the Quitline (800-TRY TO STOP) and “in person” by linking to a directory of centre based tobacco treatment programmes. Other features include a savings calculator that tracks dollars saved since the quit date and electronic cards that can be sent to family and friends announcing a visitor's decision to quit. Visitors may also email questions: responses are prepared weekly and posted on the website. Visitors can also read articles by physicians as well as successful quit stories and quit tips from former smokers.

At the heart of Massachusetts' smoking intervention strategies are tobacco treatment services, a system of highly structured centre based nicotine addiction treatment services offering face-to-face individual, group and family counselling and nicotine replacement therapy. These programmes, imbedded in hospitals, health centres, substance abuse treatment centres, and other health and human service programmes are designed to reach the 900 000 smokers in the Commonwealth of Massachusetts. Physicians, nurses, and other health professionals within these organisations screen their patient/client population to identify smokers who are then advised to quit smoking and assisted in accessing an in-house MTCP funded tobacco treatment service. Services are provided in accordance with the US Public Health Service guidelines.¹³ Tobacco treatment services are provided by counsellors who are required to become certified tobacco treatment specialists.

Massachusetts has provided leadership in creating professional standards for tobacco treatment specialists through the development of a cutting edge, competency based training and counsellor certification programme provided by the University of Massachusetts Medical Center, Division of Preventive and Behavioral Medicine. Clinicians must receive eight days of classroom training; prepare and present a case study; take a written exam; and document 2000 hours of supervised tobacco treatment counselling under the supervision of a trained professional. To date more than 250 individuals have completed the training and nearly 50 have passed rigorous requirements for full certification.¹⁴

Tobacco treatment services are reimbursed to providers based on productivity: a contractor is paid for a service unit delivered of group counselling; individual counselling; a large group lecture; a screening interview (5As—ask, assess, advise, assist, arrange) with an identified smoker; a week of the patch or gum. To assure high utilisation of service dollars,¹⁵ contract dollars are not fixed, but can be moved between providers based on demand for service. Demand for service is jointly assessed by MTCP and the contractor, based upon billing data and estimates of future billing provided by the contractor. Contracts are routinely monitored to verify that the clinical service has been delivered and documented according to contract requirements.

MTCP also funds innovative approaches that are aimed at populations that are unlikely to use centre based tobacco treatment services such as the homebound, women with young children, and recent immigrants who do not speak English. These services engage smokers in their target population and assist them in the process of quitting tobacco use. Interventions may occur in a variety of non-traditional settings such as the smokers home or in a prison.

MTCP also funds special projects to promote and support integration of tobacco treatment into other health care service systems. Initiatives include training and technical assistance, a nicotine replacement therapy pilot programme in the substance abuse treatment system, and customised health care provider training programmes and service partnership agreements with health insurers.

PROGRAMME IMPACT

The sixth annual report of the Independent evaluation of the Massachusetts Tobacco Control Program, based on the MATS surveys, prepared for the Massachusetts Department of Public Health by Abt Associates Inc, shows encouraging results (see http://www.state.ma.us/dph/mtcp/report/abtrep.htm). The report shows continued reductions in the number of adult smokers, the number of cigarettes that smokers smoke per day, and total per capita cigarettes purchases. Adult smoking rates declined from 22.6 (1.3)% in 1993 to 20.9 (2.1)% in 1999 (p = 0.18), a decrease of almost 80 000 smokers (8%).¹⁰ The decline in smoking rates to date is estimated to save a minimum of $85 million annually in public and private health care expenditures in Massachusetts.⁹

Many Massachusetts smokers are trying to quit. According to the statewide tobacco surveys, slightly under 900 000 adults smoked at some time during fiscal year 1999.¹⁰ Approximately 425 000 gave up smoking for at least one day during the year being interviewed. Over 100 000 of them were still not smoking at the time of the interview.⁹ An important sign of progress is that smokers who try to quit are more likely to succeed. The quit success rate has grown from 17% in 1993 when MTCP began to 25% in 1997-99.⁹

Those adults who continue to smoke are smoking fewer cigarettes. In 1993, Massachusetts smokers age 18 and over smoked an average of 19.7 cigarettes a day. That average fell to 15.6 cigarettes in 1999, a decline of about 20%. Over the course of the year, the average Massachusetts smoker smoked nearly 1500 fewer cigarettes in 1999 than in 1993.⁹ Cigarette purchases have also dropped 32% since MTCP began, falling from an annual rate of 118 packs per adult in fiscal year 1992 to 80 packs in fiscal year 1999. This decline is documented in cigarette sales data from the Tobacco Institute¹⁶ and confirms the survey results described above.⁹ It is interesting to note that neighbouring states to Massachusetts by and large did not tax cigarettes at the same rate as Massachusetts, and therefore a small proportion of the decline could be due to cross border, or internet, sales. Greater reductions in smoking in Massachusetts have also been found in analyses using other survey data and comparing Massachusetts with other US states not having a tobacco control programme (see Weintraub and Hamilton in this supplement¹⁷).

Massachusetts has developed a comprehensive intervention for smokers that includes social marketing and social policy change that substantially altered the environment for both smokers and non-smokers.¹⁸ The MTCP goal of helping smokers to quit assured that environmental strategies were humanely coupled with treatment strategies, as social policy change made it harder and harder for smokers to smoke in public places and smokers' attitudes changed about the safety of smoking in their own homes and around their family. Massachusetts has invested in developing this comprehensive model which has had encouraging results. This model should be useful to other states as they develop their tobacco control programmes.