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Using multiple interventions to make an impact in the community
  1. Sandra D Sandell
  1. HealthPartners, Center for Health Promotion—Mod C, PO Box 1309, Minneapolis, Minnesota 55440-1309, USA;sandra.d.sandell{at}

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[Much of the information in this presentation was published as “‘Garbage face’: a managed care organisation’s response to tobacco use” (Tobacco Control1996;5:259–261). The following explains what happened after this article was written.]

At the time of the aforementioned article, HealthPartners was about to test market a day-to-day guide (calendar) to help teenagers quit smoking. The organisation worked with students in two tenth-grade (aged 15–16) health classes in a suburban Minneapolis high school to test the calendar’s concepts. Students were presented with several questions about their attitudes toward smoking, which were displayed on a large screen along with multiple responses. Option Finder, an electronic polling system, allowed them to register their responses anonymously and see immediately how their classmates responded. The students’ statements suggested that they perceived themselves to be autonomous agents, people who made their own decisions, as evidenced by some of the responses: “Kid’s don’t encourage other kids to smoke.” “It’s my life! If I choose to smoke, that’s what I choose to do.” “That peer pressure thing is overplayed.” These sentiments were reflected in additions to the calendar: concepts such as choosing to be free of nicotine addiction and refusing to be manipulated by the tobacco companies.

The calendar met a need created in part by new legislation. At the time the “Garbage face” article was written, the Minnesota Senate had passed a bill (to reduce access by young people to tobacco) that was more extensive than tobacco control advocates could have hoped. Pending in the House, on the other hand, was a “toothless” bill which contained language preempting stronger local ordinances. Minnesota’s tobacco control advocates had been trying to pass an effective law for nearly a decade. The political clout of HealthPartners and other managed care organisations helped defeat the preemption and secure the passage of a good bill. Under the new law, municipalities are required to licence tobacco retailers, check their compliance with laws prohibiting sales to underage customers, and levy sanctions against retailers found in violation of such laws. The law also encourages local governments to provide diversion programmes to keep young violators out of the criminal justice system. Such programmes find the calendar, several thousand of which have been distributed to them, a useful resource.

HealthPartners received the Community Leadership Award of the American Association of Health Plans in 1997 for its activities in reducing smoking in young people. Rather than seeing the award as the culmination of its efforts, the organisation decided to enter a new arena of tobacco control. In March, HealthPartners joined with Medica, another managed care organisation, in a suit against the tobacco companies. HealthPartners and Medica intend to show that the tobacco companies unlawfully manipulated nicotine content, conspired to suppress information regarding the health risks of smoking, and targeted youths as consumers. The complaint alleges that such practices have resulted in a larger number of smokers, which means a less healthy population and higher healthcare costs. The state of Minnesota and Blue Cross/Blue Shield of Minnesota recently settled a similar lawsuit for $6.1 billion.

As part of the settlement, the tobacco companies agreed to modify several of their current practices, including permanently banning any marketing that targets children, establishing a smoking cessation fund in Minnesota, eliminating tobacco billboards, disbanding the tobacco industry’s scientific research organisation, and revealing exact amounts paid to lobbyists and other politicians. HealthPartners and Medica are confident that their present lawsuit will further benefit the community and that they will be looking for many new ways to make an impact there.