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OBJECTIVE: To evaluate the prevalence of smoking among young adults and to describe their characteristics. METHODS: Data were examined from the Minnesota Adult Tobacco Survey, a telephone survey of 8821 residents with a sample of 1205 young adults. RESULTS: Prevalence was 39% using the adolescent definition and 32% using the adult definition. Nearly 1 in 5 young adult smokers may be considered a "previously unrecognized smoker" who would not have been identified as a cigarette user according to the standard adult definition. CONCLUSIONS: Future studies assessing prevalence should use both adolescent and adult measures.

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BACKGROUND: Tobacco quitlines offer clinicians a means to connect their patients with evidence-based treatments. Innovative methods are needed to increase clinician referral. METHODS: This is a clinic randomized trial that compared usual care (n = 25 clinics) vs a pay-for-performance program (intervention) offering $5000 for 50 quitline referrals (n = 24 clinics). Pay-for-performance clinics also received monthly updates on their referral numbers. Patients were eligible for referral if they visited a participating clinic, were 18 years or older, currently smoked cigarettes, and intended to quit within the next 30 days. The primary outcome was the clinic's rate of quitline referral (ie, number of referrals vs number of smokers seen in clinic). RESULTS: Pay-for-performance clinics referred 11.4% of smokers (95% confidence interval [CI], 8.0%-14.9%; total referrals, 1483) compared with 4.2% (95% CI, 1.5%-6.9%; total referrals, 441) for usual care clinics (P = .001). Rates of referral were similar in intervention vs usual care clinics (n = 9) with a history of being very engaged with quality improvement activities (14.1% vs 15.1%, respectively; P = .85). Rates were substantially higher in intervention vs usual care clinics with a history of being engaged (n = 22 clinics; 10.1% vs 3.0%; P = .001) or less engaged (n = 18 clinics; 10.1% vs 1.1%; P = .02) with quality improvement. The rate of patient contact after referral was 60.2% (95% CI, 49.7%-70.7%). Among those contacted, 49.4% (95% CI, 42.8%-55.9%) enrolled, representing 27.0% (95% CI, 21.3%-32.8%) of all referrals. The marginal cost per additional quitline enrollee was $300. CONCLUSION: A pay-for-performance program increases referral to tobacco quitline services, particularly among clinics with a history of less engagement in quality improvement activities.

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BACKGROUND: Smokers have contact with many different types of health professionals. The impact of tobacco intervention by multiple types of heath professionals is not known. METHODS AND MATERIALS: As part of the 2003 Minnesota Adult Tobacco Survey, smokers (n=1723) reported on tobacco treatment by medical doctors, nurses, dentists, pharmacists, or other health professionals. This analysis examined: (1) smokers' report of tobacco intervention by different types of healthcare providers, (2) the proportion of smokers who report intervention by multiple provider types, and (3) the relationship between smokers' report of intervention by multiple provider types and readiness to quit, quit attempts, and recent quitting. RESULTS: Among past-year smokers, 65% had visits with two or more types of health professionals. Among smokers who visited health professionals (n=1523), only 34% reported being asked about smoking by two or more types of professionals. Among current smokers (n=1324), advice or assistance from more than one type of professional was uncommon (26% and 7%, respectively). Being asked about smoking by two or more types of professionals substantially increased the odds of recent quitting (OR=2.37; 95% CI=1.15-4.88). Among current smokers, being advised to quit by two or more types of professionals increased the odds of having made a quit attempt in the past year (OR=2.92; 95% CI=1.56-5.45) or intending to quit in the next 6 months (OR=2.17; 95% CI=1.10-4.29). CONCLUSIONS: Smoking-cessation interventions by more than one type of health professional have the potential to substantially increase quitting and readiness to quit in the population.

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PURPOSE: The purpose of this study was to examine the relationship between stage of change for smoking cessation and stage of change for (1) fruit and vegetable consumption and (2) physical activity. DESIGN: The data come from a cross-sectional telephone survey administered to a stratified random sample of health plan members (n = 9675). SETTING: This study was conducted at a mixed-model health plan with approximately 1 million adult members. SUBJECTS: Respondents were adults age 18 and older, who were randomly selected from five health plan product groups: commercial fully insured, commercial self-insured, two publicly subsidized plans, and Medicare supplemental insurance. Response rates ranged from 74.7% to 90.1% across these groups. MEASURES: The assessment included demographics and stage of change for smoking cessation, physical activity, and fruit and vegetable intake. Bivariate relationships among variables were analyzed with the use of contingency tables. Ordered logistic regression was used to examine the effects of stage of change for fruit and vegetable consumption and physical activity on stage of change for smoking while controlling for other factors. RESULTS: Stage of change for smoking is more clearly related to stage of change for fruit and vegetable consumption (chi2 = 161.3, p < .001; Cramer's V = .11, p < .001) than to stage of change for physical activity (chi2 = 89. 7, p < .001; Cramer's V = .08, p < .001). However, stage of change for fruit and vegetable consumption and physical activity are not strong predictors of stage of change for smoking. CONCLUSIONS: This study indicates that stage of change for both fruit and vegetable consumption and physical activity are independent constructs from stage of change for smoking cessation.

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Health plans play an important role in tobacco control. In this chapter we present an overview of the scientific research on health plan involvement in clinical and community interventions regarding tobacco use. Also included are interventions that have been undertaken by health plans to lower smoking rates among their members and the general population. We conclude with a new model that can be used to engage health plans in tobacco control efforts and a case study that outlines how one health plan has implemented this new model.

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