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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Re: Alan Blum's Comments
Perceived accessibility as a predictor of youth smoking
Re: "methodological concerns"- Author reply to John Pierce
methodological concerns
Stopping Youths from Easy Access of Purchasing Tobacco
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Chyke Doubeni, Worcester Assistant Professor, Joseph DiFranza, MD, Wenjun Li, Phd, Hassan Fouayzi, MS
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We thank Dr. Blum and Ms Johnson for their thoughtful comments about our article. They raised several important issues. However, it would have been interesting to learn about the work being done at their center, particularly how this present research might be used in their work and the role that family physicians may play in reducing youth smoking. We hope that Drs. Alan Blum and John Pierce will provide additional insights for the broader readership. We share with Dr. Blum and his colleagues the passion for curtailing tobacco use in adolescents. The cost of tobacco-related diseases including coronary artery disease, pulmonary disease and cancer is enormous. Youth are very vulnerable to the addictive effects of smoking. It is well known that people who begin smoking as adolescents are more likely to be become addicted and have prolonged exposure to the harmful effects of exposure to the tobacco smoke. Family physicians play an important role in the care of children and in reducing harm from smoking. The pathways to teen smoking and its prevention are far from being fully understood. Our paper published in this journal successfully quantified the relationship between perceived accessibility to cigarettes and initiation of smoking among adolescents, which adds new knowledge to the body of literature on tobacco control. Although the construct of perceived accessibility is well known, to our knowledge, this is the first study to carefully quantify the relationship of increased perceived accessibility with higher levels of tobacco use in the context of a well-designed longitudinal study. Our study shows that increased perceived accessibility increases the risk of future smoking for kids who have never before smoked. We also found that perceived accessibility increases the risk of escalation after kids puff on a cigarette for the first time. This makes perceived accessibility a useful measure to explore for use in clinical settings and public health programs. The sources of cigarettes for adolescents are diverse, temporally dynamic, and vary across communities depending on local enforcement measures and community norms. It has therefore not been feasible to accurately measure and track access to tobacco products in clinical practice. However, perceived accessibility is relatively easy to measure and can be routinely assessed during well-child or even sick visits. Kids might be more willing to tell their physician about whether they think they would be able to get cigarettes than to tell about their own tobacco use or intentions. Therefore, the practical importance of perceived accessibility should not be ignored as Dr. Blum and colleagues have suggested. It is supported by evidence and provides a clinically practical way to assess perceived accessibility by family physicians in primary care settings. As practicing family physicians (CAD, JRD), we agree that the challenges of medical practice are overwhelming and there is precious little time available to attend to the multiplicity of preventative care mandates that currently exist. That said, tobacco use is one of the most important public health challenges of our times. Family physicians are uniquely positioned to identify at-risk kids because of the role we play in providing care to generations within the same family. Therefore, we can use our knowledge of the families we see to help reduce the deleterious effects of smoking. Accessibility to cigarettes and the influences of family and friends are important factors that we should ask and address. We recommend that clinicians modify the way smoking risk is assessed by incorporating our findings to the assessment of kids as part of The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program. As said previously, it is feasible and of practical importance for clinicians to routinely evaluate perceived accessibility of their adolescent patients. We agree that the relationship of smoking with perceived accessibility and peer smoking is complex. We did not intend to imply that the relationship is unidirectional. Kids who have friends that smoke are more likely to perceive easy access and easy access promotes tobacco use. In addition, kids who smoke or are interested in smoking may be more likely to associate with others that smoke. Performing studies on youth is complex and our methods have limitations. The DANDY study has contributed to our understanding of youth smoking due to the strengths of the design. It is possible that kids may be reluctant to volunteer information about their smoking habits. That scenario is more likely to result in finding that there is no association between perceived accessibility and smoking. So the fact we found an association strengthens our conclusions. Moreover, the kids in the study underwent 3 rounds of interviews each year for nearly 4 years with a low attrition rate. Therefore, the interviewers were not "strangers" to the participants. This longitudinal design is very strong indeed and the repeated measures may also help reduce reporting bias. Moreover, we do not know of any research that shows that face-to-face interviewing with children in a longitudinal study is inappropriate. The quality control measures instituted for the DANDY study also strengthens the study and the findings. Unfortunately, the word limits for manuscripts limited our ability to describe all the details of the study. Additional details about the study have been published and are included in the reference list of the article. In the course of writing this response, we found several videos of the Joe Camel commercials on YouTube. Although the ads were pulled a long time ago, some children may still remember them and others may continue to be exposed to them– isn’t that what the tobacco industry wanted? This is important if the impact of bans on tobacco advertising is to be studied. It may also take many years for the impact of tobacco advertising to be erased from the minds of children who were exposed, and the nature of today’s new media may make the effects of cigarette advertising hard to undo. However, we considered but did not include the Joe Camel variable in the analyses that produced the results. We agree with the concern about the race/ethnicity categories that we used in the analyses. We were constrained by the demographics of our study population. The kids interviewed were mostly from towns with very few minority groups. This limitation of the study does not support analysis by racial subgroups. We are sorry that the Blum and Johnson were "flummoxed" by the term “person-time.” Like man-hours, this term is used as a measure of the number of subjects and the length of time they were followed and is routinely used in the context of survival analyses. The unit of time chosen is necessarily arbitrary. This could have been explained more clearly to readers who are less statistically oriented. We are open to clarify issues raised by our readers if warranted. We agree that dichotomizing the ordinal variable leads to some loss of information. However, in Table 2 we showed the results of the analyses using the original categories of perceived accessibility. That showed a strong dose-response effect - the higher the perceived access the higher the risk of smoking. In order to simplify the presentation in the paper and make the study results more accessibility to readers with less statistical training, we presented the results based on dichotomizing the variables. Since common logistic regression models were applied, the interpretation of results is straightforward and easier to understand. Our analyses show that neither our findings nor the interpretation are comprised by dichotomization of perceived accessibity. . We share Dr. Blum’s sense of outrage about the display of tobacco products. We are interested in knowing if he has suggestions on how this apparent paradox or hypocrisy might be addressed perhaps through policy changes. Competing interests: None declared |
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Alan Blum, MD, Tuscaloosa Director, The University of Alabama Center for the Study of Tobacco and Society, Tonya Johnson, MA,, Doctoral Candidate, Adult Clinical/ Health Psychology, University of Alabama
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Although we can see value in the examination of all possible variables involved in juvenile-onset cigarette smoking, and although we share the authors' hope that such study could influence intervention, their article provides scant new or practical information. Since our system of medical training can barely get practicing physicians, residents, or students to spend time discussing tobacco (for reasons that include insufficient reimbursement, the perception of the issue as intellectually simplistic, the lack of motivational skills, and the relatively low rate of success of tobacco cessation methods), we are skeptical of the authors' concluding sentence: "Studies of tailored interventions targeted at youths who perceive easy access to cigarettes may be useful." This might have merit some day, that is if we can ever educate a significant proportion of clinicians to initiate guided discussions about smoking. The paper's only tangential reference to family medicine comes in a grasping-at-straws point in the concluding section about the need for clinicians to "routinely ask youths about their perceptions of the accessibility of tobacco and exposure to peer smokers." Do the authors and editors truly feel that readers (whom we are trying to interest in family medicine research and in the challenge of addressing tobacco problems) needed to wade through an 8-page paper for such a suggestion? The authors state that "existing literature suggests that peer smoking and perceived accessibility may act jointly to influence youth smoking, but this relationship has not been examined." Actually, the article they reference (26) does examine the relationship and states that it is just not uni-directional. In regard to methods, we question the reliability and appropriateness of the interview technique: asking middle school students in a face-to- face interview with someone they don't know, in the school they go to, about their use of illegal substances. We wonder why only three demographic possibilities (Hispanic, White, and "Other") are listed and believe the lumped "Other" could limit findings of racial/ethnic differences. We are flummoxed by the use of the term "person-month." And we each did a double-take when we saw that a question about "the Joe Camel cartoon character" was asked of 6th graders beginning in 2002. We had to recheck to see if the authors' data were from the 1990s, since Joe Camel was pulled in 1997. That's a decade before the authors' own earlier study (Ref. 28) was published. And although it may be reasonable to assume that identification of the character implies exposure to ads, this item should not be extended to assume the efficacy of those ads. Lastly, we question the statistical method of dichotomizing the Likert scale into "yes, tobacco is accessible" or "no, not accessible" when it had been measured as a 5-point perception of accessibility. An addendum (by AB) regarding the comment suggesting that tobacco products be dispensed by prescription in pharmacies: As my co- author and I wrote nearly 25 years ago, pharmacies are the last place in which cigarettes should be sold (Richards JW, Blum A: Pharmacists who dispense cigarettes. New York State J Med 1985;85:350-353). Although all hospital pharmacies and the vast majority of independent pharmacies dropped tobacco products within the past two decades, more pharmacies than ever sell cigarettes because of the spread of the chain and supermarket drugstores (with only a few exceptions). These chains, as well as pharmaceutical manufacturers and health insurance plans (including Medicare), should be condemned for permitting tobacco to be sold alongside medications and health products. I believe proponents of dispensing cigarettes through pharmacies would reconsider if they saw the sign outside my local CVS that this week is flashing, "Marlboro Carton, $30.99" immediately followed by "We Accept ALL Medicare Rx Plans." Competing interests: None declared |
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Chyke A. Doubeni, Worcester, MA University of Massachusetts Medical School
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Thank you for your interest in our work. I wish to respond to your comments. 1.) WE performed analyses that were restricted to nonsmokers. Our found that “perceived accessibility increased the risk for smoking initiation among nonsmokers … in a dose-response fashion.” 2.) The second concern is very interesting. Our colleague (John Pierce) developed the concept of cognitive susceptibility. The DANDY-2 study collected information about susceptibility and we considered the issues raised by our colleague during the preparation of the paper. Susceptibility is measured using the following questions or variations thereof: 1) "Do you think that you will try a cigarette soon?" 2) "Do you think you will smoke a cigarette anytime during the next year?" and 3) "If 1 of your best friends offered you a cigarette, would you smoke it?" Therefore, we believe as many others do, that susceptibility is an endogenous factor that is on the causal pathway of tobacco use. Kids who become regular smokers could be viewed as transitioning from (for the sake of simplicity): non-smoker to being susceptible to initiating or experimenting, and then on to regular smoking. Thus, you have to have been susceptible before you can initiate or progress to the regular smoking state. Therefore, doing the analyses suggested by our colleague is analogous to including smoking initiation as a variable in a model that is specified to determine predictors of progression to regular smoking. Of course, it might be more interesting to study the relationship between perceived accessibility and susceptibility to smoke. 3.) Therefore, the questions or concerns raised are not methodological flaws. Our analyses were focused on perceived accessibility not susceptibility. On a more general note, from a public health perspective, one should be careful about saying that a factor or variable is not important because we were able to eliminate its effect by adding many confounders to a model. Competing interests: None declared |
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John P Pierce, USA Professor, UCSD Cancer Center
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It would have been preferable if this analysis was restricted to never smokers at baseline as perception of ease of getting cigarettes is strongly associated with smoking experience. It is unfortunate that this analysis did not include a measure of susceptibility to smoking among non-smokers. This intention-self efficacy measure has been validated in many studies as highly predictive of future smoking behavior. When it is added into predictive models, perception of the ease of getting cigarettes usually becomes not important. Given these methodological flaws, the conclusions expressed in this study are not convincing. Competing interests: None declared |
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James M. Walsh, Centerville, Ma., United States Retired Correction
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If tobacco products were classified the same as cocaine. Cocaine is a class-2 substance that is highly addicting and a deadly product,the same as the tobacco substance. If tobacco substance were the same classification as cocaine Children would not to be able to buy tobacco in a store. The tobacco could only be sold in a pharmacy, with a doctors prescription for the tobacco substance. As you can see the medical professionals would be regulating the tobacco substance,as in the same manner that the medical proffessionals regulate the substance cocaine. If tobacco and cocaine were classified a class-2 substance: TENS of MILLIONS of CHILDRENS lives would be saved from a deadly,dangerous,addicting,substance every year. Also this would take away the EASY ACCESS that CHILDREN have NOW TO PURCHASE TOBACCO PRODUCTS. Even the tobacco industry says: Their products are made for ADULTS, and "NOT FOR CHILDREN". Classifying tobacco substance the same as cocaine substance this would not be putting a ban on tobacco products for ADULTS. Adults could see their doctor for a prescription. What this would be doing is taking away the EASY ACCESS THAT CHILDREN HAVE NOW TO BUY TOBACCO, and also this would save tens of millions of CHILDRENS LIVES. THank-You JAMES M. WALSH 58 Dolar Davis Road Centerville, Ma. 02632 (508) 771-5463 or WalshPal@aol.com Competing interests: Youth Smoking |
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