Dianne C. Barker

Introduction A number of recent studies document the proportion of all cigarette packs that are ‘contraband’ using discarded packs to measure tax avoidance and evasion, which we call tax non-compliance. To date, academic studies using discarded packs focused on relatively small geographical areas such as a city or a neighbourhood. Methods We visited 160 communities across 38 US states in 2012 and collected data from littered cigarette packs as part of the State and Community Tobacco Control (SCTC) Research Initiative and the Bridging the Gap Community Obesity Measures Project (BTG-COMP). Data collectors were trained in a previously tested littered pack data collection protocol. Results Field teams collected 2116 packs with cellophane across 132 communities. We estimate a national tax non-compliance rate of 18.5% with considerable variation across regions. Suburban areas had lower non-compliance than urban areas as well as areas with high and low median household income areas compared with middle income areas. Discussion We present the first academic national study of tax non-compliance using littered cigarette packs. We demonstrate the feasibility of meaningful large-scale data collection using this methodology and document considerable variation in tax non-compliance across areas, suggesting that both policy differences and geography may be important in control of illicit tobacco use. Given the geography of open borders among countries with varying tax rates, this simple methodology may be appropriate to estimate tax non-compliance in countries that use tax stamps or other pack markings, such as health warnings.

Almost one-half million babies in the United States are born yearly to women who report smoking while pregnant. Almost all of these pregnant women have access to prenatal care, through federally financed health clinics, state and county health programs, or private providers. However, many pregnant smokers are unlikely to receive any type of counseling or assistance to help them stop smoking—despite the availability of evidence-based treatment and the considerable return on investment. This article recommends four next steps to ensure that tobacco dependence treatment is available for all pregnant women. These steps are (a) expanding Medicaid coverage for, and promotion of, effective counseling services for pregnant smokers, (b) improving health care systems by building the capacity of prenatal providers and health care systems to deliver effective treatments, (c) encouraging purchasers of private and public health benefit packages to demand coverage for, and promotion of, effective counseling services for pregnant smokers, and (d) redirecting state resources to ensure a statewide system of care for pregnant smokers. Implementation of these steps requires leadership, diligence, and action by the public health community—as well as ongoing monitoring to assess progress in improving coverage, capacity, and coordination.

OBJECTIVE The purpose of this study was to measure the content and comprehensiveness of pregnancy specific smoking cessation strategies within managed care organisations (MCOs) responding affirmatively to the national 1997-98 Addressing Tobacco in Managed Care (ATMC) survey. DESIGN This cross sectional follow up study consisted of a fax survey sent to medical directors and a 37 question telephone survey of program overseers about the smoking cessation strategy. SUBJECTS 147 MCOs identifying a pregnancy specific smoking cessation strategy on the 1997-98 ATMC survey served as the initial sample; 88 MCOs of 128 eligible plans completed both components, with a response rate of 69%. RESULTS Pregnancy specific smoking cessation strategies varied. 40% of respondents used the Agency for Health Care Policy and Research guidelines for clinical smoking cessation to design their strategy. Strategies included self help materials, quit classes, telephone support and brief counselling by providers, linkages to quality improvement efforts, and use of patient databases for outreach. Only 42% offered a postpartum relapse prevention element. Lack of patient interest, competing clinic priorities, and the lack of a smoker identification system were the most problematic barriers to implementing strategies, common to at least a quarter of respondents. A majority ranked best practice manuals and web site linkages as the most useful form of technical assistance, followed by peer-to-peer counselling, regional workshops, newsletters, on-site assistance, and national conferences. CONCLUSIONS The survey provides the first profile of prenatal tobacco treatment strategies in managed care. While design limitations prevent generalisation of these results to all MCOs, such information can help guide technical assistance to plans interested in reducing smoking among pregnant women.

Editor,—In 1997 the National Conference of State Legislatures in the United States conducted a survey of state Medicaid agencies for the Robert Wood Johnson Foundation to determine the extent to which states covered nicotine addiction treatment as a routine benefit under Medicaid (the government programme that provides health care to the poor). Only 22 states and the District of Columbia reported coverage for nicotine addiction treatment services under Medicaid, including only 19 of the 40 states with lawsuits against the tobacco industry to recoup Medicaid costs of smoking . These 22 states were California, Colorado, Delaware, Florida, Louisiana, Maine, Maryland, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, Vermont, and Wisconsin. A repeat survey is now underway to obtain more detailed information on these benefits and to update the …