Tobacco Control in the 21st Century: Policies to Address Traditional and Emerging Tobacco Products

Within the past decade, the US tobacco product market has transitioned from being dominated by cigarettes to now offering an expanding array of different products. Of these, electronic cigarettes (e-cigarettes) have gained in popularity and become widely used by youth and younger Americans. Given the sharp increase in high school and even middle school students vaping, there has been pressure across all levels of government to address the issue through enhanced tobacco control policies. This dissertation focuses on the ground-level implementation of recently passed policies to identify gaps in tobacco control across the US. Presented in three research papers, the overarching aim is to understand how new tobacco control policies, such as Tobacco 21 and flavor restrictions, are implemented within communities. Additionally, features of the US political system which impact implementation are explored as well as potential solutions to issues identified. In the first paper, observations from tobacco retail locations in two Michigan cities (Grand Rapids and Detroit) assessed the retail environment for presence and advertising of menthol tobacco products. These assessments were used to identify if disparities in mentholated product availability and marketing existed across racially and economically diverse neighborhoods. Contrary to previous studies, neighborhoods with a higher percentage of non-Hispanic Black residents were no more likely to have mentholated products and had higher, not lower, prices for Newport menthol cigarettes (a popular menthol brand). In this study, Hispanic communities, instead, were observed to have greater availability and advertising for mentholated products. Some retailers also had illegal self-service displays, indicating lack of effective enforcement. The focus of the second paper was testing Theda Skocpol’s theory of advocacy using Tobacco 21 as a case. The spread of policies raising the age of sale for tobacco products to 21 (Tobacco 21) has been used as a classic example of a grassroots movement in public health literature, but this does not align with Skocpol’s work which indicates politics are often driven by advocacy organizations rather than truly grassroots activists. Through interviews with public health advocates in Colorado and Virginia, I found evidence that Skocpol’s theory holds true: national advocacy organizations played a pivotal role in spreading Tobacco 21 across the US with minimal citizen involvement outside of professionals promoting the policy as a public health measure. The third and final paper studied enforcement of minimum legal sales age policies, identifying factors which differentially impact retailer compliance rates across the country. Those factors include: a network of two federal enforcement regimes along with varying state policies and a possibility for local regimes in some states; Tobacco 21 increasing the age of sale resulting in state law changes; and the COVID-19 pandemic limiting retailer inspections. Across the three studies, it is apparent that institutions within the US government and power structures which favor national advocacy organizations contribute to vastly different policies across states which are implemented to varying degrees. At the ground level, this results in some states and localities having excellent updated policies and enforcement while other regimes lack the funding and infrastructure to enforce federal mandates.PhDHealth Services Organization & PolicyUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/178060/1/kiessli_1.pd

Tobacco 21 White Paper

As more states and cities around the nation consider Tobacco 21 policies, a team of researchers conducted policy analyses on the potential effects of Tobacco 21 in Michigan, providing considerations for implementation.https://deepblue.lib.umich.edu/bitstream/2027.42/148298/1/Tobacco 21 White Paper.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/148298/3/Tobacco 21 White Paper_Mar.2019.pdfDescription of Tobacco 21 White Paper.pdf : Tobacco 21 White PaperDescription of Tobacco 21 White Paper_Mar.2019.pdf : Tobacco 21 White Pape

Health informatics interventions to minimize out-of-pocket medication costs for patients: what providers want.

ObjectiveTo explore diverse provider perspectives on: strategies for addressing patient medication cost barriers; patient medication cost information gaps; current medication cost-related informatics tools; and design features for future tool development.Materials and methodsWe conducted 38 semistructured interviews with providers (physicians, nurses, pharmacists, social workers, and administrators) in a Midwestern health system in the United States. We used 3 rounds of qualitative coding to identify themes.ResultsProviders lacked access to information about: patients' ability to pay for medications; true costs of full medication regimens; and cost impacts of patient insurance changes. Some providers said that while existing cost-related tools were helpful, they contained unclear insurance information and several questioned the information's quality. Cost-related information was not available to everyone who needed it and was not always available when needed. Fragmentation of information across sources made cost-alleviation information difficult to access. Providers desired future tools to compare medication costs more directly; provide quick references on costs to facilitate clinical conversations; streamline medication resource referrals; and provide centrally accessible visual summaries of patient affordability challenges.DiscussionThese findings can inform the next generation of informatics tools for minimizing patients' out-of-pocket costs. Future tools should support the work of a wider range of providers and situations and use cases than current tools do. Such tools would have the potential to improve prescribing decisions and better link patients to resources.ConclusionResults identified opportunities to fill multidisciplinary providers' information gaps and ways in which new tools could better support medication affordability for patients