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Susan Chaney, EdD, RN, FNP-C, FAANP Susan Sheriff, PhD, RN, CNE

Texas Nurse Practitioners 27th Annual Conference September 26, 2015

Smoking Cessation Interventions for the Medically/Economically

Underserved Populations

OBJECTIVES •  Review the etiology, health benefits of cessation,

and nurse practitioner interventions for smoking cessation for medically/economically underserved populations.

•  Describe a multifaceted approach to smoking cessation for medically/economically underserved populations.

•  Examine nicotine and non-nicotine, first line and second line medications for smoking cessation.

INTRODUCTION Ø  Tobacco use is the leading cause of preventable morbidity, mortality, and health expense in the United States, responsible for more than 480,000 deaths annually, or 1 of 5 deaths.

Ø  Smoking results in more deaths each year in the U.S. than AIDS, alcohol, cocaine, heroin, homicide, suicide, motor vehicle crashes, and fires – combined.

Ø  Smoking is responsible for 90% of lung cancer deaths, and approximately 80% of chronic obstructive pulmonary disease deaths.

(Centers for Disease Control & Prevention [CDC], 2015a)

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ETIOLOGY OF TOBACCO DEPENDENCE v  The etiology of tobacco dependence is multidimensional with

physiological, psychological, and social/behavioral factors

v  Physiological factors include raising brain levels of dopamine

v  Psychological factors evolve from positive feedback provided by pleasurable sensations

v  Social/behavioral factors include the following: §  Smoking becomes a habit or an automatic and intrinsic

part of daily activities. §  Smoking can be used as self-medication to reduce

unpleasant sensations that occur with tobacco withdrawal or stress

v The highest state prevalence rates of smoking were in Kentucky (29.0%), the Midwest (20.6%) and the South (19.7%)

v Tobacco use costs more the $289 billion annually in U.S.

DEFINING THE UNDERSERVED POPULATION v The federal Medically Underserved Area (MUA) and

Medically Underserved Population (MUP) designations identify areas and populations that have limited access to primary care services.

v MUAs include groups of census tracts that have a population-to-provider ratio indicating a shortage.

v MUPs may include groups of persons who face economic, cultural or linguistic barriers to health care and reside in a specific geographic area.

(Department of Health, n.d.)

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UNDERSERVED POPULATION:

BARRIERS TO HEALTH •  Greater risk for limited access to healthcare resources •  Low socioeconomic status (SES) associated with increased

mortality rates and greater prevalence of risk behaviors, including smoking

•  Financial barriers → medical conditions may reach an advanced stage before the individual seeks care

•  Increased prevalence of mental health issues (depression, anxiety, substance use/abuse)

•  Increased prescription medication use •  Below national rates of leisure-time physical activity •  Less likely to have completed recommended screenings for gender/

age (Alverson & Kessler, 2010; Harley et al., 2014) (CDC, 2015a)

v  Adult smoking rates in the U.S. are 18.1%: All time low!

v  The highest rates of smoking in adults: American Indians/ Alaska Natives, and adults who live below poverty level.

v  Cigarette smoking is more common in men (20.5%) than women (15.8%).

EPIDEMIOLOGY OF TOBACCO USE: ADULT

EPIDEMIOLOGY •  In the U.S., smoking prevalence remains highest among those with

less than a high school education (28.4%), those with no health insurance (28.6%), and those living below the federal poverty level (27.9%)

•  Medicaid enrollees currently smoke cigarettes at a 60% higher rate than the national average, and racial/ethnic minorities and women are disproportionately represented in this population

•  The homeless population reflects an even greater disparity, with approximately 70% tobacco prevalence (over 3x national average)

•  Smokers with lower incomes are also less likely to use evidence-based smoking cessation treatments such as pharmacotherapy and counseling than smokers with higher incomes

(Bock et al., 2014; America Lung Association [ALA], 2014b; Okuyemi et al., 2006; Fu et al., 2014)

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BENEFITS OF CESSATION

•  Within a few hours → the level of carbon monoxide in the blood begins to decline, increasing the blood’s ability to carry oxygen

•  Within a few weeks → improved circulation, produce less phlegm, less coughing/wheezing

•  Within several months → substantial improvements in lung function •  Within a few years → lower risks for chronic disease processes •  Heart rate and blood pressure begin to normalize (abnormally high

with smoking) •  Improved sense of smell, and food will taste better

Timeline of Improvement

**ONE cigarette = 11 minutes taken from your life!** (CDC, 2015b)

BENEFITS OF CESSATION •  Reduced risk of developing some lung diseases (including COPD, one

of the leading causes of death in the United States) •  Lowered risk for lung cancer and many other types of cancer •  Reduced risk for heart disease, stroke, and peripheral vascular disease •  Reduced heart disease risk within 1-2 years of quitting •  Reduced respiratory symptoms, such as coughing, wheezing, and

shortness of breath Ø  symptoms may not disappear, but do not continue to progress at the same

rate among people who quit compared with those who continue to smoke •  Reduced risk for infertility in women of childbearing age •  Smoking cessation during pregnancy reduces the risk of having a low

birth weight baby, pre-term labor, and associated complications

Long-Term Effects

(CDC, 2015b)

BARRIERS TO SMOKING CESSATION

v  Language, Acculturation, & Literacy v Nicotine Dependence (Current Use)

•  Multiple self-report tools available for free •  Higher level of dependence and increased use of mentholated

cigarettes •  Smoke higher number of cigarettes per day

v Motivation to Quit •  Lowest in low-SES population •  Over 60% of smokers express a desire to quit, but most are

unwilling to make a serious quit attempt within the next 6 months •  Low-SES smokers are also less likely to achieve cessation for ≥6 months compared to higher SES individuals

(Businelle et al., 2010)

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BARRIERS TO CESSATION

v  Increased Stressors (Coping Mechanism) •  Higher unemployment rate, lower income, increased financial

burdens, poorer health status, higher rates of separation/divorce v Co-morbid Psychiatric Issues

•  Increased prevalence of substance use/abuse, •  Higher rates of anxiety, depression, and mental illness

v Disparities in advertising to low SES communities •  Communities with more tobacco retailers •  Advertisement sizes larger, lower mean price, closer to schools

(within 1000 feet), and more likely to promote mentholated cigarettes

(Seidberg, Caughey, Rees, & Connolly, 2010)

(CONTINUED) HISTORY

•  Family and patient medical history – Heart disease, respiratory disease, or cancer

•  HPI: sputum, cough, shortness of breath, exercise tolerance

•  Social and dietary history: alcohol, coffee, use of illicit substances

•  Depression screen – Depression is 2x more common in smokers

Ø  How many packs of cigarettes do you smoke per day? Ø  What brand of cigarettes do you smoke? Ø  How many previous attempts to quit smoking? Ø  What method did you use in your previous attempts? Ø  How long did your previous attempts at quitting last? Ø  What barriers did you face during smoking cessation? Ø  How old were you when you started smoking? Ø  How many years have you been smoking? Ø  How many members of your family smoke? Ø  Do one or both of your parents smoke? Ø  Are you motivated to quit now? If so, do you have confidence in

your ability to do so?

SMOKING HISTORY QUESTIONNAIRE

(Chaney & Sheriff, 2008)

WITHDRAWAL SYMPTOMS OF NICOTINE

(CDC, 2014b; Chaney & Sheriff, 2012)

Anxiety

Cravings

↓HR & BP

Depression

Difficulty Concentrating

Drowsiness Irritability

GI Disturbances

Headaches

Increased Appetite

Weight Gain

Increased Skin Temperature

Insomnia

Restlessness

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EXAM & DIAGNOSIS Physical Examination: Ø Monitor VS, particularly BP which adds an additional risk of heart disease if elevated; tobacco use: current, former, never; weight Ø Examine ears, nose, sinuses, mouth, and pharynx, noting signs of inflammation due to irritation from tobacco Ø Perform complete exam of lungs Ø Perform complete exam of heart & peripheral vascular system Diagnostic Tests: Ø Spirometry & pulmonary function tests Ø Urine samples Ø Screen for lipid disorders to determine additional risk factors for heart disease

DIAGNOSIS •  Can bill as primary reason for visit •  ICD-9: 305.1 Tobacco use disorder •  May bill as secondary to another problem

BARRIERS TO ACCESSING TOBACCO CESSATION

TREATMENT •  Required Co-payments •  Prior Authorization Requirements •  Limits on Duration of Treatment •  Annual & Lifetime Limits on Quit

Attempts •  “Stepped Care Therapy” Requirements •  Requirements for Cessation Counseling

Know how your patient is affected by: v Coverage v Affordability

v Premiums/Penalties v Preventive/Screening Services

v Medicaid Expansion v Tobacco Cessation

& the unintended effects on the underserved

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THE AFFORDABLE CARE ACT (ACA)

(U.S. Department of Health & Human Services [USDHHS], 2015; Transamerica Center for Health Studies, n.d.)

v Coverage for ALL –  Over 16 million people gained coverage, dropping the uninsured

rate, with the largest changes seen in African Americans and those with low-SES

–  Coverage for pre-existing conditions (Ex: COPD, Lung CA)

v Affordable Plans –  Targeted for low-SES, but high premiums present affordability gap

for middle-income Americans –  Less than half (42%) of the uninsured can afford premiums of just

$100/month

ACA: PREMIUMS & PENALTIES

Goals & Regulations ● Annual fee for NO insurance ● Surcharge: Insurers and employers can charge tobacco users up to 1.5 times the regular premium ● Insurers in small group market must remove surcharge for a tobacco user who agrees to enroll in a program to help them quit

Unintended Effects •  Over 25% of the uninsured

population said that paying the tax penalty and health expenses costs less than paying for insurance

•  Average smoker may spend up to 20% of their annual income in premiums

Annual Fee for the Uninsured 2014: $95/adult, $47.50/child for up to $285/family,

OR 1% of household income, whichever is greater 2015: $325/adult, $162.50/child for up to $975/family,

OR 2% income, whichever is greater 2016: $695/adult, $374.50/child for up to $2,085/family,

OR 2.5% of income, whichever is greater (ALA, n.d.b)

ACA: MEDICAID EXPANSION (AS OF JANUARY 1, 2014)

Goals & Regulations •  Household income of 133%

of FPL or less → now eligible •  133% FPL= $16,243/year

(individual), or $33,465/year (family of four)

•  Federal government will pay for 100% of coverage

•  Minorities and low-SES most affected by expansion

Unintended Effects • States are able to set their out-of-pocket costs with copays, co-insurance, and deductibles • 23 states opted out of the Medicaid expansion, including Texas • *TEXAS = 15% of FPL*

–  Family of 3 earning >$3,700/year are “too rich” to qualify

–  Coverage gap, low-SES unaffected

(ALA, 2014b)

ACA: TOBACCO CESSATION

Goals & Regulations • ‘A’ grade by USPSTF = covered by most health plans • 2010: Comprehensive cessation free for pregnant women • 2014: Medicaid programs no longer able to exclude tobacco cessation medications from their prescription drug coverage

Unintended Effects •  No definition for treatments

included (meds/counseling) •  Guidance for what plans should

include, not actual policy •  Coverage ≠ Preferred! •  Providers often unaware of

covered services available to offer

(ALA, n.d.a; ALA, 2014a)

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Treatment Guidelines: 5As •  Ask: tobacco use at every encounter

•  Advise: advise all smokers to quit

•  Assess: identify smokers willing to make a quit attempt

•  Assist: medication, counseling, exercise

•  Arrange: frequent follow-up visits – Consider referral to intensive program

COUNSELING SESSION TOPICS

•  Week 1: Safely using NRT: dosage, times, side effects •  Week 2: Pairing participants with a “quit buddy” •  Week 3: Exciting things to do in place of smoking •  Week 4: Knowing your triggers and how to overcome •  Week 5: Avoiding people and places that sabotage success •  Week 6: Getting support from family and friends •  Week 7: Hearing success stories from ex-smokers •  Week 8: Being successful in long-term maintenance

(Chaney & Sheriff, 2012)

EXERCISE INTERVENTIONS

•  Weight gain has been identified as a barrier to smoking cessation among women. Regular exercise can prevent the normal weight gain seen when women stop smoking.

•  Exercise program of 45 minutes of aerobic walking for 3 x a week in the community

•  After 12 months, the experimental groups of walkers were able to quit smoking and continue to exercise.

(Chaney, Sheriff, & Merritt, 2015)

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(CDC, 2015b)

JUSTIFICATION •  Exercise training may help to improve

long-term maintenance of smoking cessation in women. Few studies have examined exercise.

•  Men have more success with nicotine replacement therapy (NRT) and staying abstinent. They restart smoking because they see a cigarette and want it.

PHARMACOTHERAPEUTICS

•  All smokers should be offered medication, except when contraindicated (pregnant women, smokeless tobacco users, light smokers and adolescents).

•  The 7 first-line medications include: Buproprion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch and varenicline.

•  All 7 FDA approved medications have specific contraindications, warnings, precautions and concerns, and side effects.

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PHARMACOTHERAPEUTICS

•  Higher doses of nicotine gum, lozenge and patch have been shown to be effective in highly dependent smokers.

•  Consider prescribing second-line agents, such as Clonidine and Nortriptyline for patients unable to use first-line agents.

•  Data show that Buproprion SR and NRTs (gum and lozenge) delay, but do not prevent, weight gain.

•  NRTs are safe to use in cardiovascular patients except in recent MI, serious arrhythmias or USA.

•  Combining first-line agents increases long-term abstinence rates. (see recommendations)

PHARMACOLOGICAL INTERVENTION Five first-line: Nicotine gum Nicotine patch Nicotine nasal spray Nicotine inhaler Nicotine lozenge Bupropion SR (Zyban) Varenicline (Chantix) Category C: Buproprion and Varenicline Category D: Nicotine gum, patch, nasal spray, inhaler

Nicotine replacement

therapies (NRT)

(CDC, 2014b)

Available: • Exclusively as an over-the-counter medication • 2 mg and 4 mg (per piece) doses Dosage: • 2 mg gum initially for patients smoking < 25 cigarettes/day • 4 mg for smoker > 25 cigarettes/day or failed with 2 mg • Do not exceed 30 pieces per day for using 2 mg strength • Do not exceed 20 pieces per day for using 4 mg strength Duration: • Usually for the first few months of quit attempt • Should tailor the dosage and duration of the therapy to fit the need of each patient (USDHHS, 2014)

FIVE FIRST-LINE NRT: Adverse Effects: • Mouth soreness, hiccups, dyspepsia and jaw ache

Instructions: • Patient should refrain from smoking while using the gum • Chewed slowly until a “peppery” taste emerges, then “parked” slowly between cheek and gum to facilitate nicotine absorption through the oral mucosa • Gum should be intermittently chewed and parked for about 30 minutes

(USDHHS, 2014)

FIVE FIRST-LINE NRT:

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Available: Both as an OTC and a prescription medication patch.

BRAND DOSAGE (mg/h)

DURATION (WEEKS)

NICODERM & HABITROL

21/24 14/24 7/24

4 then 2 then 2

PROSTEP 22/24 11/24

4 then 4

NICOTROL 15/16 10/16 5/16

4 then 2 then 2

(Papadakis & McPhee, 2013)

FIVE FIRST-LINE NRT: Adverse Effects: • 50% of patients will have a local skin reaction, usually mild • Local treatment with hydrocortisone cream 1% or triamcinolone cream 0.5% with rotation of sites are effective

Instructions: • Patient should refrain from smoking while using the patch • Should place a new patch on a relatively hairless location between the neck and the waist • Patches should be applied as soon as patient awakens on their quit day

FIVE FIRST-LINE NRT:

Available: Only as a prescription medication.

Dosage: 0.5mg delivery to each nostril (1 mg total ). Initial 1-2 dose per hours, increasing prn for symptom relief. Minimum recommended treatment: 8 doses/day, with maximum limit of 40 doses/day (or 5 doses/hour)

Duration: 3-6 months

Adverse Effects: Bronchospasm, mouth/throat irritation, cough, H/A, rhinitis, sinusitis, and taste change

Precaution: Hypersensitivity to menthol, MI acute in 2 weeks, pulmonary diseases, asthma, and pregnancy

Instruction: Should not sniff, swallow, or inhale while administering doses because this increases irritating effects

FIVE FIRST-LINE NRT: FIVE FIRST-LINE NRT: Available: Only as a prescription medication.

Dosage: A dose from the nicotine inhaler consists of a puff or inhalation. Each cartridge delivers a total of 4 mg of nicotine over 80 inhalations. Recommended dosage is 6–16 cartridges/day.

Duration: Recommended duration of therapy is up to 6 months. Instruct patient to taper dosage during the final 3 months of treatment.

Adverse Effects: Local irritation in the mouth and throat was observed in 40% of patients using the nicotine inhaler. Coughing (32%) and rhinitis (23%) also were common. Severity was generally rated as mild, and the frequency of such symptoms declined with continued use.

Precaution: Hypersensitivity to menthol, MI acute in 2 weeks, pulmonary diseases, asthma, and pregnancy.

Instruction: Keep in pocket in cold weather; avoid acidic beverages w/i 15” before or after use.

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FIVE FIRST LINE NRT:

Available: OTC

Dosage: 2-4 mg doses. The 2 mg dose is recommended for those who smoke more than 30” after waking; 4mg dose within 30” of waking.

Duration: Use at least 9 lozenges/day in the first 6 weeks; use for up to 12 weeks; with no more than 20 lozenges to be used per day.

Adverse Effects: Nausea, hiccups, heartburn; h/a and coughing with higher dosages.

Precaution: Pregnancy, CVD (recent MI, severe arrhythmias and USA).

Instruction: should be allowed to dissolve in mouth, do not chew or swallow it; avoid drinking anything but water w/i 15” before or after use;

Available: As a prescription medication.

Dosage: Begin with 150mg Q Am for 3 days, then increase to 150 mg BID, continued for 7-12 weeks following the quit day, begin 1-2 weeks before quitting smoking. Maintain therapy: 150mg BID up to 6 months.

Precaution: Pregnancy: should be used only if the increased likelihood of smoking abstinence, with its potential benefits, outweighs the risk of bupropion SR treatment and potential concomitant smoking.

Contraindications: Seizure disorder, eating disorder, or those who have used an MAO inhibitor in the past 14 days.

Adverse Effects: Insomnias (35-40%) and dry mouth (10%).

FIRST LINE:

(Papadakis & McPhee, 2013)

FIRST LINE: Available: by prescription

Dosage: Begin 1 week before quit date at 0.5mg daily x 3 d; 0.5mg BID x 4 d; f/b 1mg BID x 3months. (NOTE: Instruct to quit smoking on day 8 when 1mgBID begins)

Duration: May be used for up to 6 months.

Adverse Effects: Nausea, insomnia, vivid dreams

Precaution: Pregnancy Cat. C

Instruction: To reduce nausea, take on a full stomach. To reduce insomnia, take 2nd pill at supper rather than HS.

NOTE: In Feb. 2008, FDA added a warning regarding changes in behavior, suicidal ideation, depression and suicide. Obtain a psychiatric history and monitor for changes in mood or behavior.

SPECIAL SUB-POPULATIONS: PREGNANCY

•  Cigarette smoke contains thousands of chemicals, many of which may contribute to reproductive toxicity- of particular concern are carbon monoxide, nicotine, and oxidizing chemicals.

•  Because of the serious risks of smoking to the pregnant smoker and the fetus, whenever possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit.

•  As of October, 2010: ALL pregnant women with Medicaid can receive comprehensive cessation for free

•  Nicotine products for cessation are generally not recommended during pregnancy.

(ALA, 2014b)

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RELAPSE PREVENTION q  Congratulate, encourage, and stress importance of abstinence at every opportunity

q  Review benefits derived from cessation

q  Inquired about problems encountered and offer possible solutions

q  Anticipated problems or threats to maintaining abstinence

q  Help patient identify sources of support

q  Emphasize that beginning to smoke (even a puff )will increased urges and make quitting more difficult

q  Assess pharmacotherapy use and problems

q  Consider use or referral to more intensive treatment (group or individual counseling)

CONCLUSIONS Ø No single factor determines patterns of tobacco use. These patterns are the results of complex interactions of multiple factors, such as socioeconomic status, cultural characteristics, acculturation, stress, biological elements, targeted advertising, price of tobacco products, and varying capacities of communities to mount effective tobacco control initiatives.

Ø Rigorous surveillance and prevention research are needed on the changing cultural, psychosocial, and environmental factors that influence tobacco use to improve our understanding of racial/ethnic smoking patterns and identify strategic tobacco control opportunities.

(CDC, 2014b)

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REFERENCES Alverson, E., & Kessler, T. (2010). Relationships between lifestyle, health behaviors, and health status outcomes for

underserved adults. Journal of the American Academy of Nurse Practitioners, 24(6), 364-374. doi: 10.1111/j.1745-7599.2012.00697.x

American Lung Association. (n.d.a). Tobacco cessation as a preventive service: New guidance clarifies affordable care act provision. Retrieved from http://www.lung.org/stop-smoking/tobacco-control-advocacy/reports-resources/2014/tobacco-cessation-preventive-service.pdf

American Lung Association. (n.d.b). Tobacco surcharges. Retrieved from http://www.lung.org/stop-smoking/tobacco-control-advocacy/reports-resources/2013/factsheet-tobacco-surcharges-v2.pdf

American Lung Association. (2014a). Coverage of tobacco cessation medications in medicaid: Section 2502 of the affordable care act. Retrieved from http://www.lung.org/stop-smoking/tobacco-control-advocacy/reports-resources/tobacco-cessation-affordable-care-act/assets/factsheet-2014-medications.pdf

American Lung Association. (2014b). Tobacco cessation treatment and Medicaid in the affordable care act. Retrieved from http://www.lung.org/stop-smoking/tobacco-control-advocacy/reports-resources/2012/factsheet-tobacco-and-the-medicaid-expansion.pdf

Bock, B. C., Papandonatos, G. D., Stein, M. A., De Dios, M. B., Abrams, D. M., Niaura, R. J., . . . Sweeney, P. (2014). Tobacco cessation among low-income smokers: Motivational enhancement and nicotine patch treatment. Nicotine and Tobacco Research, 16(4), 413-422. doi: 10.1093/ntr/ntt166

Businelle, M., Kendzor, D., Reitzel, L., Costello, T., Cofta-Woerpel, L., Li, Y., . . . Kaplan, Robert M. (2010). Mechanisms Linking Socioeconomic Status to Smoking Cessation: A Structural Equation Modeling Approach. Health Psychology, 29(3), 262-273. doi:10.1037/a0019285

Centers for Disease Control and Prevention. (2015a). Smoking and tobacco use: Fast facts. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/

Centers for Disease Control and Prevention. (2015b). Smoking and tobacco use: Quitting smoking. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/

Chaney, S., & Sheriff, S. (2008). Weight gain among women during smoking cessation: Testing the effects of a multi-faceted program. American Association of Occupational Health Nurses Journal, 56(3), 99-105.

Chaney, S.E., & Sheriff, S. (2012). Evidence-based treatments for smoking cessation. The Nurse Practitioner, 37(4), 25-31.

Chaney, S.E., Sheriff, S.W., & Merritt, L. (2015). Gender differences in smoking behavior and cessation. Clinical Nursing Studies, 3(3), 17-22. doi: 10.5430/cns.v3n3p17

Department of Health. (n.d.). Medically underserved areas- Populations. Retrieved from http://doh.dc.gov/service/medically-underserved-areas-populations

Fu, S., Van Ryn, M., Burgess, D., Nelson, D., Clothier, B., Thomas, J., . . . Joseph, A. (2014). Proactive tobacco treatment for low income smokers: Study protocol of a randomized controlled trial. BMC Public Health, 14(337), 1-9. doi: 10.1186/1471-2458-14-337

Harley, A., Yang, M., Stoddard, A., Adamkiewicz, G., Walker, R., Tucker-Seeley, R., . . . Sorensen, G. (2014). Patterns and predictors of health behaviors among racially/ethnically diverse residents of low-income housing developments. American Journal of Health Promotion, 29(1), 59-67. doi: 10.4278/ajhp.121009-QUAN-492

REFERENCES (CONTINUED)

Okuyemi, K., Caldwell, A., Thomas, J., Born, W., Richter, K., Nollen, N., . . . Ahluwalia, J. (2006). Homelessness and smoking cessation: Insights from focus groups. Nicotine & Tobacco Research,8(2), 287-296. doi: 10.1080/14622200500494971

Papadakis MA, & McPhee, S.J. (2013) Current medical diagnosis & treatment 2011. 52nd ed. New York: McGraw-Hill Medical.

Seidenberg, A., Caughey, R., Rees, V., & Connolly, G. (2010). Storefront cigarette advertising differs by community demographic profile. American Journal of Health Promotion, 24(6), E26-31. doi: 10.4278/ajhp.090618-QUAN-196

Transamerica Center for Health Studies. (n.d.). One year in: Americans respond to the affordable care act, fact sheet: The uninsured. Retrieved from https://www.transamericacenterforhealthstudies.org/docs/default-source/fact-sheets/2014-gen-pop-fact-sheet---uninsured.pdf?sfvrsn=2

U.S. Department of Health and Human Services. (2014). A report of the surgeon general: The health consequences of smoking – 50 years of progress. Retrieved from http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf

U.S. Department of Health & Human Services. (2015). Health insurance coverage and the affordable care act. Retrieved from http://aspe.hhs.gov/sites/default/files/pdf/83966/ib_uninsured_change.pdf

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Healthy People 2020. (2015). Tobacco: Latest data. Retrieved from http://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Tobacco/data

REFERENCES (CONTINUED)