California Smokers Research Articles

The role of multiple social identities in discrimination and perceived smoking-related stigma among sexual and gender minority current or former smokers

Aims: We investigated how intersections of being a racial minority (i.e. being African American) and economically disadvantaged (i.e. housing insecurity) may influence experiences with discrimination and perceptions of smoking-related stigma among sexual and gender minority (SGM) current and former smokers.Methods: Survey data were collected from 227 SGM current and former smokers in California (19–65 years old), oversampling African American participants. Participants reported their race, ethnicity, past month housing insecurity, number of lifetime experiences with SGM discrimination, and perceptions of smoking-related stigma.Findings: Using univariate General Linear Models and controlling for age, ethnicity, and SGM visibility, we found a significant interaction between being African American and facing housing insecurity on experiences with SGM discrimination [F(1,220) = 7.21, p = .01], perceived smoker stigma [F(1,220) = 5.48, p = .02], perceived differential treatment due to smoking [F(1,220) = 10.03, p = .00], and social withdrawal from nonsmokers [F(1,220) = 6.18, p = .01]. These interactions suggest that economically disadvantaged African American SGM current or former smokers experience increased levels of SGM discrimination and perceive more smoking-related stigma compared with other SGM current and former smokers.Conclusions: Results suggest that people’s multiple identities intersect to intensify oppression and inequities for some people and raise questions about the unintended consequences of stigmatizing smokers for reducing smoking among SGM adults.

Tax Evasion and Illicit Cigarettes in California: Part I Survey Evidence on Current Behavior

Data from a novel online survey of 5,000 English-speaking adult cigarette smokers in California in advance of a recent increase in the state’s cigarette excise tax indicate that slightly more than one-quarter of that population engaged in some legal tax-avoiding behavior in the previous month, while nearly one-fifth illegally evaded taxes. (The two behaviors overlapped substantially.) Candor-inducing indirect questioning via the item count technique substantially increased those figures. Smokers who roll their own cigarettes, e-cigarette users, younger smokers, and those with more income and education are all more likely to engage in at least some of the suspect market behaviors examined. There is a much lower incidence of counterfeit product and sales of single cigarettes. This suggests that the tax increase may lead to significant amounts of adaptive behavior by smokers that will tend to reduce the intended health benefits of that policy change.

Trajectories of Responses to Pictorial Cigarette Pack Warnings.

Pictorial warnings on cigarette packs are a cost-effective policy-level intervention for smoking cessation; however, little research has examined changes in the impact of warnings over time, especially shortly following the first exposure to pictorial warnings. We sought to characterize the trajectories of responses to pictorial cigarette pack warnings soon after first exposure. Participants were 2149 adult smokers in North Carolina and California, United States. In 2014-2015, we randomized smokers to have pictorial (intervention) or text-only (control) warnings on their cigarette packs for 4 weeks. Weekly surveys assessed psychosocial and behavioral outcomes. After 1 week, smokers in the intervention arm reported higher levels of most outcomes, compared with the control arm. Over subsequent weeks, smokers in both trial arms had decreases in thinking about the harms of smoking (β = -0.046), positive (β = -0.036), and negative (β = -0.042) smoking reinforcement attitudes, and increases in quit intentions (β = 0.070) and cigarette forgoing (β = 0.137) (all p < .05). Only negative affective reactions decreased more in the intervention versus control condition (pinteraction < .01). The impact of pictorial cigarette pack warnings on emotions and cognitions may wane over time. In contrast, quit intentions and cigarette forgoing may continue to increase, at least during the initial period after introduction. Rotation of pictorial warnings may help prevent warning wear-out. Cigarette smoking is the leading cause of preventable morbidity and mortality and warnings on cigarette packs are a cost-effective policy-level intervention. Prior studies reporting on cigarette pack warning "wear out" have been limited by being short-term single-session experimental studies. Ours are the first study to experimentally examine the trajectories of several outcomes after first exposure and report that the impact of pictorial cigarette pack warnings on emotions and cognitions may wane over time while quit intentions and cigarette forgoing may continue to increase. ClinicalTrials.gov identifier: NCT02247908; https://clinicaltrials.gov/ct2/show/NCT02247908.

Impact of Smoking Cessation Counseling Prior to Total Joint Arthroplasty.

Perioperative smoking has been linked to surgical complications including poor wound healing, infection, myocardial infarction, prolonged length of stay, need for mechanical ventilation, and death. This study evaluated the effectiveness of preoperative counseling on smoking cessation for patients undergoing elective total joint arthroplasty. Thirty smokers with hip or knee osteoarthritis seeking hip or knee replacement surgery were enrolled prospectively. Interventions included counseling, referrals to smoking cessation programs including the California Smokers' Helpline and the Fontana Tobacco Treatment Program, nicotine replacement therapy (NRT), or instructing patients quit through the "cold turkey" method of abstinence. Patients were scheduled for surgery if they demonstrated abstinence from smoking, confirmed via expired carbon monoxide (CO) breath testing. Short- and long-term smoking cessation rates were evaluated. Thirty patients were enrolled; 21 patients (70%) passed the CO test, whereas 9 patients (30%) failed or did not follow up with a CO test. Thirteen of 21 patients (62%) quit using the "cold turkey" method, 5 of 21 patients (24%) quit using NRT, and 3 of 21 patients (14%) quit using outpatient treatment programs. Eighteen of 21 patients (86%) who quit smoking underwent surgery, and 14 patients had surgery within 6 months of smoking abstinence. Nine of the 14 patients (64%) remained smoke-free 6 months postoperatively confirmed through telephone questionnaire. These results suggest that elective surgery offers a strong incentive for patients to quit smoking, and surgeons can play a role offering a teachable moment and motivating this potentially life-altering behavioral change. [Orthopedics. 2017; 40(2):e323-e328.].

Recruiting Diverse Smokers: Enrollment Yields and Cost.

To help tobacco control research better include vulnerable populations, we sought to identify effective ways to recruit diverse smokers. In 2014–2015, we recruited 2149 adult cigarette smokers in California and North Carolina, United States, to participate in a randomized trial of pictorial cigarette pack warnings. The most effective means of recruiting smokers were the classified advertising website Craigslist (28% of participants), word of mouth (23%), Facebook (16%), and flyers or postcards (14%). Low-income and African American smokers were more likely to respond to interpersonal contact (including staff in-person recruitment and word of mouth) than were high-income and non-African American smokers (all p < 0.05). Hispanic and gay, lesbian, and bisexual smokers were more likely to be recruited by Craigslist than non-Hispanic and straight smokers (both p < 0.05). Of the recruitment methods requiring cost, the cheapest was Craigslist ($3–7 per smoker). The most expensive methods were newspaper ads in California ($375 per smoker) and staff in-person recruiting in North Carolina ($180 per smoker). Successfully recruiting diverse smokers requires using multiple methods including interpersonal, online, and other media. Craigslist and word of mouth are especially useful and low-cost ways to recruit diverse smokers.

The relationships among physical activity, sedentary behaviour, obesity and quitting behaviours within a cohort of smokers in California

BackgroundSmoking, insufficient physical activity (PA), sedentary behaviour (SB) and obesity are leading risk factors for morbidity and premature mortality. Few studies examining the relationship between these behavioural risk factors and quitting behaviours among cohorts of smokers have been published. PurposeThe goals of this study are to examine the cross-sectional relationships among behavioural health risk factors (insufficient PA, SB and obesity) and past year quitting behaviours within a sample of smokers. MethodsThe California Smokers Cohort, conducted from 2011 through 2013, is a population-based survey of adult smokers in California. Using follow-up data (n = 1050), participants' self-reported health behaviours and past year quitting behaviours were examined in univariate analyses and multivariate logistic regression analyses controlling for demographic covariates. ResultsIn univariate analyses examining health behaviours among smokers, all three health behaviours examined (PA, SB and obesity) were related, and significantly more obese smokers with high PA and low SB reported a ≥20% smoking rate reduction than smokers with other combinations of health behaviours (48.8%, Chi-squared = 4.765, P = 0.045). In multivariate models adjusted for sociodemographic characteristics, obese smokers (odds ratio [OR] = 1.450, 95% confidence interval [CI]: 1.088–1.932, P = 0.011) and smokers with higher levels of PA (OR = 1.448, 95% CI: 1.111–1.887, P = 0.006) were more likely to report a past year ≥24-hour quit attempt regardless of SB, and obese smokers (OR = 1.760, 95% CI: 1.095–2.828, P = 0.019) were more likely to report being quit for ≥30 days regardless of PA and SB. ConclusionsOverall, the results demonstrated that more physically active and obese smokers were more likely to report positive strides towards quitting. These findings support the potential positive effect of addressing multiple health behaviours along with smoking.

Social Interactions as a Source of Information about E-Cigarettes: A Study of U.S. Adult Smokers.

The novelty of e-cigarettes and ambiguity about their effects may foster informal sharing of information, such as through social interactions. We aimed to describe smokers’ social interactions about e-cigarettes and their recommendations that others use e-cigarettes. Data were collected from 2149 adult smokers in North Carolina and California who participated in a study of the impact of pictorial cigarette pack warnings. In the previous month, almost half of participants (45%) reported talking to at least one person about e-cigarettes and nearly a third of participants (27%) recommended e-cigarettes to someone else. Smokers recommended e-cigarettes to cut back on smoking (57%), to quit smoking (48%), for health reasons (36%), and for fun (27%). In adjusted analyses, more frequent e-cigarette use, positive views about typical e-cigarette users, and attempting to quit smoking in the past month were associated with recommending e-cigarettes for health reasons (all p < 0.05). Social interactions appear to be a popular method of information-sharing about e-cigarettes among smokers. Health communication campaigns may help to fill in the gaps of smokers’ understanding of e-cigarettes and their long-term effects.

Taiwan Report on Quitline Activities.

Aiming at reducing the smoking population, the Taiwan government adopted a successful smoking cessation quitline model from California Smokers' Helpline, commissioned a private non-profit organization-Teacher Chang Foundation, which was well-known for its quality telephone counseling service-to set up Asia's first quitline, Taiwan Smokers' Helpline (TSH) in 2003. The establishment of the quitline constituted significant progress for tobacco control in Taiwan, as it built up a cooperative model with smoking cessation clinics to increase the quit rate through assisting smokers to overcome their psychological obstacles encountered while attempting to quit smoking.

The Clinical Effort against Secondhand Smoke Exposure (CEASE) California: Implementing a Pediatric Clinical Intervention to Reduce Secondhand Smoke Exposure

Introduction: The Clinical Effort against Secondhand Smoke Exposure (CEASE) is an evidence based intervention to reduce secondhand smoke exposure (SHSE) in children. The goals of this study were: 1. To improve pediatric providers’ perceived knowledge of the consequences of and need for SHSE screening. 2. Increase screening rates of SHSE and the provision of smoking cessation support services for identified smokers including nicotine replacement therapy (NRT) and referrals to the California Smoker’s Helpline (Helpline). Methods: Pediatric clinics in Northern California were trained to implement CEASE. The evaluation had three components: (1) An evaluation of the training and its impact on participants’ knowledge and ability to implement CEASE (via anonymous post-training survey). (2) Referrals received by the California Smokers’ Helpline (Helpline); and (3) pre-post changes in perceived knowledge, screening practices, and provision of smoking cessation support (nicotine replacement therapy prescriptions and referrals to the Helpline) to family members who were identified as smokers (using a retrospective pre-post design). In addition, clinician champions were interviewed to gather information on barriers and facilitators to the implementation of CEASE 6 months after the training. Result: A total of 24 practice sites with 315 staff were trained to implement CEASE. Training participants rated the quality of the training high and most either strongly agreed or agreed that the training improved their knowledge and ability to implement CEASE. Referrals to the Helpline increased significantly and there were significant pre-post improvements in the provision of smoking cessation support services but not in rates of screening for SHSE. Barriers and facilitators to implementing CEASE are discussed. Conclusion: The CEASE California training is a practical and replicable model for pediatric providers to screen patients for SHSE and provide smoking cessation support services. Practice support tools, on-site champions, and coverage for NRT facilitated implementation of CEASE. However, not all patients referred to the Helpline followed up and there was no system for providers to track referrals. In addition, in-person trainings are costly and require significant travel time. Future interventions should leverage electronic health records to facilitate screening for SHSE and to improve referral and follow-up care for smokers. Future studies should examine other training modalities to more cost-effectively disseminate the CEASE training.

E-Cigarette Use in the Past and Quitting Behavior in the Future: A Population-Based Study

We examined whether smokers who used e-cigarettes are more likely to quit after 1 year than smokers who had never used e-cigarettes. We surveyed California smokers (n = 1000) at 2 time points 1 year apart. We conducted logistic regression analyses to determine whether history of e-cigarette use at baseline predicted quitting behavior at follow-up, adjusting for demographics and smoking behavior at baseline. We limited analyses to smokers who reported consistent e-cigarette behavior at baseline and follow-up. Compared with smokers who never used e-cigarettes, smokers who ever used e-cigarettes were significantly less likely to decrease cigarette consumption (odds ratio [OR] = 0.51; 95% confidence interval [CI] = 0.30, 0.87), and significantly less likely to quit for 30 days or more at follow-up (OR = 0.41; 95% CI = 0.18, 0.93). Ever-users of e-cigarettes were more likely to report a quit attempt, although this was not statistically significant (OR = 1.15; 95% CI = 0.67, 1.97). Smokers who have used e-cigarettes may be at increased risk for not being able to quit smoking. These findings, which need to be confirmed by longer-term cohort studies, have important policy and regulation implications regarding the use of e-cigarettes among smokers.

Predicting use of assistance when quitting: A longitudinal study of the role of quitting beliefs

BackgroundA growing literature addresses the need to reduce cigarette smoking prevalence by increasing the use of assistance when quitting. A key focus is to identify strategies for enhancing adoption of effective interventions in order to increase utilization of evidence-based treatments. PurposeTo examine the effect of beliefs regarding ability to quit on utilization of assistance for smoking cessation. A mediation model was hypothesized whereby the relationship between smoking and use of assistance is influenced by beliefs in ability to quit. MethodsThe present study includes 474 of 1000 respondents to baseline and follow-up California Smokers Cohort surveys conducted from 2011 to 2013. Included were baseline smokers who reported a 24-h quit attempt at follow-up. Baseline variables were used to predict use of assistance when quitting. ResultsThe hypothesized model was tested using a product of coefficients method, controlling for demographics. Greater heaviness of smoking and lower belief in ability to quit were significantly related to use of assistance. Quitting beliefs significantly mediated the relationship between nicotine dependence and use of assistance. ConclusionsThe present data support a mechanism whereby the effect of smoking rate on treatment utilization is mediated by beliefs in ability to quit. Greater belief in one's ability to quit may represent an obstacle to treatment utilization by reducing the likelihood of successful cessation. The present findings suggest the value of targeted messages from health care providers that normalize the need for assistance when attempting to change an addictive behavior and emphasize the difficulty of quitting without assistance.

Recall of anti-tobacco advertisements and effects on quitting behavior: results from the California smokers cohort.

We assessed whether an anti-tobacco television advertisement called "Stages," which depicted a woman giving a brief emotional narrative of her experiences with tobacco use, would be recalled more often and have a greater effect on smoking cessation than 3 other advertisements with different intended themes. Our data were derived from a sample of 2596 California adult smokers. We used multivariable log-binomial and modified Poisson regression models to calculate respondents' probability of quitting as a result of advertisement recall. More respondents recalled the "Stages" ad (58.5%) than the 3 other ads (23.1%, 23.4%, and 25.6%; P<.001). Respondents who recalled "Stages" at baseline had a higher probability than those who did not recall the ad of making a quit attempt between baseline and follow-up (adjusted risk ratio [RR]=1.18; 95% confidence interval [CI]=1.03, 1.34) and a higher probability of being in a period of smoking abstinence for at least a month at follow-up (adjusted RR=1.55; 95% CI=1.02, 2.37). Anti-tobacco television advertisements that depict visceral and personal messages may be recalled by a larger percentage of smokers and may have a greater impact on smoking cessation than other types of advertisements.

Positive and instructive anti-smoking messages speak to older smokers: a focus group study.

BackgroundSmokers over the age of 45 are the only group with an increase in smoking prevalence, are the least likely to quit smoking, and bear most of the burden of tobacco-related disease. Research characterizing older adult perceptions of warning labels and anti-tobacco messages has not been reported in the literature. The purpose of this study was to describe whether older smokers perceived warning labels and anti-tobacco messages as effective for the promotion of smoking cessation. A secondary aim was to explore what types of messages and message delivery formats are most relevant to older adult smokers.MethodsThis focus group study is part of a larger study to characterize older smokers’ perceptions of the risks and benefits associated with conventional and emerging tobacco products and determine the extent to which these perceptions relate to exposure to pro- and anti-tobacco messages. From April 2013 to August 2014 we conducted eight focus groups with 51 current and former smokers a focus group study in urban and suburban California. A semi-structured format about current use of conventional and emerging tobacco products was used. Participants were asked to recall and comment on examples of warning labels and anti-tobacco messages. Data were transcribed and thematically coded.ResultsWarning labels and anti-smoking messages were seen as ineffective for smoking cessation motivation among older California smokers. Positive framed anti-tobacco messages were identified as most effective. Text-only warnings were seen as ineffective due to desensitizing effects of repeated exposure. Negative messages were described as easy to ignore, and some trigger urges to smoke. Older adults are knowledgeable about the risks and health effects of smoking. However, they tend to be less knowledgeable about the benefits of cessation and may underestimate their ability to quit.ConclusionThese findings suggest that messages with a positive frame that outline immediate and long-term benefits of cessation would be an effective approach for long-term smokers.Current anti-tobacco messaging was generally not seen as effective for smoking cessation among long-term smokers.Electronic supplementary materialThe online version of this article (doi:10.1186/s12971-015-0027-x) contains supplementary material, which is available to authorized users.

Maximizing the Impact of Digital Media Campaigns to Promote Smoking Cessation

Digital media are often used to encourage smoking cessation by increasing quitline call volume through direct promotion to smokers or indirect promotion to smoker proxies. The documentation of a program's experiences utilizing digital media is necessary to develop both the knowledge base and a set of best practices. This case study highlights the use of digital media in a proxy-targeted campaign to promote the California Smokers' Helpline to health care professionals from October 2009 to September 2012. We describe the iterative development of the campaign's digital media activities and report campaign summaries of web metrics (website visits, webinar registrations, downloads of online materials, online orders for promotional materials) and media buy (gross impressions) tracking data. The campaign generated more than 2.7 million gross impressions from digital media sources over 3 years. Online orders for promotional materials increased almost 40% over the course of the campaign. A clearly defined campaign strategy ensured that there was a systematic approach in developing and implementing campaign activities and ensuring that lessons learned from previous years were incorporated. Discussion includes lessons learned and recommendations for future improvements reported by campaign staff to inform similar efforts using digital media.

Disseminating tobacco control information to Asians and Pacific Islanders.

The Asian Grocery Store-Based Cancer Education Program (the Program) is a proven strategy for promoting early breast cancer detection among Asian American women. The authors sought to test whether the same public health model can become an effective strategy for increasing the Asian community's awareness of the California Smokers' Helpline (the Helpline) and thereby, potentially decreasing this community's use of tobacco products. The new module, mainly staffed by four well-trained, volunteer undergraduates, explained the risks of first- and second-hand tobacco exposure and how to access the Helpline's services. A brochure, provided in English, Chinese, Korean, and Vietnamese (the Helpline's available Asian languages), was used to guide the bicultural, bilingual students' tobacco-related discussions with shoppers. The students' repeated presence at the nine partnering Asian grocery stores served as reminders of the Helpline's availability. In its first year of operation, the student trainers reached 1,052 men and 1,419 women with tobacco cessation messages. Equally important, the participating grocery stores' managers did not object to students telling their customers to quit using the tobacco products sold in their stores. The results suggest that the Program's tobacco cessation module is a viable, community-specific, public health strategy. It is also a strategy with the potential for applications to reduce other health threats.

Abstract P136: Relationships between Health Behaviors and Physical &amp; Mental Health among Smokers in California

Background: Tobacco use, physical inactivity (PA), and sedentary behavior (SB) are leading behavioral risk factors for mental and physical health problems. The combination of smoking and other unhealthy lifestyle behaviors heightens the risk from smoking alone. Examining the relationships between health behaviors and health problems in a representative sample of California smokers enables quantification of the negative health effects of engaging in multiple unhealthy lifestyle behaviors over and above any adverse health effects from smoking alone. Methods: The 2011 California Longitudinal Smokers Survey (CLSS) surveyed smokers who participated in the previous 2009 California Health Interview Survey (CHIS), a population-based random sample of California residents. The present analyses included 1,718 current smokers surveyed again two years after participating in CHIS. The sample respondents were weighted to the age, gender, geographic place of residence, and ethnicity of the population of all adult California smokers. For the current analyses, physical inactivity was defined as &lt;10 minutes of sustained PA per week; a high level of SB was defined as ≥2 hours of leisure screen time per day; obesity was determined via calculated body mass index (BMI≥30) based on respondents’ self-reported height and weight; and elevated depressive and anxiety symptoms were determined via responses to two questions comprised of clusters of symptoms for each condition on the Patient Health Questionnaire for Depression and Anxiety (PHQ-4) instrument. Results: Results revealed a significant relationship between physical inactivity and obesity (t=3.5, p &lt; 0.001) and an interaction between sex and physical inactivity, such that male smokers who reported &lt;10 min/week of PA were more likely than male smokers who reported ≥10 min/week of PA to be obese (t=2.8, p&lt; 0.01). Physical inactivity was also associated with elevated anxiety symptoms among smokers (t=2.9, p&lt;0.01). Smokers who reported ≥2 hours/day of leisure time SB were more likely to report ever receiving a diagnosis of heart disease by a physician (t=3.3, p&lt;0.005). SB was also associated with elevated depressive symptoms among smokers (t=3.7, p&lt;0.001). Conclusion: The combination of smoking and physical inactivity or excessive SB is associated with worse mental and physical health than smoking alone. The American Heart Association encourages individuals to improve their cardiovascular health by quitting smoking, increasing PA, reducing SB, and maintaining a healthy weight. Public health efforts to increase awareness of the significant benefits of improving these and other health behaviors rely upon the collection, analysis, and publication of data demonstrating the associations between health behaviors and outcomes.

Smokers who report smoking but do not consider themselves smokers: a phenomenon in need of further attention

BackgroundHeightened stigma surrounding the action of smoking may decrease the likelihood that individuals who engage in smoking identify with the label ‘smoker’. Non-identifying smokers (NIS) may undermine accurate smoking prevalence...

Smoking ban policies and their influence on smoking behaviors among current California smokers: A population-based study

ObjectiveTo assess whether smoking ban policies are associated with smoking reduction and quit attempts among California smokers. MethodsData were examined for 1718 current smokers from follow-up telephone interviews conducted in 2011 of persons previously identified as smokers in a representative sample of the adult population of California. Population weighted logistic regressions controlling for demographic and other variables were used to evaluate the association between smoking ban policies (home, work, and town) and changes in tobacco use (past year quit attempt or reduction in smoking rate). ResultsLiving in a home with a total ban was significantly associated with smoking reduction (adjusted odds ratio, AOR: 2.4, 95% CI: 1.4–4.2) and making a quit attempt (AOR: 2.3, 95% CI: 1.3–3.9) compared to living in a home with no home ban. Self-reported perception of an outdoor ban in one's city/town was associated with smoking reduction (AOR: 1.7, 95% CI: 1.02–2.7) and making a quit attempt (AOR: 1.8, 95% CI: 1.05–2.9). ConclusionThese results indicate that smoking bans not only protect nonsmokers from the harms of secondhand smoke, but are also associated with smoking reduction and cessation.

Perceived Price Sensitivity by Ethnicity and Smoking Frequency Among California Hispanic and Non-Hispanic White Smokers

Little is currently known about price sensitivity across ethnic groups as well as for non-daily smokers. To address this issue, this study compared perceived price sensitivity across smoking status (daily and non-daily) and within ethnicity (Hispanic and non-Hispanic White) in a recent representative population survey of California smokers. This study employed data from the 2008 California Tobacco Survey (CTS), a large population-based random-digit-dialed telephone survey. Participants were 1,777 non-Hispanic White and 450 Hispanic respondents who had smoked at least 100 cigarettes and currently smoked daily or on some days. Differences in perceived price sensitivity were found by ethnicity when controlling for age, gender, and cigarette consumption. Comparisons across ethnic groups indicated that Hispanic smokers, in general, have more price-sensitive perceptions than non-Hispanic White smokers. However, daily versus non-daily status had no effect on price sensitivity when controlling for cigarette quantity. These findings indicate that pricing increases may be differentially influential for Hispanic compared with non-Hispanic White smokers across smoking status categories.

Collaborating With Diabetes Educators to Promote Smoking Cessation for People With Diabetes

Smoking exacerbates the harmful effects of diabetes by increasing risk of diabetes-related complications such as cardiovascular disease, stroke, nephropathy, and neuropathy. To address the smoking cessation needs of people with diabetes, a partnership was formed among diabetes educators, the California Department of Public Health's Diabetes and Tobacco Control Programs, and the California Smokers' Helpline. A task force composed of 8 diabetes educators voluntarily designed and implemented a statewide educational campaign titled, "Do You cAARd?" The program aimed to promote referrals to the state's tobacco quitline by diabetes educators. Intervention activities included development of a "toolkit" for diabetes educators, presentations at American Association of Diabetes Educators chapter meetings, distribution of pocket-sized smoking cessation materials, and a print media campaign. The campaign reached 170 diabetes educators directly via educational presentations. A post-campaign online survey of 46 diabetes educators showed 80% had referred clients to the Helpline for smoking cessation support, 76% knew the Helpline's phone number, and 70% had distributed Helpline materials. More than 700 toolkits were downloaded, potentially reaching as many as 75% of California's 900 diabetes educators. The percentage of Helpline calls from people with diabetes and the proportion of callers referred by health care providers also increased over time. This program partnership serves as a sustainable, efficient, replicable outreach model for smoking cessation.