摘要：Objectives. We developed a method to evaluate geographic and temporal variations in community-level risk factors and prevalence estimates, and used that method to identify communities in Massachusetts that should be considered high priority communities for smoking interventions. Methods. We integrated individual-level data from the Behavioral Risk Factor Surveillance System from 1999 to 2005 with community-level data in Massachusetts. We used small-area estimation models to assess the associations of adults’ smoking status with both individual- and community-level characteristics and to estimate community-specific smoking prevalence in 398 communities. We classified communities into 8 groups according to their prevalence estimates, the precision of the estimates, and temporal trends. Results. Community-level prevalence of current cigarette smoking among adults ranged from 5% to 36% in 2005 and declined in all but 16 (4%) communities between 1999 and 2005. However, less than 15% of the communities met the national prevalence goal of 12% or less. High smoking prevalence remained in communities with lower income, higher percentage of blue-collar workers, and higher density of tobacco outlets. Conclusions. Prioritizing communities for intervention can be accomplished through the use of small-area estimation models. In Massachusetts, socioeconomically disadvantaged communities have high smoking prevalence rates and should be of high priority to those working to control tobacco use. Tobacco use remains the leading cause of preventable chronic disease and death in the United States. 1 Each year, tobacco use is responsible for more deaths than automobile accidents, AIDS, homicides, suicides, and poisonings combined. 2 Although a decline in tobacco use in the United States is evident, 3 cigarette smoking continues to be a major challenge to public health. According to national data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS), approximately 95% of states, territories, metropolitan statistical areas, and counties do not meet the national goal of smoking prevalence rates of 12% or less among the adult population. 3 The Massachusetts Tobacco Control Program, established in 1993 to coordinate and implement the state's tobacco control efforts, has developed an extensive local infrastructure, delivered comprehensive media campaigns, and led public policy on tobacco use. 4 However, significant budget cuts after 2002 have made it difficult for the program to remain effective. One way to maintain the effectiveness of the program is to focus tobacco control efforts in communities with the greatest need. For this purpose, it is essential to be able to identify communities with high smoking prevalence and formulate health polices for the specific needs of those communities. For Massachusetts, the BRFSS is the only source of population-based information on tobacco use. However, the current BRFSS does not provide health statistics at the community level (i.e., town, small city, or subdivision of a large city), in part, because the BRFSS is designed primarily for providing statewide or metropolitan area health statistics and also because the majority of communities do not have adequate sample sizes for directly calculating prevalence rates with reasonable precision. For example, in 2005, more than 58% of the communities had a sample size smaller than 15 people, and only 22% had a sample size of 30 people or more. Methods for producing reliable community-level statistics are needed. With BRFSS data, we adapted mixed-effect logistic regression models to estimate and analyze geographic variations and temporal trends in smoking prevalence rates of 398 communities (including 339 towns and small cities, and 59 subdivisions of the 12 largest cities) in Massachusetts. Such information can assist in the planning of statewide tobacco control efforts and in the allocation of limited resources to those communities most in need.
