could provide convincing evidence of their ability to reduce smoking” (US DHEW
1978, p. 54).

The 1979 Surgeon General’s Report was a watershed for smoking prevention, as well
as other smoking issues. Two chapters were devoted exclusively to smoking among
young people and its prevention, Chapter 17 (“Smoking in Children and Adolescents:
Psychosocial Determinants and Prevention Strategies”) and Chapter 20 (“Youth Educa-
tion”) (US DHEW 1979b). In merging considerations of psychosocial smoking deter-
minants among youth with considerations of more traditionally phrased “educational”
programs, the 1979 Report reflected a critical transition in the development of preven-
tion approaches and in their treatment in the Surgeon General’s Reports. The introduc-
tion to Chapter 17 began with “It is possible that prevention programs directed at
children and adolescents have generally placed too much confidence in merely com-
municating knowledge about the dangers of smoking” (p. 17-5). The Chapter then
reviewed the range of psychosocial influences on youths’ decisions to smoke, and called
for including developmental and social psychological theory in the conceptual basis of
prevention programs.

Demographic and psychosocial correlates of smoking among adolescents and smok-
ing prevention approaches, with special reference to young girls and gender differen-
ces, were reviewed in the 1980 Surgeon General’s Report on the health consequences
of smoking for women (US DHHS 1980b). The 1981 Report on the changing cigarette
(US DHHS 1981) did not consider smoking prevention per se, but briefly reviewed data
on preferences among young smokers for cigarettes with various tar and nicotine levels.
The natural history and prevention of smoking among adolescents were considered
again in the 1982 Report on cancer (US DHHS 1982). Consensus was reached in this
Report: the newly developed prevention programs based on social psychological
theory were capable of a 50-percent reduction in smoking onset. The 1982 Report also
included data on smoking cessation among adolescents. Prevention programs were not
considered in the 1983 Report on cardiovascular disease (US DHHS 1983a), the 1985
Report on cancer and chronic lung disease in the workplace (US DHHS 1985a), or,
with the exception of its review of nonsmoking policies in the schools, in the 1986
Report on involuntary smoking (US DHHS 1986b). While several smoking prevention
programs were reviewed in the 1984 Report’s review of community studies of smoking
control, it was noted that, for the most part, community studies focused on smoking
cessation among adults, rather than on prevention (US DHHS 1984). Most recently,
the 1988 Surgeon General’s Report on nicotine addiction concluded that smoking
prevention should be integrated into substance abuse prevention programs for youth
(US DHHS 1988), though the specific program options available were not reviewed.

State Health Departments

State health department initiatives to curb tobacco use have increased in the past
decade (US DHHS 1986d). Many State health departments have established smoking
education programs (US DHHS 1986a). State departments of education and depart-
ments of health often serve as clearinghouses, compiling guides to existing prevention
resources (e.g., University of the State of New York 1979). Several State health depart-

401
ments have organized special committees to develop comprehensive smoking control
plans (Coye 1988; Minnesota Department of Health 1987; US DHHS 1986a), with most
focusing on prevention rather than cessation. Several of these plans are cited in Chap-
ter 7 (Table 20). Most notable among the plans is Minnesota’s, which, in addition to a
broad range of other prevention program and policy components, earmarks a portion
of the State cigarette excise tax to support smoking control initiatives (Minnesota
Department of Health 1987).

The 1986 inventory of State and local programs (US DHHS 1986d) described preven-
tion programs operating through 20 State departments of health, State interagency coali-
tions on smoking and health, and State departments of education. These prevention in-
itiatives include a variety of approaches: implementation of existing health curricula,
the development of specific new resources and guidelines, teacher training programs,
promotion of resource centers, and community and parent programs. In an additional
nine States, county organizations, including departments of health and interagency
coalitions, were listed as undertaking specific smoking prevention projects that were
most often curriculum based.

Other Organizations and Agencies

Although tobacco control is not their central mission, other institutions, agencies, and
medical societies integrate smoking prevention programs into materials for distribution
through schools and other settings. The program materials include the March of Dimes’
for (often) young, expectant mothers; National Institute on Alcohol Abuse and Al-
coholism materials on substance abuse (US DHHS 1986a); and the American Dental
Association materials on tobacco use, especially the use of smokeless tobacco and oral
disease.

Through their professional organizations and as individuals, physicians and other
health researchers have designed materials and presentations, primarily for school as-
semblies. The American Medical Association (AMA) (1987), the American Medical
Women’s Association, and Doctors Ought to Care (DOC) are among those organiza-
tions that have designed smoking prevention materials and currently promote their
delivery through school assemblies. Volunteers for Health Awareness, a society of
health researchers and health care providers in the Boston area, have delivered anti-
smoking assemblies to junior high school students each year since 1969 (Reif 1976; US
DHEW 1979b).

In collaboration with ALA and researchers at Lawrence Hall of Science at the Univer-
sity of California, Berkeley, the American Nonsmokers’ Rights Foundation (formerly
California Nonsmokers’ Rights Foundation) has also developed smoking prevention
curricula centered around a television documentary, “Death in the West” (Bailey 1985)
and a film entitled “Second Hand Smoke” (American Nonsmokers’ Rights Foundation
1986). Addiction and tobacco industry tactics are highlighted in the curricula (Califor-
nia Nonsmokers’ Rights Foundation 1983). The foundation has also developed an ad-
junct peer-led program called “Teens as Teachers” to complement use of the films.

By 1979, it was estimated that there were thousands of smoking prevention activities
independently undertaken by schools and community groups, programs largely neither

402
formally described nor evaluated (Evans et al. 1979: US DHEW 1979b). While there
is increasing documentation of programs on the national and State level (US DHHS
1986a, 1986b), program development and implementation by schools and communities,
as special events or as part of existing health education curricula, are far less likely to
be systematically recorded and evaluated.

Problems in Dissemination of Smoking Prevention Programs

Evaluation of the development and progress of prevention programs must include
both controlled, scientific examination of program efficacy and study of the factors
characterizing actual and potential widespread use of programs and their public health
impact. This represents a merger of perspectives only recently formally considered in
the field of smoking prevention programs (NCI 1986b; Best et al. 1988; Cleary et al.
1988; Flay 1985b).

The current state of smoking prevention programs and resources reveals a gap be-
tween these two approaches. The research-driven smoking prevention curricula have
most often been developed without a mechanism for widespread application and use.
In turn, many of the materials likely to be used in the field by public health profes-
sionals, educators, and other policymakers responsible for young people’s health have
had limited evaluation, except for the comprehensive health education curricula, and
the extent and process of their dissemination have generally not been systematically
documented.

Once research-based programs are developed and initially found to have potential
impact, there have not typically been mechanisms to encourage their active distribu-
tion to school systems and other organizations. Most at best can only respond to specific
requests for information about their program or dissemination of their materials.
Recognizing this research gap, NCI (1986b) has initiated research to determine the most
effective method to integrate tobacco education programs that have been proven to be
efficacious into school programs. It is encouraging research that is focused more on
application and dissemination than on the development of new curricula and interven-
tions.

Some of the issues bearing on program dissemination are reviewed in the smoking
prevention literature (Best et al. 1988; Cleary et al. 1988); others are considered in
broader literature on health education, program adoption, and the diffusion of innova-
tion (Basch, Eveland, Portnoy 1986; Basch and Sliepcevich 1983; Murray 1986). Bar-
riers specific to widespread institutionalization of smoking-specific programs within
schools include demands on teacher time, cost of materials for specific programs and
teacher training, and the variety of competing educational and health priorities found
within a school system. (See also Kolbe and Gilbert (1984) for a discussion of obstacles
to school implementation and maintenance of new health education programs.) Ideal-
ly, the likelihood of distribution and use of prevention programs in the field should be
considered throughout the course of program design and evaluation and not restricted
to end-stage discussions of the feasibility of disseminating already developed and
evaluated programs.

403
The availability of funding to bolster dissemination of existing programs has varied
over time. Federal funding for implementation and demonstration of health education
programs was provided by the 1979 Health Education Risk Reduction Grant Program
(Kolbe and Iverson 1984). Additional funds were appropriated in 1980 for grants to
deter smoking and use of alcohol by adolescents. The reorganization of such categori-
cal grant programs into a block grant structure in 1981 resulted in a shift of Federal funds
to the State level. However, the reduction of total available funds and the restructur-
ing of the funding mechanism created competition within States for these funds and
eliminated smoking-specific demonstration grants. It also made for less secure support
of health education in general (Kolbe and Iverson 1984). Although a variety of or-
ganizational, social, and political factors can affect the likelihood of adoption and use
of a particular prevention program, the effect of availability of funds for teacher train-
ing, purchase of materials, and even the simplest of evaluations must be considered in
any analysis of the history and prospects of prevention efforts.

Dissemination mechanisms also include providing information about programs.
Federally funded databases and programs with potential for aiding the dissemination
of smoking prevention programs are available. The Combined Health Information
Database includes information on State and local programs listed in the National Status
Report on Smoking and Health (US DHHS 1986a), as well as information on programs
funded under the 1979-81 smoking and alcohol grant program (US DHHS 1986a).

The NDN of the National Institute on Education includes data on extent of diffusion
of evaluated and validated curricula. While health education is not its primary focus,
NDN does include five comprehensive health education and substance abuse preven-
tion programs into which smoking prevention has been integrated, including “‘Grow-
ing Healthy” (NDN 1988b). Other promising programs, such as “Know Your Body,”
are currently under review. By providing information on the programs, awarding grants
to further the dissemination of selected curricula, and maintaining annual records on
program dissemination among participants (NDN 1988a), NDN functions both in the
active dissemination of programs and in monitoring the extent of use of various cur-
ricula nationwide.

Complementing the need to get research-derived programs into the hands of schools
and other organizations, continued program evaluation is needed once they are out in
the field. These data are needed to address questions concerning the applicability of
programs, the extent and quality of implementation, and their effectiveness once out-
side of controlled research settings. Additionally, through inquiry into factors affect-
ing actual distribution and use of programs, these evaluations could also contribute to
the development of guidelines supporting effective dissemination of smoking preven-
tion programs.

In these evaluations of the dissemination process, statistics need to go beyond data
such as number of sets of program materials distributed, to include surveys of actual
use and degree of implementation as well as program impact. The evaluation of two
ACS elementary school health education programs, for example, included data on
teacher use of materials (Pigg et al. 1985). There was considerable variation in the per-
centage of teachers reported to have used materials in those schools that had kits avail-
able. The ACS “Usage Report Card,” a record-keeping system for use by teachers to

404
document numbers of children exposed to the materials, was not always completed and
mailed as requested, according to 75 percent of schools surveyed. Variability in extent
of use and in documenting such use contributes to the difficulty of interpreting levels
of implementation even when, in the case of this study, approximately 80,000 copies
of the programs had been distributed to schools.

Best and colleagues (1988) have outlined research needs on the diffusion of smoking
prevention programs—tresearch the authors consider at least as vital as that evaluating
effectiveness of program content. Diffusion studies, they conclude. should entail con-
sideration of five sets of factors: planned diffusion strategies, program packaging,
provider training, implementation monitoring, and costing (both cost of materials and
cost-effectiveness of the program).

Problems in Evaluation of Smoking Prevention Programs

Prevention efforts within the psychosocial, more general health education, and media
approaches have operated with very different goals, intended mechanisms for effect,
and standards for evaluation. As reviewed above, the psychosocial influence smoking
prevention curricula have been subjected to years of research development and evalua-
tion (e.g., Best et al. 1988; Biglan and Ary 1985; Flay 1985b,; McCaul and Glasgow
1985; Snow, Gilchrist, Schinke 1985). The literature contains much detail about their
effects in university-administered research projects. However, far fewer data are avail-
able on the extent of their adoption and use by others in the field and on their impact
when implemented in less-controlled settings (Best et al. 1988; Cleary et al. 1988). In
most cases, active mechanisms for dissemination of the research products are lacking.
These programs are most often not part of a system to ensure their dissemination once
the typical 3- to 5-year development and evaluation phase of the research is complete.
(See Prevention Section, Problems in Dissemination of Prevention Programs.)

Prevention programs based on PSAs, posters, brochures, and other curriculum resour-
ces sponsored by Federal agencies and professional and voluntary organizations have
been widely distributed through the tremendous efforts of these agencies and organiza-
tions. However, their effectiveness has generally been less thoroughly evaluated than
that of the psychosocial smoking prevention curricula. Reflecting the priority of using
their limited resources for dissemination, the programs and their outcomes rarely
receive a level of evaluation comparable to that found in the peer-reviewed research
literature on smoking prevention.

Continuing methodological problems in prevention research include variations in
criteria for measuring smoking outcomes in different studies, problems of attrition
(Biglan et al. 1987; McAlister and Gordon 1986), limitation to white middle-class sub-
jects (Gilchrist and Schinke 1985; Glynn in press), differences in level of analysis of
effects and level of assignment to treatment or control group (Flay 1985a), and limited
long-term followup.

405
Need for Long-Term Followup

The need for long-term perspectives and followup of the effects of smoking preven-
tion programs has been noted in the 1979 Surgeon General’s Report (US DHEW 1979b)
and by Chassin and colleagues (1985), Evans (1984), and others. Prevention effects
need to be maintained and monitored throughout the high school years to ensure that
youth pass through this risk period without becoming smokers. Although long-term
evaluation of prevention programs is frequently included in review article recommen-
dations for future research (Biglan and Ary 1985; McAlister, Perry, Maccoby 1979),
reports of 2-year or, less frequently, 3-year impact (for study subjects most often
originally in junior high) constitute the most common long-term followups (Telch et
al. 1982; Johnson et al. 1986; Chassin et al. 1985). A recent report by Flay, Thompson,
and colleagues (1987) included results for a 6-year followup of students in the Water-
loo Smoking Prevention trial. While prevention of onset of experimental smoking per-
sisted through the end of grade 8, at the next assessment, during grade 12, no significant
effect remained. Another NCI-funded smoking prevention project is currently tracing
subjects through the important transition beyond high school (Murray, described in
Glynn, in press).

There are data suggesting that de/ay in initiation can constitute a desirable preven-
tion outcome: delayed onset has been found to be associated with decreased mortality
(US DHHS 1986a) and increased likelihood of quit attempts and cessation during the
school years (Ershler et al., in press). However, variations in age of onset considered
in these studies were naturally occurring and not the result of a specific prevention
program. Thus, it remains to be confirmed that program-induced delays in onset among
contemporary youth have the same relationship to later smoking behavior and health
outcomes as do the naturally occurring variations.

Construct Validity

Another major methodological challenge posed in the evaluation of prevention
programs is the problem of construct validity (Flay 1985a; McCaul and Glasgow 1985).
With even the most highly developed programs, given their use of a multiple component
format, it has been difficult to determine the key elements responsible for a prevention
effect. Best and colleagues (1984, 1988), among others, express the more general need
to study the factors mediating program impact in order to understand what program
components work for whom. Given the current gender differential in smoking
prevalence among young people (Chapter 5), and the possibility of gender differences
in effectiveness of intervention strategies, further attention should, for example, be
given to gender differences relevant to prevention programs (Gilchrist, Schinke, Nurius,
in press; Gritz, 1986).

The studies of Hops and colleagues (1986), Murray and associates (1984), Perry and
colleagues (1983), and Botvin, Renick, and Baker (1983) are among efforts to pursue
construct validity and develop data on the efficacy and necessity of the specific program
components. Hops and colleagues (1986) focused on refusal skills training and assess-
ment of program impact through audiotaped test situations (offers to smoke). While

406
this study of seventh grade students did not include a sufficient number of smokers to
test for program impact in preventing smoking, analysis of student responses to the test
situations found that students who received a smoking prevention program involving
refusal skills training took less time to respond to the taped offer to smoke, and gave
longer responses than did the control subjects, thus confirming several measures of be-
havioral impact of the program.

The studies of Murray and associates (1984) and Perry and colleagues (1983) com-
pared program conditions varying instructors (adult or peer) and program content (long-
term health consequences, social consequences, and immediate health effects). Mur-
ray and colleagues found the short-term-influences material, both social and
physiological, to be most effective in preventing onset of smoking. Delivery of short-
term-influence messages material by same-age peer leaders was more effective than by
adult leaders. Perry and colleagues found a similar instructor by material interaction.
In this study of 10th grade students, college-age peer leaders were more effective in
delivering material on social pressures; adult classroom teachers were more effective
with the traditional health effects curriculum. In this study, however, no differences
were found overall between the effectiveness of the different curriculum programs. The
curriculum emphasizing long-term health effects was as effective as those emphasiz-
ing more immediate social and physical effects.

In their study of the impact of characteristics of program delivery of the Life Skills
Training material, Botvin, Renick and Baker (1983) found that an intensive “mini-
course” format had comparable preventive effects at | year as the same material of-
fered one classroom session per week. By the end of the second year, however, the
more intensive format had greater impact on several measures of student smoking. The
addition of “booster” sessions also added to the program’s effectiveness.

Failure to Reach Dropouts and Other Youth at Higher Risk for Smoking

An intrinsic limitation of school-based prevention programs includes failure to reach
truants and dropouts who are at higher risk for smoking (Flay, Thompson et al. 1987;
Pirie, Murray, Luepker 1988). Numerous studies have suggested that those adolescents
who skip classes and have lower grades and educational aspirations are more likely to
smoke (Flay et al. 1983; Johnston, O’Malley, Bachman 1987). The recent studies by
Pirie, Murray, and Luepker (1988) and Flay, Thompson, and coworkers (1987) con-
firmed that high school dropouts are more likely to be smokers. This limitation has im-
plications both for the effectiveness of the intervention efforts and their evaluations.
The need for more attention to high-risk youth, those young people apt to smoke and,
more generally, to be involved in multiple risk behaviors (e.g., other forms of substance
use, early sexual activity, and pregnancy) is particularly acute. Groups of youth who
are at especially high risk of smoking are likely to receive more attention in new re-
search (Glynn,in press), paralleling trends in the field of adult cessation, where inter-
est has turned to heavy smokers who appeared to experience the most difficulty in smok-
ing cessation (NCI 1984, 1986a). Gilchrist and Schinke (1985) have called attention to
the need for broader strategies for high-risk youth. Sussman and colleagues (1987) have
noted ethnic group differences in rates of smoking and in psychosocial predictors of

407
smoking among seventh and eighth grade students in southern California, differences
bearing on the effectiveness of various prevention strategies. (See Chapter 5.)

Differences in likelihood of smoking among subgroups of youth led Best and col-
leagues (1988) to raise a question of strategy for young smokers: Should efforts be
focused on groups at high smoking risk, or should prevention programs seeking full
population coverage be continued? The need to address high-risk youth, and in par-
ticular those from blue-collar socioeconomic backgrounds, is apparent in the face of
the continuing marked differences in the likelihood of smoking among youth who drop
out of school (Pirie, Murray, Luepker 1988; Flay, Thompson, et al. 1987), those who
stay in high school but without plans for further education, and those who go on for
postsecondary education (Johnston, O’Malley, Bachman 1987). (See Chapter 5.)
Marked occupational differences in smoking prevalence further reinforce
socioeconomic differences in smoking when young people enter the workplace (US
DHHS 1985a).

Population Factors Related to Diversification of Smoking Prevention Programs

The evidence so far does not support the hypothesis that a single program has been
or can be developed to prevent adolescent smoking across the board. Rather, success-
ful smoking prevention may result from the aggregate of multiple types of programs
and avenues of delivery, thus supporting continued diversification of program ap-
proaches. (See Glynn, in press; Perry et al. 1983.) Consideration of secular trends of
smoking attitudes and behavior as well as other characteristics of the population also
supports the need for program change and diversification over time.

Shifts in the effectiveness of prevention or intervention strategies may reflect as much
the target population and the historical era as the inherent quality of their design. As
Green and Green (1977) stated, any health education effort, any diffusion of a new
program or behavior must consist of a series of “time-dependent strategies.” Ap-
proaches effective with the early cohorts—for instance, the approaches that showed
promise in influencing the first cohorts of young people to avoid smoking—may not
be effective with later cohorts or with the remainder of the first cohort that was not af-
fected by the initial intervention. Flay (1987a,b), for example, with regard to media-
based adult smoking cessation programs, suggested that there are differential potentials
for program impact as the level of knowledge about the health risks of smoking changes.
Best and associates (1988) and Chassin and others (1987) have also considered the
changes in optimal prevention target populations that can occur with either differential
prior program impact or changes in secular trends in knowledge and behavior.

The effectiveness of different prevention programs has also been influenced histori-
cally by the social and demographic shifts of age and gender in smoking among young
people that occurred over the last 25 years (Chapter 5). The young smokers of the early
1960s started at more advanced ages than contemporary youth; smoking was more
prevalent among males than females. In the mid-1970s through the 1980s, the rate of
smoking by girls first matched and then exceeded the rapidly declining rate of smok-
ing by boys. (See Chapter 5). Many schools used to grant students smoking privileges.
Now schools have revoked or seem increasingly likely to revoke student smoking

408
privileges and to strengthen and enforce existing nonsmoking policies. Society, as a
whole, is in a new period of increased disapproval and regulation of smoking (Chap-
ters 4 and 7).

The relationship between these larger social trends in smoking behavior and attitudes
and the impact of prevention programs on the prevalence of smoking by youth should
also be considered. The increasing social disapproval of smoking by both adults and
young people (Johnston, O’ Malley, Bachman 1987) may reinforce prevention program
effects. Prevention programs implemented during the time when smoking behavior
was increasing among youth were swimming against the secular stream of increasing
pressures and examples to smoke; later programs could, on the other hand, benefit from
the growing attitudinal and behavioral momentum against smoking. Moskowitz (1983,
p. 239) observed that “The current social climate regarding cigarette smoking may be
essential to the success of recent programs in preventing cigarette smoking.” In con-
trast, the generally unsuccessful smoking prevention programs of the 1950s, 1960s, and
early 1970s were conducted during a period of increasing acceptance of smoking by
youth, the creation of new school-sanctioned smoking privileges, and rising rates of
smoking by young females. The prevalence of smoking by American youth did not
begin to decrease until the mid- to late 1970s, precisely the time that research on the
more successful social influence curricula began (Evans 1976). The sharpest decrease
in the smoking prevalence among youth occurred during the late 1970s.

As presented in Chapter 5, the rate of smoking among high school seniors failed to
decline in the 1980s. Should this plateau of smoking prevalence by high school seniors
persist, further shifts in prevention approaches may be needed. This could include chan-
ges in the content balance of program and policy approaches and in increased efforts
to ensure wider dissemination of existing programs. More broadly, it highlights the
need for continued adjustment of prevention strategies and the importance of diver-
sified approaches upon which to draw.

PART Il. SMOKING EDUCATION AND CESSATION ACTIVITIES

Changes in Cessation Activities Over Time

As medical research has increasingly related smoking to disease, efforts to aid smok-
ing cessation have proliferated. Organized efforts to assist smokers in stopping actual-
ly began in the late 1950s with the “Five-Day Plan to Stop Smoking,” developed by the
Seventh Day Adventist Church (McFarland 1986). This program emphasized both the
physical and psychological aspects of addiction to cigarettes. Components of the Five-
Day Plan, such as a buddy system, a public pledge to stop smoking, increased physical
activity, and changes in diet, are important elements of many of today’s cessation
programs.

Smoking cessation treatments have been available since before 1900 (Dillow 1981).
Many different methods have been advocated as effective treatments for stopping smok-
ing. These have included drug treatments such as amphetamines, tranquilizers,
lobeline, and nicotine gum, hypnosis, acupuncture, professional counseling, aversive

409
conditioning procedures such as rapid smoking and satiation smoking, and a wide range
of behavioral self-management strategies. Different types of treatments have been em-
phasized during different time periods: conditioning-based approaches were em-
phasized in the 1960s, cognitively based self-management procedures were emphasized
in the 1970s, and relapse prevention and pharmacologic interventions were emphasized
in the 1980s. The new generation of strategies concerned with relapse prevention focus
attention on weight gain, high-risk situations, and cognitive and behavioral coping be-
haviors.

While the emphasis given to different cessation treatments has varied over time and
certain relapse prevention strategies and pharmacologic approaches have been added,
other specific methods for helping people stop smoking have not changed much over
the past 25 years (Schwartz 1969, 1987; Schwartz and Rider 1978). The packaging and
marketing of cessation aids and services have become more sophisticated, with increas-
ing emphasis on tailoring approaches to special groups (e.g., worksites, pregnant
women, and black and Hispanic smokers).

In addition, the last decade has seen a rapid increase in the accessibility of smoking
intervention activities in community channels such as physicians’ offices, worksites,
and the media (Ockene 1987). This increasing availability of activities in the smoker’s
natural setting has in large part been a response to smoking as a public health issue and
the recognition that about 90 percent of former smokers report stopping without the use
of a special program (Fiore et al. 1988).

Smoking cessation researchers have long recognized smoking to be a complex be-
havior influenced by physiological, psychological, cognitive, and social factors. (See
Chapter 5.) In recent years there has been a trend toward combining elements of dif-
ferent cessation methods into programs that respond to the multifactorial nature of
smoking (Pechacek 1979; Schwartz 1987; US DHHS 1988). Research on multicom-
ponent cessation programs has been encouraging, generally producing the best results,
although evidence suggests that even with such methods the majority of smokers return
to smoking within 1 year (Schwartz 1987; US DHHS 1988). In general, most cessation
treatments yield 1-year quit rates (based on all original participants) between 10 and 40
percent (Danaher 1980; Glasgow and Lichtenstein 1987; Schwartz 1987; US DHHS
1986a; US DHHS 1988). Variation in cessation rates among treatment methods is
probably due more to differences in smoker selection of the various programs than to
the treatment methods themselves (Schwartz 1987). (Table 1 provides a summary of
6- and 12-month outcomes for different cessation methods.)

Over the decades, studies of long-term outcomes in smoking cessation programs have
consistently demonstrated that abstinence maintenance rates fall as time passes, making
maintenance procedures an important adjunct to cessation (Hunt and Bespalec 1973;
Lichtenstein and Danaher 1976; US DHHS 1986a). Thus, more recent smoking cessa-
tion research has focused on ways to prevent relapse and facilitate abstinence main-
tenance (Hall, Rugg et al. 1984; Lichtenstein and Brown 1983; Marlatt and Gordon
1985). Relapse prevention strategies have included: (1) efforts to teach smokers how
to recognize cues to smoke and use behavioral strategies for dealing with urges to smoke
(Hall, Rugg et al. 1984; Emmons et al. 1988); (2) interventions to enhance support for
not smoking (e.g., extra group sessions, telephone contacts, use of spouses and

410
llr

TABLE 1.—Summary of followup quit rates (percentages) of 416 smoking cessation trials, by method, reported 1959-85

 

Quit rate (at least 6-mo followup)

Quit rate (at least 1-yr followup)

 

 

 

Intervention Number a Percept Number Percept
method of trials Range Median 33% of trials Range Median* 33%
Self-help 11 0-33 17 18 7 12-33 18 14
Educational 7 13-50 36 71 12 15-55 25 25
Five-day plan 4 11-23 15 0 14 16-40 26 21
Group* 15 0-54 24 20 31 5-71 28 39
Medication 0-47 18 14 12 6-50 18.5 17
Nicotine chewing gum 17-33 23 33 9 8~38 11 11
Nicotine chewing gum 23-50 35 67 11 12-49 29 36
and behavioral treatment

or therapy

Hypnosis, individual i 0-60 25 36 8 13-68 19.5 38
Hypnosis, group 10 8-68 34 50 14-88 50
Acupuncture 5-61 18 29 8-32 27

Physician advice or 5-12 5 0 12 3-13 6

counseling

Physician intervention, 3 23-40 29 33 10 13-38 22.5 20
more than counseling

Physician intervention, 10 10-51 24 20 6 25-76 34.5 50

pulmonary patients
cl

 

 

 

TABLE 1.—Continued

Quit rate (at least 6-mo followup) Quit rate (at least 1-yr followup)
Intervention Number | Percent Number / Percept
method of trials Range Median® 33% of trials Range Median" 33%
Physician intervention, 5 21-69 44 80 16 11-73 43 63
cardiac patients
Risk factor 7 12-46 31 43
Rapid smoking 12 7-62 25.5 33 6 640 21 17
Rapid smoking and other 21 8-67 38 37 10 7-52 30.5 50
procedures
Satiation smoking” It 14-76 38 64 12 18-63 34.5 58
Regular-paced aversive 13 0-S6 29 31 3 20-39 26 33
smoking “
Nicotine fading” 7 2646 27 29 16 7-46 25 44
Contingency contracting’ 9 25-76 46 89 4 14-38 27 25
Multiple programs® 13 18-52 32 38 7 6-76 40 65

 

NOTE: Quit rates provided suggest overall trends. Most quit rates were based on self-reports. Some quit rates were recalculated to include all subjects, but most quit rates were based on reports by
investigators. Some quit rates omitted subjects who did not complete treatment or persons who did not reply to followups. Definitions of followup may vary between trials.

‘Median not calculated for fewer than three trials.

"Percentage of trials with quit rates of at least 33 percent.

“Three group trials had 5-month followups.

“Other procedures may have been used, and some trials may be included in more than one method.

SOURCE: Schwartz (1987).
coworkers) (Lichtenstein, Glasgow, Abrams 1986; Ockene et al. 1982): and (3)
cognitive interventions to facilitate changes in self-perception, attitudes, and cognitions
(Lichtenstein and Brown 1983; Marlatt and Gordon 1985). In general, findings in
studies using relapse prevention strategies as part of a cessation program have been
inconsistent (US DHHS 1986a).

Providers and researchers also have become more responsive to the idea that smok-
ing cessation involves a process of change rather than a discrete act. (See Chapter 5
for a discussion of stages of cessation.) The process of cessation has been characterized,
for example, as occurring in four stages: precontemplation, contemplation, action, and
maintenance or relapse (Prochaska and DiClemente 1983). The stage model of cessa-
tion posits that separate influences are at play at different stages and that differing in-
terventions may need to be tailored to these stages of smoking behavior change. This
stage approach to cessation intervention has evolved over the last decade and is sull in
an early phase of development with no data available to test its effect.

Although the number and sophistication of cessation programs have grown over the
past several decades, this does not fully account for the decreasing rate of smoking, be-
cause about 90 percent of former smokers report stopping without the benefit of any
program or device (Fiore et al. 1988). During this same period, a separate but related
development can be traced: the growing recognition of smoking as a socially mediated
practice susceptible to change in its social environment (Bailey 1986, Iglehart 1986;
Nuehring and Markle 1974; Slade 1985; Warner 1986a). Although most health agen-
cies continue to sponsor programs to assist individual smokers in stopping, these or-
ganizations also are increasingly advocating policies addressing the environmental fac-
tors that support or discourage smoking (e.g., smoking control regulations) (ACS 1976,
1978: Blum 1986; US DOD 1986, 1987; Lundberg 1985; Lundberg and Knoll 1986;
Warner et al. 1986; Whelan 1984; see Chapter 7).

As noted above, the evaluation of cessation programs and techniques has been ade-
quately covered in numerous past and recent reviews and is not the subject of this Sec-
tion. (For recent extensive reviews of cessation activities, see reviews by Schwartz
(1987) or US DHHS (1986a).) The remainder of this review will be devoted to a his-
torical perspective of the efforts of the many diverse groups involved in promoting ces-
sation activities.

National Voluntary Health Organizations

The three major national voluntary health organizations, ACS, ALA, and AHA, have
played an important role over the last 25 years in disseminating information about the
hazards of smoking and in providing assistance to those who want to stop. Introduced
in Part I, these efforts have included such interventions as the production and distribu-
tion of print and broadcast materials, including pamphlets, posters, and television and
radio public service advertising; public educational programs; direct provision of ser-
vices to smokers who want to stop smoking, including self-help materials and clinics,
and training and materials for such intermediaries as educators and health care providers
who influence smokers to stop. While the resources devoted to the antismoking effort
have varied over time and among agencies, it was estimated that the sum total of finan-

413
cial resources available from the major voluntary organizations has never exceeded 1
or 2 percent of tobacco industry expenditures for the promotion of cigarettes (ACS
1978). Itis also true that these voluntary agencies receive support in the form of donated
public service time and space and contributed effort. However, even with this support,
the level of resources devoted to antismoking efforts represents a small fraction of
tobacco industry expenditures to promote smoking.

In 1965, ACS initiated its “The Time to Stop Is Now” campaign based on recent
epidemiologic studies showing that smokers can ameliorate the ill effects of cigarettes
by quitting. ACS followed this with a series of television commercial campaigns focus-
ing on the negative aspects of smoking. In 1968, ACS issued a posthumous PSA featur-
ing television actor William Talman, a smoker who died of lung cancer. At the same
time, ACS was producing films (one nominated for an Academy Award) and pamphlets
providing advice on quitting (Patterson 1987) and was initiating a small-group public
education campaign that by the late 1980s had reached more than 60 million people.

In 1964, AHA issued the pamphlet Where There’ s Smoke There's Danger from Heart
Disease and in 1966 distributed to affiliates a kit containing broadcast media materials,
posters, pamphlets, and newspaper features. In 1967 and 1968, AHA issued television
spots highlighting nonhealth advantages of not smoking (e.g., saving money, no bad
breath). In 1968, AHA produced the film “Smoking and Heart Disease” and in 1969
issued the pamphlet How to Stop Smoking, which was its first effort to develop material
to assist smokers in stopping. Since then, AHA has produced other pamphlets and
films; however, a primary focus of its smoking control efforts has been prevention of
smoking by youth.

ALA, in 1965, produced a public education campaign against smoking, “New View-
point on Smoking,” based on the 1964 Surgeon General’s Report. ALA again produced
significant public education antismoking materials in the late 1960s, when the Federal
Communications Commission (FCC) ruled that broadcasters must present antismoking
public service messages to balance prosmoking advertisements (Patterson 1987). As
part of this campaign, ALA produced two pamphlets, Me Quit Smoking? Why? and
Me Quit Smoking? How? These booklets present the health effects of smoking and
describe cigarette use as a socially learned behavior to be broken either through quit-
ting cold turkey or by gradual withdrawal.

As noted in the previous section, in 1964 the major national voluntary and Govern-
ment agencies had joined to form the National Interagency Council on Smoking and
Health to coordinate antismoking activities. In general, the voluntary organizations
during the late 1960s and the 1970s stressed the public health education approach to dis-
ease control rather than the legislative approach.

In 1967, attorney John Banzhaf obtained a ruling from the FCC applying the Fair-
ness Doctrine to cigarette advertising and requiring broadcasters to provide a significant
amount of time to antismoking messages to balance the prosmoking message of
cigarette advertisements (Patterson 1987). In 1968, Banzhaf formed a new organiza-
tion, Action on Smoking and Health (ASH), with the immediate goal of legally defend-
ing application of the FCC Doctrine to cigarettes and monitoring broadcaster com-
pliance. (See Section on Advocacy, this Chapter).

414
The FCC’s ruling was ultimately upheld by the Supreme Court in 1969. Beginning
in mid- 1967, the ruling opened the airwaves to an unprecedented barrage of antismok-
ing messages produced by the major national voluntary agencies (Wamer 1986). At
its peak in 1970, the donated television and radio time constituted a subsidy of ap-
proximately 200 million dollars (in 1985 dollars) (Warner 1986). These messages
probably helped contribute to changing public opinion on smoking, not only because
they provided information about its health effects, but also because their mere presence
on television reflected, and may have contributed to, a normative change in attitudes
toward the entire issue (Warner 1978, 1986). In 1971, cigarette advertising disap-
peared from broadcasting, and the frequency of antismoking messages fell dramatical-
ly (Warmer 1977). (See Chapter 7.)

During the 1970s, the efforts of the voluntary agencies continued to focus on educat-
ing the public about the dangers of smoking, as exemplified by the title of ‘a film
produced by ALA in 1970: “Is It Worth Your Life?” ACS sponsored a series of
programs on smoking cessation on the Public Broadcasting System and recruited actor
Tony Curtis as its first national IQ (I Quit) Chairman. As early as 1964, ACS had used
athletes and show business personalities in poster campaigns, both to draw attention to
antismoking messages and to provide social validation of the messages. This trend con-
tinued through the 1980s.

In 1973, ALA was the first major voluntary organization to explicitly recognize the -
importance of fostering norms supportive of nonsmoking (ASH 1978). ALA had al-
ready begun addressing the issue of environmental tobacco smoke (ETS) in 1971 with
a television public service campaign and a jingle, “Mind Very Much If They Smoke.”
This campaign and those that followed almost every year thereafter portrayed smoking
as antisocial behavior and were intended both to inform smokers that their behavior of-
fended others and to reinforce nonsmokers’ rights to object to ETS.

In addressing the ETS issue, ALA had an advantage over ACS and AHA, whose ac-
tivities were restricted by their mandates to control cancer and cardiovascular disease,
which in the early 1970s had not yet been related to ETS. The 1972 Surgeon General's
Report, the first to review the evidence that ETS harms nonsmokers, provided ALA
with sufficient justification to initiate action (US DHEW 1972). In 1973, ALA estab-
lished protection of nonsmokers as a major program priority and in 1975 became the
first major agency to retain a full-time staff member dedicated to promoting smoking
restrictions.

The nonsmokers’ rights movement continued to build through the 1970s (see next
section on advocacy and Chapter 7), but for the most part it was a local, grassroots cam-
paign. In a report prepared for the Tobacco Institute, the Roper Organization (1978)
called this movement “the most dangerous development to the viability of the tobacco
industry that has yet occurred.” The movement undercut the image of smoking as a so-
cially acceptable and even socially necessary behavior, and it motivated many more
people to join in the antismoking movement out of self-interest. However, the major
voluntary organizations involved in smoking activities for the most part continued to
focus their efforts on a public education approach to the smoking problem.

In 1976, ACS announced a new initiative against smoking entitled “Target 5.”
Among other goals, it aimed to persuade 25 percent of smokers to quit and to reduce

415
cigarette tar and nicotine levels by half (ACS 1976). Toward attaining the former goal,
ACS in 1977 issued the “I Quit Kit,” a sophisticated package of materials including
booklets, posters, buttons, a calendar, stickers, and a phonograph record. The basic ces-
sation techniques included: self-monitoring of smoking pattern, deliberate changes in
daily routine, gradual reduction in the number of cigarettes smoked, and suggestions
for nonsmoking maintenance. Two years later, ALA issued its “Freedom From Smok-
ing”® program, similarly a handsomely packaged kit that has been experimentally
evaluated (Davis, Faust, Ordentlich 1984).

The effort to educate smokers about the possible reduction in danger from low-tar
and -nicotine cigarettes and to encourage the marketing of lower tar cigarettes cul-
minated in the late 1970s when NCI scientist Dr. Gio Gori and a colleague published
a paper speculating that some low-tar cigarettes, smoked in moderate amounts, might
present little health risk (Gori and Lynch 1978). The voluntary and Government agen-
cies responded with intense criticism. However, the perception existed among many
smokers that some cigarettes are less hazardous than others (see Table 3, Chapter 4),
This was probably related, at least in part, to efforts by the voluntary agencies and
Government agencies suggesting that smokers could lower their risk with steps short
of quitting (ACS 1978). This perception of the safe cigarette changed as evidence
gathered that the use of lower yield cigarettes has almost no health benefit except for
lung cancer (US DHHS 1981) and may even increase the health risk due to compensa-
tion (US DHHS 1988) (See Chapter 5).

In 1972, a no-smoking day was sponsored in Oklahoma by ALA and in 1974 in Min-
nesota by ALA, ACS, and AHA. In 1977, ACS adopted the Minnesota program and
rechristened it “The Great American Smokeout” (GASO) (Smith 1977). The program
can now be seen as a forerunner of contemporary programs to help smokers quit by
fostering social support for cessation. A nationally publicized event held on the
Thursday before Thanksgiving, GASO encourages antismoking activities in the
community and provides materials to those wishing to conduct antismoking activities
in places such as schools, worksites, and health care facilities.

Every year since 1978, ACS has commissioned a Gallup poll of public awareness
and participation in GASO, Awareness has always been high; in 1978, 82 percent of
adults polled were aware of GASO, a figure that reached 90 percent by 1987. Reported
participation by smokers has grown over time also. In 1978, 6.7 percent of smokers in-
terviewed reported abstaining from smoking on GASO day, with another 19.9 percent
Teporting they cut down. In the peak year, 1986, 12.8 percent reported that they did not
smoke and 30.9 percent cut down (Figure 1).

Only two published studies provide data on how many people maintain cessation long
term after GASO. In 1979, Dawley and Finkel (1981) followed 125 smokers at the
New Orleans Veterans Administration Hospital who registered to quit on GASO day.
Two months after GASO day, 66 percent reported that they had attempted to reduce or
quit smoking on GASO day. Of those who attempted to stop smoking on GASO day,
13 percent (9 percent of the 125 smokers in the study) reported not smoking 2 months
later. In 1984, Gritz, Carr, and Marcus (1988) followed a group of 240 smokers who

416
15-
144
134

12.8%

to. oe 11.5%

6- 6.7%

% ABSTINENCE
sw
L
ao
x

1-4

 

 

0 T T T T T T T T T- 1
1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987
YEAR

FIGURE 1.—Reported abstinence during Great American Smokeout
SOURCE:The Impact of the Great American Smokeout (1978-87), conducted by the Gallup Organization, analyzed by
Lieberman Research, inc.

pledged to quit smoking on GASO day. At 1-year followup, 25 percent reported not
smoking and 13 percent had continuously quit for the entire year.

The voluntary agencies increased antismoking efforts in the early 1980s. By then,
three of the five television spots ALA produced every year were antismoking messages.
These, as many voluntary agency spots had done, used celebrities to call attention to
the health consequences of smoking. In addition to vigorously promoting GASO, ACS
released a series of attention-getting PSAs, including a simulated “Smoking Fetus” spot
and Yul Brynner in a posthumous plea to smokers to quit.

Building on the nonsmokers’ rights movement and the trend toward health promo-
tion at worksites, the voluntary organizations have begun actively marketing smoking
policy and cessation services to businesses. ACS, with a national policy prohibiting it
from charging for any services, has been limited in its activities in this area, but both
ALA and AHA have developed self-supporting intervention programs (“Freedom From
Smoking® at Work” and “Heart at Work,” respectively). Both include consultation on
the development and implementation of smoking policies and provision of cessation
clinics and self-help materials.

In 1985, ALA worked with a local television news show in Chicago to produce a
stop-smoking series that aired during 4:30 p.m. or 10:00 p.m. news broadcasts (Flay
1987b). The series, based on the ALA“Freedom From Smoking”® self-help guide, has

417
been replicated in about 10 cities in the United States and has been planned for several
others (Flay 1987b).

ALA and ACS have also developed programs to target pregnant smokers who have
often gone unnoticed. In 1988, ACS developed a smoking cessation program, “Spe-
cial Delivery,” designed to reach low-income pregnant women in a variety of settings
where they receive prenatal health, education, and social services. The package in-
cludes a video, slides, and a stop-smoking book. In 1986, ALA developed a smoking
cessation program targeted at pregnant women, “Freedom From Smoking for You and
Your Baby,” which is distributed to health care professionals providing services to preg-
nant women. The kit includes instructions to the provider, posters, and information
leaflets and self-help materials for the pregnant woman. ALA has also developed a
special smoking intervention program for the Los Angeles Women, Infants, and
Children (WIC) nutrition program’s Healthy Mothers, Healthy Babies Coalition. This
smoking cessation program for low-income pregnant women enrolled in WIC began in
1986 and includes slides, handouts, and reminder messages.

In 1982, the three major national voluntary bodies formed the Coalition on Smoking
OR Health. The Coalition’s major roles are to monitor Federal legislative and regulatory
issues and to support those promoting nonsmoking (see the next Section). In 1986 the
three national voluntary organizations, through the Tobacco-Free Young America
Project,extended their coordinated efforts beyond the legislative sphere and began to
coordinate strategies in public education and information. This project developed an
educational approach, referred to in the preceding section, intended to produce a tobac-
co-free high school graduating class in the year 2000 (US DHHS 1986a).

Health Professional Associations

Medical and public health groups have played an important leadership role in direct-
ing efforts to curtail smoking and its promotion (Lundberg 1985). In terms of their own
smoking behavior, physicians and other health professionals were among the first
groups to respond to the evidence relating smoking and disease. In the early 1950s, 53
percent of U.S. physicians were cigarette smokers (Garfinkel and Steliman 1986). Sub-
sequently, smoking rates fell steadily (US DHHS 1985a), and today, 9 percent smoke
(Harvey and Shubat 1987).

Although in the early years many health professionals spoke out against tobacco,
many did not fully accept the epidemiologic evidence (Patterson 1987; Rosenberg
1983). Officially, the American Medical Association (AMA) and most other medical
and public health groups supported the position that research was needed to deal with
the cigarette problem (Patterson 1987; Rosenberg 1983). It was assumed that smokers
would stop smoking if the medical evidence linking smoking and disease was sound.
With regard to public education efforts, AMA and specialty groups urged their mem-
bers to persuade others to cut down or give up smoking (Cohen 1978; Rosenberg 1983)
but did not otherwise extensively support public education efforts. Even today, data
suggest that many physicians are not advising cessation to patients who smoke (Anda
et al. 1988; Ockene et al. 1987). According to a 1986 national survey of 13,031 adults
aged 17 years and older, only 45 percent of smokers reported that a physician had ever

418
advised them to stop smoking (Davis 1988b). In other studies it was determined that
the presence of disease is positively related to whether physicians advised cessation
(Anda et al. 1988; Ockene et al. 1987).

In 1964, AMA officially called smoking *. . .a serious health hazard” and recom-
mended that health education programs on smoking be developed by AMA and be made
available to the public through the media (Iglehart 1986; Lundberg 1985; Rosenberg
1983). However, no funds were appropriated to support the antismoking campaign.
AMA opposed the addition of warning labels to cigarette packages, stating in a 1964
letter to the FTC that “The health hazards of excessive smoking have been well
publicized for more than 10 years. . they are common knowledge” (Rosenberg 1983).
When warning labels were mandated by Congress in 1965, AMA reversed its position
on the labeling issue. In 1969, AMA passed a resolution to discourage smoking through
pronouncements and education programs (Rosenberg 1983).

In 1978, AMA published a report, Tobacco and Health, summarizing the results of
a tobacco research program sponsored by the AMA Education and Research Founda-
tion (AMA 1978) that included financial support from the tobacco industry. This report,
which received wide media coverage, concluded that cigarette smoking was an impor-
tant cause of cancer and chronic obstructive pulmonary disease and constituted a danger
to persons with preexisting coronary disease. The preamble to the report stated that the
findings from the project had not altered the conclusions of the 1964 Surgeon General’s
Report. Following issuance of the report, AMA allocated 45,000 dollars to support a
public service antismoking campaign emphasizing smoking cessation and research
(Rosenberg 1983).

Frustrated by the reluctance of medical organizations to take a stronger stand against
smoking, a family physician, Dr. Alan Blum, in 1977 founded the organization Doc-
tors Ought to Care (DOC), a group of health professionals who direct their attention at
tobacco advertising (Blum 1979, 1980). (See Advocacy Section, this Chapter.) Other
medical and public health organizations have recently taken strengthened stands against
the tobacco industry.

In 1986, AMA accepted a proposal for a public awareness campaign that called for
a localized public health initiative designed for implementation by local medical
societies or individual physicians (Lundberg and Knoll 1986). The result of this
proposal was the development of the “Physicians Leadership Kit” (AMA 1987). The
kit contains information on developing smoke-free health care facilities, material to
lobby legislators and other public health officials to enact antismoking laws, and infor-
mation for presentation to school groups to encourage a tobacco-free lifestyle. The kit
presents sample materials that have been used successfully in various locations around
the country and includes camera-ready copies of materials that can be easily
reproduced. A total of 3,000 kits was produced in 1987, with copies sent to 1,000 local
medical societies and auxiliaries.

In addition to AMA, several other medical and public health groups have been ac-
tive in promoting smoking control measures. As long ago as 1968, the American Col-
lege of Chest Physicians (ACCP), in conjunction with the National Clearinghouse for
Smoking and Health, cosponsored a national forum on office management of smoking
problems (Soffer 1988). The proceedings of the conference were published in ACCP’s

419
official journal, Chest (ACCP 1968). Beginning with the convocation at the 1979
Scientific Assembly and repeated at every convocation since, new ACCP fellows
pledge to make their offices and clinics centers of smoking cessation (Soffer 1980). In
1982, ACCP prepared work kits for physicians to use as teaching aids in instructing
patients about the dangers of smoking and techniques for smoking cessation (ACCP
1982).

In 1987, the American Academy of Family Physicians (AAFP) developed a stop-
smoking kit for use by family physicians in their offices (AAFP 1987). The kit includes
a physician and office staff manual, stickers to identify the charts of patients who smoke,
a smoking history form, and cessation materials for patients. The American Society of
Internal Medicine has produced three antismoking kits for its members, one with
material for physician offices (e.g., posters, tent cards, lapel pins), another with material
for lobbying, and a third with material to stimulate media coverage on smoking and
health (Davis 1988b). The American Academy of Pediatrics (AAP) is a sponsor of the
Tobacco-Free Young America Project (AAP 1987). The American Dental Association
(ADA) in 1987 published a pamphlet describing the hazards of smokeless tobacco use,
ADA has produced similar pamphlets on smoking and oral cancer.

Available evidence indicates that physicians can have a significant impact on the
smoking behavior of their patients and that cessation outcomes increase as interven-
tions such as self-help materials, development of a cessation plan, and groups are added
(Kottke et al. 1988; Ockene et al. 1988; Russell et al. 1979; Russell et al. 1983). Medi-
cal organizations such as AAFP, the American Society of Internal Medicine, and the
American Medical Women’s Association are therefore supporting programs at their na-
tional and regional meetings to train physicians to be more effective in helping smokers
to stop smoking. , ,

Through funding in 1984 from NCI’s Smoking, Tobacco, and Cancer Program, in-
vestigators involved in physician training have demonstrated that smoking intervention
training programs can have a significant impact on physician skills (e.g., Ockene et al.
1988; Wilson et al. 1988). These investigators have produced their own training pack-
ages. Other NCI-funded investigators have demonstrated the importance of office
management materials that are needed to provide systematic identification of smokers,
‘who are then given advice to stop smoking (Cohen et al. 1987; Solberg 1988). With
the use of office procedures such as chart stickers and a system to monitor smokers,
- significantly more smokers are identified and available for physician advice. These
programs indicate that physician smoking intervention skills and office practices can
-be improved with relatively brief training programs. Concern has been expressed,
though, about the lack of coordination among the many private medical organizations
and public health agencies producing materials for use by physicians to encourage
smoking cessation by patients (Davis 1988b).

The contemporary efforts of medical and public health groups to curb tobacco use
have recognized that smoking control efforts must not only attempt to persuade in-
dividual smokers to stop, but also must help change the social environment that sup-
ports smoking (Iglehart 1986; Lundberg and Knoll 1986; Kottke et al. 1988). This is
discussed later in this Chapter. .

420
Federal Government Cessation Support

Office on Smoking and Health

In January 1968, the National Clearinghouse for Smoking and Health worked close-
ly with ACS and the Public Broadcasting Service (PBS) to produce the “National Smok-
ing Test.” which was aired over the CBS television network during prime time. This
1-hr program was designed to give cigarette smokers suggestions on how to stop smok-
ing (ASH 1978).

The Clearinghouse implemented the first study of a communitywide smoking con-
trol intervention in San Diego County, CA, between 1966 and 1971 (US DHEW 1976)
(see Part I). This study included interventions aimed at schoolchildren, health profes-
sionals, and adult smokers. Although evaluation of the project was limited, the data
collected suggested that the intervention had been successful. Survey results showed
significant reductions between 1966 and 1975 in the percentage of adult smokers in
San Diego compared with those in national samples (US DHEW 1976).

The first Government antismoking poster was produced by the Clearinghouse in
1968. The poster, carrying the message “100,000 Doctors Have Quit Smoking
Cigarettes. Maybe They Know Something You Don’t,” appeared on U.S. Post Office
trucks (Davis 1988b). Between 1967 and 1971, the Clearinghouse worked with ACS,
ALA, and AHA to produce antismoking messages to be aired as a result of the FCC
Fairness Doctrine ruling (Patterson 1987). Over the years, OSH has planned and
produced several award-winning public education and information campaigns on
smoking and health (US DHHS 1986a).

National Cancer Institute: Smoking, Tobacco, and Cancer Program

As discussed in the preceding section, the primary thrust of the Smoking, Tobacco,
and Cancer Program (STCP) has been to study smoking behavior and to test interven-
tion strategies for reducing tobacco use. Research programs have been supported in
the areas of adolescent smoking prevention, self-help smoking cessation, mass media
approaches to smoking control, and the use of physicians and dentists as interveners,
as well as in special populations including blacks, Hispanics, women, and smokeless
tobacco chewers (Fanning 1988; NCI 1986a). In 1986, STCP launched a multicenter
study to evaluate the impact of a communitywide intervention effort to reduce smok-
ing prevalence, particularly among heavy smokers. Costing 42.5 million dollars over
8 years, the effort is funding 11 institutions and involves 2 million people in 22 com-
munities in North America: 11 of these 22 communities receive support to develop and
promote cessation interventions. Interventions range from communitywide approaches
including mass media and environmental change to those focused on groups of in-
dividuals, such as physician counseling, worksite programs, and self-help strategies.
The campaigns will be linked with the existing programs of major voluntary and civic
organizations in an effort to widely disseminate intervention components (Hamm 1988;
Pechacek 1988).

421
Although research has always been the primary mission of NCI, in the mid-1970s, it
began developing broad public and professional information programs on smoking
through its Office of Cancer Communications (OCC) (US DHHS 1986a). In 1977,
OCC published Clearing the Air, a self-help smoking cessation booklet. An updated
version of the booklet was produced in 1987. This booklet is among the most popular
NCI publications. It has been promoted through print and television announcements
produced by OSH and through the OCC supermarket distribution program. Since the
booklet was first produced, approximately 7 million copies have been distributed.

In 1978, OCC, in collaboration with AAFP and ALA, produced a speaker’s kit for
use by physicians and local organizations to present a community-based smoking
education program. The kit, entitled “Everyone Can Do Something About Smoking,”
consisted of a slide-tape presentation narrated by Dick Cavett, “Smoking Digest,” a
planner’s guide, physician guidelines, Clearing the Air, and a community action
pamphlet. It was promoted initially through AAFP and ALA chapters, which resulted
in about 250 orders for the kit. In 1979, the kit was duplicated for distribution through
the National Audio/Visual Center.

OCC has been active in trying to increase the involvement of health professionals in
counseling patients about cessation of tobacco use (NCI 1982). In 1978, OCC produced
“Helping Smokers Quit,” a cessation kit for use by physicians to help their patients stop
smoking. The kit emphasized the “how-to” rather than the “why” of smoking cessa-
tion and contained a physician guide, followup note, memo to the nurse, waiting room
posters, and a set of materials for 50 patients (including a repackaged version of Clear-
ing the Air). The kit was promoted beginning in 1978 through two national mailings
of a flier to 175,000 primary care physicians, several targeted direct mailings, special
activities by outside organizations, and print advertisements and editorial placements
in professional journals. About 150,000 kits were distributed over a 4-year period. A
qualitative assessment of the kit showed that physicians were generally positive about
using the materials (NCI 1982). However, a key finding was the failure of physicians
to use the followup mail piece, emphasizing the need to develop practical ways to rein-
force and maintain the smoking cessation effort begun in the physician’s office.

In 1979, the “Helping Smokers Quit” program for physicians was adapted for use by
dentists and dental professionals (NCI 1982). The program was called “Let’s Help
Smokers Quit.” Beginning in 1980, this program was promoted by direct mail to
137,000 dentists, 37,000 dental hygienists, and 25,000 dental assistants; by a targeted
mailing to specialized dental groups; through print advertisements and editorial place-
ments in journals; and through exhibits at dental meetings and conferences. About
50,000 kits were distributed. User evaluation of the kit in 1981 found that the majority
of dentists used the kit’s guidelines to counsel 25 percent or fewer of their smoking
patients. Most dentists found the kit materials to be useful and practical. The waiting
room posters and followup postcards were the least-used components of the kit (NCI
1982).

“Quit for Good,” developed in 1982, is a combined and streamlined version of the
“Helping Smokers Quit” and “Let’s Help Smokers Quit” kits and is based on the evalua-
tion results of the earlier kits (NCI 1982). It features a health professional guide, wait-
ing room materials, and 50 sets of two patient booklets, Quit /t, a redesigned version

422
of Clearing the Air, and a new piece, For Good, which focuses on maintenance of non-
smoking rather than initial cessation. The “Quit for Good” kit was promoted begin-
ning in 1984 by direct mail to 120,000 dentists, cardiologists, chest physicians, com-
munity health physicians, and black physicians, and through print advertisements,
editorial mention in professional journals, and exhibits at major medical meetings.
About 60,000 kits have been distributed to date. In collaboration with ACS, the kit is
currently being revised in response to user feedback and an official protocol that NCI
recently developed for physician stop-smoking programs.

The “Pharmacist’s Helping Smokers Quit” kit program was developed in collabora-
tion with the American Pharmaceutical Association and is similar to the physician and
dentist kits (NCI 1982). The distinctive feature of this program is its focus on drug in-
teractions in smoking. The kit contains a pharmacist’s guide, counter cards, posters,
and sets of take-home materials for 25 patients. In addition, OCC and the American
Pharmacological Association worked with a private vendor to produce a special patient
education label for containers that warn of possible adverse smoking—drug interactions.
The program was launched officially in June 1986 at a national news conference at the
American Pharmaceutical Association headquarters. The kit was promoted in succeed-
ing months by direct mail to 25,000 members of the Association, a special mailing to
chain drugstore owners, and print advertisements and editorial mention in pharmaceuti-
cal journals. A second wave of direct mail promotions was conducted during summer
1987 targeting the Nation’s 67,000 retail and hospital pharmacies. Response to these
direct mail promotions has been about 15 percent, with about 15,000 kits distributed.

In 1976, NCI established the Cancer Information Service (CIS), a toll-free telephone
public inquiry system providing information about cancer (US DHHS 1986a). CIS of-
fices are located near major cancer research centers across the United States. In addi-
tion to providing telephone assistance, CIS offers free printed materials on subjects
ranging from types of cancer and treatments to smoking cessation. Many of the
materials developed by OCC are distributed through the CIS network. CIS receives
approximately 80,000 calls from smokers annually. In summer 1986, OCC col-
laborated with the NCI Division of Cancer Prevention and Control to develop a slide
training program for CIS staff to help them better counsel patients who smoke on how
to stop. This represented the first formal training effort for CIS staff on the topic of
smoking since the service was launched.

National Heart, Lung, and Blood Institute

Like NCI, over the years, the National Heart, Lung, and Blood Institute (NHLBI) has
devoted the majority of its smoking control dollars to biomedical research document-
ing the health hazards associated with tobacco use. Smoking has long been identified
as one of the major risk factors for cardiovascular disease and the major risk factor for
chronic obstructive pulmonary disease (e.g., Doyle et al. 1964, Hammond and Horn
1958; US DHHS 1983a, 1984) (See Chapter 2.). In the mid-1970s, NHLBI undertook
a number of major clinical studies to evaluate whether risk factor intervention for car-
diovascular disease could influence disease rates. The best known of these studies was
the Multiple Risk Factor Intervention Trial (MRFIT), a randomized controlled trial to

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investigate the effect of reducing cardiovascular risk factors in a group of asymptomatic
men at high risk for cardiovascular disease (MRFIT Research Group 1982). A total of
12,866 men were randomized into two groups, special intervention (SI) and usual care
(UC), with similar baseline characteristics. Those in the SI group received an intensive
intervention program aimed at facilitating cessation of smoking, reduction in serum
cholesterol by dietary changes, and reduction of blood pressure levels for hyperten-
sives. Men in the UC group received annual medical checkups but no special program
to modify smoking or other risk factors. The smoking intervention consisted initially
of 10 weekly group classes that included smoking intervention and individual cessa-
tion counseling by health counselors and physicians (Hughes et al. 1981). After 6 years,
the SI group reduced its prevalence of smoking 18 percentage points more than the UC
group.

More recently, NHLBI has supported cardiovascular risk reduction studies involv-
ing entire communities (US DHHS 1984, 1986a). Smoking control has been a
prominent element of these clinical research studies. Currently, NHLBI is funding
several research projects on the topic of relapse prevention and cessation interventions
aimed at special patient populations (e.g., post-myocardial-infarction patients) (NHLBI
1988). In 1984, NHLBI began a multicenter study of early intervention for chronic
obstructive pulmonary disease, the Lung Health Study (NHLBI 1986). The objective
of this study is to determine whether or not an intervention program of vigorous smoking
cessation and use of an inhaled bronchodilator can slow the decline of lung function
over the course of the 5-year period of followup. Approximately 6,000 men and women
aged 35 to 59 years who are at high risk for chronic obstructive pulmonary disease based
on lung function level have been entered into the study. Followup for the study will be
completed in 1993.

In 1985, NHLBI initiated the Smoking Education Program (SEP), modeled after the
highly successful National High Blood Pressure Education Program (NHLBI 1988).
This program seeks to identify and implement strategies to reach critical target audien-
ces that can serve as intermediaries in reaching smokers. For example, health care
professionals have frequent opportunities to advise smokers to quit and are therefore
identified as key targets of SEP. SEP also is developing materials for use in worksites
where employee health programs provide an effective means of risk-factor reduction.

NHLBI efforts to develop and disseminate information to health providers on smok-
ing control initiatives began in 1983 with the publication of the physician guide How
To Help Your Hypertensive Patient Stop Smoking (US DHHS 1983b). This 24-page
color booklet presented four simple smoking cessation procedures that emphasize
patient commitment and physician followup. The guide was disseminated through print
advertisements, and over 30,000 copies were distributed.

In 1983, NHLBI produced “We Can’t Go On Like This,” a series of seven video
vignettes developed as part of MRFIT. From 3 to 7 min long, they provide a humorous
approach to the subject of helping people stop smoking permanently. Each segment of
this program helps workshop participants share and express their feelings and frustra-
tions about their decision to stop smoking (US DHHS 1986a).

In 1986, SEP produced Clinical Opportunities for Smoking Intervention: A Guide
for the Busy Physician (US DHHS 1986e). This physician guide represented an update

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of the material presented in the guide for Counseling Hypertensive Patients To Stop
Smoking. The guide describes a variety of methods for smoking intervention, includ-
ing what can be done in a waiting room and what can be done during a physical exam,
and how the briefest of interventions can have an impact on patients. Support material
was also developed for the guide, including a slide kit that can be used as part of a medi-
cal training program to alert health professionals to methods they can use to have an
impact on their smoking patients. In addition, the program distributes outreach
materials, including reproducible print advertisements and guides to State and local
programs designed to reduce smoking.

In 1986, SEP produced a guide for smoking policies at the worksite. This guide, /?’s
Your Business: Smoking Policies for the Workplace, includes practical information
about implementing smoking policies in the workplace. Facts are provided about smok-
ing in the workplace and the effects of involuntary smoking. Short passages about com-
panies that have successfully implemented smoking policies are included along witha
resource section. SEP is continuing to plan and develop approaches to provide practi-
cal how-to information for worksites that plan to establish smoke-free or limited smok-
ing environments. Future SEP initiatives will focus on reaching special populations,
including patients with chronic heart or lung disease, minorities, and blue-collar
workers (NHLBI 1988).

A joint conference on “Smoking Policies in the Workplace: Research Needs and
Potential Applications” was convened in 1987 by NHLBI, and cosponsored by NCI
and the Harvard Institute for the Study of Smoking Behavior and Policy. Proceedings
of this conference are forthcoming in the New York State Journal of Medicine (Parker
and Warner 1989).

Office of Disease Prevention and Health Promotion

ODPHP conducted a survey of worksite health promotion programs that included in-
formation on smoking cessation, education, and corporate policies (US DHHS 1987).
It collaborated with OSH to produce “A Decision-Maker’s Guide to Reducing Smok-
ing at the Worksite” (US DHHS 1985b). Between 1984 and 1988, the Office managed
the Department’s “Healthy Older People” public education program, which targeted
smoking cessation as one of six health promotion subjects of importance for people
over 55 years of age. The U.S. Preventive Services Task Force, created and staffed by
the Office, has published recommendations for clinical settings on smoking cessation
counseling, together with a supporting scientific review (U.S. Preventive Services
1988). ODPHP staffed smoking and health workshops and participated in symposia
organized by the International Union Against Cancer and delivered in Bolivia and
Columbia (1983), Brazil, Paraguay, Ecuador, and Panama (1984), Costa Rica (1986),
and Hong Kong and China (1987).

Department of Defense

There is a strong historical link between tobacco use and the military. Until 1975,
cigarettes were part of the K- and C-rations provided to soldiers and sailors. In many

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