Advancing Tobacco Control Through Evidence-Based Programs

Prevention Opportunities

• I. Community Programs to Reduce Tobacco Use
  
  
• II. Chronic Disease Control Programs to Reduce the Burden of Tobacco-Related Diseases
  
  
• III. School Programs
  
  
• IV. Enforcement
  
  
• V. Statewide Programs
  
  
• VI. Counter-Marketing
  
  
• VII. Cessation Programs
  
  
• VIII. Surveillance and Evaluation
  
  
• IX. Administration and Management
  
  

Data from California and Massachusetts show that comprehensive tobacco control programs can substantially reduce tobacco use, and in the case of California, reduce rates of death from lung cancer and cardiovascular disease. CDC recommends that such programs have four main goals:

• To prevent the initiation of tobacco use among young people (primary prevention).

• To help current smokers quit (secondary prevention).

• To eliminate ETS exposure among nonsmokers (primary and secondary prevention).

• To identify population groups disproportionately affected by tobacco use and eliminate these disparities (primary and secondary prevention).

Comprehensive tobacco control programs should attempt to create "environments" in which smoking is discouraged or banned. The primary way of doing this is by supporting legislative, regulatory, and voluntary organizational restrictions on the use of tobacco, such as on how it is sold, priced, and promoted, and where tobacco products are allowed to be used. These "environmental change" efforts should be supported by tobacco use prevention, treatment, and cessation programs and efforts to prevent people from being exposed to environmental tobacco smoke.

Comprehensive tobacco control programs should serve as a model for "cultural inclusiveness" and "cultural competency" by addressing the specific concerns of various population segments, including racial and ethnic minorities and other groups at high risk for tobacco-related diseases. They should also attempt to increase awareness of the disproportionate toll that tobacco use exacts from minorities and to convince minority advocacy groups to include tobacco control as part of their agendas.

Comprehensive tobacco control programs should attempt to partner with any group with overlapping interests that can help them reach their goals, from national nongovernmental health organizations such the American Cancer Society, to federal agencies such as CDC or NIH, to groups representing specific local constituencies such as a PTA chapter or minority advocacy group. Partnering with local groups or community leaders is essential, especially in areas with predominantly minority populations, since these local groups and leaders can help state program officials design interventions or educational campaigns that target local residents in a culturally appropriate manner.

Best Practices for Comprehensive Tobacco Control Programs⁴ recommends ways in which states can establish tobacco control programs that are comprehensive, sustainable, and accountable. Its recommendations are based largely on analyses of existing state programs, especially on those in California and Massachusetts, which were funded with revenue from state tobacco excise taxes. Although the document includes recommended funding ranges for various program components, state officials are of course responsible for funding decisions and, in making them, will have to determine what their most pressing needs are and what funds are available.

Best Practices identifies the following nine categories of programs that should be part of any comprehensive state-level tobacco control program:

I. Community Programs to Reduce Tobacco Use
Local community programs offer a wide range of prevention activities, including engaging youth in developing and implementing tobacco control interventions; developing partnerships with local organizations; conducting educational programs for young people, parents, enforcement officials, community and business leaders, health care providers, school personnel, and others; and promoting both governmental and nongovernmental policies that promote clean indoor air, restrict access to tobacco products, foster insurance coverage for smoking-cessation treatment, and support other program objectives.

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II. Chronic Disease Control Programs to Reduce the Burden of Tobacco-Related Diseases
Even if current tobacco use stopped, the accumulated effects of smoking would cause disease among past users for decades to come. Therefore, any comprehensive tobacco control program should encompass programs to prevent tobacco-related diseases and to detect them as early as possible, including cardiovascular disease prevention programs, asthma prevention programs, oral health programs, and cancer registries.

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III. School Programs
School program activities include implementing CDC's Guidelines for School Health Programs to Prevent Tobacco Use and Addiction,¹⁴ which call for tobacco-free policies, teacher training, parental involvement, cessation services, the implementation of curricula shown to be effective, and the coordination of school-based tobacco control efforts with those of local community coalitions and statewide media and educational campaigns.

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IV. Enforcement
To be effective, tobacco control policies must be vigorously enforced, particularly policies that restrict minors' access to tobacco and those that restrict smoking in public places. State enforcement efforts should be coordinated with those of the Food and Drug Administration (FDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA). California and Massachusetts have addressed enforcement issues by making enforcement a required activity for all recipients of community program grants. Florida has taken a more centralized approach by having state alcoholic beverage control officers conduct compliance checks with the help of locally recruited youth in all regions of the state.

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V. Statewide Programs
State tobacco control programs can support local programs by providing technical assistance in conducting program evaluations, using the media to discourage tobacco use, implementing smoke-free policies, and reducing minors' access to tobacco. Statewide organizations representing population segments disproportionately affected by tobacco use can be particularly helpful in devising and implementing interventions targeting those groups.

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VI. Counter-Marketing
As its name indicates, counter-marketing is used to counter the marketing efforts of tobacco companies as well as subtler social forces (such as youth peer pressure) that encourage smoking. Counter-marketing can take many forms, including paid television, radio, billboard, and print advertisements; the use of media advocacy and other public relations techniques such as press releases, local antismoking events, and health promotion activities; and efforts to reduce tobacco industry sponsorship and promotion of various events (often by helping to arrange for replacement sponsors). Counter-marketing activities can be used to promote smoking cessation and discourage smoking initiation, as well as to garner public support for tobacco control interventions. Counter-marketing campaigns should be a primary activity in all states with comprehensive tobacco control programs.

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VII. Cessation Programs
Smoking-cessation programs can yield significant health and economic benefits. Effective cessation strategies include brief advice by medical providers, counseling, and pharmacotherapy. Smoking-cessation activities of comprehensive state tobacco control programs should include establishing population-based treatment programs such as telephone cessation helplines; working to ensure that treatment for tobacco use is covered under both public and private insurance; and eliminating cost barriers to treatment for underserved populations, particularly the uninsured.

Treating Tobacco Use and Dependence,⁶ a Public Health Service-sponsored Clinical Practice Guideline, updates the 1996 Smoking Cessation, Clinical Practice Guideline No. 18 that was sponsored by AHCPR. The original guideline reflected the scientific research literature published between 1975 and 1994. This guideline was written in response to new, effective clinical treatments for tobacco dependence that have been identified since 1994, and these treatments promise to improve the rates of successful tobacco cessation. A variety of supporting materials are also available, including a quick reference guide for clinicians and consumer materials in English and Spanish. For more information, see www.surgeongeneral.gov/tobacco.

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VIII. Surveillance and Evalution
Tobacco-use surveillance involves monitoring people's tobacco-related behaviors, attitudes, and long-term health outcomes at regular intervals. Tobacco control programs should use such surveillance activities to measure both local and statewide progress toward meeting short-term and intermediate objectives.

Through coordinated surveillance and evaluation activities, tobacco control programs can demonstrate their accountability, monitor the implementation of program elements, and measure their impact over various periods of time. Logic models can help them to plan and report on these surveillance and evaluation activities, as well as to use surveillance and evaluation results to demonstrate the effectiveness of program activities to decision makers and to show program stakeholders what the program can accomplish over a given period of time (Figure 1).

An Introduction to Program Evaluation for Comprehensive Tobacco Control Programs¹⁵ from CDC recommends that tobacco control programs divide their evaluation efforts into the following six steps:

Step 1: Engage stakeholders.

Step 2: Describe the program.

Step 3: Focus the evaluation design.

Step 4: Gather credible evidence.

Step 5: Justify conclusions.

Step 6: Ensure that evaluation findings are used, and share lessons learned.

To ensure the comparability of evaluation data from state tobacco control programs throughout the country, states should consider using surveillance systems compatible with the Behavioral Risk Factor Surveillance System (BRFSS), the Youth Risk Behavior Survey (YRBS), the Adult Tobacco Survey (ATS), and the Youth Tobacco Survey (YTS). States can modify these existing systems to meet their specific needs, either by adding additional questions or survey modules, by sampling more extensively to capture local-level data, or by focusing surveillance efforts on populations with high rates of tobacco use or tobacco-related illnesses. In addition, states can combine traditional surveillance with the collection of data on "environmental indicators" such as state and local tobacco policies, pro-tobacco efforts, and taxes on tobacco products; use information from a variety of sources in program planning; and disseminate surveillance and evaluation findings in forms most appropriate for specific groups of program stakeholders.

Although state agencies should develop the capacity to manage and conduct surveillance and evaluation activities, they should also, when possible, partner with organizations capable of helping them with these activities, including universities, various health organizations, and local groups that can help them reach populations disproportionately affected by tobacco use.

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IX. Administration and Evalution
To be effective, tobacco control programs will need a strong management structure to coordinate program components, involve multiple state and local agencies (e.g., health, education, law enforcement) and levels of local government, and partner with statewide voluntary health organizations and community groups. In addition, their administration and management systems must be able to prepare and implement contracts and monitor program spending and program activities.

The management team of tobacco control programs should include people with expertise in program development, coordination, and management; fiscal management, including management of funding to state and local partners; leadership development; tobacco control and tobacco use prevention content; cultural competence; public health policy, including analysis, development, and implementation; community outreach and mobilization; training and technical assistance; health communications, including counter-marketing; the strategic use of both free and paid media messages; strategic planning; gathering and analyzing data (surveillance); and evaluation methods.

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