Surgeon General's Report

The MHHP community activities were not spe-
cifically designed as smoking prevention programs;
they were directed toward adults and addressed sev-
eral cardiovascular risk factors in addition to smok-
ing. These efforts to reduce adolescent smoking may
have resulted because young people were directly
exposed to community program messages and appeals
intended for adults, school programs had heightened
intensity from being conducted in communities
focused on developing healthy behaviors, or parents
stimulated by the community programs gave greater
attention to adolescent health behaviors. The inten-
sity, pervasiveness, and duration of the community
program may also have affected the general norms of
the community on health behavior, which in turn may
have influenced young people to decide against start-
ing to smoke.

Similar results were obtained by another youth
smoking prevention study conducted in the context
of pervasive community cardiovascular risk reduction
campaigns. The North Karelia Youth Project in Fin-
land included a school program with three sessions in
grade seven, five sessions in grade eight, and two ses-
sions in grade nine (Vartiainen et al. 1998). Intensive
community programs on cardiovascular risk reduction
were conducted for adults, including community
organization and mass communication campaigns for
cigarette smoking cessation, during the years the
school program was delivered. Significant differences
in cigarette smoking prevalence between young
people in the intervention and comparison areas were
found at each follow-up survey through age 21. At
age 28, significant differences in smoking prevalence
were found among those who were nonsmokers at the
baseline survey, in seventh grade. These results pro-
vide strong support for the findings of the MHHP Class
of 1989 Study and emphasize the potential impact on
youth smoking of combining school and community
programs.

The community component of the MPP was ex-
plicitly designed to complement the school program
to prevent substance use. Program activities that oc-
curred outside the classroom were more focused on
parents’ behaviors than is usually found in research
studies on smoking prevention. These activities in-
cluded 10 homework exercises in the first program year
and a wide range of family norm-setting activities,
similar exercises accompanied the second year of the
school curriculum. Parents helped plan and present a
parent education evening in participating schools in
the second year and participated in community orga-
nization activities in the third year.

78 Chapter 3

The only program components to directly reach
or involve the wider community were the media mes-
sages and community organization activities. The
latter component was not introduced until the third
program year and may not have had much effect on
students’ smoking behaviors. Because parents, then,
were the principal focus of educational efforts outside
the classroom, the MPP effects were likely achieved
mainly through strong and consistent parental sup-
port of the objectives of this school-based program.
The media messages may also have influenced ado-
lescents’ perceptions of peer, family, and community
smoking norms.

Results of the MPP, the MHHP, and the North
Karelia Youth Project thus offer the possible common
interpretation that the programs’ effects depended on
strong school programs supported by community pro-
grams that may have affected students in two ways:
through substantially increased efforts by parents and
through young people’s perceiving that smoking is not
normative. Although parental components similar to
the MPP homework assignments have been included
insome school-only smoking prevention programs, the
full scope of parent-oriented efforts used by the MPP
in support of the school curriculum has not been tested
previously. Further exploration of combined school
and parent programs may be a promising avenue for
future educational research studies. Similarly, these
results highlight the importance of program compo-
nents designed to influence adolescents’ normative
perceptions.

The VSMM shared with the MPP and the MHHP
the general strategy of supplementing a relatively
strong school-based smoking prevention program with
other forms of intervention but differed in several
respects. The combined school and mass media pro-
gram in the VSMM was directed toward the target ado-
lescents, and no adult participation was anticipated
outside of the classroom. The project’s resources thus
were applied to influencing adolescents’ smoking
behaviors directly through changes in the students’
beliefs, skills, and perceived norms.

The VSMM also differed in focusing on use of
the mass media as a sole supplement to the school pro-
gram. This design provided a reasonably clear indi-
cation that the magnitude and duration of a relatively
strong school curriculum to prevent smoking could
be significantly increased by a mass media component
that concentrated exclusively on the target audience
of adolescents.

Three other large-scale tests of mass media ap-
proaches to smoking prevention have been reported.
One study conducted in North Carolina tested three
mass media campaigns that were not combined with
school-based programs (Bauman et al. 1988). The
media campaigns included radio spots on the expected
consequences of smoking, a similar radio campaign
that featured a smoking prevention contest, and the
radio and contest components with television spots
added. The messages were broadcast during three
four-week periods. at levels intended to reach 75
percent of the target audience four times during each
period. Each campaign was conducted in two metro-
politan areas; four other communities served as
control areas. Adolescents aged 12-14 years were in-
terviewed through household surveys at baseline
(n =2,102); 78 percent of them were followed up 11-17
months later. Results indicated that the campaigns had
effects on the recipients’ knowledge of the conse-
quences of smoking and other mediators but not on
cigarette smoking behavior (Bauman et al. 1991).

In the Television, School, and Family Smoking
Prevention and Cessation Project (TVSFP), Flay and
colleagues (1988, 1995) tested a mass media supple-
ment to a school program. The study design was
similar to that used in the MPP. The main study was
conducted in a single metropolitan area. The mass
media component was generally available to members
of the community, and the school program was offered
only to members of the main treatment group. The
main research question thus addressed whether

a school program combined with a mass media cam- _

paign had a stronger effect than the mass media
campaign alone. The school curriculum included 10
classroom sessions delivered by trained health educa-
tors during the seventh grade. The media component
included segments that ran for two months in evening
television news shows that were linked to the class-
room sessions. Students in the main intervention con-
ditions were asked to view these segments with their
parents and to complete related homework activities
together. Seventh-grade students from 47 schools par-
ticipated in the study; they were surveyed during the
seventh, eighth, and ninth grades. Program effects
were observed in the follow-up surveys for mediating
variables but not for smoking behavior.

More promising results have been reported fora
three-year mass media campaign on youth smoking
in Norway (Hafstad et al. 1997). This campaign used
the novel approach of creating messages intended to
stimulate antismoking interactions among young
people through use of provocative messages that pre-
sented starkly negative images of adolescent smokers.
Unlike other mass media approaches, these messages
were presented as movie and newspaper advertise-
ments and posters, as well as through broadcast

Reducing Tobacco Use

media channels. Messages were broadcast or placed
at a relatively high level of intensity over one three-
week period each year for three years. Message themes
were varied each year. The impact of these campaigns
was evaluated over three years by comparing baseline
and follow-up survey results among a cohort of 11,033
young people aged 14 and 15 years for one interven-
tion county and one control county. Results showed
that young people from the intervention county were
less likely to start smoking and more likely to stop
smoking at the follow-up survey. This study demon-
strates the potential impact of relatively intensive,
highly targeted mass media smoking prevention cam-
paigns that are not combined with any other type of
smoking prevention intervention.

Results of these studies using mass media as a
primary educational strategy suggested that better
outcomes were associated with more intensive, multi-
faceted program efforts on social influences. The
TVSFP intervention included a substantial school
curriculum for the seventh grade but did not include
further sessions in later grades. The mass media
campaign included a maximum of 10 exposures over
a two-month period. The North Carolina study did
not include a direct component for interpersonal edu-
cation; the media component for this study did not
directly address social influences on adolescent smok-
ing and was delivered over a total period of three
months. These program efforts contrast sharply with
the three-year Norwegian media campaign and the 14-
to 16-session school program combined with a mass
media campaign delivered over four years in the
VSMM.

Because only relatively brief individual messages
about cigarette smoking can be delivered to adoles-
cents through the mass media, it is reasonable to
hypothesize that behavioral effects can be achieved
only when the media spots run frequently and over
many months. Other evidence discussed here indi-
cates that these types of media campaigns are most
likely to be effective when combined with some form
of coordinated interpersonal education, such as school-
based smoking prevention programs. The VSMM
results thus align with those of the MHHP and MPP
in supporting the importance of school programs. The
VSMM also directly targeted normative perceptions
in its school and media components and demonstrated
positive changes in these mediators of adolescents’
smoking behaviors.

Several guidelines for designing future educa-
tional efforts to prevent smoking can be drawn
from this review of three successful multifaceted
programs. The central role of school programs in

Effective Educational Strategies 79
surgeon General's Report

smoking prevention education was affirmed by the
results of all three studies. The MHHP and the MPP
results both suggested the power of influencing ado-
lescents’ perceptions of cigarette smoking norms
through community programs that enhance the effect
of school programs; the MPP results demonstrated the
effectiveness of parents’ participation as a specific strat-
egy for enhancing school prevention programs; and
the VSMM demonstrated that long-term mass media
campaigns targeted to adolescents’ beliefs, skills, and

perceived norms could enhance the effect of school
programs.

On a cautionary note, the theoretical and dem-
onstrated ability of these programs to alter the smok-
ing behavior of young people must be viewed in
the larger context of their practicality. As noted
earlier, the ability to disseminate such programs has
been a matter of active public health engagement. The
following section examines the current status of such
dissemination.

Diffusing Programs to Prevent Tobacco Use

 

In the mid-1990s, several surveys were under-
taken to assess the extent to which national guidelines
for tobacco prevention in schools (CDC 1994b) were
being implemented. One of these, the School Health
Policies and Programs Study (SHPPS), queried state
and local education districts directly about their ad-
herence to guidelines (Collins et al. 1995). A second
survey used health department tobacco coordinators
as the primary information source about tobacco pre-
vention programs in schools (J.K. Worden and B.S.
Flynn, Tobacco use prevention education in the United
States, 1994, unpublished data, September 1995).

National Guidelines

According to the CDC’s “Guidelines for School
Health Programs to Prevent Tobacco Use and Addic-
tion” (CDC 1994b), all schools should, for developmen-
tally appropriate ages, provide instruction about the
short-term and long-term negative physiological
and social consequences of tobacco use, about social
influences on tobacco use, about peer norms regard-
ing tobacco use, and about refusal skills. Local school
districts and schools are advised to “review these con-
cepts in accordance with student needs and educa-
tional policies to determine in which grades students
should receive particular instruction” (CDC 1994b,
p. 9). The guidelines recommend that students in kin-
dergarten through the 12th grade receive curricula for
preventing tobacco use. Because tobacco use often
begins in the 6th-8th grades (USDHHS 1994), more
intensive instructional programs should be provided
in these grades, and students should receive annual
prevention education thereafter through the 12th

80 Chapter 3

grade. The guidelines also recommend that programs
include support from families, support from commu-
nity organizations, tobacco-related policies, and adver-
tising campaigns for preventing smoking, because
school-based efforts appear to be enhanced by comple-
mentary programs in the community. Finally, an on-
going assessment should monitor whether an adequate
tobacco education program is being maintained.

School Health Policies and Programs Study

The SHPPS survey, in a follow-up to a similar
survey conducted by the American School Health As-
sociation in 1989, examined state-, district-, school-, and
classroom-level data (Collins et al. 1995). SHPPS ex-
amined specific instruction provided in six critical ar-
eas: intentional and unintentional injury, alcohol and
other drug use, tobacco use, sexual behaviors, dietary
patterns, and physical activity. The education agencies
in all 50 states and the District of Columbia, a national
sample of 413 school districts, a national sample of
607 middle/junior and senior high schools, and 1,040
randomly selected health education teachers were sur-
veyed. State and district data were collected with self-
administered questionnaires mailed to the person most
knowledgeable about or responsible for each compo-
nent of the school health program. School and class-
room data were collected through on-site personal
interviews with lead health education and classroom
teachers. The multiple levels of data collection were
necessitated by the embedded tradition of local control
in determining educational requirements and content
of instruction. The data from SHPPS are most clearly
assessed by their relationship to the CDC guidelines.
Guideline: All schools should develop and enforce a school
policy on tobacco use. Policies should prohibit tobacco use
by all students, staff, and visitors during school-related
activity.

Almost two-thirds of schools had smoke-free
building policies in place in 1994, though significantly
fewer (37 percent) had prohibited the use of tobacco
products by all persons on school property, in school
vehicles, and at school-sponsored functions away from
the school site. Most schools (83 percent) prohibited
tobacco use by athletes and coaches during school-
sponsored events, and most (89 percent) provided writ-
ten copies of the policy to students, staff, and parents.
Schools were significantly more likely to have used
exclusively punitive consequences (58 percent) in
response to the most recent violation of their school’s
tobacco use policy than exclusively remedial conse-
quences (2 percent) or a combination of punitive and
remedial consequences (30 percent); few (8 percent)
invoked attendance at a tobacco use prevention pro-
gram as remediation for violations. Only 30 percent
of schools offered tobacco cessation services in or
through the school.

Guideline: All schools should provide tobacco prevention
education in kindergarten through 12th grade. The instruc-
tion should be especially intensive in middle and junior high
school and reinforced in high school.

In 1994, tobacco use prevention education was
required in 37 states (72 percent) and in 83 percent of
school districts. At the school level, 91 percent of
middle/junior high schools and 82 percent of senior
high schools included tobacco use prevention educa-
tion in a required course. However, only 55 percent of
middle/junior high school teachers and 47 percent of
senior high school teachers of health education re-
ported tobacco use prevention as a “major” topic in
their courses. Of the middle/junior and senior high
school teachers who included tobacco use prevention
education as a major topic, only 21 percent spent six
or more class periods on the topic.

Guideline: Schools should provide instruction about the
immediate and long-term consequences of tobacco use, about
social norms regarding tobacco use and the reasons why
adolescents say they smoke, and about social influences that
promote tobacco use. Schools should provide behavioral skills
for resisting social influences that promote tobacco use.

Of the approximately 50 percent of teachers who
taught tobacco use prevention as a major topic, 74
percent taught both short- and long-term effects of
cigarette smoking. Fewer (61 percent) taught both

Reducing Tobacco Use

short- and long-term effects associated with using
smokeless tobacco. Although 61 percent of teachers
addressed group attitudes (i.e., social norms) about
tobacco use, only 42 percent taught about the actual
amount of smoking and tobacco use among adoles-
cents and adults. Less than half (48 percent) of this
group of teachers provided instruction about “healthy
alternatives” to tobacco use. Sixty-eight percent in-
cluded instruction on social influences. Most teachers
taught behavioral and social skills, though it is unclear
if these skills were taught specifically within the
context of tobacco use prevention education. For ex-
ample, 89 percent of teachers taught decision-making
skills, 87 percent taught skills for resisting social pres-
sures, 81 percent taught communication skills, and 78
percent taught goal-setting skills.

Guideline: Improve curriculum implementation and
overall program effectiveness.

In 1994, 82 percent of states had offered in-
service training on teaching tobacco use prevention
during the past two years. However, only 24 percent
of school districts had offered in-service training on
tobacco use prevention. Consequently, it is not sur-
prising that only 9 percent of teachers of health edu-
cation received training on tobacco use prevention
education during the same time period. Although
state-level training is typically designed for district
staff, district-level training is the most common source
of training for teachers. Increased training opportu-
nities for teachers are needed to improve the effective-
ness of tobacco use prevention education.

The 1994 SHPPS data were analyzed to examine
the extent to which U.S. schools were implementing
the CDC’s “Guidelines for School Health Programs to
Prevent Tobacco Use and Addiction” (Crossett et al.
1999). Although data do not exist in SHPPS that spe-
cifically assess adherence to each of the six recom-
mended program areas, three criteria were selected
that reflect a “comprehensive” approach to tobacco use
prevention (Crossett et al. 1999): (1) a tobacco-free
policy consistent with CDC guidelines, (2) at least one
teacher who taught tobacco as a major topic and cov-
ered four essential content areas (short-term health
effects, groups’ attitudes toward tobacco, social influ-
ences, and life/refusal skills), and (3) access to tobacco
cessation services for students. Only 4 percent of
middle schools, junior high schools, and high schools
nationwide met all three criteria. Twenty-six percent
met two of the three criteria, and 41 percent met one
of the three. More than one-fourth of schools (29 per-
cent) met none of the three criteria. This analysis is

Effective Educational Strategies 81
Surgeon General's Report

limited, because not all of the CDC guideline recom-
mendations could be measured directly by SHPPS.
Nevertheless, these findings indicated that very few
schools were fully implementing the CDC recommen-
dations in 1994,

Schools are faced with many competing demands
for instruction and classroom content. Currently, most
of this nation’s schools are providing students with
some basic tobacco use prevention education. How-
ever, the recent increases in tobacco use prevalence
among youth and the overwhelming documentation
of the health consequences of tobacco addiction em-
phasize the need for improvement in what schools are
doing to reduce tobacco use and nicotine addiction
among their students, faculty, and staff.

A State-Based Assessment

To estimate current program activity in smoking
prevention education across the United States, tobacco
control coordinators in all 50 states and the District of
Columbia were asked to participate in a survey
(Worden and Flynn, unpublished data; unless other-
wise noted, cited data in this section are derived from
this survey). The position of tobacco control coordina-
tor was established to oversee tobacco control and edu-
cation efforts in each state health department, through
either the American Stop Smoking Intervention
Study (ASSIST) program of the National Cancer
Institute (NCI) (Shopland 1993) or the Initiatives to
Mobilize for the Prevention and Control of Tobacco
Use (IMPACT) program of the CDC (USDHHS 1995).
The survey was conducted between December 1994
and March 1995. The tobacco control coordinators
were asked to describe any educational programs to
prevent tobacco use—including school, community,
and mass media activities—that were being imple-
mented in their state during 1994 and to send writ-
ten descriptions or examples of materials used in
these programs. This survey differed from SHPPS in
its primary reliance on health department rather than
education department personnel and in the absence
of a multilevel sampling approach. The state-based
survey, on the other hand, focused more on the types
of materials used.

Basic Curriculum

The state-based survey determined that school
systems were generally left to create their own tobacco
use prevention programs or to decide which of several
available commercial programs would be imple-
mented. Examples such as Here’s Looking At You,

82. Chapter 3

2000 or the LST Program (Bosworth and Sailes 1993;
Glynn 1994) were mentioned by a few of the states. A
number of states had implemented some school-based
educational programs on tobacco use that were supple-
mental to statewide school curricula. Among the
supplementary programs, the most popular was Teens
As Teachers (American Nonsmokers’ Rights Founda-
tion 1994). Reported in 10 states, this program trains
older high school youth to discuss with younger
students the physiological and social consequences of
tobacco use. The older youth also may convey the
accurate norm that most young people do not use to-
bacco. Six states reported using the Tar Wars program,
in which medical professionals discuss the conse-
quences of tobacco use with junior high school students
(Tar Wars 1995). Save a Sweet Heart, a program that
emphasizes social influences on tobacco use for junior
high school and high school youth (American Heart
Association 1989), was reported in three states. Spo-
radic use was reported for several other programs, in-
cluding Growing Healthy*; Teenage Health Teaching
Modules, a version of D.A.R.E. that includes tobacco
use prevention; the Minnesota Smoking Prevention
Program; and a curriculum developed at the Univer-
sity of Vermont (Bosworth and Sailes 1993; Gerstain and
Green 1993; Glynn 1994). In several states, either a vol-
untary health agency or a community or school group
originated its own supplement to a school program.

Supplemental Programs

During 1994, two states—Massachusetts and Cali-
fornia (see Chapter 7)—were particularly active in
developing and implementing supplemental programs
(i.e., in addition to statewide curricula) using mass
media in smoking prevention. Although smoking
prevention was one of several aims of the generic me-
dia campaigns funded through tobacco tax revenues
in each state, the topic was clearly emphasized in a set
of media spots specifically targeting youth in 1994 in
each state. The Massachusetts campaign was compre-
hensive; seven messages addressed various topics
suggested in the CDC guidelines (Massachusetts De-
partment of Public Health 1994). The 1994 California
campaign used seven television spots and six radio
spots to describe the physiological consequences of
smoking. Using humorous vignettes, the campaign
identified toxic substances in cigarette smoke, such as
arsenic, formaldehyde, ammonia, methane, and
dichlorodiphenyltrichloroethane (DDT).

On a smaller scale, supplemental efforts with
comprehensive coverage also occurred in West Virginia
and in Denver, Colorado. In West Virginia, through a
contest sponsored by the American Cancer Society,
four winning scripts for radio spots on smokeless to-
bacco use and on environmental tobacco smoke were
selected from more than 300 entries from students in
kindergarten through the 12th grade. The spots were
broadcast on 22 stations and included several topics,
although the only one related to the CDC guidelines
concerned the physiological consequences of tobacco
use. In Denver, a three-month billboard campaign
promoted the theme “Smoking Doesn’t Add Up,”
which suggested the financial consequences of tobacco
use (Colorado ASSIST Alliance 1994).

Programs Including Families

Only two states reported large-scale supplemental
programs that included families: New Jersey in its
community grants programs and Oregon ina program
entitled Parenting for a Positive Future. Three other
states reported using the Unpuffables program, which
requires parents’ participation and includes the topics
of social influences and refusal skills (Perry et al.
1990b). It should be noted, however, that this estimate
of parental involvement is likely to be low, since
districts and schools, which vary considerably in the
degree to which they involve parents in school activi-
ties, were not queried directly.

Community Programs

In general, virtually no states reported community
organization programs dedicated to supplementing
educational programs to prevent tobacco use. Several
programs—including the Kids Against Tobacco program,
which involved 5,000 young people in northwestern
Louisiana—combined tobacco education and advocacy,
but the main emphasis was on inspiring young people
to advocate against tobacco use.

Combined Activities

At the time of the Worden and Flynn survey, only
Pennsylvania reported combining a mandated school
curriculum with supplemental school, community, and
mass media programs in an educational strategy to
prevent tobacco use. The statewide Youth Against To-
bacco program was sponsored by the state’s health and
education departments along with the American Can-
cer Society and the Pennsylvania Medical Society.
These sponsors asked community organizations
throughout the state to participate in the program,
which ran from 1992 through 1995. More than 175,000
young people in 47 counties participated with local

Reducing Tobacco Use

Boy Scouts and Girl Scouts, Boys’ & Girls’ Clubs, health
organizations, Students Against Driving Drunk,
D.A.R.E., and other groups. Community events in-
cluded the 1994 Farm Show, in which 8,444 young
people pledged not to smoke. The 1994 mass media
program included a rap radio message aired by 223
stations in January and 280 stations in June. Declar-
ing it “not cool” to smoke, the message described the
social consequences of smoking (Pennsylvania Depart-
ment of Health 1992).

Monitoring Program Objectives

Only Vermont reported having a system in place
to annually assess school program activity. Act 51
stipulates that schools in Vermont annually report the
number of schools implementing a curriculum. In
1994, 219 schools reported using the Here’s Looking
At You, 2000 program, 25 used the LST Program, and
19 used other programs (Glynn 1994). Arkansas, In-
diana, Missouri, Pennsylvania, and Rhode Island were
able to report the estimated number of students re-
ceiving specific programs run by voluntary agencies
or local school districts. For example, Indiana reported
that 15 percent of its students received the Growing
Healthy program.

Interpreting the Diffusion Process

Because of the methodological differences, the
results of SHPPS cannot be compared directly with
those of the state-based survey conducted by Worden
and Flynn. In particular, it is likely that the latter
underestimated the type and amount of tobacco use
prevention activity that may have been occurring on
the local level. The two surveys concurred, however,
in their overall assessment: considerable progress has
been made, but comprehensive school health educa-
tion can be improved in some areas, including tobacco
use prevention. SHPPS, which focused on multiple
activity levels, concluded that few schools met all the
major criteria provided in the CDC guidelines (CDC
1994a; Crossett et al. 1999). Asa result of its focus, the
state-based survey concluded that optimal use had not
yet been made of the available research on multichan-
nel methods for maximizing the impact of school
health education programs for tobacco use prevention.

Thus, the review of reported program activity in
1994 indicated that we are far from attaining an ideal,
national level of educational programs to prevent to-
bacco use. By one set of criteria, only 4 percent of the
middle, junior, and high schools in this nation were

Effective Educational Strategies 83
Surgeon General's Report

meeting three criteria of a comprehensive tobacco use
prevention program in 1994 (Crossett et al. 1999). Sev-
eral reasons have been offered for this shortcoming at
the time. One reason is that the year 1994 fell between
two periods that may have been more active. The first
period was the late 1980s and early 1990s, when the
states of Minnesota and California were implement-
ing large-scale campaigns to reduce tobacco use that
were financed by tax revenues from cigarette sales. For
a brief time, Michigan also developed mass media
spots for preventing smoking among adolescents.
Resources for these efforts apparently shrank (Begay
et al. 1993), and the campaigns faded by 1994. A sec-
ond period, which follows the 1994 activities reported
here, arguably began with the 1994 publication of the
Surgeon General's report Preventing Tobacco Use Among
Young People (USDHHS 1994). That report seems to
have stimulated development of a new set of guide-
lines. In addition, by this time all states had received
support to coordinate their education and policy
efforts to reduce tobacco use. This support came
through the ASSIST program, which began such
activities as early as 1991, and through the IMPACT
program, which supplemented ASSIST coverage.
Therefore, 1994 may represent an interregnum in the
enthusiasm for tobacco prevention education. This
view is supported by the events of the late 1990s. The
major legal and legislative activities (see Chapter 5)
were instrumental in mobilizing several states to
intensify multichannel efforts at tobacco prevention
(described in detail in Chapter 7).

A second reason is that there has been little
evidence that the community-based approaches to
prevent tobacco use that have been shown to be effec-
tive in controlled research studies have been adapted
effectively to statewide use. Two states, California
and Minnesota, have attempted some evaluation of
community-based programs to prevent smoking on a
statewide scale. In both cases, marketing research tech-
niques similar to those described as diagnostic and
formative research in the VSMM (Worden et al. 1988,
1996) were applied in developing mass media cam-
paigns. Several creative messages for preventing
smoking were developed in each state, but the num-
ber of messages dedicated to young people was
limited; exposure also was limited, because paid ad-
vertising slots were allocated to target groups of adults
as well as youths (Kizer et al. 1990; Minnesota Depart-
ment of Health 1991).

Although awareness of each of these campaigns
appeared to be high among adolescents, there was no
reduction in smoking behavior (Murray et al. 1994;
Pierce et al. 1994; Popham et al. 1994). Part of the

84 Chapter 3

difficulty may have been the absence of a sufficiently
strong school-based program having similar educa-
tional objectives. It is also possible that, with funds
divided to reach many targeted groups, the media
could not be concentrated sufficiently on smoking pre-
vention among youth to have a measurable effect.

A third reason is that programs implemented on
a day-by-day basis over the years often lack the essen-
tial ingredients for success that were evident when they
were created and evaluated by researchers. To be ef-
fective, programs should be taught as designed
(Rohrbach et al. 1993). For many curricula, teachers
require training—if not to encourage adoption of the
program, then at least to ensure that the curriculum is
correctly and completely delivered (Perry et al. 1990a;
Smith et al. 1993). Many teachers are resistant to train-
ing (Brink et al. 1991), and teachers who smoke may
be particularly uncomfortable with a curriculum that
discourages smoking. Such resistance may not affect
the quality of a brief, single-pronged program format,
such as the Smoke Free Class of 2000, but may jeopar-
dize the integrity of more long-term and comprehen-
sive curricula. It also has been found that a school
system’s decision to use a curriculum is simply not
enough to ensure successful implementation; teach-
ers should be brought in at the earliest stages of adop-
tion (Rohrbach et al. 1993). Teachers and school
administrators with prior experience in tobacco use
prevention education should be involved in orienting
and inspiring other teachers, who will then be more
likely to deliver the curriculum faithfully and effec-
tively (Smith et al. 1993). Successful implementation
also depends on the size of the school organization;
smaller organizations are more likely to adopt new
programs quickly, whereas larger organizations are
more likely to maintain a program once it is adopted
(McCormick et al. 1995).

A fourth reason is that there appears to be a short-
age of linking agents, who have been found to be
essential for maintaining educational programs to pre-
vent tobacco use (Dijkstra et al. 1993) and have been
recommended in several diffusion studies (Brink et al.
1991; Goodman et al. 1992; Rohrbach et al. 1993), Link-
ing agents are persons or groups that have a strong
incentive for maintaining a program and promoting
its continuation by consistently and faithfully coordi-
nating all of the necessary resources for implementa-
tion. Potential candidates for local linking agents are
school health teachers, principals, volunteers, and
health professionals; each could ensure that school
curricula include a strong component for preventing
tobacco use, much as local voluntary agencies have
supported the Smoke Free Class of 2000 effort (Brink
et al. 1991). These individuals, working through a
coalition, could also coordinate community program
efforts involving families, community organizations,
and mass media.

Ona state level, the natural linking agents would
be the tobacco control coordinators, who could work
through coalitions or other state agencies to accom-
plish several long-term, comprehensive aims: (1) es-
tablish legislation mandating school-based tobacco use
prevention with guidelines specifying effective cur-
ricula; (2) establish a curriculum training program,
through the state education department, that would
involve school administrators and teachers in the on-
going implementation of school-based curricula to
prevent tobacco use; (3) establish a monitoring and
support system to determine the penetration and qual-
ity of programs throughout the school system and
improve instruction with ongoing teacher training;
(4) work with parents’ groups and volunteer organi-
zations to support the schoo] program; and (5) work
with interested citizens to place media messages that
support each of the content areas recommended by the
CDC guidelines.

On a national level, linking agents could be agen-
cies, such as the NCI or the CDC, that could support
local and state efforts to reduce tobacco use with
funding and continued coordination, such as by regu-
larly convening state coordinators to share program
ideas. These national linking agents might focus their
diffusion efforts on using the mass media, because
youth in different markets respond equally well to
media-based messages for preventing tobacco use
(Flynn et al. 1992). Considerable opportunity exists

Conclusions

Reducing Tobacco Use

for enhanced diffusion of programs that have demon-
strated effectiveness (Parcel et al. 1989a,b, 1995; O’Hara
et al. 1991; Brink et al. 1995; Parcel 1995; McCormick
and Tompkins 1998; Siegel and Biener 2000). As an
example of such diffusions, the CDC’s Division of
Adolescent and School Health initiated the Research
to Classroom project. Through this project, CDC iden-
tified programs with credible evidence of effectiveness
in reducing health risk behaviors among young people.
So far, CDC has identified curricula for sexuality and
tobacco use prevention. The CDC staff review elec-
tronic databases, literature reviews, meta-analyses, and
reports to identify evaluation studies that meet the
criteria for consideration in the Research to Classroom
project. Two external panels, one of evaluation experts
and the other of program experts, review the curricula
and their evaluations. If both panels recommend adop-
tion of the curriculum, based on attainment of identi-
fied criteria, CDC designates the curriculum as a
Program that Works. The Research to Classroom
project identified Project Towards No Tobacco Use and
Life Skills Training as appropriate tobacco use preven-
tion curricula. Research to Classroom also provides
information and training on these curricula for inter-
ested educators from state and local education
agencies, departments of health, and national nongov-
ernmental organizations. The CDC identifies and
disseminates information on Programs that Work to
help inform local and state choices. The choice to
adopt a curriculum ultimately rests with local deci-
sion makers and must address community standards
and needs.

 

1. Educational strategies, conducted in conjunction
with community- and media-based activities, can
postpone or prevent smoking onset in 20 to 40
percent of adolescents.

2. Although most U.S. schools have tobacco use pre-
vention policies and programs in place, current
practice is not optimal.

3. More consistent implementation of effective
educational strategies to prevent tobacco use will
require continuing efforts to build strong,
multiyear prevention units into school health
education curricula and expanded efforts to make
use of the influence of parents, the mass media,
and other community resources.

Effective Educational Strategies 85
Surgeon General’s Report

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Chapter 4
Management of Nicotine Addiction

 

Introduction 97

Methods for Managing Nicotine Addiction 100

Self-Help Manuals 100
Efficacy 100
Relevant Process Measures 101
Summary 102
Minimal Clinical Interventions 102
Efficacy 104
Relevant Process Measures 105
Summary 105
Intensive Clinical Interventions 105
Problem Solving/Skills Training 106
Rapid Smoking 107
Other Aversive-Smoking Strategies 108
Cue Exposure 108
Nicotine Fading 109
Motivational Rewards 710
Social Support 110
Weight Control 111
Hypnosis 112
Acupuncture 112
Summary of Intensive Clinical Interventions 112
Pharmacologic Interventions 113
Nicotine Polacrilex 113
Transdermal Nicotine 116
Nicotine Nasal Spray 118
Nicotine Inhaler 120
Bupropion 121
Clonidine 122
Nortriptylene 123
Other Antidepressants and Anxiolytics 124
Summary of Pharmacologic Interventions 124
Large-Scale Public Health Programs 125
Media-Based Programs 125
Worksite Programs 126
Community Programs 127
Statewide Programs 128
Summary of Large-Scale Public Health Programs 128

Contemporary Issues in Research on Tobacco Addiction 128

Epidemiologic Concerns and Clinical Issues 128
Nicotine Dependence 129
Stages of Change 129
Negative Affect 130
Sen-ppecitic Differences 130

Withdrawal Svmptoms = /30

Weight Gain 131

Early Relapse 131

Dose-Response 131

Treatment Components 732

Individualized Treatment 732

Dissemination and the Role of the Clinician 132
Cost-Effectiveness 733

Conclusions 134

References 135
Introduction

Reducing Tobacco Use

 

Preventing tobacco addiction among young
people and promoting abstinence among current
smokers are the final common denominators for pub-
lic health strategies to reduce smoking prevalence. Al-
though prevention efforts are increasingly regarded as
the most promising long-term approach for reducing
tobacco use (Lynch and Bonnie 1994; U.S. Department
of Health and Human Services [USDHHS] 1994), about
1.2 million youths become regular smokers each year
in the United States—adding to the millions of adult
smokers who are candidates for addiction manage-
ment (Leventhal et al. 1991; Centers for Disease Con-
trol and Prevention [CDC] 1998; see “Trends in Tobacco
Use Among Young People” in Chapter 3). Effective
treatments do exist for smoking cessation, and they
are available for both the clinical and the public health
context (Fiore et al. 1996). These treatments compose
an important modality in the effort to eradicate tobacco
use. Many of the adverse health effects of tobacco use
are reversible by cessation (USDHHS 1989)—a fact im-
portant to the millions of adults who already smoke,
as well as to the large numbers of young people who
continue to take up smoking.

Since the 1964 release of the first Surgeon
General's report on the health consequences of smok-
ing, the prevalence of cigarette smoking among adults
in the United States has decreased by 41 percent, fall-
ing from 42.2 percent in 1965 to 24.7 percent in 1997
(Giovino et al. 1994; CDC 1999a). Although these data
represent significant progress in the public health cam-
paign against tobacco use, the steady decline of 0.5
percentage points per year observed from 1965 to 1985
has lessened in recent years. In 1997, approximately
48 million adult Americans smoked; the prevalence
was higher among men (27.6 percent) than among
women (22.1 percent) and among American Indians
and Alaska Natives (34.1 percent) than among blacks
(26.7 percent), whites (25.3 percent), Hispanics (20.4
percent), or Asian Americans and Pacific Islanders (16.9
percent) (Table 4.1). Smoking prevalence was also
lower among college graduates (11.6 percent) than
among high school dropouts (35.4 percent) and higher
among those below the poverty level (33.3 percent)
than above it (24.6 percent) (CDC 1999a). Since smok-
ing prevalence did not decline at a more rapid rate
than that observed in the past few years, the Healthy
People 2000 goal of an adult smoking prevalence of 15
percent or less by the year 2000 (USDHHS 1991) was

not met. Unless smoking prevalence declines at a more
rapid rate than that observed in the past, we will not
achieve the Healthy People 2010 goal of an adult smok-
ing prevalence of 12 percent or less by the year 2010
(USDHHS 2000).

Considered over the time frame of the last 30
years, however, smoking cessation has increased dra-
matically. Self-reported data from 1997 suggest that
almost 50 percent (44 million) of people who have ever
smoked have successfully quit smoking (Thomas and
Larsen 1993). In 1991, the earliest year for which so-
cioeconomic data are available, the prevalence of
smoking cessation was greater among male, white,
older, more educated, and wealthier persons (Table 4.2)
(Giovino et al. 1994). An encouraging finding from
the 1993 National Health Interview Survey was that
most (70 percent) current adult smokers were inter-
ested in quitting. Such interest was higher among
women, African Americans, and younger persons
(Thomas and Larsen 1993). :

Cessation represents a desired end result to what
is usually a lengthy, demanding, and often frustrating
undertaking. Data on cessation should be interpreted
in light of the fact that for every successful attempt to
quit using tobacco, many more attempts fail. Although
millions of Americans say they want to quit smoking,
studies suggest that only about 6 percent of persons
who try to quit smoking at any given time are suc-
cessful for more than one month (CDC 1993a). Re-
search into tobacco cessation seeks tools that will
translate the desire to quit into prolonged abstinence
from tobacco. Such treatments hold a greater poten-
tial for immediate public health returns than do pre-
vention methods, and cessation treatments may also
be cost-effective (see “Cost-Effectiveness” later in this
chapter).

In the course of this chapter, the terms “smoking
cessation” and “management of tobacco addiction” are
used interchangeably. Though the former is the more
familiar, the latter better conveys a more rigorous and
systematized approach to a complex addiction behav-
ior. Value judgments on the impact of a particular
modality should be interpreted within a qualitative
system for judging costs and benefits. A small impact
may be viewed favorably if achieved with minimal
intervention. More intense intervention may have a
larger impact, but may not be justified by the resources
it requires.

Management of Nicotine Addiction 97
Surgeon General's Report

Table 4.1. Percentage of adults aged 218 years who were current cigarette smokers,* by sex, race/ethnicity,
education, age, and poverty status—United States, National Health Interview Survey, 1997

 

 

 

Men Women Total
(n = 15,361) (n = 20,455) (n = 35,816)
Characteristic % (95% CI*) % (95% CI) % (95% Cl)
Race/Ethnicity!
White, non-Hispanic 27.4 (+1.0) 23.3 (+0.8) 25.3 (£0.7)
Black, non-Hispanic 32.1 (+2.4) 224 (+17) 26.7 (41.4)
Hispanic 26.2 (42.1) 14.3 (+1.4) 20.4 (41.4)
American Indian/ Alaska Native$ 37.9 (+13.7) 31.3. (+8.8) 34.1 (47.7)
Asian American/ Pacific Islander 21.6 (+44) 12.4 (43.5) 16.9 (42.7)
Education (years)4
<8 29.9 (+3.0) 15.1 (42.2) 22.5 (41.9)
9-11 41.3 (43.1) 30.5 (42.4) 35.4 (42.0)
12 31.8 (41.7) 25.7 (+1.3) 284 (+1.0)
13-15 27.4 (+1.7) 23.4 (41.4) 25.1 (+1.1)
216 13.0 (41.2) 10.1 (41.0) 11.6 (40.8)
Age (years)
18-24 31.7 (42.8) 25.7 (42.4) 28.7 (+1.9)
25-44 31.2. (+1.3) 26.1 (41.1) 28.6 (+0.8)
45-64 27.6 (+1.5) 21.5 (41.3) 24.4 (41.0)
265 12.8  (+1.4) 11.5 (41.1) 12.0 (40.9)
Poverty status!
At or above 27.3 (#+1.0) 21.8 (40.8) 24.6 (+0.7)
Below 38.7 (42.8) 29.8 (41.9) 33.3. (1.7)
Unknown 23.4 (+2.0) 18.2. (41.5) 20.5 (41.2)
Total 27.6 (+0.9) 22.1 (+0.7) 24.7 (40.6)

 

*Persons who reported having smoked at least 100 cigarettes during their lifetime and who reported currently

smoking every day or some days. Excludes 300 respondents with unknown smoking status.

t95% confidence interval.

+Excludes 74 respondents of unknown, multiple, and other racial/ethnic categories.
SWide variances on estimates reflect the small sample sizes.

APersons aged > 25 years. Excludes 305 respondents with unknown years of education.

‘IPublished 1996 poverty thresholds from the Bureau of the Census are used in these calculations.
Source: Centers for Disease Control and Prevention 1999a.

98 Chapter 4
Reducing Tobacco Use

Table 4.2. Percentage of adults* who abstained from smoking cigarettes in the previous year, by sex,
race/ethnicity, age, education, and poverty status—United States, National Health Interview

 

 

 

 

Survey, 1991'
Maintenance? among
all persons who
Abstinence for Maintenance were daily smokers
21 day among abstainers 1 year earlier®
Characteristic % (95% CB) % (95% CI) % (95% CI)
Sex
Male 42.6 (40.8~44.4) 13.8 (12.0-15.6) 5.8 (5.0-6.6)
Female 41.5 (40.0-43.0) 13.7 (12.0-15.4) 5.6 (4.9-6.3)
Race/Ethnicity
White4 40.3 (39.0~41.6) 14.0 (12.6-15.4) 5.6 (5.0-6.2)
Black* 48.7 (45.2-52.2) 7.9 (5.1-10.7) 3.8 (2.45.2)
Hispanic 52.1 (46.4-57.8) 16.3 (10.3-22.2) 8.5 (5.2-11.8)
American Indian/ 53.3 (39.7-67.0) NA? NA!
Alaska Native
Asian American/ 45.0 (33.7-56.3) NA1 NA!
Pacific Islander
Age (years)
18-24 56.7 (52.9-60.5) 14.0 (9.9-18.1) 7.9 (5.6-10.3)
25-44 43.4 (41.8-45.0) 12.7. (11.0-14.4) 5.4 (4.7-6.1)
45-64 36.1 (33.9-38.3) 14.1 (11.4-16.8) 5.0 (4.0-6.0)
265 35.7 (32.2-39.2) 19.4 (14.6-24.2) 6.8 (5.1-8.5)
Education (years)
<12 36.5 (34.1-38.9) 12.9 (10.2-15.6) 4.7 (3.7-5.7)
12 42.5 (40.8-44.2) 12.8  (10.9-14.7) 5.3 (4.5-6.1)
13-15 46.9 (44.2-49.6) 14.3. (11.4-17.2) 6.6 (5.2-8.0)
216 45.9 (42.5-49.3) 18.8  (14.9-22.7) 8.5 (7.0-10.0)
Poverty status**
At or above 42.7 (41.4-44.0) 14.8  (13.4-16.3) 6.2 (5.6-6.8)
Below 42.9 (39.5-46.3) 7.5 (4.7-10.3) 3.2 (2.0-4.4)
Unknown 35.2 (31.2-39.2) 12.6 (8.3-16.9) 4.4 (2.9-6.0)
Total 42.1 (40.9-43.3) 13.8 (12.5-15.1) 5.7 (5.2-6.3)

 

"Persons aged 218 years who reported having smoked at least 100 cigarettes in their lifetime and smoked
cigarettes daily 1 year earlier and who provided information of their current smoking status.

‘Sample size = 9,703; race/ethnicity variable excludes 34 respondents of other, unknown, or multiple race;
education variable excludes 24 respondents of unknown education level.

Abstinence from smoking cigarettes for at least 1 month at the time of the survey. Excludes 92 respondents who
were abstinent from cigarettes for <1 month or for whom duration of abstinence was unknown.

SConfidence interval.

“Excludes persons of Hispanic origin.

ISample sizes too small to derive reliable estimate.

**Poverty statistics are based on definitions developed by the Social Security Administration, which includes a set
of income thresholds that vary by family size and composition.

Source: National Center for Health Statistics, public use data tape, 1991.

Management of Nicotine Addiction 99
Surgeon General's Report

Methods for Managing Nicotine Addiction

 

Historically, the great majority of smokers (more
than 90 percent) who successfully quit smoking did
so “on their own”—that is, without the assistance of
formal cessation programs (USDHHS 19839; Fiore et al.
1990). With the advent of new treatments, including
pharmaceuticals, more smokers (20 percent) are using
some form of assistance when trying to quit (Zhu et
al. 2000). The success rate among this large group of
unassisted quitters is half that observed for those who
use some form of assistance. Although more than 1
million smokers quit each year, 75-80 percent relapse
within six months (Carmody 1992). Those who quit
may relapse at any time (even after a period of years),
and a substantial portion of quitters go through cycles
of quitting and relapse (Cohen et al. 1989a). Given
this complex context in which the natural history of
smoking occurs (an important leitmotif in the man-
agement of tobacco addiction), it is difficult to assign
a single number to the proportion who quit on their
own. Nonetheless, in the current environment of
declining prevalence, the end result of this cyclic pro-
cess, and of all the interventional efforts brought to
bear on it, is that each year about 3-5 percent of smok-
ers quit for a year, for longer, or for good.

The success of smoking cessation methods
should be evaluated in terms of both process and out-
come measures. Process measures are designed to as-
sess those variables that are affected by treatments and
that influence outcomes. Ideally, process measures
should target the specific change mechanisms that
treatments are intended to influence. For instance, if a
treatment is intended to provide smokers with coping
skills, process measures might assess a patient’s abil-
ity to anticipate and generate appropriate responses
to stresses. If a treatment is intended to promote ces-
sation by reducing withdrawal symptoms, then a with-
drawal symptom scale might be used as a process
measure. Clinically significant outcome measures in-
clude attempts at quitting and abstinence success.
Withdrawal symptom severity and concomitants of
cessation attempts, such as weight gain, may be viewed
as outcomes as well.

Some of the efficacy evaluations reported here
incorporate the results of published meta-analyses.
Meta-analysis is a statistical technique that assesses the
impact of a variable (or, in this context, a treatment)
across a set of related investigations (Dickersin and
Berlin 1992). Meta-analyses may present a more

100 Chapter 4

objective assessment of accumulated research findings
than do traditional narrative reviews (e.g., Cooper and
Rosenthal 1980) and can be useful for identifying study
or treatment characteristics that are associated with
differences in study outcomes (Dickersin and Berlin
1992). Meta-analyses of smoking cessation treatments
have used different techniques for estimating the size
of treatment effects. The precise methods used to cal-
culate and pool these estimates vary (for detailed de-
scriptions, see Fleiss 1981 and Cooper and Hedges
1994). In both meta-analyses and individual studies,
the most frequently encountered measures are the odds
ratio (an estimate of the relative risk for the outcome
in control versus treatment groups) and some form of
effect size (difference in effect between treatment and
control groups).

Self-Help Manuals

Because of the size of the population who try
quitting on their own, the broad dissemination of ma-
terials that can help them in their efforts—without re-
quiring them to participate in a formal cessation
program—may be a potent strategy at the national
level for decreasing the prevalence of smoking (Glynn
et al. 1990a; Curry 1993). A wide array of self-help
strategies has been developed for smoking cessation
(Curry 1993). This section discusses the efficacy of
written manuals, the most extensively investigated
self-help materials (Curry 1993). The discussion is lim-
ited to studies of such manuals distributed to relatively
small populations of smokers. Self-help materials de-
livered to large populations are discussed later in the
chapter in association with nonprint messages and pro-
grams (self-help or supervised) included in mass me-
dia and community-based efforts.

Efficacy

Ina review of the research literature on self-help
manuals, the median long-term prevalence of cessation
associated with manual-based interventions was about
5 percent (Curry 1993). This proportion is lower than
those of face-to-face cessation programs (Schwartz 1987;
Lichtenstein and Glasgow 1992; Lando 1993). Further-
more, recent evidence suggests that self-help manuals,
when used by themselves, may produce negligible
increases in long-term cessation (Gritz et al. 1992;
Petersen et al. 1992; Gomel et al. 1993; Fiore et al. 2000).

Because self-help manuals can be distributed, at
low cost, to very large numbers of smokers, even rela-
tively small cessation success could translate into large
numbers of successful quitters. Since 30-40 percent of
smokers each year make a serious effort to quit, self-
help aids could have a vast influence on public health
(Hatziandreu et al. 1990; CDC 1993b, 1999b). The avail-
able evidence suggests that self-help manuals work
better for smokers who are less dependent on nico-
tine, more motivated, and more confident of quitting
(Curry 1993), but the relationship between motivation
and success is complex. Less addicted smokers may
be less likely to seek formal treatment (Fiore et al. 1990;
Zhu et al. 2000) and are therefore an apt audience for
self-help manuals. More addicted smokers are more
likely to seek formal self-help programs (Wagner et al.
1990) but may be less successful in quitting (Schoen-
bach et al. 1992). Thus, in view of both their uncertain
effectiveness and their potential to be cost-effective, it
is important to determine whether self-help manuals
have a consistent, albeit small, benefit.

Although many self-help manuals have been de-
veloped, there is little evidence that they differ in their
effectiveness (Cummings et al. 1988; Glynn et al. 1990a;
Curry 1993). Accordingly, an Expert Advisory Panel
convened by the National Cancer Institute (NCI) has
recommended that public health professionals try to
increase the availability of existing manuals rather than
refine them or develop new ones (Glynn et al. 1990a).
The committee also concluded that if new materials are
deemed necessary, they should, ata minimum, contain
the following components: (1) information about
the social and health effects of smoking; (2) specific
strategies and exercises for quitting; and (3) specific strat-
egies and exercises to avoid relapse and, in the event of
relapse, to try quitting again (Glynn et al. 1990a).

Manuals tailored to special populations of smok-
ers, such as pregnant women, older adults, African
Americans, and Hispanics, have been developed and
tested (Windsor et al. 1985; Glynn et al. 1990b; Davis
et al. 1992; USDHHS 1998). Although manuals tar-
geted to specific populations have not had consistently
greater success than generic manuals at helping mem-
bers of relevant populations quit (Curry 1993; Rimer
et al. 1994), such manuals have the potential to reach
smokers missed by traditional materials (Curry 1993).

It appears that combining multiple types of
seli-help materials (manuals, videotapes, etc.) does not
improve long-term cessation rates. A meta-analysis of
21 studies using multiple types of self-help without
person-to-person contact found no significant difference

Reducing Tobacco Use

between multiple types of self-help and no self-help at
all (Fiore et al. 2000).

Reading level has been increasingly recognized
as an important attribute of self-help manuals. Since
the early 1970s, trends in smoking prevalence have
been different for those with differing levels of educa-
tional attainment (Pierce et al. 1989). Smoking preva-
lence has dropped sharply among persons with a
college education (10.1 percentage points between 1974
and 1985) but has declined only marginally among
high school dropouts (2.1 percentage points during the
same period). Concerns about literacy have led to the
recommendation that self-help materials for smoking
cessation be written at no more than a seventh-grade
reading level (Glynn et al. 1990a), although this level
may be too high in some situations.

Adjuncts to self-help manuals, such as telephone
counseling (Orleans et a]. 1991; Curry et al. 1992; Lando
et al. 1992), hot lines (Ossip-Klein et al. 1991), and per-
sonalized feedback (Curry et al. 1991; Prochaska et al.
1993), have also been evaluated. These adjunctive in-
terventions have met with varying success (Curry
1993). For example, self-help treatments that include
nicotine gum as well as smoking cessation manuals have
not had greater long-term efficacy than the manuals
alone (Harackiewicz et al. 1988; Killen et al. 1990b).
Computer-generated personalized feedback (Curry et
al. 1991) and telephone outreach, however, have im-
proved cessation success (Orleans et al. 1991; Lando et
al. 1992; Prochaska et al. 1993; Strecher et al. 1994). At
present, research suggests that such adjuvants materi-
ally improve the effectiveness of self-help manuals.

Adjunctive interventions that require financial
and personnel resources, however, may undercut the
potential population impact of self-help interventions.
The addition of other components to self-help manu-
als may also mark the point at which the self-help
modality merges with more formal assistance, which,
as mentioned earlier, have not appealed to as large a
population of smokers motivated to quit. But at least
one such treatment, proactive telephone counseling (as
opposed to reactive approaches, such as help lines
smokers must call), appears to be effective when used
as an adjuvant (Fisher et al. 1993).

Relevant Process Measures

Most studies of self-help manuals lack process
measures, and the specific measures used across stud-
ies vary considerably (Curry 1993). Two distinct pro-
cess measures, manual reading and manual use, have
been assessed in some studies of self-help manuals for
smoking cessation. Reading measures simply ask

Management of Nicotine Addiction 101
Surgeon General's Report

smokers whether they read most or all of the manual.
Use measures assess the extent to which smokers
performed the specific exercises recommended in the
manual. In theory, persons who actually read a manual
or practice manual-recommended exercises should be
more successful than those who merely possess a
manual. Curry (1993) concluded that although read-
ing has sometimes been related to program success,
use has been more consistently related to improved
outcomes. Further work is needed to determine with
some certainty whether the information conveyed by
the manuals, rather than nonspecific motivational ef-
fects, is responsible for their efficacy.

Summary

Although self-help manuals have had only mod-
est and inconsistent success at helping smokers quit,
manuals can be easily distributed to the vast popula-
tion of smokers who try to quit on their own each year.
Adjuvant behavioral interventions, particularly pro-
active telephone counseling, may increase the effect
of self-help materials. Process measures are not rou-
tinely incorporated into self-help investigations, but
the available process data suggest that persons who
not only have a self-help manual but also perform the
exercises recommended in the manual are more likely
to quit smoking.

Minimal Clinical Interventions

Minimal clinical interventions are those that can
be delivered briefly to smokers by health care profes-
sionals during the course of a regular health care en-
counter. These strategies may be as simple as advising
smokers to quit, or they may be as complex as using
computers to tailor the intervention to the individual
smokers. Minimal clinical interventions could have a
great influence at a national level on smoking cessa-
tion, but they have been underused. Findings from a
1985 (Ockene et al. 1987), a 1991 (CDC 1993b), and a
1992 national survey (Tomar et al. 1996) suggest that
nearly 70 percent of American smokers (nearly 36 mil-
lion) make at least one outpatient health care visit each
year; however, only 40-52 percent of the smokers in
the surveys reported that during the preceding year
they had been advised by a health care professional to
quit smoking. Ina separate study, 48.8 percent of 2,710
current smokers had been advised by their physician
to stop smoking or to smoke less (Frank et al. 1991).
More than 50 percent of adult smokers in the United
States saw a dentist in 1992, but fewer than 25 percent

102 Chapter 4

of those who saw a dentist in the preceding year re-
ported that the dentist had advised them to quit smok-
ing (Tomar et al. 1996). Among adult users of
smokeless tobacco, 18 percent reported that they had
ever been advised by a dentist and 15 percent had ever
been advised by a physician to quit (Tomar et al. 1996).

Many clinicians may believe that they are not
equipped to help smokers quit (Wells et al. 1984; Glynn
1988) or that a physician can help a smoker quit
(Ockene et al. 1988a). Training programs for clinicians
have been developed to address this problem (Ockene
et al. 1988b; Cummings et al. 1989a,b; Duncan et al.
1991; Manley et al. 1991; Strecher et al. 1991); however,
data suggest that simply training clinicians may not
be effective (Dietrich et al. 1992; Carney et al. 1995;
Klein et al. 1995). However, implementing reminder
systems in the clinic has been shown to triple clinician
intervention with smokers (Fiore et al. 1996, 2000).
Some evidence suggests that the delivery of these mini-
mal clinical interventions is becoming more common
(Gilpin et al. 1992).

Surveys suggest that smokers who are white, fe-
male, older, better educated, or ill, or who smoke more
cigarettes per day are more likely than others to re-
ceive clinical advice to quit (Ockene et al. 1987; Frank
et al. 1991; Gilpin et al. 1992; CDC 1993b). At present,
clinicians apparently do not ensure that all of their
patients who smoke receive cessation advice and as-
sistance, in part because of structural and policy is-
sues (such as reimbursement) related to medical care
delivery. Nonetheless, such efforts might be more com-
mon if clinicians were trained to view smoking as a
chronic disease, marked by periods of remission and
relapse, rather than as an acute disorder (Fiore and
Baker 1995).

Researchers have shown that institutional changes
can increase the systematic delivery of minimal clinical
interventions for smoking cessation. For example, brief
physician training, availability of nicotine gum, and
patient chart stickers documenting smoking status can
increase the amount of time physicians spend in cessa-
tion counseling and increase successful cessation by a
factor of 2 to 6 (Cohen et al. 1989b; Ockene et al. 1991).
One proposed change is to expand patient vital signs
to include an assessment of tobacco use (Fiore 1991).
This simple institutional change has been shown to
increase markedly the proportion of patients who re-
port that their health care providers asked and coun-
seled them about smoking cessation (Fiore et al. 1995;
Robinson et al. 1995).

Finally, institutional changes are critical for
prompting more clinicians to play a role in smoking
cessation. Currently, clinicians are only sporadically