Surgeon General's Report received healthy lifestyle advice by mail and by worksite posters. Men in the intervention sites found at baseline to be at high risk for cardiovascular dis- ease were provided medical counseling on risk factor change, including smoking cessation. At the end of the intervention in 1977-1978, a small but significant reduction in smoking prevalence had occurred among the high-risk smokers in the intervention site (Rose et al. 1980). Five intervention and five control worksites were resurveyed in 1983, approximately 12 years after the baseline screening and at least 5 years after the end of the intervention program (Bauer et al. 1985). There was no significant difference in the prevalence of smok- ing between intervention and control factories, but the smokers at the intervention sites reported smoking sig- nificantly fewer cigarettes per day. The initial design and implementation of the North Karelia and Stanford Three-Community trials led to the design of several other cardiovascular disease prevention trials around the world. These included the Swiss National Research Program from 1977 to 1980 (Gutzwiller et al. 1985), the South African Coronary Risk Factor Study from 1979 to 1984 (Steenkamp et al. 1991), and the Australian North Coast Healthy Lifestyle Programme from 1978 to 1980 (Egger et al. 1983). The early trials also influenced the development of two communitywide mass media-based smoking cessation trials implemented in Australia in the 1980s, in Sydney from 1983 to 1986 and in Melbourne from 1984 to 1986 (Pierce et al. 1986, 1990; Macaskill et al. 1992). In the Swiss trial, two towns in the French- speaking and two towns in the German-speaking regions of the country were assigned to either interven- tion or reference status (Gutzwiller et al. 1985). Baseline surveys of risk factors for cardiovascular disease were conducted among random samples of residents aged 16 to 69 years in all four towns in 1977-1978 and repeated at the final assessments in 1980-1981. In the interval, community wide health education and health promotion interventions were conducted in the two intervention towns, including media campaigns, counseling of high-risk individuals, and community organization efforts to encourage environmental and social changes. The prevalence of smoking in the com- munities declined from 32.8 to 27.4 percent in the intervention towns and from 37.1 to 35.3 percent in the reference towns, a significant net effect of 3.6 percent decline. In the South African Coronary Risk Factor Study, three rural communities, matched in size, socioeco- nomic status, and cultural factors, were assigned to low-intensity prevention, high-intensity prevention, and control status (Steenkamp et al. 1991). Both 378 = Chapter 7 the low- and the high-intensity sites received a mass media educational campaign using so-called small media, such as posters, billboards, mailings, and coverage in local newspapers. In the high-intensity community, high-risk individuals, including smokers, received personal interventions from health care pro- viders. Risk factors for cardiovascular disease were measured in a cohort of residents aged 15 to 64 years from each community in 1979 and in 1983. The baseline prevalence of smoking was higher among men (49.2 vs. 44.4 percent) and women (17.0 vs. 14.5 percent) in the high-intensity intervention community than in the control community, but the difference was not sta- tistically significant. After the four-year intervention, the net change in smoking prevalence in the high- intensity community, relative to the control commu- nity, was not significant for men but was significant for women. Women in both the low- and the high- intensity intervention communities had significantly higher rates of quitting than women in the control com- munity, but no differences were observed for men. The Australian North Coast Healthy Lifestyle Programme replicated the design of the Stanford Three-Community Study (Egger et al. 1983). In 1978, three communities in northern New South Wales, Aus- tralia, were assigned to a media intervention, media intervention plus community program, or control sta- tus. A two-year study for preventing cardiovascular disease was conducted, including a smoking cessation component called “Quit for Life.” The media inter- ventions used professional commercial media and advertising techniques and a social marketing and health promotion framework involving print, posters, radio, television, and other advertising techniques. The community programs for smoking cessation in- cluded promotions of smoking cessation organizations, kits handed out by doctors, distribution of self-help materials, and telephone help lines. The smoking ces- sation campaigns also incorporated other community activities—such as organized runs, stress management training, and computerized health testing—that con- veyed the overall program’s broader theme of healthy lifestyles. Risk factors for cardiovascular disease, in- cluding smoking, were measured in random samples of residents aged 18 years and older in each commu- nity in 1978 (baseline), 1980, and 1981. In the multiple logistic regression analysis model, which controlled for baseline differences among the three communities in age and sex distributions, there was a statistically greater decline in smoking in the two intervention com- munities than in the comparison community, with the largest differences among young smokers. Declines in the prevalence of smoking in the area assigned to media intervention plus community program ranged trom 13.7 percent among men aged 18-25 vears to 6.1 percent among women aged 65 vears and older. In the 1980s, a communitywide mass media- based smoking cessation campaign was conducted in Sydney and Melbourne, Australia (Dwver et al. 1986; Pierce et al. 1986). The Sydney campaign began in mid- 1983, and the Melbourne campaign began one vear later (during the preceding vear, Melbourne was used as a control city for the Svdnev campaign). The “Quit tor Life” campaigns involved innovative and provoca- tive smoking cessation messages delivered through paid spots on the radio, on television, and in newspa- pers. These messages were supported by a telephone “Quit Line,” self-help “Quit Kits,” anda hospital-based “Quit Centre,” all of which were promoted at the end of the paid advertisements used in the campaigns. The campaigns were evaluated through monthly random telephone surveys in the two communities. In addi- tion, a cohort of residents was interviewed in April- June 1983 and again in Mav 1984. In the cohort, 23 percent of smokers in Svdney and 9 percent in Melbourne quit during the initial (control) year before the campaign was begun in Melbourne (Pierce et al. 1986). The monthly prevalence estimates demonstrated an approximately I-percent decline in Svdney in com- parison with the rest of Australia (Dwver et al. 1986). The media campaigns were continued through 1986, along with additional programs in conjunction with physician-, school-, and community-based activities. Long-term evaluation of trends in smoking in the two cities from 1981 to 1987 suggests that the sustained campaigns may have contributed toa decline in smok- ing prevalence of about 1.5 percentage points per year in both communities among men but had little impact on women (Pierce et al. 1990). An analysis of the campaign’s potential differential impact across educa- tional levels suggested that the Australian mass media and community campaigns did not contribute to an increase in the gap in smoking prevalence between educational groups (Pierce 1989; Macaskill et al. 1992). The lack of a consistently positive effect from these initial community trials was attributed more to an incomplete understanding of comprehensive interven- tions and to the relatively weak, quasi-experimental designs of the studies than to concern about the effi- cacy of the overall approach (Farquhar 1978). The con- tinuing enthusiasm for the potential efficacy of the communitywide approach was reflected in both na- tional and international reviews and guidelines (Blackburn 1983; WHO 1982; USDHHS 1983; National Cholesterol Education Program Expert Panel 1988; Shea and Basch 1990a,b). Similarly, the positive results Reduciie Tobacco Use from the Australian communitywide antismoking media campaigns and smoking cessation data from the North Karelia trial encouraged the planning of smoking-specific community efforts in the United States in the late 1980s. Three major community-based trials for prevent- ing cardiovascular disease were funded by the Na- tional Heart, Lung, and Blood Institute (NHLBI) in the early 1980s: the Stanford Five-City Project, the Min- nesota Heart Health Program, and the Pawtucket Heart Health Program. Each had comparison and in- tervention communities and stronger designs and evaluation methodologies than the studies initiated in the 1970s. Each study was developed by an indepen- dent team of investigators, and the NHLBI maintained a collaborative research relationship among the stud- ies (Winkleby et al. 1997). All three shared common intervention approaches that lasted five to eight years and focused on the major risk factors for cardiovascu- lar disease (hypertension, cigarette smoking, high di- etary fat, obesity, and sedentary lifestyle). Each project used mass media, community mobilization, and mul- tiple educational channels, such as health care provid- ers, schools, worksites, and voluntary agencies. The programs integrated individual and social change ap- proaches, emploving some combination of social learn- ing theory, social network diffusion theory, and social marketing to guide the planning and implementation of the interventions (Bandura 1977; McGuire 1973; Rothman 1979; Rogers 1983). The three projects dif- tered initially in their relative emphasis on specific modalities (Stanford emphasized media; Minnesota, population screening; and Pawtucket, community or- ganizations) (Shea and Basch 1990a), but frequent col- laborations among projects decreased these differences over time. Many innovative strategies were devel- oped, and the process evaluations on specific smok- ing prevention and cessation interventions were posi- tive (Glasgow et al. 1985; Sallis et al. 1985; Altman et al. 1987; Elder et al. 1987, 1993; King et al. 1987; Lando etal. 1990, 1991; Perry et al. 1992; Pechacek et al. 1994). Nonetheless, the overall impact of the three interven- tions on smoking prevalence was modest. The Stanford Five-City Project began with baseline surveys in 1979, Five cities in Northern California were selected on the basis of location, size, and media mar- kets (Farquhar et al. 1985). Monterey and Salinas shared a media market and were assigned to the intervention group. The three control cities (Modesto, San Luis Obispo, and Santa Maria) were isolated from the me- dia market of the intervention communities. The communitvwide educational campaigns began in 1980 in collaboration with existing community Comprehtensice Programs — 379 Surgeon General's Report organizations. The two treatment cities received con- tinual exposure for five years; each vear, four to five separate risk factor education campaigns took place, one of which focused on smoking. Evaluations in- cluded independent, cross-sectional population samples aged 25 to 74 years surveyed at baseline and at 25, 51, and 73 months, as well as a cohort formed from the baseline survey that was resurveyed at 17, 39, and 60 months. Initially, the cohort samples in the intervention communities experienced a significantly greater decline in smoking prevalence than those in the control communities (-7.66 vs. -3.76 percent) (Farquhar et al. 1990; Fortmann et al. 1993). By the end of the intervention in 1986, the cross-sectional surveys showed no such difference in declining prevalence. At the final follow-up in 1989-1990, a more rapid though nonsignificant decline was detected in the control communities than in the intervention com- munities (Winkleby et al. 1996). In the Minnesota Heart Health Project, three pairs of communities were selected, with one of each pair assigned to educational intervention and the other to comparison status (Jacobs et al. 1986; Murray et al. 1994). The communities were matched on size, com- munity type, and distance from the Minneapolis- St. Paul metropolitan area. After a 16-month baseline assessment period, a 5- to 6-year intervention program was started in November 1981 in the first education site, Mankato, Minnesota (Luepker et al. 1994). The second and third education sites, Fargo-Moorhead on the North Dakota-Minnesota border and Bloomington, Minnesota, were started 22 and 28 months later in 1983. The staggered entry allowed for a gradual develop- ment of the intervention program and a stronger evalu- ation design (Luepker et al. 1994). Starting in 1980, annual cross-sectional surveys among residents aged 25 to 74 years were conducted in all six sites. A ran- dom sample of residents surveyed before the start of the education program was resurveyed. For long-term smoking cessation, the cross-sectional survey data provided evidence of an intervention effect for women but not for men; no such effect was observed for ei- ther sex in the cohort sample (Luepker et al. 1994; Lando et al. 1995). Unexpectedly, large declines in smoking prevalence, especially among men, were ob- served in comparison communities. In the Pawtucket Heart Health Program, the impact of a communitywide program for reducing risks for cardiovascular disease in Pawtucket, Rhode Island, was compared with trends in a nearby matched community in southern Massachusetts (name withheld to honor a confidentiality agreement with the city gov- ernment) (Carleton et al. 1995). Pawtucket was selected 380 Chapter 7 as the intervention site from among a pool of nine potential northeastern New England cities; the comparison site had similar sociodemographic char- acteristics. Surveys of risk factors for cardiovascular disease were conducted with random samples of residents aged 18 to 64 years in the two communities at two-year intervals, beginning in 1981 and continu- ing until 1993. Communitywide educational strategies emphasized public awareness campaigns, behavior change through existing community resources and volunteers, and community activation to promote in- volvement and environmental changes (Elder et al. 1987, 1993; Lefebvre et al. 1987). During the seven- year intervention program from 1984 to 1991, more than 500 community organizations were involved, including schools, religious and social organizations, larger worksites, and city government departments. Overall projected risk for cardiovascular disease declined significantly in Pawtucket during the educa- tional program, but the prevalence of cigarette smoking declined only slightly and did so more in the comparison than in the intervention community (Carleton et al. 1995). : Concurrent with the community-based cardiovascular disease prevention trials in the United States, an antitobacco community education program was initiated in India (Anantha et al. 1995). The trial was conducted between 1986 and 1992 in the Karnataka State. One intervention area (117 villages) and two control areas (136 and 120 villages) were se- lected within the Kolar District. A baseline survey was conducted in 1986, and follow-up surveys were con- ducted two and five years later. Villages were ran- domly sampled in each of the three areas, and the to- bacco use habits of all residents of each household were assessed. A subsample of the villages selected at baseline was resurveyed two and five years later to provide cohort follow-up. After the baseline survey, a three-year educational campaign used health worker staft from Primary Health Centres to visit each village at least once a week and deliver health education mes- sages about the risks of cigarette smoking and other forms of tobacco use, particularly chewing. Handbills, photographs, posters, and films in multiple languages were used to reinforce health education counseling de- livered to individuals and small discussion groups. Among tobacco users in the intervention area, preva- lence declined 26.5 percent for men and 36.7 percent for women. The proportional reduction in the preva- lence of any tobacco use was significantly greater in both men and women in the intervention area than in the two control areas (10.2 vs. 2.1 and 0.5 percent for men and 16.3 vs. 2.9 and 0.6 percent for women). The Federal Republic of Germany began the Ger- man Cardiovascular Prevention (GCP) Study in the mid-1980s (GCP Study Group 1988). The seven-year prevention campaign in the GCP Study targeted more than 1 million people in six intervention regions whose demographic and socioeconomic structure reflected that of the West German population. The reference population was sampled from the total West German population. The goal of the campaign was to reduce four risk factors for cardiovascular disease (hyperten- sion, hypercholesterolemia, smoking, and obesity) by using a multifaceted prevention program. Public health services, voluntary welfare federations, institutions for adult education, sports and consumer associations, and other existing community resources and facilities were used extensively. The campaigns sought the involve- ment of health care providers and emphasized consum- ers’ access to them. Special emphasis was placed on improving community knowledge and awareness of healthy nutrition, the benefits of physical activity, and the importance of quitting smoking. To identify per- sons at high risk for hypertension and hypercholester- olemia, screenings were conducted at social events, in factories, and at other community settings in close cooperation with physicians, pharmacists, and health insurance companies. To discourage smoking, non- smoking restrictions were extended in public places, and educational campaigns were conducted in the media and in community settings to promote smoking cessation and to help smokers quit. For the evaluation of risk factor trends, representative samples of residents aged 25-69 years from the intervention regions and of the national population of West Germany were sur- veyed before the intervention (May 1984 to March 1986), at midstudy (February 1988 to April 1989), and at the end of the intervention (April 1991 to April 1992) (Hoffmeister et al. 1996). In the national reference sample, the prevalence of smoking declined from 34.0 percent at baseline to 33.5 percent at the end of the study. In the intervention region, the prevalence of smoking declined from 35.4 percent at baseline to 32.5 percent at the end of the study, for a net change of -6.7 percent (P < 0.001). The decline occurred exclusively among men (net change of -7.9 percent, P < 0.001). Among women, the prevalence of smoking increased in both the intervention regions and nationwide, and no inter- vention impact was noted (net change of -1.8 percent). Using a somewhat different design, the Com- munity Intervention Trial for Smoking Cessation (COMMIT) was started in the late 1980s (COMMIT Re- search Group 1991). COMMIT focused solely on smok- ing cessation and built on the initial experience in the Reducing Tobacco Use ongoing trials to prevent cardiovascular disease. COM- MIT was planned as a randomized community trial with 11 pairs of communities and had adequate statistical power to detect relatively small intervention effects (Gail etal. 1992). One community of each pair was randomly allocated to the intervention program, and the other was monitored as a control. The 11 intervention com- munities received a four-year educational program that focused on adult cessation, with special empha- sis on “heavy” cigarette smokers (those who smoked 25 or more cigarettes per day). The intervention philosophy of the trial assumed that a comprehensive communitywide strategy would make it difficult for residents in the 11 targeted sites to avoid exposure to messages about the importance of nonsmoking and would alert smokers to the many opportunities for cessation. Interventions focused on four primary edu- cational channels: media-based and communitywide events, health care providers (e.g., physicians and den- tists), worksites and other organizations, and cessa- tion resources. Within these channels, the centrally developed protocol specified 58 mandated activities, designed to be carried out largely by community vol- unteers and local staff or agencies with limited external resources (Lichtenstein et al. 1990-1991). Intervention activities started after the baseline survey and random- ization, beginning with community mobilization in January 1989 and continuing with protocol-defined intervention through December 1992. A telephone sur- vey was conducted in each of the 22 sites to estimate baseline prevalence and identify cohorts of heavy and light-to-moderate smokers. Cohort members were contacted annually by telephone, with a final assess- ment in early 1993. A final prevalence survey was conducted in all 22 communities from August 1993 to January 1994. There was a high degree of community owner- ship within the 11 intervention sites (Bracht et al. 1994; Lichtenstein et al. 1996), and program staff and com- munity organizations diligently delivered the 58 man- dated activities. Hence, the modest effects observed in this trial were sobering for the public health com- munity (Fisher 1995; Susser 1995), No cessation effect was observed for the “heavy” smokers for whom the trial was specifically designed (COMMIT Research Group 1995a). Among the evaluation cohort of light- to-moderate smokers, a significantly greater propor- tion quit in the intervention than in the control communities (30.6 vs. 27.5 percent) over the four-year intervention period, and the effect was strongest among the less educated residents of the communi- ties. Overall the prevalence of smoking declined Comprehensive Programs 381 Surgeon General's Report slightly (but nonsignificantly) more in the interven- tion communities (3.5 percentage points) than in the comparison communities (3.2 percentage points) (COMMIT Research Group 1995b). The quality and statistical power of the overall trial design (Gail et al. 1992) make it unlikely that any true intervention effects were missed. The COMMIT intervention pro- tocol sought to apply the most effective smoking ces- sation strategies as defined by the published literature (Lichtenstein et al. 1990-1991; COMMIT Research Group 1991). The investigators were limited, however, in their ability to be involved in many of the recom- mended ecological and policy-oriented health promo- tion strategies (WHO 1979; Green and Richard 1993) because of restrictions imposed by federal funding of the study (Fisher 1995; Susser 1995). In addition, process data showed that implemented protocol did not have a significant impact on many important in- termediate variables (e.g., physician and dentist coun- seling rates, worksite smoking bans, public attitudes toward smoking) (Glasgow et al. 1997; Ockene et al. Statewide Interventions 1997, Taylor et al. 1998). Therefore, the failure of the COMMIT interventions to use certain strategies or to change intermediate social and policy variables suggests that the study was not an adequate test of the efficacy of the social-environmental approach to reducing to- bacco use. Several reviewers have provided some perspec- tives on the modest smoking cessation effects observed in these community trials (Green and Richard 1993. Luepker 1994; Winkleby 1994; Fisher 1995; Susser 1995). Common themes are (1) the difficulty in ob- serving intervention effects because of the large secular declines in risk factors for cardiovascular dis- ease, including smoking, that occurred during the period when the trials were implemented and (2) the need for a more comprehensive health promotion ap- proach. A more complete understanding is needed of why such modest and mixed smoking cessation effects have been observed in numerous well-designed and well-implemented communitywide trials. Concurrent with the implementation of the com- munity intervention trials, a broader national move- ment to reduce tobacco use began to emerge in the 1980s. Unlike the community intervention trials, this movement, and the large-scale interventions that developed from it, was not structured around research hypotheses and preplanned evaluation designs. Rather, the movement was characterized by commu- nity mobilization at the national, state, and local levels and encompassed the principles of health pro- motion as a social movement that evolves (Kickbusch 1989; Allison and Rootman 1996; Downie et al. 1996; Nutbeam 1998). Funding for these efforts came from both federal and private sources; however, an impor- tant manifestation of this national movement was the establishment of statewide interventions funded by increases in cigarette excise taxes or settlements with the tobacco industry. Such increases were the result of voter initiatives, beginning with those in California in 1990 and Massachusetts in 1993. The next section of this chapter reviews the main elements of the na- tional movement. 382 Chapter 7 Community Mobilization A significant step in organizing the movement to reduce tobacco use was the founding in 1981 of the Coa- lition on Smoking OR Health, which consisted of repre- sentatives from three major volunteer health agencies: the American Cancer Society (ACS), the American Heart Association, and the American Lung Association. The formation of a national coalition prompted state- and Jocal-level leaders of these organizations to form similar triagency coalitions. Some of these state and lo- cal coalitions expanded to include representatives from other groups, such as medical societies, other volunteer health organizations, and state health departments. These coalitions were among the first efforts to mobi- lize communities at the state and local levels. The consensus of the 1985 International Summit of Smoking Control Leaders in Washington, DC, was that only unified, broadly based, strategically cohvr- ent, and flexible national movements for reducing smoking were destined to be successful. To help build such movements, the summit participants recom. mended producing a handbook on coalition building. The resulting ACS publication, Smoke Fighting: A Smok- ing Control Movement Building Guide (Pertschuk and Erickson 1987), examined the strengths and weak- nesses of networks and coalitions and gave sugges- tions for building and strengthening these forums. This guide was one of the earliest produced on com- munity organizing to reduce tobacco use. A survey conducted by the Association of State and Territorial Health Officials determined that as of December 31, 1989, coalitions for reducing tobacco use had been formed in 46 states and the District of Columbia (CDC 1990). Only Hawaii, Kentucky, Mis- sissippi, and South Carolina did not have state-level coalitions at that time. Of the 47 coalitions, 44 concen- trated on reducing tobacco use; the remaining 3 ad- dressed tobacco use, as well as other chronic disease risk factors. Although Colorado established the first tobacco-related coalition in 1963, coalitions in 28 states were not established until after 1984. Coalition activi- ties included lobbying, providing public education, educating health care professionals, conducting re- search and evaluation, and developing and implement- ing a state plan for reducing tobacco use (Pertschuk and Erickson 1987). Until recently, the United States remained with- out a national program for tobacco-related risk reduc- tion analogous to those established for hypertension and hypercholesterolemia. During the 1990s, three nationally funded programs—two by the federal gov- ernment and one by a private foundation—and one federally funded research project have helped states and localities mobilize for reducing tobacco use. As noted, several states provided funds for state and local community organizing. National Programs ASSIST The American Stop Smoking Intervention Study (ASSIST) for Cancer Prevention is a partnership be- tween the NCI and the ACS to establish coalitions that focus on using public policy change to reduce tobacco use (see also “Community Programs” in Chapter 4). The ASSIST project was developed after many NCI consultants had recommended that community-based coalitions for reducing tobacco use be established in entire states or in large metropolitan areas. The ASSIST guidelines provided both the rationale for the coalition model and the flavor of the overall project: Reducity lobacee Use * Smoking is a public health problem that affects ev- eryone in a community, not only smokers. The solution to the smoking problem requires the ac- tive involvement of a broad range of groups and individuals. ° Significant and enduring changes in smoking be- havior require a change in social norms, that is, that smoke-free environments and lifestyles are preferred and encouraged among all social groups. Changes in social norms occur over time with the involvement and support of a broad representa- tion of interest groups. * Tremendous resources are invested each minute of every day to encourage young people to begin smoking as a normal and acceptable behavior. The resources required to counter this effort and to ef- fect a significant change in smoking behavior far exceed the funds available through this [ASSIST] project. A large contribution of direct and in-kind support in the form of time, energy, volunteers, and other resources will be required. Only through the commitment of a variety of groups and organiza- tions can adequate resources be made available. ¢ The intent of ASSIST is not to create a new insti- tution devoted to smoking control but rather to increase the capacity for existing groups and or- ganizations to sustain and enhance their role as smoking control agents beyond the life of ASSIST. Activities by different groups will be coordinated and efforts thereby magnified, and strategies and training will be disseminated and institutional- ized in each coalition member group (NCI 1991, pp. 1-2). ASSIST included an initial planning phase (1991- 1993) and a subsequent implementation phase (1993- 1998) for the 17 states chosen for participation. The implementation phase was then extended to Septem- ber 1999. During the planning phase, the coalitions performed comprehensive site analysis and developed a plan for reducing tobacco use. For planning, each state received approximately $400,000 per year to de- velop its own comprehensive, five-year plan (Manley et al. 1997a). During the implementation phase, states have been receiving an average of approximately $1.2 million per year to carry out the action steps in accor- dance with NCI guidelines and ASSIST program ob- jectives. Intensive training of state health department and voluntary agency personnel in the ASSIST states was a primary activity during the planning phase and Comprehensive Programs — 383 Surgeon General's Report early vears of the implementation. This training fo- cused on the program objectives, including policy changes, media advocacy, and community mobiliza- tion. An interim evaluation of impact (Manley et al. 1997b) found that per capita cigarette consumption and inflation-adjusted cigarette prices were nearly identi- cal in the 17 ASSIST states and the remaining non- ASSIST states (excluding California) before 1993, when full funding for the ASSIST intervention began. By 1996, per capita consumption in the ASSIST states was about 7 percent less than in the non-ASSIST states. This decrease occurred in the face of a general decline in cigarette prices during the period of evaluation. These interim results suggest that the ASSIST program has been associated with a significant decrease in cigarette consumption and that increased price from taxation may not be the only program influence. IMPACT In its Initiatives to Mobilize for the Prevention and Control of Tobacco Use UMPACT) program, the CDC has funded the District of Columbia and 32 states that do not receive funding from the ASSIST project. The exception is California, which is not funded by ASSIST or by the CDC but since 1989 has had a to- bacco control program funded by the state excise tax on cigarettes. (The California program is described later in this chapter.) A portion of IMPACT funds sup- ports community mobilization at the state and local levels, with particular focus on racial and ethnic mi- nority groups and women. The IMPACT program also provides extensive training to representatives of state coalitions in subjects such as media advocacy, policy advocacy, and coalition building. Recently, the IMPACT program has been ex- panded to include key national organizations to help them mobilize their constituencies in efforts to reduce tobacco use. Funds have been especially directed to organizations that serve populations targeted by the tobacco industry’s marketing plans and that are his- torically underrepresented in the movement to reduce tobacco use (Farquhar et al. 1985; USDHHS 1998). SmokeLess States Program In 1994, the Robert Wood Johnson Foundation initiated the SmokeLess States program to provide additional funds to state coalitions. In the initial round of funding, the program awarded more than $13 mil- lion in either four-year implementation grants or two- year capacity-building grants to 19 state coalitions and also funded a vouth-specific project in Tucson, Arizona 384 Chapter 7 (Robert Wood Johnson Foundation 1994}. Two years later, funding for the SmokeLess States program was expanded to $20 million. In this second round of fund- ing, awards were made to 13 new states; in addition, implementation grants were made to some of the states that had previously received capacity-building grants. In 1998, SmokeLess States funded another $6 million in grants to eight states that had been funded for four years each. Currently, the SmokeLess States program funds 28 states and 2 cities at a total of $39 million per year. The SmokeLess States program focuses on help- ing state coalitions develop policy options, including prevention programs similar to those in place in Cali- fornia and Massachusetts (as discussed later in this chapter) and other efforts aimed at reducing tobacco consumption, especially among young people. Ad- ministered by the American Medical Association (1998), this grant program differs from ASSIST and IMPACT in that it does not have strict requirements concerning the makeup of the coalition, although com- munity mobilization is a required program activity. National Programs to Reduce Youth Access to Tobacco In 1996, SAMHSA issued regulations to imple- ment the Synar Legislation. These regulations and the provisions of the Synar Amendment to the 1992 ADAMHA (Alcohol, Drug Abuse, and Mental Health Administration) Reorganization Act established a na- tionwide effort to reduce youth access to tobacco by requiring states to have and enforce laws prohibiting the sale of tobacco products to anyone under age 18. Failure to meet the requirements of the Synar legisla- tion could result in penalties against a state’s Substance Abuse Prevention and Treatment Block Grant. The full discussion of the state efforts to meet these require- ments is provided in Chapter 5. By establishing a coordinated program in all 50 states and the District of Columbia to address this problem, SAMHSA has provided a core resource to the tobacco control effort across this country. In 1996, the Food and Drug Administration (FDA) issued a rule mandating that tobacco retailers not sell tobacco to anyone under age 18 and that they require a picture identification card from anyone un- der the age of 27 who attempts to purchase tobacco (Federal Register 1996). In support of this rule, the FDA entered into contracts with state agencies to institute compliance checks of retailers and has implemented mass media and direct education campaigns to inform retailers of this rule. However, the March 21, 2000, ruling of the United States Supreme Court held that the FDA lacks jurisdiction to regulate tobacco prod- ucts as customarily marketed. Following this decision, the FDA immediately began the process of terminat- ing the contracts with state agencies and shutting down its enforcement program. The full discussion of this Program is provided in Chapter 5. States Currently Funded in the Nationwide Program to Reduce Tobacco Use In 1998, 49 state health departments and the Dis- trict of Columbia received funding from the USDHHS for activities to reduce tobacco use. The NCI’s ASSIST project provided 17 states with approximately $21.5 million, and the CDC's IMPACT program funded 32 states and the District of Columbia with approximately $12 million. In February 1998, the CDC and the NCI were given joint responsibility to assist states and na- tional organizations in amalgamating the findings of comprehensive research projects, the CDC and NCI programs, and the state and local programs funded by tax initiatives and legal settlements with the tobacco industry. This process will continue the evaluation of a national program that includes all States, the District of Columbia, territories, and tribes and aims to bring synchrony and coherence to the efforts of all groups working to reduce tobacco use. In May 1999, the CDC launched the National Tobacco Control Program (NTCP) transitioning fund- ing through various federal initiatives into one national Program. The purpose of the NTCP is to build and maintain a coordinated national effort to reduce the health and economic burden of tobacco use. Federal funding is intended to support core public health to- bacco control functions or to enhance existing tobacco control programs within state and territorial health departments. The program framework is based on the comprehensive tobacco control framework outlined earlier in the chapter (see “Description of Comprehen- sive Programs”). The NTCP funds tobacco contro] programs in all states, the District of Columbia, and seven U.S. territories. The NTCP also includes initia- tives to fund American Indian tribal organizations to develop or improve tobacco-related regional resource networks and outreach to tribes. In 2000, the NTCP launched a new initiative to aid in the elimination of disparities in health status and outcomes among popu- lations as it relates to tobacco use. In fiscal year 1999, the NTCP awarded $50 million to 50 states, the District of Columbia, and seven territories for a five-year Sooperative agreement starting June 1, 1999, to May 30, 2004. In fiscal year 2000, funding to the states, the Dis- trict of Columbia, and territories totaled $59 million. The Reducing Tobacco Use average award for states and the District of Columbia is $1.13 million. The average award for territories is $140,000. The total includes supplemental awards of $499,400 for asthma and ETS, funded in conjunction with the Environmental Protection Agency, and $244,000 for Smoke-Free Kids and Soccer. The state awards almost clase the funding gap between the former NCI-funded states (ASSIST) and the other states. States with excise tax or settlement-funded pro- 8rams are required to match federal funds 4 to 1. For all others, the match is 1 to 10. Examples of Major State Programs State coalitions have encouraged both legislation and voters’ initiatives to raise state excise tax levels on tobacco products and earmark some portion of the new revenue for tobacco prevention and control programs (Shultz et al. 1986; Nicholl] 1998). In 1985, the Minne- sota Coalition for a Smoke-Free Society 2000 led a legislative effort that was the first to Pass tobacco use prevention legislation that centered on an increase in the state cigarette excise tax. Since 1985, more than 40 other states have increased their excise tax on ciga- rettes; as part of the appropriations process, some of these states have also funded selected tobacco control activities with this revenue increase. One such state— Maine—in May 1997 legislated an excise tax increase that earmarked funds for a more comprehensive to- bacco control program. In some states, voters’ initiative process, rather than the legislative process, has been the primary mechanism by which new revenue from an excise tax increase of tobacco products has been earmarked for tobacco prevention. Voters in 24 states and the Dis- trict of Columbia are permitted to sign petitions that place a proposed law on the state ballot for referen- dum (Nicholl 1996). Since 1988, in eight such states, coalitions have tried to use the voters’ initiative pro- cess to fund statewide tobacco control programs. State coalitions were successful in winning voter approval in four of these states: California in 1988, Massachu- setts in 1992, Arizona in 1994, and Oregon in 1996, Initiatives were unsuccessful in Montana (1990), Nebraska (1992), Arkansas (1992), and Colorado (1994) (Moon et al. 1993: Ross 1996; Nicholl 1998), The four state programs funded by successful voters’ initiatives are described in the next sections of this chapter. They follow discussions of the two state programs (in Minnesota and Maine) that were estab- lished by legislated appropriations for a comprehen- sive tobacco control plan. Comprehensive Programs — 385 Surgeon General's Report Minnesota In 1975, Minnesota was one of the first states that passed statewide comprehensive legislation for clean indoor air. In 1983, the Commissioner of Health formed the Center for Nonsmoking and Health, which oversaw the development of The Minnesota Plan for Nonsmoking and Health (Minnesota Department of Health 1984) by a multidisciplinary technical advisory committee in 1984. In that same year, nearly 30 public and private organizations within the state formed the Minnesota Coalition for a Smoke-Free Society 2000. By drawing increased attention to the hazards of smoking and of ETS exposure, the Minnesota Depart- ment of Health, together with civic and community leaders, stimulated legislation to implement the rec- ommendations of The Minnesota Plan for Nonsmoking and Health. The legislative history and debate sur- rounding the passage of the resulting 1985 compre- hensive legislation for preventing tobacco use have been summarized by Shultz and colleagues (1986). The legislation provided for an increase in the state ciga- rette excise tax from $0.18 to $0.23, with one cent of the revenue increase earmarked for a public health fund, approximately one-half of which was to be set aside for preventing tobacco use. Further, this legisla- tion authorized the Commissioner of Health to launch a major statewide initiative—the Minnesota Tobacco- Use Prevention Initiative—to promote nonsmoking and established state aid for school-based programs to prevent tobacco use. The legislation allocated funding to support the school-based programs at the rate of $0.52 per student during the 1985-1986 school vear and $0.54 per student during future years. School districts were authorized to use these new funds for staff in-service training, cur- ricula and materials, community and parent awareness programs, and evaluation. Three principles guided the state’s tobacco con- trol programs. First, a broad base of public support was developed by the collaboration of the Minnesota Coalition for a Smoke-Free Saciety 2000, the Associa- tion for Nonsmokers—Minnesota, voluntary health agencies, health professionals, and insurers. Second, the program maintained a positive approach that stressed the consequences of tobacco use rather than attacked the tobacco industry or blamed smokers. Third, the program focused on preventing tobacco use among adolescents and young women who had not yet become addicted to cigarettes or smokeless tobacco. 386 Chapter 7 The mass media campaigns were the most vis- ible component. The campaigns included paid televi- sion, radio, and outdoor/ transit advertising directed at two target populations: 12- to 13-year-old boys and girls and 18- to 24-year-old women. The goal of the media campaign was to change a social climate that encouraged the use of tobacco. Advertisements fo- cused on increasing the awareness of the negative as- pects of tobacco use that are most important to young people—unpleasant social and personal consequences, such as bad breath, smelly clothes, and addiction. To foster community tobacco control programs, The Minnesota Plan for Nonsmoking and Health recom- mended that schools, health services, and other community organizations be involved in providing prevention and education programs about tobacco use. A granting program was established in 1986 to fund 21 proposals from local organizations that could dem- onstrate a coordinated approach for involving multiple local organizations in the prevention effort. A second cycle of local projects was funded in 1988. Schools throughout the state were involved in an intensive effort to plan, implement, and evaluate effec- tive programs for students from kindergarten (K) to grade 12 and in technical institutes. Since the start of these programs in the 1986-1987 school year, the per- centage of school districts addressing smoking in grades K-4 steadily increased but remained fairly constant in grades 5-10. The number of school districts in the state with a tobacco-free policy, however, steadily increased. Each of the main program elements funded by the Minnesota Tobacco-Use Prevention Initiative has been evaluated (Minnesota Department of Health 1989, 1991). Youth and adults targeted by the program were aware of the media campaign, and the evaluation data suggested that the campaign improved young people’s attitudes toward tobacco use (Minnesota Department of Health 1991). There was a steady increase in the number of school districts whose curricula included components for preventing tobacco use (Minnesota Department of Health 1991). Nonetheless, a prospec- tive study indicated that schools using the prevention curricula were not more effective in reducing adoles- cent tobacco use than were a randomized control group of schools (Murray et al. 1992). In that study, a com- parison of trends in adolescent tobacco use in Minne- sota and Wisconsin between 1986 and 1990 found a slightly larger (but nonsignificant) net decline in Min- nesota. The investigators suggested that greater reach and penetration of preventive efforts may be required to produce statewide reductions in adolescent tobacco use (Murray et al. 1992), California In November 1988, the Tobacco Tax and Health Promotion Act (Proposition 99) was passed by Cali- fornia voters, thus mandating the start of California’s Tobacco Control Program. The program is the largest and most comprehensive undertaken in the United States to reduce tobacco use. Initially, the program defined three long-term objectives: (1) to reduce the initiation of cigarette smoking by children and youth under age 19 from the 1987 rate of 26.4 percent to no more than 6.5 percent by 1999, (2) to reduce cigarette smoking among adults aged 20 years and older from the 1987 rate of 26.0 percent to 6.5 percent by 1999, and (3) to reduce smokeless tobacco use among males aged 12-24 years from the 1987 rate of 8.9 percent to no more than 2.2 percent by 1999 (Tobacco Education Oversight Committee 1991). The excise tax rate on cigarettes in California rose from $0.10 to $0.35 on Janu- ary 1, 1989, when Proposition 99 was implemented. On January 1, 1994, the tax increased to $0.37, where it remained in 1999. Funding for tobacco control efforts began during fiscal year 1989 (July 1989-June 1990). The fiscal year 1999 budget in California was $126.8 million ($3.90 per capita) for tobacco control activities funded by the Department of Health Services and the Department of Education. The NCI's planning framework (NCI 1991) was used to establish the program’s target groups, in- tervention channels, and interventions to reach them (Bal et al. 1990). Community mobilization is a kev part of California’s extensive program for reducing tobacco use. Community-based programs are the responsibil- ity of the California Department of Health Services and 61 local health departments (58 county and 3 city). These local agencies, advised by local coalitions, es- tablished multiple subcontracts with community- based organizations to conduct events, programs, and presentations for diverse racial and ethnic groups (To- bacco Education Oversight Committee 1991). Local lead agencies have been a cornerstone of the program by mobilizing communities to eliminate exposure to ETS, by closing channels for minors’ access to tobacco, and by advising local policymakers. The local lead agencies receive approximately 20 percent of funds allocated for education programs to achieve these ends. The statewide media campaign, which receives about 12 percent of funds, has been the program’s most visible element. Launched in 1990, the media cam- paign has focused primarily on changing public opin- ion to denormalize tobacco use. In particular, it has sought to raise public awareness of the tobacco industry’s manipulative and deceptive marketing Reducing Tobacco Use tactics and of the dangers of ETS. Although young people are a direct target audience for some campaign messages, the campaign has focused more on chang- ing social norms and reducing adult tobacco use to influence youth, many of whom begin using tobacco to be more adultlike. Funding for the statewide me- dia campaign was about $24 million ($0.75 per capita) in 1998 but has varied considerably over the years, as is discussed later in this section. About 16 percent of education funds are spent on competitive grants to community-based organizations. More than two-thirds of these grants have targeted racial and ethnic minority communities. The competi- tive grants program has had multiple funding cycles, and 46 separate projects were funded in 1993. In ad- dition, the competitive grants program funds several statewide projects, such as the Tobacco Education Clearinghouse of California, which distributes library and video materials, and the California Tobacco Con- trol Resource Partnership, which provides technical assistance and training to local lead agencies. The com- petitive grants program has also been used to estab- lish regional linkages among local governments and local nongovernmental organizations. Twenty-four percent of the education funds go to school-based programs to prevent tobacco use and are distributed through the California Department of Education. The project estimated that it would reach approximately 350,000 students through programs implemented be- tween 1994 and 1996. The single largest share, by far, of the education funds—39 percent through 1996—goes to the medical care programs. This percentage is notably higher than the 45 percent specified by the legislation (Novotny and Siegel 1996). Asa result of this redistribution, the portions of the program that deal with reducing to- bacco use—designated for 20 percent of the fund— have never been fully financed. In the first year, 16.5 percent of funds were allocated for such program efforts; in the second cycle, 12 percent were allocated; in the third, 10 percent. This diversion of funds was the result of executive decisions and was strongly sup- ported by the tobacco industry and the California Medical Association. After the third diversion, civil action was initiated by Americans for Nonsmokers’ Rights, supported by the American Lung Association and the ACS, to prevent the reallocation. The Sacra- mento Superior Court found in favor of the plaintiffs in early 1995. The state appealed, and the judgment for the plaintiffs was upheld in December 1996 (Ameri- cans for Nonsmokers’ Rights v. State of California). The complicated course of these events, as de- tailed by Novotny and Siegel (1996), has highlighted Comprehensive Programs — 387 Surgeon General’s Report the role of the tobacco industry in countering efforts to reduce the use of its products and the opposing strat- egy of health advocates. Begay and colleagues (1993) have pointed out that since Proposition 99 passed, the tobacco industry’s political expenditures in California have risen tenfold, from $790,050 in the 1985-1986 elec- tion to $7,615,091 in the 1991-1992 election, during which the tobacco industry contributed more heavily to candidates for the California legislature than to can- didates for the U.S. Congress. In a further analysis, this same research group (Traynor et al. 1993) detailed the specific industry strategies to prevent local con- trol of tobacco use. Using case studies, they docu- mented the industry‘s use of front groups to conceal its involvement, its organization of local referenda to defeat or suspend local ordinances, and its financing of local election campaigns to repeal ordinances by popular vote. Glantz and Begay (1994) have also analyzed the relationship between campaign contri- butions and votes on individual tobacco-related bills in the California legislature. Using a “tobacco policy score” (p. 1178) that ranked legislators according to their stance for or against reducing tobacco use, they found a significant relationship between the amount of money received from tobacco sources and a protobacco position. This ongoing documentation of tobacco industry influence, though not a formal part of the California Tobacco Control Program, has been one of its notable features, and it provides a model of health advocacy for other states and localities. The program, which has evolved considerably since 1989, remains a multifocal, multichannel ap- proach to the broad range of issues that confront large- scale efforts to reduce tobacco use (Tobacco Education and Research Oversight Committee 1995; Pierce et al. 1998a). In 1993, the California Tobacco Control Program was revised, and program priorities were refocused (Pierce et al. 1998a). Four broad priority areas, or policy themes, were established for use in the program planning and funding decisions: e¢ Protecting people from exposure to ETS. ¢ Revealing and countering tobacco industry influence. * Reducing young people’s access to tobacco products. ¢ Providing cessation services. The California Tobacco Control Program contin- ues to place its primary emphasis on a broad statewide infrastructure that reaches into communities across the state. The program’s basic structure is composed of a 388 = Clupter 7 state-level office and several statewide and regional programs that foster a collaborative grassroots approach to serve a decentralized structure of community pro- grams across the state (Pierce et al. 1998a). Surveillance and evaluation activities to assess program performance and impact were established as part of the initial program structure (Bal et al. 1990; Tobacco Education Oversight Committee 1991). The evaluation is composed of large triennial surveys (Pierce et al. 1994, 1998a) and smaller ongoing sur- veys (Pierce et al. 1998b), a more targeted evaluation of program components (Independent Evaluation Consortium 1998), and a wide array of local program evaluation efforts. Evaluation is complicated, how- ever, by the multiplicity of prevalence surveys avail- able and by potential error from using data from surveys with differing methods (Novotny and Siegel 1996; Siegel et al. 2000). Establishing specific rela- tionships between large-scale social interventions and a change in tobacco use is difficult, but the temporal relationship between the decline in California’s to- bacco consumption and the efforts generated by Proposition 99 can be clearly observed. Per Capita Cigarette Consumption Before the implementation of the program in 1989, the rate of decline in monthly per capita ciga- rette consumption was 0.42 packs, which was signitfi- cantly greater than the rate of 0.36 in the rest of the country (Pierce et al. 1998a,b). From January 1989 through December 1993, the decline in California in- creased significantly, to 0.65 packs, while the decline in the rest of the United States increased nonsignifi- cantly, to 0.45 packs. Until early 1992, the media pro- gram was the only part of the tobacco control program that was fully implemented. An econometric analysis (Hu et al. 1995) has estimated that of the 1,051-million pack decrease in sales between 1990 and 1992, approxi- mately 232 million (22 percent) were attributed to the media campaign and the remaining 819 million (78 percent) to the excise tax increase. Between 1993 and 1996, the rate of decline in per capita consumption in California slowed significantly, to 0.17, but virtually halted altogether in the rest of the country (at 0.04 packs) (Pierce et al. 1998b). Consumption decreased more rapidly in California than in the rest of the coun- try, even though the California cigarette excise tax changed only slightly during this period (from $0.35 in 1993 to $0.37 in 1994). Between 1993 and 1996, how- ever, expenditures for tobacco control were reduced by more than 50 percent from their initial funding lev- els in fiscal year 1990 and 1991. During 1989-1993, spending for advertising and promotions by the tobacco industry exceeded tobacco control expendi- tures in California by a ratio of about 5 to 1; from 1993 to 1996, that ratio increased to nearly 10 to 1 (Pierce et al. 1998b). Adult Smoking Prevalence Data on adult patterns of smoking prevalence are not as consistent or as easy to evaluate as consump- tion trends (Novotny and Siegel 1996). Nevertheless, the trends in these data are consistent with the pat- terns noted in the per capita consumption analyses. From 1989 to 1993, smoking prevalence declined in California almost twice as rapidly as in the rest of the country (Pierce et al. 1998b). However, from 1994 to 1997, the rate of decline in California appeared to slow. Overall, smoking prevalence has declined from 26.7 percent in 1988 to 16.7 percent in 1995 in California and from 30.2 percent in 1988 to 24.7 percent in 1995 in the rest of the country (CDC 1996; Pierce et al. 1998b). A recent analysis of trends in adult prevalence of smok- ing in California compared with the rest of the United States observed a significant decline in smoking preva- lence in California from 1985 to 1990 and a slower but still significant decline from 1990 to 1994, a period in which there was no significant decline in the remain- der of the nation (Siegel et al. 2000). Youth Tobacco Use Prevalence The lack of consistent youth smoking surveil- lance data between California and other states has impeded the evaluation of program impact on tobacco use among young people in California. However, one multivariate analysis of data from the school-based Monitoring the Future survey of 8th-, 10th-, and 12th- grade students showed that from 1992 to 1994, the in- crease in youth smoking rates that was experienced nationwide was slowed significantly in California (P < 0.001, controlling for price, smoking policies, and other nonprogram effects) as a result of the combined effect of the tax increase in 1994 and the implementa- tion of the state’s tobacco control programs (Chaloupka and Grossman 1996). Pierce and colleagues (1994) have concluded that the media campaign was successful in stopping the rise in teen smoking that had been oc- curring in California before the campaign launch. Results from other analyses of youth tobacco use data are consistent with the result found by Chaloupka and Grossman (1996). In data reported by the Califor- nia Independent Evaluation Consortium, between 1991 and 1996, rates of smoking during the past 30 days among California youth in the 8th and 10th grades in the Monitoring the Future survey increased, but the Reducing Tobacco Use increase in California was less pronounced than in other states (Independent Evaluation Consortium 1998). Among 8th-grade youth, since 1993 the preva- lence of smoking during the past month has varied from 12 to 14 percent in California while steadily in- creasing from 17 to 22 percent in the rest of the coun- try. Similarly, among 10th-grade youth, past-month smoking prevalence in California has been about 18 to 19 percent since 1992 while increasing from 22 to 32 percent in the rest of the country. Data from the telephone-based California Youth Tobacco Survey in- dicate that the prevalence of smoking during the past 30 days among 12- to 17-year-olds increased from ap- proximately 9 percent in the early 1990s to 11.9 per- cent in 1995, Prevalence declined gradually after 1995, to 10.9 percent in 1997, while increasing in the rest of the country (Pierce et al. 1998a). Other Findings Since the start of the program in 1990, numerous changes in intermediate outcomes have been noted related to changes in social norms; clean indoor air policies in public places, worksites, and bars; and vol- . untary policies to ban smoking in homes. Massachusetts In November 1992, Massachusetts voters ap- proved an initiative petition known as Question 1, establishing the Health Protection Fund with revenue generated from a 25-cent increase in the state’s ciga- rette excise tax and a 25-cent increase in the wholesale price of smokeless tobacco products. Revenues have been used to fund the Massachusetts Tobacco Control Program, a comprehensive set of activities and services that emphasize prevention programs at the local level and that focus on young people. The Massachusetts program was modeled, in part, on California’s pro- gram. The overall goal of the program was to reduce tobacco use in Massachusetts by 50 percent by the end of 1999 (Abt Associates Inc. 1995). With the passage of Question 1, the excise tax on cigarettes in Massa- chusetts rose from $0.26 to $0.51 on January 1, 1993. This tax was fully absorbed by the industry through wholesale price reductions (CDC 1996). However, in October 1996 the cigarette tax increased to $0.76 per pack (with comparable increases on smokeless tobacco products), where it currently remains. Funding for tobacco control efforts began with a large media campaign in October 1993. In late 1993 and early 1994, funding for local agencies was begun, and several statewide initiatives were undertaken to provide direct services, as well as technical assistance, Comprehensive Programs 389 Surgeon General's Report training, and materials for localities. Starting in late 1994, with the first year of complete implementation, the program received $43.1 million (33.7 percent) of the $127.8 million placed in the Health Promotion Fund created by the revenues from the excise tax increase. Other key programs receiving appropriations from the Health Promotion Fund were those for comprehensive school health education ($28.8 million, or 22.5 percent of the Health Promotion Fund in fiscal year 1995), drug education ($5.0 million, or 3.9 percent), and other health-related programs ($50.7 million, or 39.7 percent) (Abt Associates Inc. 1995). After the first funding year, the program's budget declined to $41.8 million in 1995- 1996 and to $36.8 million in 1996-1997. Funding was increased for other programs receiving appropriations from the Health Promotion Fund (Abt Associates Inc. 1997). Community-based education activities and pre- vention activities are two main elements of the Mas- sachusetts program. The state’s 10 regionally based, primary care Prevention Centers have added a com- ponent for reducing tobacco use and provide ongoing technical assistance and training to local community programs. Local community initiatives have included programs to increase community awareness about the hazards of tobacco use, to promote tobacco-free workplaces and public facilities, and to enforce local regulations and ordinances for reducing tobacco use; needs assessments in the community; mobilization of youth service agencies to prevent and reduce tobacco use among children and adolescents; funding of community-based agencies to work with at-risk adult populations, including cultural and linguistic minority groups, women of childbearing age, and blue-collar workers; and funding of school-based health centers (Abt Associates Inc. 1995). Per Capita Cigarette Consumption As in California, Massachusetts has experienced a persistent pattern of decline in per capita cigarette consumption. Before the 1993 implementation of these tobacco control programs, per capita cigarette con- sumption was declining in Massachusetts at a rate approximately equivalent to that of the rest of the coun- try (6.4 percent in Massachusetts and 5.8 percent in the states other than California [CDC 1996]). Between 1992 and 1997, per capita consumption in Massachu- setts declined by 31 percent (from 117 to 81 packs per adult), while the decline in the remaining 48 states was only 8 percent (Abt Associates Inc. 1997). Between 1993 and 1996, the decline in per capita consumption has been more consistent in Massachusetts than in California (CDC 1996). Although program funding declined about 390 Chapter 7 15 percent in Massachusetts from 1995-1996 to 1996- 1997 (Abt Associates Inc. 1997), it declined less than in California. Adult Smoking Prevalence Adult smoking prevalence has been monitored in Massachusetts both by the annual survey conducted through the Behavioral Risk Factor Surveillance Sys- tem (BRFSS) and by special Massachusetts Adult To- bacco Surveys conducted in 1993, 1996, and 1997. Data from the BRFSS indicate that adult smoking prevalence in Massachusetts declined from an average of 23.5 percent for 1990-1992 to 20.6 percent in 1997. In the rest of the country (excluding California), prevalence declined from 24.1 percent in 1990-1992 to 23.4 per- cent in 1993-1995 (CDC 1996; Abt Associates Inc. 1997). The Massachusetts survey produced different preva- lence estimates but corroborated a similar decline in the prevalence of smoking among adults in Massachu- setts (from 22.6 percent in 1993 to 21.1 percent in 1996 and 20.6 percent in 1997) (Abt Associates Inc. 1997). Youth Tobacco Use Prevalence As in California, the observed nationwide in- crease in the prevalence of smoking among young people from 1992 to 1994 was significantly less evi- dent in Massachusetts (Chaloupka and Grossman 1996). Follow-up data from the Youth Risk Behavior Survey (YRBS) indicated that the prevalence of cur- rent smoking among Massachusetts high school stu- dents (grades 9 to 12) declined from 35.7 percent in 1995 to 34.4 percent in 1997 while increasing from 34.4 to 36.4 percent nationwide (CDC 1996, 1998). Data from the YRBS and other survey sources suggest a dif- ferential pattern by age: the prevalence of current smoking increased in Massachusetts among older stu- dents in a manner similar to that of the rest of the coun- try but declined among younger students. Between 1993 and 1996, the prevalence of smoking during the past 30 days among 8th-grade students in Massachu- setts declined from 26.5 to 26.0 percent but increased from 16.7 to 21.0 percent nationwide (Briton et al. 1997). For Massachusetts, the prevalence of current smoke- less tobacco use among 9th-12th graders decreased from 8.4 percent in 1995 to 6.0 percent in 1997; for males, the decline was from 15.1 to 10.3 percent (Kann etal. 1998). In the nation as a whole between 1993 and 1996, lifetime use of smokeless tobacco among 9th- 12th graders decreased from 25 to 20 percent, and cur- rent use decreased from 9 to 6 percent (Briton et al. 1997). The most recent data from the 1999 YRBS in Massachusetts indicated a continuing decline in the prevalence of current smoking, down to 30.3 percent among 9th-12th graders (Goodenow 2000): however, national comparison data for 1999 are not yet available. A 1996 survey of 12- to 14-year-olds in Massachu- setts and a national comparison sample (Houston Herstek Favat, Youth exploratory 1996, Massachusetts Department of Public Health, presentation of findings, unpublished data) found that Massachusetts youth had significantly higher levels of agreement with issues addressed in the state media campaign. For example, 59 percent of Massachusetts youth but only 35 percent of youth in the national sample agreed with the state- ment, “Smoking cigarettes decreases your stamina and smokers have a hard time keeping up in sports.” Re- sults from a longitudinal survey of Massachusetts youth provided additional support for the efficacy of the Massachusetts antismoking media campaign (Siegel and Biener 2000). Ina four-year follow-up of youth aged 12 to 15 years in 1993, this study found that among the younger adolescents (aged 12 to 13 years at baseline), those exposed to antismoking advertisements were significantly less likely to progress to established smoking. However, among older adolescents (aged 14 to 15 years at baseline), exposure did not prevent pro- gression to established smoking. Other Findings There have been multiple changes in intermedi- ate measures of program impacts related to youth access, protection of nonsmokers from ETS, and avail- ability of cessation services (Abt Associates Inc. 1999), For example, by 1999, nearly two-thirds of Massachu- setts residents lived in cities and towns with some kind of smoking restriction in restaurants, and 26 percent were protected by complete bans. Prior to the start of the program, less than 1 percent of Massachusetts resi- dents lived in towns with complete bans. Additionally, the local restaurant smoking restrictions were found to be more restrictive in communities receiving funding from the Massachusetts Tobacco Control Program. Arizona In November 1994, Arizona voters passed Propo- sition 200, which increased the state cigarette excise tax from $0.18 to $0.58. Revenues from the tax increase were earmarked for the state’s Medicaid program (70 percent of revenues), for programs for preventing and reducing tobacco use (23 percent), for research on pre- vention and treatment of tobacco-related disease and addiction (5 percent), and for an “adjustment account” (Arizona Tobacco Tax and Health Care Act 1994, sec. 2C4) to offset lost revenue to other state programs Reducing Tobacco Use currently funded by revenue from the existing $0.18 excise tax (2 percent). The petition drive to place the initiative on the November 1994 state ballot and the campaign to win voter approval was led by the Ari- zona for a Healthy Future coalition. Although public support for the initiative was strong when it was first proposed in 1993 (71 percent in favor, with 56 percent indicating strong support), the initiative was vigor- ously opposed in a well-funded advertising effort on television, in posters, and by direct mail. Proposition 200 was narrowly approved, garnering approximately 51 percent of the vote (Nicholl 1998). With the passage of Proposition 200, analysts estimated that the revenues earmarked for tobacco prevention and education programs would be ap- proximately $25 million per year (Meister 1998), However, measures passed during the 1995 session gave the legislature control over the funds and lim- ited expenditures to $10 million per year (Madonna 1998). Additionally, multiple restrictions were placed on how the funds could be used, and an advisory com- mittee was appointed that included legislative and business representatives hostile to the program (Meister 1998). Although the Coalition for Tobacco- Free Arizona led an effort to keep the goals of the newly created Arizona Tobacco Education and Prevention Program (AzTEPP) “comprehensive,” the program efforts were narrowed to a focus on youth prevention; adult cessation activities were restricted to pregnant women and their partners. Not until the fiscal year that began on July 1, 1997, with a new governor and health department director, were the programmatic restrictions lifted from the health department and the program allowed to proceed with the implementation of the “draft” comprehensive tobacco control plan originally proposed by the Coalition for Tobacco-Free Arizona. The expenditures of AzTEPP reflect the political history of the program: $9.7 million in fiscal year 1996, $18.2 million in 1997, and $28.2 million in 1998. Al- though the countermarketing campaign has expanded (with spending increasing from $7.4 million in 1996 to $13.2 million in 1998) (Riester and Linton 1988), the greatest expansion in the program has been in the scope and focus of the local programs (Meister 1998) (with funding increasing from $1.7 million in 1996 to $9.4 million in 1998). Recent program efforts have focused on all of the elements in the coalition’s draft comprehensive tobacco control plan (Meister 1998), thereby expanding its adult cessation activities (discussed at the fourth annual AzTEPP meeting in February 1999), but one of the factors that had been minimized in early health department efforts was Comprehensive Programs 391 Surgeon General's Report evaluation. Only recently have baseline data collec- tion surveys been initiated (Meister 1998); as a result, no outcome data have been reported on the program, and subsequent evaluation efforts will be compro- mised by the lack of baseline data collected before the start of the multiple large-scale program efforts. Respondents to an initial statewide telephone survey conducted in 1998 (Arizona Cancer Center 1998), about two and a half years after the media campaign’s launch, reported that the advertising cam- paign, which stressed how damaging tobacco use is and how unappealing it is to the user, to peers, and to the opposite sex, had influenced their attitudes in the intended direction. For example, 80 percent of young people reported that the advertisements made them think about the negative aspects of tobacco use, and 58 percent of pregnant or postpartum women said the advertisements made them uncomfortable around smokers. Young people who had been exposed to the television advertisements in the previous 30 days were less likely to be susceptible to using tobacco than were youth who had not seen the advertisements. The campaign’s impact on reported behaviors is less clear, especially among young people. Among respondents who were using tobacco at the start of the campaign, 23 percent of adults, 37 percent of pregnant or post- partum women, and 27 percent of young people said the advertising campaign had convinced them to try quitting. However, 23 percent of young people also reported that the campaign had convinced them to increase their tobacco use. Cummings and Clarke (1998) noted that such an unintended effect, if it is real, might represent young smokers’ negative reaction to a narrowly focused youth campaign with no messages directed at changing broader social norms. In response to a request from the Arizona Joint Legislative Audit Committee, the State Auditor Gen- eral conducted a performance audit of the AzTEPP (State of Arizona, Office of the Auditor General 1999). This audit noted that evaluations of the state and local levels of programs have not yet produced an adequate assessment of the program’s tobacco contro! efforts. Thus, the audit recommended that the program needed to improve its evaluations to measure its ef- fectiveness in preventing youth from starting to use tobacco, encouraging and assisting tobacco users to quit, and reducing exposure to secondhand smoke. Specifically, the audit found that the program had been unable to establish a baseline on tobacco use among youth and had only preliminary assessments in place to assess cessation services. The program has estab- lished adequate methodologies to measure the preva- lence of adult smoking; however, follow-up results are 392 Chapter 7 not yet available. Thus, the audit concluded that “The progranr’s evaluation approach to date leaves it far short of knowing whether its programs are working” (p-ii). In response to this audit, the Arizona Department of Health Services (AzDOHS) has implemented changes in its surveillance and evaluation systems. Expanded surveillance systems for youth have been planned and will be implemented in 2000; however, no baseline data are available on youth smoking rates, For adults, a baseline survey of adults was conducted in 1996 and repeated in 1999. Using methodology simi- lar to that used by the state BRFSS, the 1996 and 1999 Arizona Adult Tobacco Surveys were conducted by telephone interviews on representative samples of more than 4,500 adults in Arizona aged 18 years and older. Results from these surveys indicate that the prevalence of smoking among adults declined from 23.8 percent to 18.8 percent overall (AzDOHS 2000). Among adults aged 18 to 24 years, a significant de- cline was observed also, from 27.3 percent in 1996 to 21.0 percent in 1999, Both of these rates compare very favorably to national trends, where rates overall among adults have not declined in recent years and rates among younger adults have been increasing. Finally, smoking rates among Hispanics declined from 23.5 percent to 14.6 percent, which was the largest decline seen in any race/ethnic group in the state. Multiple other indicator variables suggest that these changes may be related to increases in smoke-free policies, ad- vice from doctors and dentists, and exposure to tele- vision antismoking information. Finally, these declines in smoking prevalence are consistent with declines in per capita sales (Orzechowski and Walker 2000) that indicate that declines in Arizona since 19% are larger than those observed in the rest of the country. Oregon On November 5, 1996, Oregon voters approved Measure 44, raising the state cigarette excise tax from 90.38 to $0.68 (with a proportional increase in the tax rate on other tobacco products) and designating 90 percent of the increased revenue for the Oregon Health Plan (to expand insurance for medically underserved state residents) and the remaining 10 percent for a statewide tobacco prevention and edu- cation program managed by the Oregon Health Divi- sion. Survey data indicated that support for the initiative was increased by having the new revenue earmarked in this way (CDC 1997; Nicholl 1998). The Oregon campaign to place the initiative on the Novem- ber 1996 ballot was initially led by the Committee to Support the Oregon Health Plan, which represented primarily the private health care sector. Nonprofit and public health organizations added their support and worked ina loosely organized network led by the ACS. Later in the campaign, both groups combined efforts and resources. The measure had strong support from state media (receiving endorsements from all major newspapers and a majority of the smaller ones), from leading business groups, and from the governor, who conducted a three-day supportive media tour before the election. The Oregon Health Division used its existing Oregon Tobacco Contro] Plan as the model for the new statewide program. Revenue from Measure 44 dur- ing the 1997-1999 biennium was projected to be $170 million; of this, 10 percent (approximately $17 million) per biennium was appropriated to fund the Tobacco Use Reduction Account administered by the Oregon Health Division. The resulting Oregon Tobacco Pre- vention and Education Program has eight elements: (1) local community-based coalitions, (2) comprehen- sive school-based programs, (3) statewide public awareness and education campaigns, (4) a cessation help line, (5) tribal tobacco prevention programs, (6) multicultural outreach and education, (7) demon- stration and innovation projects, and (8) statewide leadership, coordination, and evaluation. The 1997-1999 biennium budget for these eight elements is combined into five categories: (1) local coalitions—$6.5 million (38 percent), (2) public aware- ness and education—$4.6 million (27 percent), (3) state- wide and regional projects—$2.75 million (16 percent), (4) schools—$2 million (12 percent), and (5) statewide coordination and evaluation—$1.2 million (7 percent). Evaluation data from Oregon indicate that the program has successfully implemented each of the program elements and is achieving its performance objectives (Oregon Health Division 1999). Local community-based coalitions were created in all 36 Oregon counties. Twenty-four school projects were funded, reaching 58 of the 198 (30 percent) school dis- tricts in the state. Surveys indicated that approxi- mately 75 percent of adults and 84 percent of the young people recalled seeing the state’s public awareness campaign. In January 1999, more than 1,500 Orego- nians called the cessation help line. All nine federally recognized Indian tribes in Oregon are now receiving funding to implement prevention and education pro- grams to reduce tobacco use. Multicultural outreach and education programs have been established for Hispanic, Asian/Pacific Islander, and African Ameri- can populations in Oregon. Five demonstration projects have been funded focusing on pregnant women, health care delivery systems, and creative Reducing Tobacco Use ways to reach youth audiences. The program has also established a comprehensive and multifaceted surveil- lance and evaluation system and has strengthened program management. Trends in per capita consumption in Oregon were compared with the remainder of the country (exclud- ing California, Massachusetts, and Arizona) for the period before program implementation (1993-1996) and after (1997-1998). From 1993 to 1996, consump- tion increased 2.2 percent in Oregon and decreased 0.6 percent in the rest of the country (CDC 1999b). In 1997 and 1998, per capita consumption declined 11.3 percent in Oregon (from 92 to 82 packs per adult). Be- tween 1996 and 1997, per capita consumption in the rest of the country declined only 1.0 percent (from 93 packs per adult to 92 packs per adult). Smoking prevalence among adults in Oregon has been consistent with the observed declines in per capita consumption. Data from the BRFSS indicate that the prevalence of smoking among adults aged 18 years and older in Oregon declined from 23.4 percent in 1996 to 21.9 percent in 1998 (Oregon Tobacco Prevention and Education Program 1999). The proportion of women who smoked during pregnancy, as reported on state birth certificates, dropped from 17.7 percent in 1996 to 15.2 percent in 1998. Data suggest that smoking rates among young people are continuing to increase as in the rest of the country. Maine In June 1997, the Maine legislature approved HP. 1357, An Act to Discourage Smoking, Provide Tax Re- lief and Improve the Health of Maine Citizens, which increased the state cigarette excise tax from $0.37 to $0.74 and earmarked the increased revenue for the Tobacco Tax Relief Fund. The act established the To- bacco Prevention and Control Program within the Maine Bureau of Health and provided $3.5 million in funding for fiscal years 1998 and 1999. The legislative effort to gain passage of the act was a combined effort of the state public health community, legislative lead- ership, and executive branch support. The Bureau of Health has developed the Maine Tobacco Prevention and Control Program to expand the existing ASSIST program structure and to meet the legislative requirement of the 1997 state statute. The legislation specified that the program include an on- going, major media campaign; grants for funding community-based programs; program surveillance and evaluation; and law enforcement efforts regard- ing transportation, distribution, and sale of tobacco products. The program’s initial $4.35 million annual Comprehensive Programs 393 Surgeon General's Report budget included $1.6 million for a multimedia cam- paign, $1.25 million for community and school grants, $625,000 for statewide cross-cutting activities, $400,000 for state staffing, $400,000 for evaluation, and $75,000 for enforcing youth access provisions. In April 2000, legislation was passed in Maine that appropriated additional funds to expand the Maine Tobacco Prevention and Control Program; a total of $18.3 million from the settlement is going to tobacco control. Of this total amount, $8.35 million will be used for community and school-based grants, funding communities and schools to achieve the goal of reducing tobacco addiction and use and resulting disease, with a focus on those at highest risk such as youth and disadvantaged populations. About $6.75 million will be used for cessation and statewide mul- timedia campaigns; $1.2 million is for evaluation for independent program evaluation, research, and out- comes monitoring; $200,000 funds five positions in the Bureau of Health for administering the programs; and $1.8 million for improved prevention and treatment of tobacco-related diseases for those with Medicaid Insurance. Programs Funded by State Settlements With the Tobacco Industry As was discussed earlier in this report (see “Legislative Developments” and “Master Settlement Agreement” in Chapter 5), all 50 states, the District of Columbia, and five commonwealths and territories have settled lawsuits with the tobacco industry to re- claim statewide costs spent treating Medicaid patients for diseases related to tobacco use. Four of those states settled their individual lawsuits with the industry— Mississippi in July 1997, Florida in September 1997, Texas in January 1998, and Minnesota in May 1998— and the remaining parties jointly settled in November 1998 in the multistate Master Settlement Agreement. Because of a “most favored nation” clause (ex- plained in “Recovery Claims by Third-Party Health Care Payers” in Chapter 5), the four separate settle- ments have been closely linked, particularly in how the terms of their awards affect the kind of compre- hensive programs discussed in this chapter. Most notably, when the State of Florida received in its settlement $200 million that was earmarked for a two-year pilot program to reduce tobacco use among young people, the State of Mississippi, though it had settled its lawsuit earlier, received $62 million for the same type of pilot program specified in its lawsuit. Texas and Minnesota received no such additional 394 Chapter 7 award, because their lawsuits did not specifically set aside funds fora parallel pilot program, although Min- nesota received funds earmarked for smoking cessa- tion and tobacco-related research. Language in the Texas and Minnesota settlements, however, released Florida and Mississippi from existing requirements to use their pilot program funding within two years and to direct their programs exclusively to young people. Because program planning in Florida and Mis- sissippi was already in place when the youth-only restriction was removed, an emphasis on preventing tobacco use among young people has been evident in their pilot programs’ first years of activities. These activities are described in the next two sections of this chapter. Brief descriptions of settlement-funded plans in Texas and Minnesota follow. This report does not attempt to describe the various plans and legislative proposals that are developing (at the time of this writ- ing) in the 46 states, the District of Columbia, and the five commonwealths and territories included in the joint settlement of January 1998. Mississippi The Partnership for a Healthy Mississippi, a nonprofit corporation representing a broad range of public and private interests, plans and manages the state’s pilot program. The program’s mission is to cre- ate a youth-centered, statewide collaboration dedicated to tostering a healthier Mississippi and eliminating to- bacco use among Mississippi youth. The partnership will award grants in five designated areas: (1) commu- nity/school/vouth activities and partnerships, (2) law enforcement, (3) public awareness, (4) health care ser- vices and research, and (5) evaluation. In the first year, with a budget of $23.7 million, approximately 25 community and youth partnership coalitions were funded, and more are planned for the second year. Local coalitions—one-quarter of whose membership must be young people—-are among the statewide and regional organizations supported by community assistance statewide partner grants to provide training, tobacco prevention activities for ra- cial and ethnic minority groups, and other technical as- sistance. Specific programs that have been funded by the partnership are 4-H Youth Programs, Frontline (an advocacy organization for 14- to 18-year-olds), com- prehensive school health programs, and a comprehen- sive school health nurses pilot project. In the first two years, $4 million has been allocated to these activities. The law enforcement program has awarded grants to municipalities to enforce the Mississippi Juvenile Tobacco Access Prevention Act of 1997. These awards will range (according to population size) from a minimum of $5,000 per municipality toa maximum of $250,000. A total of $12.65 million has been bud- geted over the first two vears of the program for these awards. The grants will require municipalities to con- duct periodic enforcement checks on the illegal sale of tobacco to minors, provide retailer education pro- grams, provide education programs in schools, orga- nize youth partnerships, and work with community coalitions on enforcement issues. Other enforcement activities are being performed statewide by the Mis- sissippi Attorney General’s Office. The partnership has budgeted $12.5 million for a countermarketing media campaign and other pub- lic awareness activities to be conducted during the first two years. The health care services and research com- ponent focuses on nicotine addiction and cessation among young people. An expenditure of $5 million is anticipated for the first and second vears for training health providers in cessation counseling, for research- ing childhood and adolescent tobacco abuse, and for coordinating cessation services in the state, including a telephone help line. The Mississippi State Depart- ment of Health will manage the evaluation of the pi- lot program and will focus on program effectiveness in preventing initial tobacco use among young people, helping young people quit smoking, and reducing young people’s exposure to ETS. An expenditure of $2 million is anticipated for the first and second years’ evaluation activities. Since 1998, the Partnership for a Healthy Missis- sippi has managed the pilot program to reduce youth tobacco use through a seven-member Board of Direc- tors (www.healthy-miss.org) (McMillen et al. 1999). The major youth programs that have been implemented have included (1) the Reject All Tobacco (RAT) pro- gram among students in grades K-3, (2) the Students Working Against Tobacco (SWAT) Program for students in grades 4-7, and (3) the Frontline youth advocacy movement. Community programs have involved 26 community/youth partnership grants, targeted pro- grams in collaboration with statewide organizations, and the school nurse program in 52 Mississippi school districts. Grants have funded 245 municipalities and 74 counties to empower the local law enforcement agen- cies to reduce sales to minors. Cessation services have included the Adolescent and Child Tobacco Treatment Center and a Mississippi Tobacco Quitline. Finally, a “Question It” public awareness campaign has focused on the 12- to 17-year-old audience. The Mississippi State Department of Health has established a consortium of evaluation contracts in- volving multiple state universities to implement Reducing Tebacco Use program evaluation efforts. The overall coordination is being managed by the Social Science Research Cen- ter at Mississippi State University, with the evaluation of the media component conducted by the University of Mississippi, community programs conducted by Jackson State University, law enforcement component by Mississippi State University, and the school nurses component by Mississippi State University (McMillen et al. 1999). A baseline Social Climate Survey of To- bacco Control and Tobacco Use was conducted in 1999 among 3,040 adults aged 18 vears and older that provided benchmark data on several social norm intermediate indicator variables (McMillen et al. 1999). Surveillance of youth tobacco use patterns is being con- ducted by the Mississippi State Department of Health. The Youth Risk Behavior Survey was conducted among students in grades 9 to 12 in 1993, 1995, 1997, and 1999 and among students in grades 6 to 8 and 9 to 12 in 1998 and 1999. Results indicate that in Mississippi, smok- ing rates among students in grades 9 to 12 had been increasing, as in the rest of country, between 1993 and 1997 (Mississippi State Department of Health 2000), Between 1997 and 1999, smoking rates among students in grades 9 to 12 appear to have stopped increasing and leveled off. Among students in grades 6 to 8, smoking rates did not decline between 1998 and 1999. Florida Program planning and implementation initially were managed by the Governor’s Office, with direct leadership provided by Governor Lawton Chiles, who was a party to the state’s lawsuit and a member of the small team who negotiated the settlement agreement. The Florida Tobacco Pilot Program is now managed by the Office of Tobacco Control within the Florida De- partment of Health. The program has sought the input of Florida youth in planning the program focus and materials and in working toward the main goals of changing young people’s attitudes about tobacco use, increasing youth empowerment through community involvement, reducing young people’s access to tobacco products, and reducing youth exposure to ETS. These four goals will be addressed through program compo- nents similar to those of the Mississippi program: * Marketing and communications initiatives are planned to directly counter the tobacco industry‘s marketing efforts. A commercial advertising firm, working closely with teen advisors, has developed the “Truth” campaign, a direct attack on the image of smoking as cool and rebellious. The campaign’s multichannel approach—based on techniques used Comprehensive Programs 395 Surgeon General's Report by the tobacco industry—includes television, print, and billboard advertising, as well as consumer items, such as “Truth”-imprinted T-shirts and stickers. ° Youth programming and community partnership activities recruited young people to a Teen Tobacco Summit in early 1998 to advise on the overall de- velopment of the program. Chapters of Students Working Against Tobacco are currently active in all 67 counties. e Education and training programs focus on school- aged children. Conducted in partnership with communities, schools, voluntary agencies, profes- sional organizations, and universities, these pro- grams ensure that effective tobacco prevention curricula are presented in middle and high schools across the state and that tobacco prevention strat- egies are being implemented in grades K-12 in conjunction with the Sunshine State Standards. * Enforcement initiatives are aimed at improving Florida’s efforts to reduce the accessibility of to- bacco products to minors. The Florida Department of Business and Professional Regulation, Division of Alcoholic Beverages and Tobacco, provides en- forcement, educational, and marketing initiatives to ensure compliance with all tobacco laws. e The evaluation and research component monitors the performance of each of the program initiatives and the progress of the overall program in meeting goals and objectives. Under the leadership of the Florida Department of Health, and with the con- sultation of the University of Miami, baseline data were collected by Florida universities in all major areas before the pilot program began in early 1998. In the first full year of operation, the program budget was approximately $70 million, with program component allocations of approximately $26 million for marketing and communications, $10 million for youth programming and community partnerships, 513 mil- lion for education and training, $8.5 million for enforce- ment, and $4 million for evaluation and research. An additional $5 million was budgeted for programs tar- geting minority populations and $3.5 million for ad- ministration and management. In the second year, approximately $45 million more was appropriated for program operations; however, there were significant unexpended funds from the first year of operations that enabled major program components, such as the mar- keting and communications activities, to continue a level of expenditure similar to the first year. 396 Chapter 7 Youth Tobacco Use Prevalence Between 1998 and 1999, the prevalence of cur. rent cigarette use among middle school students (grades 6 to 8) declined from 18.5 to 15.0 percent (CDC 1999c¢). Among high school students (grades 9 to |2), current cigarette use declined from 27.4 to 25.2 per- cent. However, these declines were significant only for non-Hispanic white students; the change in cur- rent smoking among non-Hispanic black and Hispanic middle and high school students was small and non- significant. Current cigar use declined significantly only for middle school students (from 14.1 to 11.9 per- cent), and this decline was almost entirely among males. Similarly, current smokeless tobacco use de- clined only among middle school students (from 6.9 to 4.9 percent) and remained unchanged among high school students. In early 2000, additional declines in youth to- bacco use were observed (Florida Department of Health 2000). Current cigarette use among middle school students declined to 8.6 percent, or an overall 54-percent decline since the 1998 baseline. Among high school students, current cigarette use declined to 20.9 percent, or an overall 24-percent decline since the 1998 baseline. Although declines between 1998 and 1999 were significant only for non-Hispanic white students, the declines observed in 2000 were significant among all racial/ethnic groups, except among the non- Hispanic black and “other” categories of high school students. Declines in current tobacco use, which in- clude the use of cigars and smokeless tobacco, also were significant. Since the 1998 baseline survey, cur- rent cigar use declined by 46 percent among middle school students and 21 percent among high school stu- dents. Smokeless tobacco use declined by 54 percent among middle school students and by 19 percent among high school students. Declines in current to- bacco use were consistent across grade, gender, and ethnicity as well. Using additional data collected as part of the overall program evaluation, the Florida Tobacco Con- trol Program has connected the declines in youth smoking prevalence with program activities (Univer- sity of Miami 1999). Results suggest that students who reported receiving elements of a comprehensive to- bacco use prevention education in school had greater declines in smoking between 1998 and 1999 than those students who reported not receiving such education in school. Similarly, the Community Partnerships in the 67 Florida counties were classified as “excellent,” “average,” or “needing improvement” based upon program record data, and these ratings were linked to data from the Florida Youth Tobacco Survey for 1998 and 1999 in those counties. Declines in smoking prevalence were related to the classification, with the greatest declines among middle and high school stu- dents in counties rated as “average” or “excellent.” Similar ratings of counties on the level of local enforce- ment of youth access laws were related to youth smok- ing prevalence, with the highest levels of enforcement in counties with the lowest prevalence. Finally, data from the Florida Anti-Tobacco Media Evaluation (FAME) have indicated that the “Truth” campaign is producing impressive awareness among, vouth and changes in attitudes and knowledge consistent with the campaign themes. Between 1998 and 1999, the prevalence of Florida youth aged 16 vears and under with antitobacco attitudes increased from 59 to 64 per- cent but decreased slightly nationwide. National data against which to compare the Florida data from 1998 and 1999 are not yet available, but some data suggest that the prevalence of tobacco use among young people may have peaked nation- wide and could be starting to decline (University of Michigan 1998). In addition, the impact of state excise tax increases that have occurred since the 1998 baseline data collection might be assessed. Adult Smoking Prevalence In 1998, the Florida Behavioral Risk Factor Surveillance System (BRFSS) expanded its assessment of tobacco issues. The tobacco module will enable changes to be assessed in tobacco use prevalence, cessation behaviors, family rules about tobacco use, environmental tobacco smoke exposure at home, and workplace policies regarding smoking. Texas The legislative plan developed by the Texas Interagency Tobacco Task Force (1998) incorporated the CDC recommendations for community and school- based programs to reduce tobacco use. The plan in- cludes a public awareness campaign, cessation and nicotine addiction treatment, programs for diverse or special populations, enforcement of laws to reduce minors’ access, surveillance and evaluation, and state- wide program administration. The plan requests $20.75 million for fiscal year 2000 and $61.25 million for fiscal year 2001 to implement, evaluate, and ad- minister the programs proposed. In the fall of 1999, the Texas legislature created an endowment fund of $200 million and requested the Texas Department of Health to conduct a pilot study based upon recommended interventions included in the 1998 tobacco task force plan. This pilot would be Reducing Tobacco Use funded by investment revenue from the endowment fund, approximately $9 million per year. In response to this requirement, the Texas Department of Health has begun an Intervention Effectiveness Pilot Study in conjunction with universities in the state. To assess the impact of tobacco use prevention activities in the state, the Texas Department of Health has conducted the Texas Youth Tobacco Survey in 1998 and 1999 among middle and high school students from a sample of students statewide and in eight regions of the state. Results from the 1998 survey indicated 31 percent of middle school students and 43 percent of high school students were currently using some form of tobacco products (Texas Department of Health). For cigarettes alone, 21 percent of middle school students and 33 percent of high schoo] students were current smokers, Minnesota Settlement Program In Minnesota, the Minnesota Partnership for Ac- tion Against Tobacco, the Tobacco Work Group of the Minnesota Health Improvement Partnership, and the Minnesota Blue Cross and Blue Shield (which received a separate 5469-million settlement award [see “Recov- ery Claims by Third-Party Health Care Payers” in Chap- ter 5}) all have developed plans for the statewide effort to reduce tobacco use. In the 1999 Omnibus Health and Human Services appropriation bill, the Minnesota legislature set aside $968 million from the state’s tobacco settlement to establish two health-related endowments: one for preventing tobacco use and supporting local public health efforts ($590 million) and the other for tobacco-related medical education and research ($378 million). The interest earned from these endowments will support long-term programs. The 1999 Minnesota Omnibus Health and Human Services bill established an ambitious goal to reduce tobacco use among young people by 30 per- cent by the year 2005. In response to this, the Minne- sota Department of Health developed the Minnesota Youth Tobacco Prevention Initiative: Strategic Plan (Min- nesota Department of Health 1999). This plan defined major activities that will be funded from January 1, 2000, through June 30, 2001, in four component areas: Statewide Public Information and Education Cam- paign, Statewide Programs, Community-Based Prevention Programs, and Youth Leadership Projects. The strategic plan established “initial indicators of suc- cess” for each program component to enable program performance to be assessed. The Statewide Public Information and Educa- tion Campaign will have a proposed budget of $7.5 Comprehenstee Pregranis 397 Surgeon General’s Report million for the 18-month period. The campaign will include both a media component and grassroots organizing efforts focused on the target audience of 12- to 17-year-old youth. The Statewide Programs will be budgeted at $3.55 million for the initial 18-month period. Evaluation activities, training, and technical assistance services will be funded along with statewide organizations to support the community-based efforts. The Community-Based Prevention Programs will be budgeted at $4.4 million for the initial 18-month period. Community-based prevention efforts will include tobacco-use prevention activities at the local level and projects that focus on populations at risk. Finally, the Youth Leadership Projects will be budgeted at $1 million for the initial 18-month period and will work in conjunction with the community-based prevention efforts. These activities will seek to em- power Minnesota’s youth to take leadership in the planning and implementation of tobacco prevention and control programs at the local level. The Minne- sota Department of Health has established an evalua- tion plan to track progress of the initiative, with the first comprehensive report on program effectiveness to be delivered to the legislature in January 2003. Programs Meeting the Needs of Special Populations The recent Surgeon General’s report Tobacco Use Among ULS. Racial/Ethnic Minority Groups provided a summary of the various approaches that have been used to prevent and control tobacco use among racial/eth- nic minority groups in the United States (LUSDHHS 1998). This report highlighted the need for more re- search on the effect of culturally appropriate programs to address this problem. Few new findings have emerged since the publication of that report; hence, the elimination of disparities in health among population groups remains hampered by the lack of culturally ap- propriate programs of proven efficacy. Below are some examples of community-based interventions that have proven to be effective and that may serve as examples for the development of future program initiatives. Uniting and mobilizing the movement to reduce tobacco use among racial/ethnic groups have not been easy. Tension frequently occurs between various orga- nizations within the community regarding appropriate strategies to achieve particular goals, “turf” disagree- ments, competition for fund-raising dollars, and other issues. Many of these problems were identified during the 1989-1992 COMMIT trial. Though COMMIT researchers did not attribute to internal dissension the 398 Chapter 7 programrs inability to reach its goals (Thompson et al. 1993), internecine rivalry can splinter community mo- bilization efforts and greatly impair the effectiveness of any program trying to reduce tobacco use. Diverse views and dissent are an expected part of organizing activity. A more serious issue for com- munity mobilization has been a lag in engendering support from all segments of society. Historically, the movement to reduce tobacco use has been dominated by organizations composed of middle- and upper-class white Americans and often led by white males (see Chapter 2). For many years, participation in the move- ment was further limited to organizations concerned with health and medical issues and nonsmokers’ rights. In the early 1980s, increasing dissatisfaction was voiced by women and underrepresented communities who felt that their issues and contributions were not adequately integrated into mainstream efforts to reduce tobacco use (Jacobson 1983). In recent years, a number of persons and organizations representing more diverse perspectives have assumed a greater role (see the text boxes “Uptown,” “X,” and “Dakota”). Particularly in view of the tobacco industry's targeted marketing to women, African Americans, Hispanics, and young people (USDHHS 1994, 1998), such heightened activity is of critical importance to ensure a nonsmoking norm within diverse communities. In some instances-— exemplified by the low and declining smoking preva- lence among African American youth (USDHHS 1994)—such a norm may have already taken hold. Programs for the African American Community Several leadership groups, such as the National Black Leadership Initiative on Cancer, which is funded by the NCI, and the National Association of African Americans for Positive Imagery, funded in part by the CDC, have begun to have a voice in activities to re- duce tobacco use in the African American community. For example, in 1989, a strong coalition guided com- munity mobilization efforts to mount a successful cam- paign against the test-marketing of Uptown, a new brand of cigarettes targeting African Americans (see the text box “Uptown”). A similar community- organized campaign in 1995 resulted in the withdrawal of X, another new brand seemingly intended for the African American community (see the text box “X”). In 1992 and 1993, the ACS provided funds for community demonstration projects to use Pathways to Freedom: Winning the Fight Against Tobacco, a self-help guide for African American smokers (Robinson et al. Reducing Tobacco Use Uptown n mid-December 1989, R.J. Reynolds Tobacco Company announced that on February 5, 1990, it would begin test-marketing a new cigarette in Phila- delphia, Pennsylvania. The cigarette, to be named Uptown, was the first to be marketed directly to African American smokers. Within 10 days of this announcement, the Coalition Against Uptown Ciga- rettes (CAUC) was formed. Using existing church and community organizations and word of mouth, the coalition grew to include 26 diverse organiza- tions representing health, religious, and community groups. The group’s leaders were African Ameri- cans with long-standing ties to the Philadelphia African American community. The Philadelphia chapter of the National Black Leadership Initiative on Cancer, an organization funded in part by the National Cancer Institute and dedicated to reduc- ing cancer in the African American community, and the Committee to Prevent Cancer Among Blacks facilitated the coalition’s formation. Also active in the CAUC were several other organizations that addressed local issues on cancer control. These groups included chapters of the American Cancer Society and the American Lung Association, as well as the Fox Chase Cancer Center. The CAUC decided that its initial goal would be to limit R.J. Reynolds’ ability to use Philadelphia as a test market by convincing African American smokers to boycott the new cigarette. The coalition mobilized both smokers and nonsmckers in support of this goal by focusing on RJ. Reynolds’ strategy to promote tobacco use among African Americans. The coalition initially used local media to reinforce the messages being sent through grassroots channels and did not seek out national coverage, which the coali- tion members believed would hinder their goal of 1992). Awardees used Pathways to Freedom to bring tobacco control efforts to the African American com- munity. Through these demonstration projects, many ACS divisions began or enhanced their work in the African American community. A recent study in three predominately low- income, African American neighborhoods has demon- strated that culturally appropriate interventions can produce significant declines in smoking behaviors (Fisher et al. 1998). The Neighbors for a Smoke Free building a local, grassroots constituency. On behalf of the CAUC campaign, Dr. Louis Sullivan, then Secretary of Health and Human Services, addressed the University of Pennsylvania School of Medicine on January 18, 1990. In his remarks, Secretary Sullivan said that “at a time when [African Ameri- cans} desperately need the message of health pro- motion, Lptown’s message is more disease, more suffering and more death for a group of people al- ready bearing more than its share of smoking- related illness and mortality” (quoted in Heller 1990, pp. 32-3). The national media embraced the story. Sec- retary Sullivan’s remarks were prominently fea- tured in the evening news and were front-page headlines across the country. R.J. Reynolds initially responded by defending their targeted marketing strategy, but the company later claimed that Up- town was not aimed specifically at African Ameri- cans. On January 19, 1990, R.J. Reynolds canceled the Philadelphia test-marketing of Lptown. On January 31, 1990, the company canceled production of the cigarette. The course of events suggests that the Uptown coalition plaved a decisive role in altering R.J. Reynolds’ targeting strategy. A united response from Philadelphia’s African American community, an or- ganized local grassroots effort, the strategic alliance with a national figure, and media management were associated with product cancellation less than two months after introduction. The episode highlights the importance of timing in measures to reduce to- bacco use. In this instance, a marketing campaign appears to have been derailed in its beginning stages by short-term, high-intensity media advocacy (see “Media Advocacy,” later in this chapter). North Side organized residents in wellness councils to encourage nonsmoking in their areas. A citywide advisory council, composed mostly of African Ameri- cans, carried out central planning for the program and provided linkages to community resources and tech- nical assistance to neighborhood councils. The pro- gram implemented a wide range of activities over a 24-month period, including smoking cessation classes, billboard public education campaigns, door-to-door campaigns, and a “gospelfest.” A quasi-experimental Comprehensive Progrants 399 Surgeon Geieral’s Report LT early 1995, the memory of the grassroots vic- tory against Uptown cigarettes (see the previous text box, “Uptown”) served as a rallying cry in the African American community in Boston against the potential threat of a new brand—x cigarettes. As with Uptown in Philadelphia, the first information about this cigarette brand came in local media— in X’s case, in articles in the Boston Globe and the Boston Herald. This distinctive menthol cigarette brand was packaged in the Afrocentric colors red, black, and green and featured a prominent “X,” a symbol fre- quently associated with the well-known, deceased African American leader Malcolm X. Community leaders in Boston and throughout the United States thought that the product had the potential to attract young African Americans—a group whose smok- ing rates had dropped dramatically in recent years. The use of “X” ona cigarette brand also was seen as a defamation of Malcolm X, a noted nonsmoker. Al- though manufactured and distributed by two com- panies without large marketing budgets, there was a fear that even a small success with X cigarettes would stimulate the creation of similar products by the major tobacco companies, which would have significant resources for advertising and promotion in African American communities. The National Association of African Americans for Positive Imagery (NAAAPID and the Boston- based organization Churches Organized to Stop Tobacco took the lead in opposing X cigarettes. Two NAAAPI leaders, Reverend Jesse W. Brown, Jr, and design was used to evaluate the impact of this pro- gram. The three intervention neighborhoods in St. Louis were matched by ethnicity, income, and educa- tion with three comparison zip code areas in Kansas City, Missouri. Baseline and follow-up random-digit dialing telephone surveys were conducted among adults (aged 18 years or older) in the three interven- tion and three comparison areas in 1990 and in 1992. Smoking prevalence declined significantly in the St. Louis neighborhoods, from 34 to 27 percent, but declined only slightly in the Kansas City comparison areas, from 34 to 33 percent. Thus, the results of this trial suggest that a culturally appropriate community- organizing approach to smoking cessation that 400 9 Chapter 7 Charyn D. Sutton, both of whom had been involved in the Coalition Against Uptown Cigarettes, spoke in Boston in February 1995 about the need for com- munities to mobilize against tobacco marketing. Their visits were covered extensively by print and broadcast media. As a result of NAAAPI’s orga- nizing efforts, the manufacturer and distributor of X cigarettes received calls from around the coun- try, most notably from the organizations involved in the African American Tobacco Education Net- work of California. Because the brand’s marketing seemed to be confined to the Boston area, NAAAPI decided to demand in writing that X cigarettes be withdrawn immediately to prevent any wider distribution. The manufacturer (Star Tobacco Corporation, Petersburg, Virginia) and distributor (Stowecroft Brook Distribu- tors, Charlestown, Massachusetts) both responded within 10 days to that request, although they contin- ued to insist that the cigarette brand had not been specifically targeted to the African American com- munity. On March 16, 1995, news conferences were held in Boston and Los Angeles by tobacco advo- cates to announce the withdrawal of X cigarettes from the market. The course of events suggests that the actions of activist groups had direct influence on the out- come. As was the case with the Uptown protest, the X experience suggests the critical role of a rapid but organized community response in efforts to prevent the targeted marketing of tobacco products to racial and ethnic minority groups. emphasizes local authority and involvement in pro- gram planning can have a significant impact on the smoking behavior among residents of low-income, African American neighborhoods. Programs for Women The Women vs. Smoking Network, a project of the Advocacy Institute, was the first national network of women’s organizations and women’s leaders to focus on reducing tobacco use among women. With financial support from the NCI, the network provided technical assistance and information to women’s orga- nizations in an effort to interest them in the movement to reduce tobacco use. The network also focused on obtaining media coverage for issues concerning women and smoking. The network’s most notable ef- tort was the release of a plan by R.J. Reynolds to mar- ket cigarettes to young, uneducated women (see the text box “Dakota”). Subsequent media attention made this one of the most widely covered tobacco stories of 1990 (Pertschuk 1992), The network was short-lived (1989-1991), however, because of lack of funding. The International Network of Women Against Tobacco (INWAT) was established in 1990 as an international organization to counter the marketing and promotion of tobacco products to women and to foster the devel- opment of programs for the prevention and cessation of tobacco use among women. Through support from the American Public Health Association, INWAT has worked to draw attention to issues concerning women and tobacco and has sought to unite and inform women’s advocates around the world. Asa record of its Herstories project, INWAT assisted in preparing an issue of World Smoking and Health (NWAT 1994) that was a collection of brief essays about the role of to- bacco in women’s lives in various countries. INWAT has also published and distributed an international directory that lists women who are advocates for reducing tobacco use and includes their areas of spe- cialization (American Public Health Association 1994), The National Coalition for Women Against Tobacco, whose sponsoring organization is the American Medi- cal Women’s Association, provides educational mate- rials and advocacy messages to counteract tobacco industry marketing and combat tobacco use among women and girls (hitp:// www.womenagainst.org). Federal and State Programs At the federal level, the CDC’s IMPACT program awarded three-year cooperative agreements in 1994 to selected national organizations to enhance their work in reducing tobacco use at the national, state, and local levels. Organizations were chosen on the basis of their ability to provide services and outreach to young people, women, blue-collar and agricultural workers, African Americans, Hispanics, Asian Ameri- cans and Pacific Islanders, and American Indians. Among the states, California has made a concerted effort to involve racial and ethnic minority groups and women in its efforts funded—by Proposition 99—to reduce tobacco use (see the section on California, ear- lier in this chapter). In 1990, four organizations were funded to form networks among Hispanics, African Americans, Asian Americans and Pacific Islanders, and American Indians. Members of the networks convene Reducing Tobacco Use meetings, share experiences, participate in the devel- opment of culturally appropriate materials, and help community organizations reach their respective com- munities. These networks currently conduct programs and campaigns to build a strong statewide coalition among their respective populations (Tobacco Educa- tion Oversight Committee 2000). California also has funded a statewide organization, Women and Girls Against Tobacco, to focus on tobacco product market- ing that targets females. Created in 1992, the organi- zation focuses on empowering women’s and girls’ organizations to divest themselves of tobacco indus- try sponsorship and funding and on eliminating tobacco advertising in leading magazines with read- ership among voung women (Women and Girls Against Tobacco, n.d.). Religious Organizations Although not specifically representative of minority or underserved groups, some religious orga- nizations that have an important impact in minority communities have had long-standing involvement in issues related to reducing tobacco use. The Interfaith Center on Corporate Responsibility, a coalition of 250 Roman Catholic and Protestant institutional investors, pioneered the corporate responsibility movement in the early 1970s. The value of their combined portfo- lios is estimated at $40 billion. In 1981, the Province of St. Joseph of the Capuchin Order was the first mem- ber of the coalition to file a shareholder resolution with a tobacco company on the issue of smoking and health. Since then, the coalition has filed numerous share- holder resolutions with the major tobacco companies. These resolutions are a unique opportunity to engage in a public dialogue with executives of major tobacco companies; the shareholder meetings frequently re- ceive media attention. Amore recent effort to involve religious organiza- tions and thereby diversify efforts to reduce tobacco use is the formation of the Interreligious Coalition on Smoking OR Health. The stated purpose of the group is to mobilize the faith communities in the United States to improve the effectiveness of public policy concerning tobacco. The Coalition is con- cerned with policies affecting United States cor- porations involved in the manufacture and sale of tobacco products. The primary focus of the Coalition is educating policy makers within both the legislative and executive branches of the United States federal government (Interreligious Coalition on Smoking OR Health 1993, p. 1). Comprehensive Programs 401 Surgeon General's Report Dakota he Women vs. Smoking Network, under the aegis of the Advocacy Institute, was a project aimed at informing and uniting women’s organi- zations to oppose the tobacco industry’s etforts to market its products specifically to women. In No- vember 1989, the network sent a letter to the editor of more than 100 newspapers nationwide. Several newspapers printed the letter, which responded to a Philip Morris advertisement that had previously run in these newspapers as a mock apology to women for alleged “shortages” of their new ciga- rette, Virginia Slims Super. Asa result, several ma- jor national papers and ABC News subsequently ran stories on tobacco advertising that targeted women. Soon thereafter, the controversy and media cover- age surrounding the planned test-marketing of Uptown cigarettes to African Americans began (see the text box “Uptown”). In response, many jour- nalists wrote stories on the related issue of targeted marketing to women. These stories prepared the public for the events that followed. In February 1990, an anonymous source sent the Women vs. Smoking Network copies of confi- dential] marketing documents for a new cigarette brand, Dakota. The cigarette, produced by R_J. Reynolds Tobacco Company, was scheduled for test- marketing in April 1990. The marketing documents, entitled “Dakota Field Marketing Concepts,” con- sisted of more than 200 pages of test-marketing pro- posals from two different advertising firms. The marketing documents described Dakota, which was The coalition was formed in cooperation with leading organizations within the mainstream tobacco control community. As of January 1994, the coalition had enlisted 16 main religious organizations, includ- ing Catholic, Muslim, and Protestant denominations, in the effort to support a large increase in the federal excise tax on a pack of cigarettes (Interreligious Coali- tion on Smoking OR Health 1994). Special Efforts to Reduce Chewing Tobacco Use In 1995, Oral Health America established the National Spit Tobacco Education Program (NSTEP), 402 Chapter 7 code-named Project Virile Female, as a cigarette ex- plicitly for young women (18-20 years old). The demographic and psychological profile prepared by Trone Advertising Inc. of the typical Dakota smoker described her as a “caucasian female, 18-20 years old, with no education beyond high school, work- ing at whatever job she can get” (Butler 1990, p. 1, citing Trone Advertising Inc.). She aspired to have an ongoing relationship with a man and “to get married in her early twenties and have a family.” She spent her free time “with her boyfriend doing whatever he is doing.” The marketing documents also included specific promotional strategies to attract young women to the new cigarette. Recognizing the value of the documents, staff of the Advocacy Institute negotiated with the Wash- ington Post for front-page coverage of the story in exchange for initial exclusive release of what the institute staff called “Dakota Papers.” The Wash- iigton Post ran the story on Saturday, February 17, 1990, with the headline, “Marketers Target ‘Virile Female’: R.J. Reynolds Plans to Introduce Ciga- rette” (Specter 1990). The Advocacy Institute held back further details on the documents until Tues- dav, February 20, so that the director of the Women vs. Smoking Network could appear on CBS Tius Morning with Dr. Louis Sullivan, then Secretary of Health and Human Services, to “release” the story of the documents. Secretary Sullivan strongly con- demned R.J. Reynolds’ plans to target women in its marketing strategies. continued on text page an effort aimed at reducing the use of smokeless to- bacco among youth in sports. Oral Health America teamed up former major league baseball players, such as Joe Garagiola, Hank Aaron, and Bill Tuttle, to help get the message out that smokeless tobacco products are nota safe alternative to smoking. The components of NSTEP include in-stadium events, public service announcements that have been televised during ma- jor league baseball games, printed materials, and edu- cational videos. An external evaluation of NSTEP is being developed to address all levels of the program and its public health impact. Significant successes of the program include the inclusion of spit tobacco on the national tobacco policy agenda, with specific credit to NSTEP and national